The health care situation in South Africa

A few of you asked how it was that I could / did admit my children just a few hours after they started puking.

I thought I would explain how it woks here in South Africa. Please note this is not a scientific or political explanation, it is simply my understanding and experience of health care in South Africa.

There is no ‘health care system’ in South Africa. There is government funded health care that the poor have to use, and there is the private health system that only the wealthy and insured have access to. The difference between the two is stark and enormous. One only has to look at the difference between the state of private and public hospitals to see this difference vividly expressed. The private hospitals are like hotels. Spotless, swanky, luxurious. Expensive. The government hospitals are over extended, under staffed and poorly funded. Dark, dingy, dirty.

If you are privately insured, as I am, then you have access to the best medical care in the world. Literally. We have top class medical expertise here, among the best in the world. However, medical insurance, or what we refer to as medical aid, is very expensive. There is no way the poor could afford it. My monthly medical insurance payment is more than some people earn in a month.

There are various types of medical cover you can purchase, from what is known as a ‘hospital plan’ – you are covered by the medical insurance to attend a private hospital, but all ‘out of hospital’ expenses are for your own account.  Or you can have full comprehensive cover, such as I do, which means that all your medical bills are covered. You pay through your nose for that benefit, but having small kids (and being able to afford it), I think it’s worth it.

If you don’t have medical insurance, you are forced to use the government or public hospitals and health care.  The medical expertise is again, world class, but the facilities are horrendous. The hospitals are overloaded, under-funded and not in a good state. There are no pillows, because people steal them. People sometimes have to wait for hours to be seen or even share beds. Which is why my sister has taken on her local hospital as her charity. Go have a look at her blog and see real life examples of government hospitals. The prem babies have to share incubators with other babies, because there are simply not enough incubators.  It used to be that babies under 2.2 pounds (1 kg) are not put on ventilators or life support because there aren’t enough funds and equipment for them.  Not sure whether that is still the case. And sadly, nurses are very badly paid. Which is such a crime.

So there you have it, the stark difference between the haves and the have nots. Never more evident that it is in terms of access to health care.  People without medical insurance and / or sufficient funds have to make use of what is available to them. They basically have to take a number and wait.

However, those of us who are insured are in a totally different space. We decide who we want to see, when etc. We hardly ever have to wait for appointments, even specialist appointments like ENT etc. If I want an ENT appointment tomorrow, I’ll get one. Because I am a paying customer and if you don’t want my business I’ll find someone who does. I suppose we are lucky we have so many top class doctors here.

It is not as if we (the private patients) call the shots, but private medical care has a fairly well entrenched commercial customer service orientation. I am the paying customer and therefore I demand excellent care on the terms I want.

However, a lot of what happened yesterday (i.e. early admission etc) is because of who I am and how I am. I absolutely refuse to take any chances with my children, and yes, as I have been accused by other people, I am probably a little paranoid.

My thinking is, why wait until things get really bad? I know my kids and I am not going to let them get dehydrated and then only go to the doctor. Adam started puking for the first time at 5am on Friday. At 8am when the Paed’s office opened, I called and got an appointment for 11. By this time Adam had kept nothing down. We were admitted at 12 to be put on a drip and for observation and testing. The bloods taken at 12 showed that he was on the verge of becoming dehydrated. Why wait for that? What would have happened if I had waited 24 hours? I’d rather not find out.

Then, when Kate started vomiting at 4pm, I knew what I was in for. I called the Paed straight away and he gave me a prescription for some suppositories. Two hours later she was still puking so at 7pm I called the Paed (on a Saturday night! poor guy works so, so hard) and he said “I’m still in my rooms, bring her in and let’s admit her”. And that’s it.

I am so unbelievably fortunate that I can afford private medical insurance. That my decision on whether to take my child to a doctor or specialist is not based on whether I can afford it. Believe me; I know how lucky I am. I live here, I’ve seen what it is like not to have money. And it makes me realize yet again how very lucky I am.  

Comments

[Angie]

That's fantastic. Here they'd tell us to wait it out. If we showed up at the hospital with a kid not at death's door, they'd send us the bill. That bill would be on top of the $900 a month we pay for this "insurance".

