Unearthing a South African JEWEL
GEMS: Private bag X782. Cape Town 8000 Tel: 0860 00 4367
www.gems.gov.za
Our tale begins in the heart of Southern Africa, under a scarlet, ruby skyline. It’s a tale of splendour, success and instance that sets the pace for others to follow. As our story unfolds, we discover one of the true jewels of South Africa: GEMS For thousands of years, we have collected, hoarded, traded and searched for cut and polished stones of various sorts. By far, the stones most highly prized by cultures around the world are those we classify as gemstones. Wars have been waged over their allure while the mystique and power we have imbued in these glittering stones have spawned legends. Gemstones do not magically appear but are the result of powerful forces of nature working harmoniously to create the stone, whose shape and sparkle is further refined by skilled human hands.
Both started life in a rough, undefined state. And like a gemstone, a great deal of focused energy, expertise and passion has been necessary to transform GEMS into South Africa’s leading medical scheme. The GEMS journey was not always an easy one, but it is a story of how challenges can be overcome and visions realised when we apply fresh thinking and work together in the unrelenting pursuit of the exceptional. Join us on this intriguing journey which began many years ago…
So was it fate or fancy that the acronym for the Government Employees Medical Scheme is GEMS? It may just be that the creation of a gemstone is not unlike that of this particular medical scheme.
Surround yourself with only people who are going to lift you higher. OPRAH WINFREY
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What was life like before GEMS? To climb steep hills requires a slow pace at first.
Let’s consider for a moment life without gemstones. It paints a picture of a world without sparkle – a place where rocks in their natural form are adequate. Unearthing the unknown is no easy feat and before the establishment of GEMS, a number of challenges existed in the fragmented healthcare landscape. While public servants could choose from a selection of open schemes and an employer subsidy made healthcare cover more affordable for certain groups of Government employees, the situation was far from acceptable. If truth be told, a lack of control, stability and uniformity meant that healthcare cover for public servants lacked equality and real value. Many found medical scheme membership unaffordable and did not belong to a medical scheme, relying on the already-overburdened public healthcare sector. Those who did opt to join an open medical scheme were faced with products that were not specifically designed around their unique needs. Optimal health management takes place in an integrated environment. However the highly fragmented
SHAKESPEARE
landscape made quality management and integration with other employee wellness interventions in the public services workplace a distant dream. The burning question was how to unearth the gem within this unstructured, fragmented landscape which could form the nucleus for the development of a healthcare solution that Government, public servants and indeed, all South Africans, could be proud of. Where to start? Some would argue that buying raw material in the hopes of creating a finished, polished and valuable gemstone is not unlike a game of soccer or cricket. No one can predict the exact outcome. You may have a team of potential star performers – but will they perform when it really matters? Similarly, you know the gems exist but at the start, they are simply rocks and no more. How to transform sound intentions and visionary insights into a reality that addressed the many challenges and silenced the naysayers (of which there were many) was the question that kept many leaders in Government awake at night.
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Begin with the End in Mind… All great stories start with an inspiring vision. And the story of GEMS is no different. The vision shared by the creators of GEMS was simple, yet ambitious and inspiring. The “creation of a leading medical scheme which pursues excellence in all its endeavours and creates new benchmarks in the quest for giving ALL public servants access to affordable, quality healthcare,” was no mean feat. While water, temperature, time and space are the essential ingredients for gemstones to form, Government required a very different mix of variables to be in place to give life to GEMS. A benefit design, uniquely structured around the specific needs of public servants, had to be developed. The implementation of the scheme had to be entrusted to a skilled, passionate team and managed from a robust governance and risk management platform. Behaviour change is always one of the greatest challenges any new innovation faces. Effective marketing, communication and seamless member enrolment processes were essential to create awareness and a desire to join the new scheme amongst public servants.
