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BHF360° JULY 2015

into healthcare

Healthcare accountability – a roadmap to a sustainable health system COVER: Dr Anuschka Coovadia, Head of Health Africa, KPMG p. 16-19


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BHF360°

F O R EWORD

into healthcare

Editor in Chief: Zola Mtshiya Sub-editor: Peter Wagenaar Design & Layout: Mariette du Plessis

Advertising t. 011 5370236 e. marketing@bhfglobal.com Editorial e. zolam@bhfglobal.com Published by the Board of Healthcare Funders of Southern Africa Non-Profit Company Registration no. 2001/003387/08 Lower Ground Floor, South Tower 1Sixty Jan Smuts Avenue Cnr Tyrwhitt Ave Rosebank, Johannesburg P O Box 2324, Parklands, 2121 Tel: +27 11 537-0200 Fax: +27 11 880-8798 Client Services: 0861 30 20 10 e-mail: bhf@bhfglobal.com web: www.bhfglobal.com

From the EDITOR'S DESK W

elcome to this, the second edition of BHF360° – which once again brings you a look at the current healthcare landscape from all angles. In conjunction with our annual conference, it aims to provide thought leadership on current hot topics as we work in unity towards the healthcare system we all want. I hope you will find it a stimulating and insightful read. Topics under the spotlight include a look at the Netherlands’ healthcare system and how we can learn from that country’s experiences. There’s an in-depth overview of the do’s and don’ts of procedural sedation and analgesia outside the hospital environment and a detailed piece by our MD, Dr Humphrey Zokufa, on the BHF’s vision of how low-cost benefit options should be incorporated into the current landscape. We also have some updates from neighbouring countries and words from our sponsors, whose support is greatly appreciated. I would also like to welcome all delegates – partners, sponsors and speakers – to the 16th Annual BHF Southern African Conference. This is the annual forum that brings together from various sectors countries within the healthcare industry. It is our hope that this year’s conference, with its theme ‘Healthcare Accountability: Partnering for Success’ produces practical strategies that will challenge the industry to take accountability and change the current status quo. The intention is to collectively craft a roadmap that plots our route to where we want to be in the future. As always, my heartfelt thanks to our members for their unfailing support of BHF. Be assured that we have your interests at heart at all times. Zola Mtshiya Manager: Marketing, Branding and Communications | BHF

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IN THIS IS S UE

CONTENTS 4

SHAPING THE SOUTH AFRICAN HEALTH SYSTEM

– looking at the Netherlands

The Dutch system combines a public sense of solidarity with the hands-off approach of private systems, where competition stimulates improvement. – By Dr Anna van Pouke, Partner Healthcare, KPMG Plexus, the Netherlands

»»p.4

7 BHF PERSPECTIVES Amendments to Regulation 8 . . . . . . . . . . . . . . . . . . . . . . . 7 Negotiated tariffs for 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Low-cost medical schemes – the way forward . . . . . . . . . 11

16 WOMEN IN HEALTHCARE

– too many walls, not enough bridges

»»p.14

Women comprise an overwhelming majority of South Africa’s healthcare workforce, yet they are significantly underrepresented in leadership positions. – By Dr Anuschka Coovadia, Head of Health Africa, KPMG

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19 ON THE COVER

– Meet Dr Anuschka Coovadia

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Healthcare and social responsibility are part of her DNA and she has a passion for innovation, strategy, entrepreneurship and development.

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I N T HIS ISSUE

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HEALTHCARE INSIGHTS

Procedural sedation and analgesia (PSA) . . . . . . . . . . . . . 20 Low back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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16th ANNUAL BHF CONFERENCE

Leaders in healthcare chart a course for the future . . . . 26 »»p.20

»»p.28

Medical schemes – a vehicle to improve employee health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Low-cost options – how do we bring more members into the schemes environment? . . . . . . . . . . . . 30 The legal status of CMS circulars . . . . . . . . . . . . . . . . . . . . 31 A prescription for access . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Listing of sponsors & exhibitors . . . . . . . . . . . . . . . . . . . . . 45

33 »»p.30

»»p.31

2015 TITANIUM AWARDS

Award nominees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

59

REGIONAL UPDATES

Botswana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Mozambique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Zimbabwe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

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BHF MEMBERS

South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 SADC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

ADVERTISER INDEX Universal Healthcare. . . . . . . . . . . . . . . . . . . . . IFC

Sanlam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

PCNS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Sanlam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IBC

Mediscor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

KPMG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBC

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SHAPING THE SOUTH AFRICAN HEALTH SYSTEM – looking at the Netherlands After more than 25 years of working in the Dutch health system – as a hospital director, director of the Dutch DRG office, consultant and researcher – I have developed a good understanding of the way the Dutch health system works. I experienced first-hand the forces at work that shape the way care is delivered to Dutch citizens. But my recent travels to explore other health systems – as part of my membership of KPMG’s global health centre of excellence – have really put into perspective the uniqueness of the Dutch system and the inspiration it can be for other countries. In this article I outline some of the key elements of the system; not presuming to give a complete description, but rather to highlight those points I believe can prove valuable in shaping the South African health system. By Dr Anna van Pouke PARTNER HEALTHCARE, KPMG PLEXUS, THE NETHERLANDS

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he Health Insurance Act of 2006 created a legislative framework to stimulate managed competition in the Dutch health system. Patients have mandatory insurance with a private in-

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surer at the cost of approximately 1 100-1 200 euro per annum. If a patient needs care, a combination of the patient’s preference and the contracts in place between insurers and providers influences which provider the patient visits. Insurers negotiate with providers based on price and quality and are responsible for continuity of care

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on a regional level, for instance allowing access to emergency care within a 45-minute drive of the patient’s location. Patients exercise influence through their insurer; on 1 January each year they can switch to a different insurer. This creates the triangle shown in Figure 1, creating push and pull in the system to stimulate change directed at improving care delivery.