[Paula]

It's so depressing - here in the US as well - to think about the huge disparity in access to health care. My mom has cancer and with a few phone calls (and great insurance) she was seen quickly by the top oncologists, operated on by the best brain surgeon, and pays $10 a month for her current treatment, which is a single pill that costs $100 a day. In the middle of thinking of how amazingly fortunate we are is a push to figure out a way to make sure everyone has these benefits. It's sobering to look around the hospital, in New York City, and see the stark breakdown: patients are white, and the people who take care of them (in the low-paid, aide jobs, not doctors and nurses) are not. The life expectancy for her (terminal) condition is 8 months, but the aggressive and highly competent treatment she's had has kept her relatively well for over 2 years. It's simply heartbreaking that it's basically luck that determines who gets those extra years.

Besides wonderful organizations like your sister's, the very structure of the health care system is S. Africa and the US needs to change. But the risk of providing better average care across class and ethnic lines is that, like in Canada and the UK, people like us (your ENT example, my mom) won't be seen the second they pick up the phone in non-emergencies.

What's surprising to me about Adam and Kate is that they were admitted so early - it's actually way, way more dangerous to be in the hospital (because of medical errors and infection risk) than not. My experience with top doctors is that they'll do everything possible to keep patients out of hospitals, even if it means inching up on dehydration, for the ironic benefit of their health.

[jennifer]

I guess what really amazes me is that your insurance is willing to pay the bill. Here, I suppose I could do the same if I could pay the hospital bill myself, but since my insurance would never approve the claim, I really can't afford it. My insurance, which is supposed to be top of the line here, will only pay for medically necessary charges. So if I go to the ER for a minor thing, I have to worry that they won't pay the bill. Like when my son bit through his lip at 10:30PM on a Saturday night. They didn't pay that ER bill, because the total was less than the $150 copay. (I was amazed at how small the bill was) I don't know if they would have paid anything if the bill had been bigger or not.

[colicmommy]

I guess the only reason I could see not to go the hospital early for a stomach bug is the IV. Really, it was so awful to get colicboy IV'd that one time we had to. I'd rather wait it out at home, with him in his bed and us all comfy here at home, with the pedialyte and gatorade and crackers. He's had upwards of 6 stomach bugs in his 4 short years, and actually, none of them resulted in IV (the IV time was for something totally unrelated to a stomach bug). Yes, it's always hard to have a sick kid and change sheets and jammies a million times and keep up the pedialyte on schedule, but he was so much happier than he would have been in the hospital. (he also has some sensory issues, like adam. Mild ones, but enough). And, anyway, we have fabulous ins. for the US, really, we don't need referrals or anything, we just go where we want. Still, I doubt they would have covered admission until clinical dehydration set in.

BUT, if your ins. will actually pay to admit for the stomach flu, then you are very lucky, and I see why you did it. Hope everyone is feeling better!!

[Orange]

I was talking to a German mom on the playground outside my kid's school (in the U.S.) the other day about health care. Germany, of course, has a national health care plan that covers everyone (noncitizens, too? I don't know) for medical care and prescription medications. Maria said the only thing that produces any sacrifices or waiting is the fact that people tend to overuse their free health care—such as going to the doctor for a cut on your finger rather than handling it yourself.

So Paula, I'm not sure that expanding America's coverage to provide universal health care access will actually deprive the "haves" of anything at all. I suspect the Republicans and the health-insurance companies' lobbyists like for everyone to think that huge sacrifices will be needed in order for those 46 million uninsured Americans to have coverage—but maybe the sacrifices would be small (and well worth it if it means 46 million more Americans will be able to have office visits instead of waiting until they're sick enough for a costly emergency room visit).

[colicmommy]

Hm, I don't know, Orange. My husband is Dutch, and his family is very "Have", if you know what I mean. Yet, they still cross the border to Belgium to get health care frequently, because the universal health care system in the Netherlands produces long, long waits for everyone, haves and have-nots. My husband needed an eye surgery as a child, and needed it within weeks. The Dutch system could have gotten him booked in to a surgeon in two YEARS. That's right. They are quite well-off and pay for the best "upgrade" to the national insurance, still.... They crossed the border, paid out of pocket and got the surgery in days.

It really depends on how a univerasl system is designed. I'm not saying it's not a good idea, but I'm also not saying that having one wouldn't mean a lot of sacrifices for some people.

[anon]

It amazes me that no matter what the topic of conversation, the republicans/Bush/believers always managed to get blamed for it. Every time. Good grief.

