NATIONAL CONGRESS & COUNCIL Pretoria, 22 to 24 April 1991 COUNCIL MEETING: OPENING ADDRESS SOME COMMENTS ON THE HEALTH-CARE PROFESSION IN THE NEW SOUTH AFRICA Professor S A Strauss Thank you for the honour you have done me to invite me to come and say a few words to you on this occasion. I intend giving you a few thoughts on the health-care profession in the new South Africa as it may be shaped by developments in the legal and constitutional field. Some weeks ago I was asked by a group of doctors to talk on this topic. When I had concluded a fairly lengthy address and ques­ tion time arrived, there was a deafening silence, which I found quite unusual. The chairman repeated his invitation for questions, and a single questioner stepped forward, with a single question: “How far is Canada from South Africa?” And I thought I had given an optim ­ istic, if at the same time realistic, appraisal from the point o f view of a lawyer with more than a passing interest in medical practice and the legal problems surrounding medicine! If I were to sum up in a single sentence the present socio-econ- omic character of our system of medical and health care services, I would say this: What we have today is largely the product of a policy o f laissez-faire , with a good deal of legislative interference. The end-result is that although the practice of medicine (and I include physiotherapy and other health care professions) is typically that of a capitalist society, in a state which has applied socialist policies in respect o f certain sectors - we do no t have an entirely free-market system o r an entirely socialist system. N or do we have a national health service. Put in positive terms, what we do have is the following: • Privately practising health-care workers are legally speaking free contractors - except when it comes to fees, which are legislatively controlled for the majority of practitioners, by - the Medical and Dental Act 56 of 1974 (section 53) which gives the South African Medical and Dental Council the jurisdiction to decide what fee charged by a practitioner registered under the Act is reasonable, and - the Medical Schemes Act of 1967, section 29, whereby a scale of benefits is promulgated for doctors and some other professional groups. It may therefore be said that there is a “socialist” element in fee-determination, in the sense that the practitioner is not free to charge any fee that he or she wishes, o r that is agreed upon with the patient. • The public sector is still the largest supplier of hospital services and perhaps also of medical services. But the role of the private sector is increasing rapidly, particularly in providing hospital services. • Medical schemes have become a major and crucial factor over the past three to four decades in financing medical service. This, of course, is not a “socialist” but a capitalist feature, because the medical schemes are largely funded by their mem­ bers who may require medical services. Any attempt at describing in brief the socio-economic-political dynamics o f our time will be controversial. As I see it, the number one factor is a population explosion which has assumed huge proportions. Secondly, there has been a change-over within a relatively short period of time from one model of social engineering to a completely different model. Thirdly, over the last decade South Africa has experienced a gradual economic decline, the causes of which are manifold and some of which lie beyond our borders, o r were otherwise beyond our control. Fourthly - in the context o f discussing the health-care profes­ sions - there has been an increasing sophistication in the nature, quality and range of medical services and medicines. This was a development that went hand in hand with some of these services and goods becoming more and more expensive - regrettably at a time when productivity and per capita income have decreased . Now, looking into the crystal ball - a n d ' remember, it is the am ateur fortune-teller speaking! In line with what Confucius said: “The only thing which is certain, is that things will change.” On the positive side, there is a far greater willingness in our society today to accept the inevitability of change, and a desire to give positive direction (stukrag) to change. On the negative side, I want to mention only three factors • an underestimation by some o f the importance of economic advancement, • an unwillingness shown by some o f our leaders to bury the hatchet and to forget and forgive past mistakes, and • a tendency by some to think in terms o f instant solutions, immediate Utopia, rather than gradualism and carefully pre­ p a re d an d e x e c u te d d e v e lo p m e n t p ro g ra m m e s w hich will benefit society as a whole in due course. Taking an optimistic view of future constitutional trends, we may - with a good deal o f luck - achieve a democratic system of government with a bill of rights, sooner o r later. But its success can only be secured if the introduction goes hand in hand with social stability, which means self-discipline and a preparedness to work hard. Economic advancement and productivity will be the kingpin of a successful new South Africa. If this can be achieved (and it is a big IF) within the next decade o r two, or even three, there will be a future for all o f us and for our professions. I, for one, foresee no Utopia for the health-care professions. The pressure on government for a national health service will prob­ ably become irresistible. Its cost will become a major debit against State finances. O ther services will assume a lesser priority, especially renewal and expansion o f infrastructure. In the health-care field, private practice will, nevertheless, remain a major component of health services. The professions will probably be less rigidly regulated. That may be good news in a way, but the recognised professions will have to Compete to a larger extent with “informal” health-care providers. Because of the escalating cost o f “formal" medical services, there will also be a trend towards self-medication and self-treatment. The medical schemes - already in difficulties - will face an increasing crisis in financing medical and hospital costs. Many of us will have to work harder and be prepared to earn relatively less for the same work. People in government will have to realise that any drastic interference with free-market forces, or over-taxing of health-care providers, may bring about a decline in quality and availability which will impact negatively on the training of the future generation of practitioners: in sum, the very viability o f important branches o f the profession will be at stake should there be any attem pt at steering o ur economic system towards the ill-fated Marxist model. But I am not going to end this brief talk on a doomsday note. A s I see it, th e r e will b e a n e v e r-in c re a sin g d e m a n d fo r physiotherapists. A prominent personality has been reported in the press as saying that 80 percent of the population does not know about * Prof S A Strauss, Professor of Law at UNISA and Honorary Vice-President of the SASP Bladsy 48 Fisioterapie, Augustus 1991, dee147 no 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) NATIONAL CONGRESS & COUNCIL