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Patient To level the playing field for insurers and to prevent adverse selection, there is risk equalisation, which means the revenues of insurers are balanced out based on their specific case-mixes. The primary care infrastructure is built on a foundation of general practitioners (GPs), who work individually or in joint practices. GP practices can include support from, for example, nurses and mental health workers. The GP is the first point of contact for citizens when it comes to their health. Long-term care is currently undergoing major reform with three areas of care being devolved from national to local government through the 2014 Social Support Act. The goal is to deliver better social care at the local level while curbing costs. The devolved areas include: 1. Care for the frail and elderly with long-term conditions living at home 2. Non-hospital care for children (0-18 years) including mental healthcare 3. Support to vulnerable populations, such as people with disabilities or mental health conditions, to increase their participation in their communities

Insurer

Provider

Figure 1: The push and pull effect created in the system to stimulate change directed at improving care delivery.

HIGHLIGHTS A. Solidarity

B. Driving improvement

Looking at systems across the globe you see a split between (largely) public and (largely) private systems. The Dutch system combines a public sense of solidarity with the hands-off approach of private systems, where competition stimulates improvement. Mandatory insurance means that all citizens take part in the system and the legal framework creates strong public safeguards, for instance through risk equalisation, the setting of a basic insured package that de facto includes all primary and acute medical care, including mental health, and national regulators and inspection to govern the system.

“The Dutch system combines a public sense of solidarity with the hands-off approach of private systems, where competition stimulates improvement”

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In the acute care landscape, it’s the private parties that shape the way care is delivered and paid for. We see that the insurers play a key role in getting the stakeholders in a local health economy around the table to assess the sustainability of the system and develop strategies to maintain quality, access and affordability of care. Citizens can ‘vote with their feet’ if developments are not to their liking and insurers have purchasing power to incentivise providers. As insurers are responsible for making sure citizens have access to care, they are incentivised to work with providers to make sure demand and supply are aligned.

C. Giving it time There is no silver bullet to major health reform and even with a great plan, a system will need time to adjust. After the introduction of the Health Insurance Act in 2006, the stakeholders in the system needed several years to grow into their new position in the landscape, for example insurers

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HEALTHCARE 360º

Specific lessons for South Africa Despite its challenges, the Dutch healthcare system is commonly viewed as one of the better healthcare systems in the world. It is also a system which depends on the participation of a vibrant, competitive private sector, within strong regulatory and governance frameworks provided for by the State. As such, it holds a wealth of experience and information for the designers and constructors of a more effective, sustainable, inclusive, integrated healthcare system for South Africa. Notable examples of this include:

needed to grow into their increased purchasing powers. A gradual increase in the number of DRGs eligible for open negotiations between providers and insurers was one of the ways in which reform got a chance to take shape. The introduction of the Social Support Act teaches us again that a system is never ‘ready’ for reform. Reform puts stress on the system and reaping the benefits can take several years. This means that it’s wise to develop strategies that create gradual change and make sure stakeholders get a chance to grow into new roles.

CHALLENGES All in all, the Dutch health system performs well and public satisfaction is high. But the system is not perfect and faces its own challenges to continue delivering high-value care.

3. Integrating health and social care

The ambition to deliver more care close to and in people’s homes is at the heart of the Social Support Act. This is still a major challenge requiring integration of and coordination between stakeholders across the care continuum. In parallel it requires improvements in primary care, community services and home care to substitute care delivery in hospital settings. A high number of stakeholders, ongoing system reform and challenges around funding and incentives make change go slowly.

4. Funding and incentives

Change in the delivery system needs to go hand in hand with change in the way care is contracted. This requires a move from volume to value that rewards prevention, care that is first-timeright and care that is delivered in the most appropriate care setting. So far, health insurers seem to lack the ability (or ambition) to develop new ways of contracting that reward high-value care.

• The interplay between managed competition and social solidarity,

1. Increasing transparency

which is particularly relevant to the

emerging health economy in South Africa. • Mandatory coverage, a risk equalisation fund and consumer choice, which are all fundamental components that contribute to the effectiveness of the system. • The constant drive towards high-

There is a need to address the lack of transparency on quality of care by different providers and deal with information asymmetry between patients, insurers and care providers. This is key to increasing patient engagement.

2. Maintaining solidarity

quality, low-cost care, which resonates well with local requirements, as the South African healthcare system needs to ‘do more with less’.

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There is pressure on the affordability of the system, leading to higher co-payments for patients. This threatens accessibility to care for lower-income groups and can lead to patients waiting too long before seeking help. A growing number of people feel that higher-income earners should pay higher premiums than lower-income groups.

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As a final thought, the obvious parallel between both systems, and every healthcare system in the world, is the deep interconnectedness that exists between payers, providers and patients. We need to understand the systems and incentives that drive these connections as they will determine how we accelerate progress and drive outcomes-based solutions that are mutually acceptable and effective at a societal level.