We may have all come on different ships, but we’re in the same boat now. MARTIN LUTHER KING JR
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Service delivery was always going to be the cornerstone for implementation. However the complexity and scale of the undertaking created the risk that this could potentially be an area where the ball was dropped. A vital ingredient was a seamless platform of service excellence – underpinned by a range of medical scheme administration and managed care services delivered by market-leading providers. The question of funding and effective financial management controls had to be addressed and involved a range of different stakeholders across various government departments. Having started transformation of the healthcare and medical scheme industry a few years earlier, Government now faced one of its greatest challenges yet – the establishment of a medical scheme for its own employees, which could become a benchmark for all medical schemes and employers in the country, and possibly even the foundation for a National Health Insurance system one day. The challenges were many. There was no shortage of criticism. And while the vision and intention was noble, it is fair to say that some questioned the wisdom and ability of Government to rise to the challenge. Coupled with this, there seemed to be some who even wished to see the venture fail.
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The process of refining a gemstone is not a hurried one. It goes without saying that patience, perseverance and dedication are vital. Fundamental to the success of the process are the people involved, each bringing a different set of special skills to the process. The inspired creators of GEMS knew that a talented team of the right players was absolutely vital if the vision was to become reality. They set about securing the services of the best service providers in the land by way of a transparent and extensive tender process. The first and most critical step in the processing of a gem in the rough is to remove all fractures and rough edges. This process must be done very carefully and thoughtfully, as this step determines the gem’s shape and size. A wrong move means the difference between success and failure. At this vital juncture, much time and energy was invested in the establishment of a carefully selected service provider network who would be capable and willing to push the envelope and set new delivery benchmarks for the industry. Leaders of the process were acutely aware that selection of the right providers and the successful operation of this network would be critical to the realisation of the GEMS vision.
Providers were appointed in the disciplines of banking, actuarial, medical scheme administration, pharmaceutical benefit management, managed care, HIV management, ambulance and emergency transport, chronic medication provision, media management and public relations. However membership of this unique provider network required more than simple participation and delivery of agreed services. All providers within this network shared the GEMS vision to create something new and exceptional. All were committed to work together, push the envelope and deliver standards and innovation beyond the norm. All knew that they had a vital role to play in ensuring that this gem sparkled.
Smooth seas do not make skilful sailors. AFRICAN PROVERB
gave birth to a GEMS service model which constantly reinvents itself, pushing standards of service and innovation ever higher. “Yesterday’s excellence is today’s standard” is the mantra that GEMS leadership and Service Providers live by – simple yet highly effective in the results it inspires.
Rising to the Challenges… It has been a journey of challenge and exploration for all members of the GEMS Service Provider Network. Driven and inspired by a relentless pursuit of excellence, right from the start GEMS leadership set the bar high for all members of this network. A total quality management approach and a philosophy of continuous improvement There were many challenges that had to be overcome. For one, the scale of the operations was substantial and the time-lines challenging. Part of the challenge was that there was no reference point. Never before had a venture of such a magnitude been undertaken in the South African medical schemes industry. Standards and expectations were high, as they should be in any ground-breaking innovation of this nature. Creating a seamless and integrated service experience for members was essential, despite the many different service providers involved.
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The answer: a state-of-the-art centralised Administration Service Center which provides a seamless interface with the service centers of all Service Provider Network partners. From extraction to refinement, there are many carefully considered approaches that need to be precisely followed in order to get that special sparkle. Innovative technology solutions that included robust and real-time interfaces, required to remain robust at scale, and the “home-grown” development of unique call centre technology software, were just some of the many challenges in the IT arena. Whether mining or undertaking the establishment of a medical scheme, the people behind the scenes make it happen. And if there is one magic element that made, and continues to make the difference between mediocre delivery and a sterling performance, it is the people who deliver services to GEMS members. Service providers faced many challenges when it came to selecting and preparing those who would be entrusted with this vital role. Mass quality recruitment… language representation across all 11 official languages… the implementation of a 6-day work week… required unique and innovative approaches to recruitment, training and leadership development. The GEMS member has been, and continues to be at the heart of all decision-making. At the start, some of the challenges included developing
The future depends on what we do in the present.
