Tšepong fights back
Queen ’Mamohato Memorial Hospital (QMMH) management says it will always act in the best interest of its patients and will not “unnecessarily” refer them to South Africa “because of the financial implications.”
Tšepong, as the hospital is widely known, was in the news at the weekend after it emerged Lesotho owed South Africa M86 million for cancer patients referred to its Free State hospitals by QMMH.
The bill, according to Health Minister Dr ’Molotsi Monyamane, had accumulated since 2014.
Tšepong, which was opened in 2011 as the country’s only referral hospital, refers cancer patients to Pelonomi, Univesitus and National hospitals, with government footing the bill.
The hospital is owned by the government but is run by the Tšepong consortium of five companies, namely Netcare Healthcare Group and Afri’nnai of South Africa, as well as Excel Health, Women Investment and D10 Investments from Lesotho.
According to South Africa’s Health Minister Dr Aaron Motsoaledi, the Lesotho government wanted out of the Tšepong deal which is however, supposed to end in 2026.
Dr Motsoaledi made revelation on Friday last week in Cape Town while appearing before a special committee investigating the cost of private healthcare in the country.
Netcare’s Director of Strategy and Health Policy, Melanie Da Costa, also appeared before the inquiry, and explained how the company was “assisting Basotho by providing quality healthcare at lower costs compared to South Africa”. Netcare is the majority shareholder in the Tšepong consortium.
However, Dr Motsoaledi told the inquiry that contrary to what Netcare had presented, “the contract with Lesotho has plunged the country into financial distress”.
Dr Motsoaledi also said his Lesotho counterpart, Dr Monyamane, was relying on the South African government for assistance to get out of the Tšepong contract.
Dr Monyamane subsequently told the Lesotho Times’ sister publication, the Sunday Express, that he was fully aware of what transpired in Cape Town last week.
“I know about Dr Motsoaledi’s appearance before the inquiry on Friday. I know about his submissions and the M86 million debt. What he said before the inquiry is what we discussed some three weeks ago. I will say the same thing if I could be summoned before the same inquiry,” Dr Monyamane told the Sunday Express.
“We are making plans to pay up the debt and also curb the flow of Basotho cancer patients referred to public hospitals in South Africa. A delegation from the Free State provincial government was here three weeks ago. We agreed on a plan to have a team, from our side, which will regulate the flow of cancer patients being transferred from Tšepong to Pelonomi, Univesitus and National Hospital in the Free State. We further agreed on how we are going to pay up our debt. We are committed to paying up the debt in batches until we have settled it in full.”
Dr Monyamane also told the Sunday Express that it was “reckless” that Tšepong was not being regulated regarding the referrals.
“There is no arrangement to the effect that when Tšepong decides to send patients to South Africa, they should consult with the government first. As we speak, the hospital just decides that on its own. This is why now we find ourselves in such a big debt. It seems Tšepong sends patients to South Africa even for minor issues. Our patients are even attended to by junior doctors there in South Africa, yet we have Basotho specialist doctors who can best attend to the problem.
“As a ministry, we are going to employ as many of them as possible. Some of the doctors will be deployed at Tšepong premises to curb this problem of referrals.
“We are going to rebuild Queen II. It was wrong to close down the hospital (in 2011 and replaced by QMMH) in the first place. I have been instructed by parliament to do all this in the first quarter of the financial year.”
The Ministry of Health was allocated M1.78 billion for the 2016/17 financial year and Dr Monyamane said it was unfair a large chunk of the money would be directed to Tšepong hospital.
“It is very unfair that one-third of the ministry’s budget is directed to Tšepong, yet it is not the only hospital we have in this country. Health issues are so diverse and we cannot only be dealing with Tšepong,” he said.
However, QMMH spokesperson Dr Limpho Seeiso, yesterday explained how the hospitals refers patients to South Africa.
Dr Seeiso said: “There are specific services that are excluded from the Public Private Partnership (PPP) agreement between Tšepong and the Government of Lesotho. The exclusions were informed by a number of factors, including an assessment of whether patient volumes would support a local treatment programme in Maseru, operational costs, utilisation patterns, and whether the services could be accommodated within Lesotho’s health system expenditure framework.