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BOARD OF HEALTHCARE FUNDERS welcomes amendments to Regulation 8

By Zola Mtshiya MANAGER: MARKETING, BRANDING AND COMMUNICATIONS, BHF

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n what is being hailed by the Southern African Board of Healthcare Funders (BHF) as a victorious move by exceptional leadership, the Department of Health has issued bold amendments to Regulation 8 of the Medical Schemes Act. According to Dr Humphrey Zokufa, BHF managing director, the changes will not only benefit medical schemes, but also medical scheme members. Medical schemes will be obliged to pay in full a regulated fee and therefore no longer be forced to be 'reckless with their members’ money because of healthcare providers having a blank cheque’. Medical scheme members will not be faced with co-payments, as medical schemes must pay in full the regulated fee. This is the case even when the

This is good news for medical schemes and its members, as there will now be certainty with regard to fees and this will prevent the exploitation of the medical funding system. fees are negotiated outside the 2006 NHRPL model. The amendments relate to the medical schemes’ prescribed minimum benefits (PMBs). Currently, the fees that healthcare providers charge for PMBs are unregulated, meaning that healthcare providers registered with the Health Professions Council of South Africa (HPCSA) can charge medical schemes whatever they like for these services. This significantly contributes to the high cost of private healthcare. “It is therefore not surprising that the current regulations created a skewed picture favouring healthcare providers.” The only person who could correct this imbalance is the Minister of Health,

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deriving such powers from Section 27 of the South African Constitution, which promotes access to affordable healthcare. This section obliges the Ministry to take steps, including legislative changes, to achieve these goals. “We therefore applaud Dr Aaron Motsoaledi for taking such decisive leadership and amending the regulations to balance the scales, something that will make private healthcare more affordable and accessible,” says Zokufa. Amendments, which were released for comment on 14 July, effectively regulate the fees charged by healthcare professionals by stating that: “In respect of any service rendered by a healthcare professional who is registered with the Health Profes-

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the Gauteng High Court to issue a declaratory order to clarify the interpretation. Unfortunately the Regulator: Council for Medical Schemes and various healthcare providers opposed this initiative. The Gauteng High Court judge unfortunately did not provide the declaration. Since then BHF has been having various meetings with the Dr Aaron Motsoaledi on this matter, asking him to intervene appropriately. “We are happy that he has ultimately done so.” SAMWUMED, a member of the BHF, also hails the recent amendments after requesting a review of the regulation for many years, saying that it may lead to a reduction in medical aid contributions by members. Zokufa expects the regulation to be signed into law by as early as October this year, after input and comments by the healthcare industry and review by the Department of Health.

DR HUMPHREY ZOKUFA Managing Director, BHF sions Council of South Africa, medical schemes are liable for payment for services in accordance with the billing rules and the tariff codes of the 2006 NHRPL tariffs published by the Council, the Rand value of which has been adjusted annually in accordance with the Consumer Price Index as published by Statistics South Africa; or schemes may negotiate alternative tariffs with any provider of any relevant health service for which no co-payment or deductible is payable by a member.”

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“This is good news for medical schemes and its members, as there will now be certainty with regard to fees and this will prevent the exploitation of the medical funding system. In addition, medical schemes will be liable to pay the healthcare provider’s fee in full, and members will no longer be out of pocket with regard to PMBs, as they are not liable for payment,” says Zokufa. He adds that the BHF has been fighting the current interpretation of Regulation 8 on its members’ behalf since 2010/2011, when it asked

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“Should the current amendments be contested by aggrieved parties in a way that seeks to destroy the implementation thereof, rather than enriching the process, we will continue to stand firmly by the Minister of Health and fully support the implementation of the proposed regulation,” concludes Zokufa. This will be to the benefit of the medical scheme member, medical schemes and healthcare professionals.


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THE NEED FOR

negotiated tariffs for 2016 By Dr Rajesh Patel HEAD: BENEFIT AND RISK DEPARTMENT, BHF

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edical schemes and their members can no longer support the often exorbitant fees charged by providers in the absence of a negotiated tariff. Neither can they continue to await a solution further to the Competition Commission’s ongoing inquiry into private healthcare – something that might take another 2-3 years. This is the view of Dr Rajesh Patel, Head: Benefit and Risk, Board of Healthcare Funders (BHF). “First the Competition Commission ‘interfered’ in healthcare in 2003, putting a stop to the negotiated tariffs that schemes used to guide reimbursement. Further to that, first the Council for Medical Schemes and then the Department of Health took over control of coding and pricing to fill the void. A legal challenge with disastrous results ensued and there have been no guideline tariffs in place since 2010, when a court struck down the guideline Reference Price List drawn up by the Department of Health.”

In its submission to the Competition Commission’s inquiry, the BHF says medical specialists have become a huge cost driver for medical schemes because of the excessively high fees they charge. “For the past five years we have had a vacuum related to tariffs and the service environment. Now the BHF is drawing the line and demanding a solution. The current regulatory framework is clearly not working, and the regulators have not fixed it, as they have failed to intervene to protect the public and members of medical schemes from out-of-pocket payments. Even the Minister of Health, Dr Aaron Motsoaledi, acknowledges this.”

“Coding is about scope of practice and professional service - it is not about pricing - so the BHF is within its mandate to discuss it with stakeholders. Constructive meetings have already been held with the South African Dental Association (SADA). The dentists are keen to implement new codes in a responsible way.”

