Traditional and Complementary Medicine

1. Traditional and Complementary Medicine Consumers driving change May 2009

2. Use of Herbal Medicine Source: WHO Global Atlas of Traditional, Complementary and Alternative Medicine, 2005.

3. Widespread Usage • This is a consumer-led movement: • Use of traditional medicine (TM) remains widespread in developing countries: in some Asian and African countries, 80% of the population depend on traditional medicine for primary health care. • Use of complementary and alternative medicine (CAM) is increasing rapidly in developed countries: in many developed countries, 70% to 80% of the population has used some form of alternative or complementary medicine. • More than 100 countries have regulations for herbal medicines. • Counterfeit, poor quality, or adulterated herbal products in international markets are serious patient safety threats. Source: WHO Traditional Medicine Strategy 2002–2005; WHO Fact sheet on Traditional Medicine

4. Terminology of TM/CAM • “Traditional medicine” (TM) is used to refer to systems such as traditional Chinese medicine, Indian Ayurveda and Arabic Unani Tibb medicine, and to various forms of indigenous medicine in Africa, Latin America, South-East Asia and the Western Pacific. • In countries where the dominant health care system is based on allopathic medicine, or where TM has not been incorporated into the national system, it is termed “complementary and alternative” (CAM). For example in Europe, North America and Australia. • When referring in a general sense to all of the regions, the comprehensive TM/CAM is used. • Allopathic medicine refers to the broad category of medical practice that is sometimes called Western medicine, biomedicine, scientific medicine, or modern medicine. [also “urban medicine”] Source: WHO Traditional Medicine Strategy 2002–2005

5. World Health Organization Policy • Framework for action for WHO and its partners, to enable TM/CAM to play a far greater role. Four objectives: • Policy: integrate TM/CAM with national health care systems. • Safety, efficacy and quality: expand knowledgebase on TM/CAM; provide guidance on regulatory and quality assurance standards. • Access: increase availability and affordability of TM/CAM, with an emphasis on access for poor populations. • Rational use: promote therapeutically sound use of appropriate TM/CAM by providers and consumers. Source: WHO Traditional Medicine Strategy 2002–2005

6. Beijing Declaration 8 November 2008 • Governments have a responsibility for the health of their people and should formulate national policies, regulations and standards, as part of comprehensive national health systems to ensure appropriate, safe and effective use of traditional medicine. • Recognizing the progress of many governments to date in integrating traditional medicine into their national health systems, we call on those who have not yet done so to take action. • Governments should establish systems for the qualification, accreditation or licensing of traditional medicine practitioners. • The communication between conventional and traditional medicine providers should be strengthened and appropriate training programmes be established for health professionals, medical students and relevant researchers. Source: WHO Beijing Declaration, 8 November 2008

7. Including TM/CAM in the Health System

8. TM/CAM Legislation and Policy Source: WHO Global Atlas of Traditional, Complementary and Alternative Medicine, 2005.

9. Public Financing for TM/CAM “any public contribution to any TM/CAM therapy” South Africa ? Source: WHO Global Atlas of Traditional, Complementary and Alternative Medicine, 2005.

10. PROFESSIONAL BOARD 1 FOR: The Professional Boards of the Allied Health Professions Council ALLIED HEALTH PROFESSIONS COUNCIL PROFESSIONAL BOARD 2 FOR : PROFESSIONAL BOARD 3 FOR : PROFESSIONAL BOARD 4 FOR : Therapeutic Aromatherapy Ayurveda Homeopathy Chiropractic Unani Tibb Therapeutic Massage Therapy Naturopathy Osteopathy Phytotherapy Therapeutic Reflexology Chinese Medicine and Acupuncture 3,622 practitioners in May 2007.

11. International Cover for Homeopathy, Naturopathy and Phytotherapy Available extensively in Europe, the region in which these therapies were developed. Some public coverage elsewhere but not in Africa. Source: Helen Young (2008) The Incorporation of Traditional and Complementary Medicine Benefits in Healthcare Funding Systems: A Worldwide Review Of Practice. Unpublished UCT project with Prof McLeod.

12. International Cover for Trad. Chinese Medicine, Ayurveda and Unani-Tibb Acupuncture enjoys the most global popularity. South-East Asia, the region of origin of Ayurveda and Unani Tibb, offers extensive public coverage. Source: Helen Young (2008) The Incorporation of Traditional and Complementary Medicine Benefits in Healthcare Funding Systems: A Worldwide Review Of Practice. Unpublished UCT project with Prof McLeod.