“The excluded services include all transplants excluding corneal transplants; chemotherapy and radiation therapy (cancer treatment); in-vitro fertilisation and advanced fertility treatments; cosmetic dentistry; chronic (end stage) renal disease treatment; all elective cardiac and great vessels surgery; all joint-replacements other than hip-replacements; and plastic surgery other than basic, essential reconstructive surgery and with medical need.
“The agreement therefore excludes these services from being offered at Tšepong. Since the inception of the project, 54.2 percent of all referrals to South Africa related to clinical services carved out from the PPP agreement, 80 percent of which are patients requiring oncology treatment. When a patient in particular requires chemotherapy and or radiation they are referred to Bloemfontein provincial hospitals as these services are, by design, not available at Tšepong.
“The cost for treatment of cancer patients is not included in the unitary fee paid to Tšepong and is borne directly by the Government. The outstanding fees payable to the provincial hospitals are therefore for services that are directly for the account of the Ministry of Health. Tšepong pays for referrals relating to its contractual responsibility from the unitary fee, at no additional cost to the Government and we are able to confirm that the payments are up to date.”
Dr Seeiso said the reason for referral was based on clinical indications “in the interest of obtaining the best possible treatment for the patient”.
The government, Dr Seeiso said, was only responsible for settling the bill for conditions not included in the PPP agreement “and Tšepong is responsible for all payments relating to other referrals mostly for second opinions or super specialist consultations. The process for referral is well regulated at the hospital”.
She explained referrals were initiated by the attending doctor, approved by the head of the referring department and authorized and counter-signed by the Clinical Manager.
Dr Seeiso also said although junior doctors may act as access-points to enter the system, specialist services are provided by specialists.
“One should also be cognizant that the Bloemfontein facilities are teaching facilities and like all other hospitals, are staffed with different categories of clinical staff,” she said.
“It is indeed the role of the Ministry of Health to provide primary operational oversight on behalf of the Government of Lesotho. It would not be abnormal for the ministry to engage and regulate operations at the hospital. Actually, there are existing committees in the design of the PPP agreement with oversight roles on the operations of the hospital. Referrals are regulated by the agreement.
“Tšepong will always act in the best interest of the patient and will not refer patients unnecessarily because of the financial implications. The referrals were initially managed by the Ministry of Health but Tšepong was asked to take over the responsibility because the ministry did not have the resources to manage the process. It is noteworthy that total referrals to Bloemfontein have reduced by 16 percent since 2012.”
According to Dr Seeiso, patient numbers are based on the disease burden. Cancer alone, she said, accounted for 80 percent of all excluded services referred to Bloemfontein.
“For the period January to December 2012, cancer of the breast and cancer of the cervix accounted for 21.7 percent and 21.3 percent of all cancer referrals to Bloemfontein and this trend is still observed.
“These two cancers are worth mentioning not only because they are the most common but because they are preventable. Early detection can prevent prolonged, debilitating and expensive treatment. It is therefore important to rigorously engage in early detection initiatives through health promotion at national level rather than regulating the treatment of those already afflicted.”
On the issue of the government revising the Tšepong contract, Dr Seeiso said: “Tšepong has not had any engagement with the Ministry of Health on any proposed changes to date but dialogue between the partners will be a good point of departure.”
Dr Seeiso also dismissed allegations that the hospital mainly employed foreign doctors, who are not even specialists, over qualified Basotho medical practitioners.
She said: “There are 85 doctors permanently employed by Tšepong. These exclude 17 medical interns currently training at the hospital. Twenty-six percent (22) of these are specialists duly registered as such by the Lesotho Medical, Dental and Pharmacy Council. This specialist list excludes visiting specialists in ophthalmology, maxilla facial surgery, maxilla facial prosthodontics, ENT surgery and orthopaedic surgery who visit the hospital on predetermined intervals.
“As a matter of fact, the number of specialists has more than doubled since the hospital had to take over the specialists that were based at Queen Elizabeth II Hospital. Attracting newly qualified Basotho medical professionals and those in the diaspora to work in Lesotho has been a priority recruitment intervention of the Ministry of Health for a very long time. The problem is thus not unique to Tšepong.