Patel says the BHF is now exploring legal ways in which to publish codes or tariffs that reflect reasonable levels of pricing and provide certainty, affordable healthcare access and sustainability for all like-minded stakeholders looking for solutions. At the BHF’s annual conference he will outline these proposed codes/tariffs and make it clear that the BHF’s plan will not ‘pander to the fringe element’ who want ‘ridiculous, unjustifiable tariffs’.

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LOW-COST MEDICAL SCHEME PLANS – the way forward MD, BOARD OF HEALTHCARE FUNDERS

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arlier this month, the Council for Medical Schemes (CMS) issued Circular 9 of 2015 introducing the concept of low-cost benefit options. The CMS also hosted an indaba in Cape Town on 15 June to present its views and allow for stakeholder comment. The CMS is currently developing guidelines for the industry in this regard. Some of the broader principles for consideration are the

Low-cost plans need to be integrated into a larger, long-term reform process – including a radical review of the current PMBs, which

By Dr Humphrey Zokufa,

sees the latter better aligned with government priorities like preventive and primary care.

protection of risk pooling, benefit design, continuation of care, solvency protection and non-health expenditure. The Circular invited proposals on the benefit design and

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pricing that would form part of the minimum set of benefits. These submissions will inform the development of guidelines. The Board of Healthcare Funders (BHF) fully supports the CMS initiative and the concept of low-cost medical scheme plans for low-income households, believing they can certainly add value to the lives of those who are currently uninsured. However, in the long term the creation of low-cost options with limited benefits as a separate add-on to those products already on the market is potentially discriminatory and will only serve to make an already fragmented and complex environment more so. Rather the introduction of such options needs to form part of a larger road map to an overall reform of the private healthcare funding environment. This is potentially a 3-5 year process, a critical part of which will be a serious review and reworking of the prescribed minimum benefits (PMBs) and a new way of thinking about healthcare funding priorities.

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For low-cost options to deliver real value, they will need in due course to be integrated into this new healthcare landscape.

BHF’s position is that if one is to focus on health first, one needs to start with defining the essential services that impact positively on health status.

The BHF’s position is set out below.

The current PMBs reflect the aforementioned emphasis on catastrophic care and BHF has long been on record as having major reservations about the PMBs as they are currently structured.

FOCUS ON HEALTH FIRST, FINANCES SECOND Various commissions of inquiry over the past decades have sought to address escalating healthcare costs. The unintended outcome, most notably consequent on the findings of the Melamet Commission in 1989, has been the increased tendency to take a finance-centric view of healthcare, with the use of models and frameworks akin to those of the insurance industry. This finance-centric view ignores much public health thinking. BHF views matters differently. The primary business of a medical scheme is health, while finances are important and need to be looked after, they remain a secondary consideration. There should therefore be a move away from the current focus on catastrophic care and day-to-day medical expenditure being viewed as discretionary. We need to unwind the developments of the last 25 years.

While agreeing that the principle behind them is good, BHF feels their content is not based on sound health policy. They disproportionately emphasise high-cost, late-stage interventions that are mostly adult-, hospitaland specialist-centric. These not only carry a considerable financial burden, but are also at odds with government’s prioritisation of preventive and primary care as envisaged in the Constitution and subsequently included in the National Health Act (NHA).

ADDRESS EXORBITANT COSTS OF THE PMBS The exorbitant costs associated with the PMBs have played a key role in the lack of membership growth in the schemes environment in recent

There should be a move away from the current focus on catastrophic care and day-to-day medical expenditure being viewed as discretionary. We need to unwind the developments of the last 25 years.

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years – and this is reflected in a trend whereby fewer and fewer 20-30-yearolds are entering the system. As a result, the cross-subsidy component of healthcare funding – whereby the premiums paid by the young and healthy offset the costs incurred by those who are older and sicker – is being lost. If left unchecked, healthcare expenditure will simply continue to escalate. Bringing more young individuals, including those who are currently uninsured, into the schemes environment will have the double benefit of helping to reverse this alarming trend, while also taking the pressure off of overburdened public sector resources. The low-cost benefit plan could potentially play an important role in helping to achieve this. However, it is unlikely to succeed if this option is marketed as something separate from the existing products on offer, with the clear implication that it is somehow inferior. BHF therefore contends that what is good enough for a low-income earner should be good enough for everyone and that realignment of the PMBs can help to achieve this. Government’s intention is to promote primary care and to ensure access to that care as envisaged in the country’s Constitution. The PMBs as they stand are contrary to government policy and legislation. We therefore need to marry two different dispensations – the low-cost benefit option and the current PMBs


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– if we are to grow the private sector and make it more egalitarian.

We need to move away from the current model which favours

EMPHASISE PRIMARY AND PREVENTIVE CARE

access to care only for some people with some diseases.

BHF feels that part of the solution to the current fragmentation, which is highly undesirable, is to revise the PMBs in line with public health policy to reflect a much greater orientation toward primary care. The heart of all medical scheme benefit options further to this would be the adapted lowcost benefit option with amendments – which would also exist as a plan in its own right for all options (Consider CMS Circular 8 of 2006). This would make them consistent with the NHA and the constitution.

Essential Drug List (EDL) medicines and devices.