a far deeper understanding of the potential GEMS member and engaging with previously uninsured public servants in a meaningful and relevant manner as they slowly opened up to a new experience – medical scheme membership. Development and creation of a trustworthy GEMS brand required that all service providers delivered consistently on the brand promise. The pursuit of excellence may sound good on paper, but how does this manifest in the lives of GEMS members? For the GEMS service providers, delivering service excellence is not simply about doing what a service level agreement requires of a provider. Rather it is about whether members perceive GEMS to be delivering on their specifications – the needs and expectations they have in their hearts and minds when it comes to service excellence and quality,
affordable healthcare. GEMS leadership selected service providers who genuinely embrace this thinking and it remains the cornerstone for all current and future plans. In fact this thinking is part of the DNA that makes GEMS the success it is. Leadership will accept nothing less. A range of pioneering innovations and developments emerged as this gem was polished and refined. The Friends of GEMS network… a range of mobile health solutions… service offerings in all official languages… a consumerism plan to empower members… automated member surveys – these have been just some of the innovations that have emerged as the GEMS journey continues.
MAHATMA GANDHI
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And in an environment where the spotlight shines harshly on all healthcare costs, particularly nonhealthcare benefit costs, the ability to deliver service excellence at a far more affordable price than traditional industry norms was always going to be critical. How do economies of scale coupled with a highly efficient service model translate into cost savings and more affordable healthcare, while still ensuring the high and consistent levels of service excellence that GEMS leadership requires? Experience to date proves that service fees consistently lower than industry norms (by nearly 50%) along with high levels of service satisfaction amongst GEMS members as measured by external, independent research surveys, clearly demonstrates that affordable service fees and service excellence can indeed exist side by side. Yet another gem unearthed in this journey.
Achievements to be celebrated…
been known to refer to the growth rate of the scheme as ‘phenomenal’ and ‘unprecedented’.
A number of remarkable achievements have emerged along the GEMS journey.
Much of the GEMS success can be attributed to the strength of its governance and management structure. Under the leadership of the Minister of the Department of Public Services and Administration (DPSA), Richard Baloyi, GEMS Chairman, Professor Richard Levin and GEMS CEO, Dr Eugene Watson, an unrelenting focus on governance and excellence of the highest standard has always been non-negotiable. The results of this uncompromising commitment to governance standards were visible yet again in an unqualified audit for the 2010 Financial Year. Sound ethical management – also a non-negotiable – ensures the scheme’s reputation is protected from potential disrepute at all times. One of the areas this translates into is a highly transparent tender process. In an industry where instances of poor governance continue to grow at an alarming rate, the GEMS governance platform sets a shining benchmark that all industry participants would do well to aspire to.
Membership growth has continued consistently since inception, making GEMS the fastest growing scheme in the history of the country. Another fundamental achievement is the origin of members. The experience has been that more than half new GEMS entrants in recent times have been public servants who were previously NOT part of a medical scheme i.e. the uninsured. In fact GEMS remains the largest contributor to the overall growth of what would have otherwise been a static or declining medical scheme sector. Even the Council for Medical Schemes Annual Report has
True to its mission of meeting members’ unique needs as well as continuously improving the GEMS proposition, capitated arrangements have been replaced with performancebased managed care arrangements
To create something exceptional, your mind-set must be relentlessly focused on the smallest detail.