“Nonetheless, 16 percent of all doctors at the hospital are Basotho. We have two Basotho specialists on site and three Basotho nationals who are studying under sponsorship of Tšepong towards postgraduate degrees in Internal medicine, Obstetrics and Gynaecology and Anaesthetics and we are expecting their return to the hospital during 2017. There are also 14 Basotho interns currently training at the hospital and four who completed their internship in December 2015”
Commenting on the “large chunk” of the health sector’s budget being directed to Tšepong, Dr Seeiso said: “The healthcare budget tabled in parliament last week was M1, 776,493,710. The total unitary fee for the year is M458, 561,576, which is only 25.8 percent of the budget. This unitary fee includes the capital cost and finance charges relating to the repayment of the DBSA (Development Bank of Southern Africa) loan as well as the clinical cost of providing services to 310,000 outpatients and 20,000 inpatients per annum. The inclusion of capital works naturally relieves expenditure in other departments of GoL such as public works.
“Statistics released during the Annual Joint Review confirmed that with 25.8 percent of the Ministry of Health’s budget, the Tšepong health system (Queen ‘Mamohato Memorial Hospital and Likotsi, Mabote and Qoaling filter clinics) is responsible for more than 70 percent of all hospital admissions countrywide and 25 percent of all primary care services delivered in Lesotho.”
Meanwhile, Dr Seeiso also commented about the blood shortage in the country which has affected Tšepong operations.
“The shortage of blood is a national problem. The relevant authorities are driving measures to ensure that the blood bank has blood. However, QMMH as a big hospital, has experienced operational problems due to this national shortage and had to cancel planned operations. The hospital has, in instances, also appealed to relatives of patients to donate blood and members of Tšepong staff have also donated blood to save patients,” she said.
Dr Seeiso added high patient volumes remained the biggest challenge facing the hospital.
“The hospital continues to see more patients than expected. This is, in part, due to self-referrals to the hospital as well as some referrals that with adequate support and resources to the district hospitals, could be attended to at district level,” she said.
She added a study performed by a student from Wales found that more than 70 percent of patients bypassed other hospitals to obtain services at Tšepong.
“Many of the district hospitals are no longer performing basic procedures and are sending these patients to QMMH. Statistics released during the Annual Joint Review confirmed that Tšepong was responsible for more than 70 percent of all hospital admissions and 25 percent of all primary care services delivered in Lesotho.
“Patients still don’t understand that we sieve patients in the emergency department according to the severity of their clinical condition and often demand to be seen first for minor ailments. The current nationwide blood shortage is a challenge that negatively affects patient and relatives satisfaction when elective cases are postponed.”
Dr Seeiso indicated the hospital had notable achievements, which Basotho should embrace.
“Any life saved is a notable achievement. The hospital continues to deliver and surpass expectations on set targets. With improved skill and access to technology, the in-patient mortality rate has reduced by 57.5 percent from 12 percent at Queen Elizabeth II to 5.1 percent while Paediatric pneumonia death rates have reduced by 76.4 percent from 34 percent at Queen Elizabeth II to 8.1 percent. Most importantly, we have also seen the survival of very low birth-weight babies who have previously never survived in Lesotho.
“Twenty five percent of all the admissions to the Emergency Department require resuscitation and 97 percent of these patients have been resuscitated successfully. Going back to referrals to Bloemfontein, the hospital has since February 2015, performed 28 hip and eight knee-replacement procedures and has eradicated the waiting list of people who have waited for years to get these replacements in South Africa.
“This is done through engaging orthopaedic surgeons from the University of Cape Town to visit the country quarterly and engage in weekend long surgical camps to attend to these patients. We have successfully completed an integrated emergency response exercise involving other emergency service providers in Lesotho demonstrating the hospital’s capability to respond to mass casualties. Tšepong is committed to improving our services and the health outcomes for all our patients. Tšepong and the staff here can however, not do this alone, in a hostile environment. It should be the responsibility of all of us to care for our health, to prevent illness and disease through continuous education and leading a healthy lifestyle.”