Everyone on a medical scheme plan would therefore automatically get the core benefit as their basic package. Scheme members would then have the option to ‘top up’ the core benefit according to their ability to afford additional benefits. This primary care focus will also ensure a move away from the current disproportionate emphasis on catastrophic and chronic disease and the prevailing view that acute conditions be considered ‘discretionary’. We need to move away from the current model which favours access to care only for some people with some diseases. Access will be assured, with all patients being eligible for that first critical consultation along with a basket of additional essential services, such as some pathology, radiology,

MOVE AWAY FROM DIAGNOSIS-BASED BENEFIT DESIGNS Another critical change envisaged by BHF, and which the measures outlined above will hopefully achieve, is a move away from benefit designs that are diagnosis based towards ones that promote essential services. Severity-based and diagnosis-based designs are not only discriminatory, but also lead to anomalies and inconsistencies in health access. Drugs that are termed ‘essential’ for one PMB diagnosis may be viewed as discretionary or ‘not PMB’ for another where they are equally appropriate. To cite just one example: ‘DMARD’, which is a group of medicines used for PMB autoimmune diseases, is not available as a regulated benefit to patients with non-PMB listed autoimmune diseases. We need to dispense with the many complex algorithms currently used. Any medicine in the EDL formulary should be a PMB when appropriately prescribed. Furthermore, there is significant information asymmetry related to tax credits for medical scheme contributions. The opportunity tax credits offer must be considered in this context.

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To sum up, BHF’s position is as follows: Low-cost options have great promise for bringing more individuals into the schemes environment, thus alleviating pressure on the public sector and helping to address funders’ cross-subsidisation issues. However, simply introducing a new separate range of low-cost plans into the current system will only exacerbate an already fragmented and discriminatory scenario in the long term. Rather they need to be integrated into a larger, long-term reform process in healthcare funding; this needs to include a radical review of the current PMBs, which sees the latter better aligned with legislated government priorities like preventive and primary care. Once this is achieved, a low-cost package of benefits should form the core of all medical plans (CMS Circular 8 of 2006), rather than the low-cost benefit plan being an exempted model for those unable to afford better. Those who can afford more will have the option to pay for additional top-up benefits. The revised PMB benefit design will ensure better overall access, as well as care that is servicerather than diagnosis-based and not skewed in favour of chronic disease and late-stage, high-cost medical interventions.

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A sneak preview of the MMR 2014 results and findings:  1.8% of the increase was due to an increase in the cost of medicine, while utilisation contributed 2.4% to this increase.  New chemical entities constituted

Medicine Medicine expenditure Medicine expenditure expenditure in numbers per in numbers beneficiary

1.1% of total medicine expenditure.

 Utilisation of speciality medicines

continues to increase, due to

increases in both prevalence and intensity of use.

increased by Mediscor is an independent managed care organisation  The Single Exit Price (SEP) of a 4.2% basket of medicines available and has been servicing the healthcare industry foron more from 2013 to the market during 2012 to 2014 than 26 years. 2014 increased on average by 3.6% from 2013 to 2014. As part of the Mediscor Vision, we strive to be the most

 Generic utilisation continued to trusted pharmaceutical benefit management (PBM)

increase 54.5% in 2013 toOne solution in our market and to from set the benchmark.

55.6% 2014. of the areas where we haveinachieved this, is with our

Mediscor Medicine Review (MMR), a report we have published on an annual basis since 2002, which is highly For more information or a copy of the report, go to regarded and used as a reference by industry. www.mediscor.net. A sneak preview of the MMR 2014 results and findings:  1.8% of the increase was due to an increase in the cost of medicine, while utilisation contributed 2.4% to this increase.  New chemical entities constituted

Medicine expenditure per beneficiary

1.1% of total medicine expenditure.  Utilisation of speciality medicines

continues to increase, due to increases in both prevalence and intensity of use.


trusted pharmaceutical benefit management (PBM) solution in our market and to set the benchmark. One of the areas where we have achieved this, is with our

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Mediscor Medicine Review (MMR), a report we have

A DVE R TOR IAL

published on an annual basis since 2002, which is highly regarded and used as a reference by industry. A sneak preview of the MMR 2014 results and findings:  1.8% of the increase was due to an increase in the cost of medicine, while utilisation contributed 2.4% to this increase.  New chemical entities constituted

Medicine expenditure per beneficiary increased by 4.2% from 2013 to 2014

1.1% of total medicine expenditure.  Utilisation of speciality medicines

continues to increase, due to increases in both prevalence and intensity of use.  The Single Exit Price (SEP) of a

basket of medicines available on the market during 2012 to 2014 increased on average by 3.6% from 2013 to 2014.  Generic utilisation continued to increase from 54.5% in 2013 to 55.6% in 2014.

For more information or a copy of the report, go to www.mediscor.net.


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WOMEN IN HEALTHCARE

– too many walls, not enough bridges

By Dr Anuschka Coovadia

Women comprise an overwhelming majority of South Africa’s healthcare workforce, yet they are significantly underrepresented in leadership positions

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HEAD OF HEALTH AFRICA, KPMG

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outh African women carry a disproportionate burden of disease. Not only does our country have the highest prevalence of HIV/AIDS in the world, but HIV is eight times more prevalent in young women than in men. Of the 7000 new infections that occur every week among young women

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globally, 2363 occur in South African women between the ages of 15 and 24 years. In addition, we have one of the highest burdens of tuberculosis in the world – accounting for up to 10% of deaths in women. High rates of rape, abuse, deaths during childbirth, cancers and lifestyle diseases, such as obesity and diabetes, also affect the women of our country disproportionately, as they are overwhelmingly

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unempowered consumers and pursuers of health and well-being. The need for leadership in healthcare is therefore an urgent priority – and the need for women in leadership in healthcare, in particular, is a core imperative if we wish to correct the injustices of the past, create social cohesion, build a healthy nation and unlock our true economic potential. According to Johanna More, Chief Directorate: Gauteng


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WO M E N I N H E A LTH CARE

Current operational structures in

the clinical environment do not sup-

port the important role that women

also play as mothers who need to care for their families and the elderly.