13. International Cover for All South African CAM Modalities Public coverage extensive in Europe and South-East Asia. Globally, public coverage is almost three times more common than private coverage. In total, over one third of the 130 countries considered offer some form of coverage for SA-CAM therapies. Source: Helen Young (2008) The Incorporation of Traditional and Complementary Medicine Benefits in Healthcare Funding Systems: A Worldwide Review Of Practice. Unpublished UCT project with Prof McLeod.

14. Denial and The Power of Exposure

15. “Fall of the Bamboo Curtain” • The first definitive study of the use of complementary medicine in the U.S.A. (Eisenberg et al 1993) estimated that more than one-third of Americans used alternative therapies. • Three-quarters of this amount was not reimbursed by insurers or medical systems. • The Eisenberg study prompted a fundamental reassessment by healthcare funders of the direction in which consumers were leading them. A further study (Eisenberg et al 1998) showed that alternative medicine visits exceeded visits to primary care physicians. Source: Caldis, McLeod and Smith (2001) The Fall of the Bamboo Curtain : A Review of Complementary Medicine in South Africa, South African Actuarial Journal

16. “Fall of the Bamboo Curtain” • 17 December 1997 was heralded as “The Fall of the Bamboo Curtain”. It marks the date on which the Journal of the American Medical Association committed to publishing papers on complementary therapies as a result of pressure from its readers. • Internal surveys show ranking of CAM moving from 68 to “the top three” in the space of one year. • AMA editors called for papers on CAM, announced a special issue of JAMA each year on CAM and committed all publications in the group to carrying more reports on CAM topics. • John Weeks, editor of the newsletter Alternative Medicine Integration and Coverage, explained the metaphor of the bamboo curtain as “being, appropriately, from the era of the Cold War. The freeze in communication between the medicines, behind which lies were told (on both sides), is officially melting”. Source: Caldis, McLeod and Smith (2001) The Fall of the Bamboo Curtain : A Review of Complementary Medicine in South Africa, South African Actuarial Journal

17. TM/CAM in US Hospitals • The 3rdComplementary and Alternative Medicine (CAM) Survey of Hospitals from the American Hospital Association found that the percentage of hospitals with at least some CAM services jumped to 37.4% in 2007 from 26.5% in 2005. This is up from 7.7% in 1999, the first year the AHA included a question on CAM in one of its surveys. • “Hospitals across the USA are responding to patient demand and integrating complementary and alternative medicine (CAM) services with the conventional services they normally provide.” • Reasons for introducing CAM: 84% of hospitals cited patient demand; 67% cite they found CAM clinically effective; 40% to attract new patients; 4% insurance coverage. • “CAM services reflect hospitals' desire to treat the whole person-body, mind and spirit." Source: American Hospital Association Health Forum (2008) Complementary and Alternative Medicine Survey of Hospitals. Summary of Results.

18. TM/CAM in Teaching Hospitals • “Teaching hospitals accounted for 38.9% of the respondents with CAM services.” • “According to the Association of American Medical Colleges (AAMC). The percentage of medical schools offering a required course in CAM has increased from 26% in 2001 to 91% for the graduating class of 2009. • “CAM is gaining more popularity and interest by the new generation of physicians hastened by the growing consumer interest.” Source: American Hospital Association Health Forum (2008) Complementary and Alternative Medicine Survey of Hospitals. Summary of Results.

19. TM/CAM in US Managed Care • “Today more Americans are using complementary and alternative care to help manage or prevent many health conditions. Many adopt them as part of their cultural and personal beliefs and to promote a greater sense of emotional, physical, and spiritual well-being.” • “The Center for Complementary Medicine is part of Kaiser Permanente’s integrated delivery system. If you are a member, you will receive coordinated care from your whole Kaiser Permanente team. Your complementary medical practitioner, your primary care physician, and any specialists you are seeing will be able to access your electronic medical record to learn your health history and communicate with each other to design a program of care that meets your unique needs.” Source: www.kpccm.org/index.html

20. Board of Healthcare Funders • 2006 Annual Conference : • Over 70% of audience voted that TM and CAM was important to pursue in medical schemes

21. African Traditional Medicine Day and Decade • In Africa 80 per cent of people have used traditional medicine at one time or another in their lives. • African Traditional Medicine Day is commemorated annually on 31 August to raise awareness and the profile of traditional medicine in the region, and to promote its integration into national health systems. • First commemorated 2003, six times since then … • African Ministers of health in July 2001 declared the period 2001 - 2010 as the Decade of African Traditional Medicine. Did you know about this ?

22. TM/CAM in South Africa

23. “People have the right of access to traditional practitioners as part of their cultural heritage and belief system.” ANC Health Plan of 1994 Source: ANC Health Plan 1994; South African Health Review 2007, Chapter 12.