That aside, my sister doesn't have insurance. When my nephew was 5 he got pushed off the monkey bars at school, and got a very bad break on his upper leg. (The bone separated about an inch) Because she is uninsured, the only place that would accept her was Shriners/Doernbecher (sp?) which is a non profit children's hospital. They didn't have to pay a penny for any of it. (Dyllan had to have metal pins put in, to set the bone). It's sad to me that she had to drive by 4 major hospitals to get him there... But, while Shriners was old, and not as nice as the other hospitals, it was clean and the staff was wonderful. The walls were banged up a little, and everything looked a bit older, but like I said, it was clean and he got excellent care...

[21stCenturyMom]

Sounds just like the States only here you both pay through the nose AND wait hours to be seen. It's really special. At least once you do get admitted the hospital is pretty nice. As others have said, our government funded and run hospitals are not so nice.

[Rachel]

Hi Tertia!

This is an interesting post, I always love when you write about South Africa and the differences and similarities in your way of life.
Here in Canada we have a medical system which is equal on most levels and open to everyone in the same way. This does sometimes mean waiting up to one month or more for a specialists appointment, sometimes depending on the severity of the situation. I do feel however that the care my family and I have received has been excellent. I feel that the equality of the system is something that I take for granted and find it shocking that even in the US some people have access to better health care than others. It seems that if you are able to afford more, your life is worth more and this seems so unjust to me. When it comes to health, if nothing else, don't we all deserve the same good care?
I do know that it is a complicated situation, and even here in Canada there are a lot of issues to be debated.
On another note, I saw that movie "Blood Diamond" last night and found it quite moving. I was wondering if you've seen it and what you thought about it. I often also find myself curious about what you thought about the end of apartheid--what do you remember from this time and how has life in South Africa changed? Did things change quickly? That must have been an amazing thing to witness.
Anyway...totally off topic! Thanks for your great insight, love your blog.

Rach.

[Rushil]

nice blog!

[Suzie-Q.]

Here in the U.S. it not only makes a difference IF you have health insurance, you must also have VERY GOOD (read as: expensive) health insurance because there are a million variations on the theme (different types of plans) and you usually get what you pay for.
That being said, what also works miracles in this country for faster, better treatment is knowing a doctor personally. When i broke my neck, i was at a small, remote, mountain hospital with no big specialist. My friend, a nurse, lived/worked 1.5 hours away at a world class orthopedic hospital. She drove to me, picked me up and drove me back to her hospital after making a phone call to one of the world's best surgeons that she worked with and knew personally.
They bumped everyone else who had surgeries scheduled for months and took me in immediately all because i was a friend of Debbie's. I didn't even know the doctor!!!
Recently, when my dad needed a cardiologist for a routine check-up i insisted he start seeing my dear friend's husband... just in case something bad ever happened. That way we would have a "hook" and know that we would get extra special treatment, care and priority by being a friend of the family...
Say what you will, but, i ALWAYS exploit my friendships/relationships if i think it will help me with medical care...
And the list is endlesss....

How is Kate doing?
xoxo
Suz

[Stephanie]

I think you're very, very lucky. Here (US, Michigan at the time), all insurance is looking at the bottom line-so not everything is covered. When my godson was little-maybe 11 months? He was sick with high fever and dehydration, and couldn't keep anything down. We were at the hospital 2, maybe 3 nights- we'd take him to the ER, they'd put him in a room and watch him a bit, then send him home, telling us to bring him back if he didn't get better. So, the next night, we'd take him back- same as the first. Hospital stays are expensive, so they don't admit if they don't have to. Now my godson was on state aid at the time-but I do't know that the treatment would've been radically different if he wasn't. I've seen the same thing happen with private insurance.

[marsh]

Please tell us how Kate is. We are all sending her good wishes! (And Harrison, Marko, and you, too...not necessarily in that order!)
Thank you so much for answering our questions! You are so supportive of your readers. We love you for it! I found your post fascinating. I agree with Rachel about loving when you write about South Africa. I enjoy the world's variety! You do a fabulous job of describing your life, your family, and customs in your country. I'll never get tired of reading So Close!
Marsh

[Michelle]

In Canada, we are not allowed the choice. We have government hospitals and health care, and are not allowed to have a private system as well - the poor oppose it.

So, despite that I *could* afford access such as you describe, I am not allowed.