Department of Health, “Only women are capable of leading the agenda of health – not only with their heads, but with their hearts, to ensure implementable solutions.”

contribution of women is undervalued and women are underrepresented in leadership positions.

Throughout the world, and South Africa is no exception, women are the key decision-makers in families and communities when it comes to health in the home. It is therefore only logical that women should also be in healthcare leadership positions so that the needs, perceptions and vulnerabilities of the nation are represented and catered for.

In an interview with a prominent academic, Professor Ames Dhai, Head of the Steve Biko Centre for Bioethics, the healthcare sector was described as leading the transformational agenda of South Africa – yet she added that despite tremendous progress, it regrettably still lags behind when it comes to having a large enough pool of trained, skilled, experienced women leaders and senior management, who can steer the overall direction of healthcare reformation in our country.

Unfortunately, we have failed to achieve a sufficient level of meaningful participation of women in leadership positions in the industry, despite the fact that the majority of the healthcare workforce is female. The

According to Professor Dhai, “Women can’t just get on in their careers because they are women – we must respect ourselves enough to achieve success because we have the necessary skills and expertise.”

MORE IN LEADERSHIP POSITIONS

Professor Ames Dhai, Head of the Steve Biko Centre for Bioethics She raised concerns about the lack of consideration given to the special training needs of women in the sector, who often have to work long hours in harsh environments, despite the fact that they may be pregnant or have young children. She also noted that the majority of entrants into medical schools are now female, but the proportion of women who enter specialist programmes tends to be lower, particularly for surgical specialties. Institutions need to re-examine their training regimes so that women are able to stay in specialist programmes

and not be deterred from raising children at the same time, as this is the basis of a strong, healthy society.

OPERATIONAL SUPPORT IN THE WORKPLACE Dr Carol Marshall, CEO of the Office for Health Standards Compliance, advised that many of the current operational structures in the clinical environment do not support the important role that women also play as mothers who need to care for their families and the elderly. At the same time, they are expected to provide

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of a total of seven. Similar gender imbalances are evident in the composition of many boards of hospitals, pharmaceutical companies, medical schemes and administrators too.

Dr Carol Marshall, Acting CEO of the Office of Standards Compliance of the National Department of Health in South Africa. empathetic, patient-centric care to patients in their work environment. She observed that many female nurses and doctors lead chaotic lives, trying to balance their personal and professional worlds, a phenomenon that commonly leads to burn-out, stress-related conditions and low levels of motivation and compassion. This cycle inadvertently creates barriers to effective patient care at the frontiers of service delivery. In the private healthcare sector in South Africa, there is currently an underrepresentation of women in senior executive positions

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and on the boards of many leading organisations, including regulatory bodies and industry forums. The Board of Healthcare Funders (BHF), which is the leading industry body for medical schemes, has 2/18 women on its board; the Health Professions Council of South Africa (HPCSA), which regulates all professionals working in the sector, has 3/10 women in leadership positions; and the Innovative Pharmaceutical Association of South Africa (IPASA), which is an industry body representing the originator pharmaceutical industry, has only one woman on its executive out

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Out of the 86 medical schemes in the country, only 23 have female principal officers. This lack of representation is detrimental to the effectiveness and inclusiveness of the industry, particularly with regard to the representation of the voices of the female membership for whom these schemes provide coverage. Many women in these organisations are highly skilled, experienced, ambitious and keen to play a leading role in the healthcare sector; however, they are currently struggling to reach the executive office, facing glass ceilings, sticky floors, competing priorities and lack of access to support and guidance. In conclusion, women comprise an overwhelming majority of South Africa’s healthcare workforce, yet they are significantly underrepresented in leadership positions, particularly at senior management, execu-

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tive and board levels. However, it is clear that women are uniquely positioned to leverage traits such as compassion, transparency and the ability to encourage teamwork – all of which are necessary to lead our healthcare system into the next phase of its evolution. In the future, the pace at which women gain access to senior positions within healthcare organisations, in both the private and public sector, will accelerate as many more South African organisations embrace diversity and select the best qualified leaders in terms of both experience and leadership style. This will support the growth of an integrated, sustainable, patient-centric healthcare system. And it is our hope that as we grow, we also grow closer together – understanding that our interconnectedness means we need more bridges and fewer walls.

Article provided courtesy of the Businesswomen’s Association of South Africa – Extracted from the 2015 BWA Women in Leadership Census


BHF360° | SEPTEMBER 2014

ON THE COVER

I N S I D E HE A LTH CARE

Meet Dr Anuschka Coovadia She subsequently moved into the funding environment. She worked for both Momentum and Metropolitan (as Head of GEMS Clinical Services) before moving to KPMG, where she has worked for the last three years.

Dr Anuschka Coovadia is currently Head of Healthcare at KPMG Africa. Her healthcare centre of excellence operates throughout the continent, offering advisory services to governments/ policy makers, donors and funders, hospital groups, pharmaceutical manufacturers, medical professionals, private equity and health IT operations.

