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
20022005 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
20022005
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
20022005
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
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 3rd Complementary 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 Permanentes 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.

22
TM/CAM in South Africa
23
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 Association formed 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
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 Registrars 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
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 Price List
  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
Peoples 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.
• Peoples Charter calls for the provision of
  universal and comprehensive primary health care,
  irrespective of peoples 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 Peoples 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_at_sportron.co.za http//www
.hpasa.co.za/
48
Professor Heather McLeod hmcleod_at_iafrica.com www.h
mcleod.moonfruit.com