that are proving far more successful and have been positively received by members as well as the provider community. GEMS leadership repeatedly demonstrate their ability to proactively manage change – a certainty within the dynamic South African healthcare environment. When the High Court ruled that the National Reference Price List (NRPL) published by the Department of health was invalid, the scheme responded quickly and, following a thorough analysis of implications, amended rules and established a unique GEMS tariff. It is often easy to overlook achievements which are a result of the establishment of GEMS but which
manifest in other areas or sectors. Apart from the impact GEMS has had in removing some of the pressure on the public health sector by bringing previously uninsured public servants into the insurance net, a further sector GEMS has had a very positive impact on is that of employment. By way of illustration, GEMS enabled their Administrator – Metropolitan Health – to make more than 1000 appointments – all in line with Government’s vision of transformation. The new employment opportunities that the GEMS contract created provided leverage for Metropolitan Health in their transformation journey. Driven by a relentless drive to transform their business into an organisation that is a leader in the socio-economic transformation of South African society, these growth opportunities contributed significantly towards Metropolitan Health recently being awarded the Broad-based BEE status of level 1 Contributor. And members? Are they delighted by the sparkle of this gem or sadly disappointed by its dullness as they get closer?
GIORGIO ARMANI
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Regular independent satisfaction surveys reveal that this gem certainly shines in the eyes of GEMS membership, with a recent independent member satisfaction survey showing that the vast majority of all GEMS members are delighted with the services that they receive.
The road travelled… While the journey has been long and arduous at times, the results have been highly consistent and most satisfying. From registration of its first member in December 2005, GEMS has become the largest restricted membership scheme in the country with more than 600,000 families covered (and still growing at 10,000 families per month). As at May 2011 GEMS provided health cover to more than 1.6 million beneficiaries, and continues to grow at a rate of at least a 1,000 beneficiaries every day. By 2011, within just over 5 years in operation, the Government Employee Medical Scheme has become a sparkling celebration of a Vision achieved. A uniquely and proudly South African brand in which a focused team of inspired government leaders and leading private sector players joined forces to achieve what few believed possible. But how is this all possible? What was the magic formula that brought GEMS to where it is today?
Unlocking the power of focus and partnership… Vision is the art of seeing things invisible. JONATHAN SWIFT
Both created success by unlocking the power of focus and partnerships. The staging of the 2010 Soccer World Cup united a range of critical stakeholders – from Government to big and small business to members of the public – all working together towards a common goal. Everyone had to pull together to achieve what many critics from around the world believed impossible. The GEMS story is no different. The success of GEMS is testament to the ability, willingness and commitment of stakeholders from all corners to join hands and work together in giving life to the GEMS Vision. Examples of these partnerships are evident at a number of different levels. Although the Department of Public Service and Administration (DPSA) was the driver behind GEMS, the commitment and support of other Ministries such as Health (DOH) and National Treasury have been critical to the success achieved to date. These three Government Departments aligned fully behind the GEMS Vision and were fundamental in making it work. Then there were the partnerships that were formed at service provider level within the Service Provider Network. This required a number of players,
often companies who compete against one another in the market place, to join hands and work harmoniously together to achieve common goals. Public Sector Trade unions have been key partners in supporting and enabling the GEMS vision, actively communicating the GEMS proposition to their members. Healthcare Providers across all disciplines are also vital partners, embracing and offering their support to the GEMS vision at all times. Another illustration of robust partnering exists between the DPSA and GEMS. The establishment of GEMS has made greater levels of integration between the various DPSA Health and Wellness initiatives and medical scheme funding possible. Working closely with DPSA, GEMS performs an important role as central integrator, providing high-level data across all sectors of public servants. Analysis of this highlevel data guides implementation of Workplace-based health and wellness interventions, highlighting where focus areas should be.
Let us consider another uniquely South African gem – the successful staging of the 2010 Soccer World Cup. What do GEMS and the 2010 World Cup in Africa have in common? Although not immediately obvious, GEMS and the 2010 Soccer World Cup actually have a lot more in common than meets the eye.
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it goes without saying that we should expect to see many new great, groundbreaking developments emerging from GEMS and its network of like-minded, committed service providers as all continue to shine brightly.
Pursuit of excellence. A common vision uniting all partners. Overcoming all odds. The First of its kind. It therefore certainly appears evident that the Soccer World Cup and GEMS do indeed share a magic formula for achieving the seemingly impossible.