“I have a passion for innovation, strategy, entrepreneurship and development. I love working with people who are courageous and constantly bring fresh ideas to the table,” she says.

Healthcare and social responsibility are part of her DNA. She is the daughter of a paediatrician and a dermatologist, Professor Jerry Coovadia and Dr Zubie Hamed, who were active in the struggle against apartheid and who worked tirelessly to dismantle racial barriers when it came to ensuring healthcare access.

“We need this if we’re to move forward, expand access to healthcare and address the critical stumbling blocks that hinder the delivery of better quality, patient-centric care. I enjoy moving across all the different components of the healthcare ecosystem - learning from people who have deep vertical experience and capabilities and then applying those skills more broadly, in the interest of creating a better healthcare system for all Africans.”

So when the time came to choose a career, she knew she wanted to focus on working towards the further development of the country and its healthcare services in particular. She qualified as a doctor in 2000, at the peak of the HIV epidemic, which hit KwaZulu-Natal especially hard, so her initial experiences were indeed the proverbial baptism of fire.

In addition to her work at KPMG, she is very committed to giving back to the community. She addresses many health and educational forums, contributes to relevant publications and hosts forums for global and local leaders to find areas for collaboration.

“It was both a dramatic and a traumatic environment,” she recalls. “Hospitals were overwhelmed, the mortality rate was high, denialism was paralysing and one also had to deal with the stigmatisation that went with the disease.”

In her ‘spare time’, among others, she works on a programme that mentors young girls from rural backgrounds with a view to grooming them for tertiary education, specifically in the sciences.

The experience made her realise that she needed to be more than just a clinician – in order to effect positive change in the healthcare system as a whole. “I subsequently worked on various projects that crossed over between health, development and economics.” A stint with pharmaceutical giant, Novartis, gave her deep experience in Africa, further to which she obtained a Masters in Economics and started a degree in actuarial sciences. BOARD

She also works with local business forums to stimulate female entrepreneurship at a community level. “If we wish to correct the injustices of the past, create social cohesion, build a healthy nation and unlock our true economic potential, then our healthcare system needs urgent prioritisation.”

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HE ALTHC A RE IN S IG H T S

Procedural sedation and analgesia (PSA) an alternative to general anaesthesia for surgical procedures outside the hospital environment UNIVERSITY OF THE WESTERN CAPE

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e are in the midst of a dynamic time for sedation practice as this is probably the fastest growing area in anaesthesia care. According to all sedation guidelines, including the 2015 SASA guidelines on PSA, we can administer PSA outside the hospital in medical or dental surgeries, offices, facilities and sedation clinics. This makes PSA such an attractive option for us. PSA outside the hospital environment involves a multitude of providers, and non-anaesthesiologists will be and are part of this group. The choice of which provider delivers this care and the techniques and drugs used are usually specific to each institution/ country and largely dependent on the availability of trained providers. In developing countries we face other challenges. There are not enough

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anaesthesiologists and other healthcare providers available to provide anaesthesia services for all in-hospital procedures. PSA then becomes a very attractive option for certain surgical procedures. One needs to realise that the concept of ‘sedation’ outside the operating theatre presents challenges. Training is necessary, accreditation of sedation providers should become mandatory, and we need practice inspection where procedures are done outside a hospital setting. The problem is: how do we bring this all together? The 2015 SASA Guidelines on Procedural Sedation and Analgesia provide sedation practitioners and healthcare

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funders with guidance on safe sedation practice.

MANY CHALLENGES The evolution and revolution of safe sedation practice will bring challenges. Sedation practice continues to change, particularly when it comes to sedation providers. Who can do it and how should it be done? Maybe our biggest challenge is the issue of anaesthesiologists and non-anaesthesiologists as sedation providers. Another important challenge in future will be the drugs we use: which ones, how do we administer them, are they safe for use outside the operating theatre, and the biggest issue of all, who can administer which drug? There

By Professor James Roelofse

Sedation services will become more popular as an alternative to general anaesthesia for certain procedures outside the operating theatre. This is a worldwide trend.

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HE A LT HC A R E I NSIGH TS

PSA outside the hospital environment involves a multitude of providers, and nonanaesthesiologists will be and are part of this group. The choice of which provider delivers this care and the techniques and drugs used are usually specific to each institution/country and largely dependent on the availability of trained providers. is still resistance from some anaesthesia societies and departments of anaesthesia on who should be allowed to give 'general anaesthetic’ agents like propofol and ketamine, which are in common use in sedation practice. Some anaesthesiologists

still believe the ‘Pandora’s box’ should be closed; propofol is just for use by anaesthesiologists. One wonders, is this challenge really important with the shortage of anaesthesiologists and other healthcare providers we have, and our commitment to sedation training not only in South Africa but worldwide? There is enough evidence available that nonanaesthesiologists trained in sedation can safely administer PSA. Accredited university training in specific sedation techniques barely exists in Africa, and is currently only available in Cape Town. This is a serious challenge to safe sedation practice.

A POPULAR ALTERNATIVE TO GENERAL ANAESTHESIA Sedation services will become more

popular as an alternative to general anaesthesia for certain procedures outside the operating theatre. Published research is available that shows PSA to be a safe option for procedures outside the hospital environment. In a recent 500 case study (in press) on patient satisfaction after sedation, 94% of patients indicated that they would prefer sedation to general anaesthesia; only 2% want general anaesthesia as an option. The low side-effect profile, e.g. low incidence of nausea and vomiting, pain, and cost-effectiveness of PSA make it an attractive option for the future.