[RainbowW]

i have medical insurance here in texas, and i -still- can't afford to take my kids to the doctor. "full coverage" here means they pay 80% of the charges AFTER the fisrt $1800 (which you must pay cash, thank you very much).

[Howard]

First, Tertia, I have to commend you for knowing what you have and what others don't have. I'm not sure if I give it all that much thought most of the time; like most of us, we are all running, running, through life, and we sort of take for granted a lot of what is given to us. I agree with you on one point in particular: that when it comes to kids, we don't mess around. And if we can afford it, we're going to pay it, because it's our kids' health. So the fact that you can get the private coverage should be seen as a blessing, pure and simple.

Thanks for the post, and the reminder that "all good gifts come from above."

******
http://surfcountry.blogspot.com

[jodie]

Here in Australia we have the "haves" (medical insurance) and the "have nots". It makes a huge difference for non-emergency stuff. You can see a specialist much more quickly (but never in a day or so - usually a few weeks unless it's urgent) and get elective surgery when you want it. For emergency stuff and kids though you generally go public, and the care is excellent.

The hospitals here would never admit a child for gastro that's lasted less than a couple of days. Generally they feel it's less stressful for the child to be at home in bed sipping water than in a hospital with an iv. 99% of the time kids will just get over it. Plus in hospital they are exposed to a lot more bugs than at home.

[Laura(southernxy)]

As an adult, I've had a GI virus severe enough to need IV rehydration after just 24 hours. Got it at the doctor's office, though. I remember the sensation of tears returning to my eyes and saliva to my mouth.

Tertia, do you have money because you're lucky, or because you work your butt off for it?

[lori]

Michelle - I am also Canadian, and am offended by your statement that there is no private health care because "the poor oppose it." Many people, including those who are not poor (myself included), oppose the introduction of a two tier health system. Please do not present your elitist comments and opinions as being shared by all Canadians.

[gillian]

Any Canadian with money can cross the border and pay for their health care in the USA..and dont have to wait the endless wait to see a specialist in Canada.
We do it all the time and are fortunate to be able to do it that way. So many (both USA and Canada) use the E.R. for their own doctors because in the USA they have no insurance and can not be legally turned away from the ER and in Canada their is a terrible shortage of M.D.s so many people do not have their own MD to go to..its really a lose-lose for both countries.

[liz]

I hope your baby girl feels better soon!

And thank you for the inside look at SA health care.

[Andrea]

Oh my God, is somebody (Laura) actually suggesting that only people who work their butts off have money, and that those who are poor are poor because they don't work their butts off?
While Tertia certainly does seem to have quite the work ethic, I suspect she'd be the first to say that there are some pretty severe economic ineqalities in her country where many laborers (even nannies?) bust their buts for subpar wages.
Anyway, reading your description of SA health care made me think that maybe our very flawed U.S. system is actually better than yours. We have huge numbers of uninsured, and but as someone who walked into an emergency room just last week for dehydration, I can tell you I was treated without any questions about whether I had insurance, they only asked me about insurance on my way out the door after I'd been treated. It may be hard to see a doctor here in the U.S. (and I am not boasting about our healthcare by any stretch) but you can get emergency room treatment, usually no questions asked. And the rich and the poor often end up in the same hospitals. I shudder to imagine a system that has entirely different hospitals for rich and poor.
A friend of mine has a mom who is an undocumented resident from Mexico. She has no money and no health insurance but is still getting pretty decent treatment from a hospital. Maybe our healthcare system isn't the worst in the world!

[Laura(southernxy)]

"Oh my God, is somebody (Laura) actually suggesting that only people who work their butts off have money, and that those who are poor are poor because they don't work their butts off?"

Do you think Tertia has money because it fell on her out of the sky, and she works her butt off because she just doesn't want to be around her kids all the time?

[Orange]

Ooh, Laura, that's provocative. Many people who have money have it because they have good-paying jobs, those available to people with a good college or postgraduate education. Who gets that kind of education? Often the people who come from families that are already doing well enough financially. It is much, much harder for poor kids to afford college and grad school, at least in the U.S.—both because school is expensive and because they may not have grown up with an expectation that college is important.

Someone without a degree who works 40 hours a week as a nurses' aide and works a second job at Wal-Mart to make ends meet is working her butt off. Someone who works 50 hours in a professional job may also be working her butt off. But only one of them will be able to afford nice things.

Like Jim Hightower said of a politician born in the elite, "He was born on third base but thought he had hit a triple." It's a lot easier to score a run if you don't have to scratch your way to third base. (Sorry for the baseball metaphors, Tertia.)

[Laura(southernxy)]

If suggesting that Tertia has money because she works very hard for it provokes you, Orange, then you must be easily provoked.

[akeeyu]

If you remove Tertia from this and boil the statement down to

Rich = Industrious
Poor = Lazy

...then, yes, I can see why Orange finds it objectionable.

Regarding the statement that you can be poor in America and get health care? Well, if you're too poor to afford health insurance but not poor enough to be on Medicaid, yes, you can get health care! And then they will bill you for the full price of it! And then they will send you to collections over it! And then they will ruin your credit, making it difficult to obstain housing and loans!

Yay for the American health care system!

[Sue]

Tertia, I too want to commend you for knowing what you have and looking at the system objectively. Spurred me to comment briefly on the state of things in the US, Canada, and SA: http://nobaddays.wordpress.com/2007/04/29/248/
Glad to hear you are all on the mend.

[Stephanie]

What irks me about health care in the US is that those least able to afford it are charged MUCH higher rates than those who can. Insurance largely works as a discount scheme, with insurance companies geeting huge discounts from the medical care providers-then they cover the rest, minus a co pay. If I go to my doctor, I pay $15, my insurance gets a 70% discount and then they pay the balance of $35. If I were uninsured, that same visit would cost $165. That's pretty inequitable, since if you don't have healthcare in the US, it's not cause you're rich!!!
As for the class discussion- gotta agree with Orange. My family helped me go to college, which allows me to work hard at a better paying job than if I hadn't gotten the degree. Do i work hard for what I have? Absolutely. But I also had luck, and some advantages when I started. I don't think you can discount those.

[Orange]

Laura, Tertia could slack off and spend her days at the office filing her nails and planning long lunches with wine, and (until her boss figured out she ought to be fired for doing nothing), she'd still earn more than someone without an education and a relatively privileged background.

Hard work and money do not always go hand in hand. I have two friends who work their asses off in stressful jobs. The one who runs a Head Start program probably makes about $40,000 (which isn't much for someone with 20 years of work experience and a master's degree), while the one who works in business and IT is probably making about $200,000 a year. They work similar hours, they're both white, they went to the same high school, they both grew up with families expecting them to go to college. Oh! And the one who makes a lot more? She replaced a guy who'd slacked off for years, making the same salary.

[Laura(southernxy)]

So what is Tertia working and spending her time away from her precious children for, if not to be able to provide for them? That's my point. She feels bad about not being with them more, but she works for a reason: to be able to do things like take them to the doctor of her choice when she needs to. That's the payoff.

[Emma]

A side note on South African health care - here in Canada (having been immersed in the health care system during my daughter's care)we have met LOADS of South African doctors and nurses. Wonderful doctors and nurses, I might add - and quite a few in all areas of care. What a great export :-)

[K]

This is a very interesting discussion. I would like to add just one thing: Contrary to statements above, in the USA no hospital which participates in Medicare can deny emergency care to anyone, as per EMTALA regulations. Nor can you be transferred from one facility to another because of inability to pay. If you know of such a violation, report it. You can be transferred if it is determined that the facility cannot provide the care you require, however (i.e. if you have a head injury and the facility does not have a neurosurgeon).

[Kristin]

Michelle, in Alberta, we sadly do have it. I needed extensive jaw surgery and it came down to : wait 2 years for it to be covered under Alberta Health and have it done at the regular hospital or I could pay for it and claim it under my work benefits and receive some/most of it back. I paid for it. It cost me $2900 for an hour and a half surgery - for the drugs, the doctor, my nurse, my bed and my recovery time. Granted I got back the majority through my private insurance however, I don't believe in a tiered system and the absolute only reason I paid for it rather than waiting was because I couldn't take the pain any longer. A tiered system isn't going to solve the problems with the health care system in Canada, and right now I'm too tired to type a list of plausible solutions or ideas.

I'm glad that you have wonderful health care in SA, Tertia and I'm glad your monkeys are on the mend.

[angel]

i too am fortunate enough to be able to afford a medical aid with full coverage.
why, just today damien and i got new glasses for reading, and we don't have to wait for doctor's appointments or tests. we also see damien's adhd doctor once a month while others wait weeks and months for an appointment.

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