24. Regulation of Practitioners Department of Health Health Professions Council Allied Health Professions Council Dental Technicians Council Traditional Healers Council Nursing Council Pharmacy Council

25. Healthcare Practitioners in SA • Some 34,000 doctors (including some 7,000 GPs in private practice); • 11,000 pharmacists; • 100,000 professional nurses; • 84,000 staff nurses and auxiliaries; • 3,600 complementary medicine practitioners; and • 185,500 traditional medicine practitioners. Why are all these TM and CAM practitioners not covered by medical schemes ? Source: SAHR 2006; SAHR 2007, Chapter 12.

26. Complementary Medicine Trade • Health Product Associationformed 1978 as association of manufacturers, importers and distributors of complementary medicines and health products. • 1996 survey: combined turnover of members was R0.881 billion. • 2003 survey: 53% increase to sales revenue of R1.348 billion. • In 2003, the market at consumer level was some R1.9 billion. This is 22% of the medicine expenditure by medical schemes of R8.6 bn. But seldom reimbursed by medical schemes at present. • Amount spent on CAM medicines is considerably higher than spent on CAM practitioners. In line with worldwide trends to self-medication using complementary medicine. Source: South African Health Review 2007, Chapter 12.

27. HPA Turnover relative to Medical Scheme Medicines HPA spend usually out-of-pocket by consumers HPA products at consumer level were 22% of medical scheme spend on medicines outside hospital in 2003. In 2007, HPA turnover estimated to be 43% of medical scheme spend on medicines. Source: South African Health Review 2007, Chapter 12; Council for Medical Schemes Annual Reports; latest HPA Survey.

28. Traditional Medicine Trade • TM trade in South Africa is a large and growing industry. There are some 27 million consumers of traditional medicine. Trade of these medicines contributes some R2.9 billion to the economy (2006). • The amount spent represents 5.6% of the National Health budget, or equal to the whole Mpumalanga Health budget, or equal to the KZN Provincial Hospital budget. • 72% of the Black African population in SA estimated to use TM. Use not confined to poor, rural and uneducated users. • The average frequency of TM use per consumer is 4.8 times per year. • The use of TM is a positive choice made by consumers, who are often prepared to pay a premium price for these products and services, even when this exceeds the cost of western treatments. • At least 133,000 income earning opportunities, including 63,000 plant harvesters, 3,000 street traders and 68,000 full-time herbalists. Source: South African Health Review 2007, Chapter 13.

29. Formal Sector TM Trade Source: South African Health Review 2007, Chapter 13.

30. TM/CAM in Medical Schemes

31. Day-to-day benefits: primary care practitioners and acute medicine Major Medical: in-hospital and chronic medicine Above threshold benefit Above PMBs Self-funding gap Medical Savings Account Prescribed Minimum Benefits (PMBs) Pooled benefits – annual routine benefits Paid from risk pool with no limits or co-payments Paid from risk pool with limits, co-payments, deductibles Self-funded Generic Medical Scheme Benefit Structure TM/CAM paid out-of-pocket, if at all.

32. Medical Scheme Benefits 1990 Hospital and specialist expenditure has escalated faster than other areas. Massive shift to covering hospital and specialist visits and away from primary care. Primary care covered more from out-of-pocket money. 2006 Source: Registrar’s Annual Reports

33. Medical Scheme Spend on CAM Definitions have altered for “Other” over the years. 2000 to 2003 data looks odd. Steady growth – BUT total CAM spend was 1.7% of that on GPs in 2007. Not always captured as CAM ... Mostly not covered: people paying out-of-pocket. Source: Council for Medical Schemes Annual Reports

34. Private Insurers in Australia The Journal of the Australian Traditional-Medicine Society gives a summary of coverage of TM/CAM therapies by Australian private health insurers as at March 2008. Covers all 38 registered insurers. Source: Helen Young (2008) The Incorporation of Traditional and Complementary Medicine Benefits in Healthcare Funding Systems: A Worldwide Review Of Practice. Unpublished UCT project with Prof McLeod.

35. Government Employees Medical Scheme • Major positive development is return by Government to a restricted scheme for public sector workers. • Very rapid growth from January 2006. • By end 2007, was already the third largest medical scheme in South Africa and the largest restricted (employer or union-based) scheme. • Late 2008: GEMS now has 300 000 principal members and provides healthcare cover to over 800 000 people. "What is more, 54% of GEMS' members previously did not access the employer subsidy for medical schemes. This means that in excess of 430 000 people who did not previously have healthcare cover now do." Source: GEMS web-site: www.gems.gov.za

36. Major positive development is return by Government to a restricted scheme for public sector workers. Covers 10 CAM modalities and Traditional healers Source: GEMS web-site: www.gems.gov.za