Pretoria, 22 to 24 April 1991 physiotherapy. I, myself, and members of my immediate circle of relatives and friends, have benefited greatly from you science. So we certainly know about you! Apart from alleviating pain, discomfort and misery, physiother­ apy must undoubtedly, in the industrial society, contribute enor­ mously to productivity. It must be one of the most cost-effective forms of medical treatment. I believe that statistical studies have been done in the USA and elsewhere which demonstrate this clearly. Perhaps one of you will be so good as to furnish me with the results of such a study. Let me conclude with a statem ent of faith: It is my belief that there is a sufficiently large body o f well-meaning, hardworking ideal­ ists and talented people in this country to see us through a phase of our history which is critical, but at the same time most challenging. PRESIDENTIAL ADDRESS K M Levy Madam Chairman, Professor Strauss, members o f the N a­ tio n a l E x ecu tiv e C o m m itte e , m e m b e rs o f C o u n cil, lad ies and gentlemen. This will be my last address to Council in my official capacity as President. It is therefore appropriate that I should look back over the years and note some of the changes that have taken place since I attended my first Council Meeting some forty years ago. As only to be expected, there have been many changes both in the training of physiotherapists and in the practice of physiotherapy, not only in South Africa, but throughout the world, and in particular in those countries who are in membership of the “World Confeder­ ation for Physical Therapy”. As you are aware, the Society was founded in the mid-twenties by a small group of dedicated physiotherapists. Meetings were held in the large centres and the first Council Meetings were held in the treatment rooms of private practices established in the area. The Society is indeed deeply indebted to the early members who set us on our present successful path. These included Miss Susie Oosthuizen and Miss Marjorie Catt. Miss Oosthuizen, o r “O ur Susie” as she was affectionately known, was the main pillar of strength upon which the foundations o f the Society were laid. I well remember my farewell from the Principal of my training centre in London when I was instructed to contact “Susie” as soon as I arrived in Johannesburg and make myself useful to her and the Society. This I did, and I trust that I have followed her instructions! Miss Catt, like her confederate, was an extremely busy private practitioner but, none the less found time to take an active part in the affairs o f the Southern Transvaal and the Society as a whole. We are all most grateful to her for the substantial endowments she left to both the Southern Transvaal Branch and the National Executive Committee without which the purchase of the premises which now house the Secretariat would not have been possible. May I suggest for consideration by the Council that her name be associated perm a­ nently in some way with the new premises. Recognition should also be given to stalwarts of the early years such as Miss Jean Blair and Miss Margaret Emslie who were respon­ sible for the early training at the University of the Witwatersrand and the Pretoria Hospital. It should also include Mr Fred Rothberg whose professional legal knowledge in addition to his professional physiotherapy excellence was invaluable in matters affecting the Constitution. There are of course many others who contributed to the development of the Society to its present proud state by giving generously of their time and efforts without thought to financial compensation. It can surely be said that the success of the present members of the Society can be attributed to the fact that they are standing on the shoulders o f giants. The Society was a founder member of the “World Confeder­ ation for Physiotherapy”. During the years the status of South A fri­ Mrs Molly Levy, President can physiotherapy was recognised by members of the Society being elected to the Executive Committee o f the Confederation as early as the nineteen-sixties. More recently however, politics reared its ugly head and there was a strong move by the Nordic countries in particu­ lar, to have the Society expelled from membership because national political policies were alleged to be contrary to the Code of Ethics of the World body. Fortunately, Sheena Irwin-Carruthers and I were able to prove to the satisfaction of the Executive Committee and later the full Council that there are no racial barriers in the SASP Con­ stitution nor in the practice o f physiotherapy in South Africa. It was pointed out in fact that the Society had been instrumental in having the clause which debars racial discrimination inserted in the original Code of Ethics. During the course of 1990 an Africa Division of the W CPT was formed. The Society is very proud of Sheena Irwin-Carruthers who was elected its President. This recognition of South Africa’s leader­ ship in physiotherapy in Africa carries with it a responsibility of advising and assisting where possible in the provision of affordable physiotherapy services appropriate to the needs o f the various A fri­ can communities. It is o f the utmost importance that we recognise this responsi­ bility and it should be high on the list of priorities for the incoming Council. But enough of the past. What o f the future? How are we as a Society and as individual physiotherapists going to ensure that we emerge from the past and move forward ready to cope with all eventualities? The future of physiotherapy in this country will be dictated largely by Physiotherapy’s contribution to the services that will be needed to provide adequate, appropriate and affordable health schemes for the total population of the new South Africa. This will place a tremendous strain on the medical profession whose numbers are totally inadequate in relation to the whole popu­ lation. There will have to be changes to optimise the use o f the limited number of personnel at present available. It has been pointed out by numerous authorities lately, includ­ ing our Minister of Health in her opening address to the Congress, that this can best be done by the establishment of community health services th r o u g h o u t th e c o u n try to provide, inter alia, p rim ary physiotherapy. If the physiotherapy profession is unable to meet these de­ mands there is a real danger that elementary physiotherapy proce­ d u r e s will be a d m in is te re d by o t h e r b ra n c h e s o f th e m e d ic a l profession. I am aware that this problem has been receiving the attention of the Society for some time, but the unforeseen rapid rate of change in South Africa has given it a new urgency. The solution in the contact of total medical care will have to be found in a short space of time. The Society faces the daunting task o f providing for the basic physiotherapy needs of the total population of the country without dropping its standards. It must continue to strive for excellence in research and in the development and practice of new techniques and procedures. The close personal relationship that must always exist Physiotherapy, August 1991 Vol 41 no 3 Page 49 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )