ASSA presidential address. No man is an island. ASSA-SAGES Congress, Cape Town, 7 August 2004.

Mr Chairman, distinguished invited guests, ladies and gentlemen, welcome to the ASSA Conference of 2004. Professor Krige, Dr Panieri and the local organising committee, thank you for all the trouble, energy and effort that have gone into years of planning the scientific programme, poster sessions, banquets and social events, accommodation, air tickets and other details of the conference. We also know that much time has been spent weighing up ideas, negotiating, mediating and bargaining over tariffs, sponsors’ space and so forth — the list is endless. Thank you for doing a very challenging job so exceptionally well. In South Africa we are in a very privileged and interesting position — living where the First and Third Worlds meet. The ‘haves’ and ‘have nots’ rub shoulders on a daily basis. In many places there are too many doctors who over-service, and in other areas many doctors are forced to under-service a majority of the population, as a result of the milieu in which they work. In most instances it is the specialists who are responsible for the over-servicing of patients. The government has a duty to deliver a health care service that is advantageous to all sectors of the population. At the moment health care is enjoying tremendous prominence in the media and in politics at large, and there is legislation in place or being designed that will: • reduce profit margins for pharmacists • regulate dispensing by doctors • restrict the freedom with which practitioners can ‘open shop’ by means of the required certificate of need • ensure that there are doctors in government service, through community service and imported doctors, who are inadequately equipped for South African circumstances. Legislation concerning the inclusion and exclusion criteria for admission to intensive care has been published. At the heart of all this is the fact that there is not enough money in the Department of Health to go round. There is a maldistribution of services. With the over-servicing of some and the under-servicing of others, Government is obliged to reorganise and plan to make services available in the periphery. At present Government has not yet clamped down on specialists, but this will come. If we do not work and plan well to determine our own destiny, the Government, politicians and the state auditors certainly will. We have to have the answers, and implement them, or else others will supply the answers — and they will not always be to our advantage or to the advantage of our patients. I will illustrate four scenarios.