37. TM/CAM in the future National Health Insurance system?

38. Public-Private Coverage Source: McIntyre D., van den Heever A. Social or National Health Insurance. In: Harrison S., Bhana R., Ntuli A., editors. South African Health Review 2007. Durban: Health Systems Trust; 2007. URL: http://www.hst.org.za/publications/711

39. Current Healthcare Financing General taxation (SARS) Bargaining Council Funds Medical Schemes Tax relief Out-of-pocket Social Insurance (RAF, COIDA) Revenue collection Provincial Health Departments National Treasury allocation to Provinces No pooling (individual purchasing) Pooling Other governmental Purchasing Private providers Provision / Delivery NHI debate is a debate about the future role of medical schemes Kutzin Framework diagram drawn using value of expenditure

40. Two Paths to Universal Coverage Through SHI to NHI Direct to NHI • Policy from 1994 to 2007 • Gradual, begin with highest paid workers and their families. Need subsidies for workers earning below tax threshold. • Medical Schemes are vehicles for NHI, buy from private and (increasingly) public providers. • Competitive schemes, with Risk Equalisation Fund. • “Post-Polokwane” Dec 2007 • ANC election promise: immediate “within 5 years” • Tax and progressive social security contribution. • One central fund, with public and private providers. • Role for medical schemes undefined – perhaps top-up only? • Package “free” but not defined. Not yet in public domain

41. ANC Manifesto on NHI “The ANC is determined to end the huge inequalities that exist in the public and private sectors by making sure that these sectors work together.” • Introduction of the National Health Insurance System (NHI) system, which will be phased in over the next five years. The principles of NHI will include the following: • NHI will be publicly funded and publicly administered and will provide the right of every South African with access to quality health care, which will be free at the point of delivery. People will have a choice of which service provider to use within a district. • The social solidarity principle will be applied and those who are eligible to contribute will be required to do so, according to their ability to pay, but access to health care will not be according to payment. • Participation of private doctors working in other health facilities, in group practices and hospitals, will be encouraged to participate in the NHI system. Source: African National Congress 2009 Manifesto Policy Framework

42. TM/CAM and Universal Coverage Through SHI to NHI Direct to NHI • Medical scheme minimum benefits exclude TM/CAM in definitions for chronic disease treatment. • A patient using TM/CAM not seen as a “treated patient” for the Risk Equalisation Fund. Schemes would not be reimbursed for a chronic person using this treatment. • Medical schemes cover TM/CAM through savings accounts, if at all. • One central buyer. Nothing said about including TM or CAM healthcare providers. • Package of cover not yet defined. Not yet in public domain

43. TM/CAM Integration in South Africa • Health legislation which includes TM/CAM • Draft National Policy on African Traditional Medicine – July 2008 • Technical barriers to exclusion largely removed: • Registration and licensing of practitioners. • [Allied Health Professions Council of SA] • [Interim Traditional Health Practitioners Council of SA] • Practice code numbers [Board of Healthcare Funders under mandate from Council for Medical Schemes]. • Inclusion in National Health Reference PriceList [national DoH]. • NAPPI coding of all medicines [industry bodies]. • ICD-10 coding by practitioners for billing medical schemes Source: South African Health Review 2007, Chapter 12.

44. Consumer Action on TM/CAM • Help break the silence on TM and CAM usage. • Medical schemes are owned by their members and managed by boards of trustees: 50% elected by members. • Need medical schemes members to ask at AGMs why TM and CAM benefits have not been included. • Press briefings by medical schemes: ask about TM and CAM usage and why benefits have not been included. • Definition of Prescribed Minimum Benefits and Risk Equalisation Fund (Council for Medical Scheme briefings): keep asking about TM and CAM and why they are excluded. • National Health Insurance: ask why proposals for NHI are not in the public domain. Where is the TM and CAM cover in the proposal ?

45. People’s Charter for Health • The People's Charter for Health is a statement of shared vision, goals, principles and calls for action. It is the most widely endorsed consensus document on health since the Alma Ata Declaration of 1978. • People’s Charter calls for the provision of universal and comprehensive primary health care, irrespective of people’s ability to pay. • Calls on people of the world to: • Support, recognise and promote traditional and holistic healing systems and practitioners and their integration into Primary Health Care. Source: People’s Charter for Health, adopted in Dhaka, Bangladesh, December 2000

46. National Health Insurance Want a National Health Insurance system that integrates medical schemes With a benefit package based on primary care That fully integrates Traditional Medicine and Complementary Medicine To enable consumers to choose according to their cultural heritage and belief systems.

47. Dr Alan Tomlinson docwat@sportron.co.za http://www.hpasa.co.za/

48. Professor Heather McLeod hmcleod@iafrica.com www.hmcleod.moonfruit.com