The end…or the beginning…? Having established a platform of excellence and innovation, and now delivering affordable, quality healthcare cover to over 1.6 million beneficiaries,
The successful establishment of GEMS sees a further step towards the fulfilment of government’s stated policy objectives regarding the restructuring of the medical assistance dispensation. GEMS encompasses many of the principles of the ideal of Social Health Insurance (SHI), structured around social solidarity and providing equitable access to comprehensive and affordable healthcare benefits for all those who participate. The successful implementation of GEMS is a shining example to all South African employers that the provision of innovative medical benefits is possible for all employees. GEMS has also demonstrated how economies of scale and sound governance can unlock greater efficiencies and set new benchmarks for excellence. Indeed regulatory authorities and medical schemes across the industry are looking to GEMS more and more as the industry leader for setting benchmarks and providing direction in areas from governance to benefit design.
What comes next…? The healthcare industry is already all abuzz with talk of National Health Insurance (NHI). Is the country really ready for a venture of such a magnitude? Look at some of the dismal failures of National Health Insurance schemes in some other countries. The cynics are already taking aim and shooting at NHI. However, there are many who are optimistic and confident that a successful NHI vision can be achieved. Surely GEMS is testament to the solid foundation of excellence and expertise that already exists and that could form a robust platform from which to launch a successful NHI implementation? It certainly is evident that the GEMS experience has created a wealth of expertise that can contribute significantly towards the meaningful and successful implementation of NHI. Like many industries around the world, the South African healthcare industry faces formidable challenges as it prepares to address the provision of equitable, affordable and quality healthcare for ALL South Africans. There are no easy answers. However, home grown centres of excellence such as GEMS can provide inspiration and many useful lessons as we seek the rare yet vital insights and pragmatic approaches necessary to facilitate the successful transformation of our healthcare system. The GEMS story is a remarkable story of pioneering exploration driven by vision and determination. One that easily allows us to forget the humble beginnings and the extent of work required to mould it into the valuable entity it has become. As we celebrate the achievements of GEMS to date, we look forward to unearthing new gems in the transformation of our healthcare system – Proudly South African stories that will set new standards of excellence, locally and internationally.
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Coming together is a beginning. Keeping together is progress. Working together is success. Henry Ford
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Acknowledgements The GEMS story shared in these pages would not have been possible had it not been for the leadership, tenacity and visionary insights of certain exceptional individuals and organisations.
• The Ministry of Public Service and Administration – providing exceptional leadership and support, particularly during difficult times, ensuring this gem shines brighter year after year.
• Professor Richard Levin – Chairperson of GEMS from inception to present time – providing invaluable and highly-respected guidance and insights to help pave the way for the success of the scheme today.
• The Ministry of Health – focused and passionate in their commitment to transform the South African healthcare system to give all South Africans access to affordable, quality healthcare – inspires us all to join hands and work together to address the challenges ahead.
• Dr Eugene Watson – Principal Officer of GEMS from its inception – whose vision and steadfast commitment to excellence of the highest standards has inspired all players involved in this journey to up their game, driving the elevation of standards across the industry.
“It always seems impossible until it’s done” NELSON MANDELA
• The GEMS Board of Trustees – entrusted with the vital task of governing the affairs of the scheme, providing strategic direction and overseeing the implementation of strategic plans – have been unrelenting in their commitment to governance and management excellence of the highest standard.
• The various organisations who have participated within the GEMS Service Provider Network, rising to the challenges that were handed to them with the vigour, passion and expertise which ensured success and the increase of benchmarks across the industry. Metropolitan Health as Scheme Administrators, Qualsa – Medicine clearing house, Maternity Programme and Strategic Management Contract and Network Management, Medscheme Health Risk Solutions – Managed Care, Pinnacle Health Solutions – Marketing, Medipost – Chronic dispensing service providers and Europ Assistance South Africa – Emergency Medical Services. There are indeed many who have worked tirelessly in making GEMS what it is today. Although it is practically not possible to list all organisations or individuals in these pages, we celebrate their contribution towards achieving what many thought impossible.
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