BRINGING IT ALL TOGETHER How are we going to bring this all together so that sedation becomes a safe option for procedures outside the operating room?

PROFESSOR JAMES ROELOFSE University of the Western Cape Visiting Professor, University College London, London UK

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HE ALTHC A RE IN S IG H T S

to the demand for sedation provision with

As sedation trainers we have responded

training and CPD activities. We have empowered healthcare professionals to become safe sedation providers.

where sedation was done as well as the technique used, comply with SASA recommendations for safe sedation practice, and have evidence available of updated qualifications in airway certification.

The obvious answer is that nobody should provide paediatric/adult sedation, including anaesthesiologists, without training. Recent guidelines by the Academy of Medical Royal Colleges in the UK (2013) state clearly, “Safety will be optimised only if sedation practitioners use defined methods of sedation for which they have received formal training.” This includes everyone involved in sedation practice.

QUALIFICATIONS & TRAINING REQUIREMENTS In South Africa the SASA guidelines on PSA (2015) state, “Relevant qualifications and ongoing training remain the foundation of safe sedation practice.” It is recommended that sedation practitioners: have a primary, registered medical qualification, have full registration with the Health Professions Council of South Africa (HPCSA), have formal training in standard and advanced sedation techniques, have provide evidence of regular and recent sedation-related CPD activity, keep a logbook reflecting cases

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To optimise patient safety, sedation practitioners should only use the specific sedation techniques for which they have received formal training. Operator-sedationists should only use simple or standard sedation techniques and should not administer combinations of drugs. Currently both anaesthesiologists and non-anaesthesiologists are involved in sedation practice in our country and worldwide for a wide variety of procedures outside the hospital environment, e.g. endoscopic procedures such as gastroscopies, colonoscopies and bronchoscopies, egg retrievals, dentistry, minor surgical procedures, plastic procedures and orthopaedic operations. Sedation for interventional radiology is a fast growing field. Laser therapy for lesions in small children is often done under PSA.

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GUIDELINES ENSURE SAFE PRACTICE The SASA guidelines are seen as the current guidance to safe sedation practice. They are for use by all medical practitioners and their teams. What then about the future? Sedation services will become more popular as an alternative to general anaesthesia for certain procedures outside the operating theatre. This is a worldwide trend. For clinical governance, accreditation of sedation services and practice inspections are suggested in the SASA guidelines. All practitioners involved in sedation practice must keep a logbook of cases performed under sedation and are required to document and report adverse events. The drivers of sedation practice in the future will be the private healthcare sector, public service, medical insurance and patients. We often forget about patient satisfaction. In studies done by us, patients consistently rate sedation as a better option than general anaesthesia for certain procedures outside the operating theatre; the low side-effect profile, cost effectiveness and quick recovery characteristics play a significant role in their choice. As sedation trainers we have responded to the demand for sedation provision with training and CPD activities. We have empowered healthcare professionals to become safe sedation providers.


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HE A LT HC A R E I NSIGH TS

Low back pain – getting the right treatment to the right person at the right cost: risk stratification and targeted treatment By Lorraine Jacobs

development of chronic pain and secondary disability, and suggests targeted physiotherapy management strategies for each of these categories.

Physiotherapist in Private Practice

A

ll around the world the cost of managing low back pain has escalated.

It has been used to reduce costs in the National Health System in the UK, as well as in the USA. It has currently been translated into 22 languages.

Some of these costs can be attributed to the increased use of imaging (including MRIs), hospitalisation, surgical interventions and dependence on drugs, as these desperate patients seek to address their pain. Acute pain has a role in protecting tissues during healing, but chronic pain that persists beyond the duration of healing (longer than 2-3 months) no longer serves that purpose. As our understanding of the mechanisms of chronic pain improves, we know that one in five patients has a more complex presentation, which may include barriers to improvement such as fear of aggravating their condition or causing further tissue damage, together with an intense focus on their pain, increased anxiety about their prognosis and a sense of helplessness in respect

of self-management of their pain. If this group of patients is identified early, these risk factors (which are modifiable) can be taken into account during management. Keele University in the UK has developed a questionnaire called the STarT Back Screening Tool (http://www.keele. ac.uk/sbst/). This tool enables primary care practitioners to stratify patients into categories of low-, medium- and high-risk for the

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The South African Society of Physiotherapy recommends the STarT Back Screening Tool and targeted treatment strategies in their Clinical Guidelines for the Management of Recent Onset Low Back Pain, and is currently training physiotherapists in the use of the tool together with the targeted treatment strategies, especially for the complex high-risk category. Physiotherapists are ideally placed to deliver appropriate and cost-effective management of low back pain. Retrospective analyses of patient records in the USA show that early referral for physiotherapy results in cost savings consequent on reduced imaging and surgical interventions.

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Sanlam’s healthcare services At Sanlam we understand that people work hard for their money in order to create a better future for themselves and their families. Whether they have a lot of money or a little, we treat it as if it were our own, with a respect for what went into making it and an appreciation for what can be made of it. This is also true of the way in which we approach healthcare. Sanlam’s healthcare division is a proud part of the Group’s solution set to clients. From a fully-fledged range of services to medical schemes, corporates and individuals to customised products and integrated IT systems, the division ensures effective administration and optimal management of medical expenses. This includes from paying and managing claims to improve solvency rates, acquisition of new members and balance sheet solutions to value added services like a loyalty programme.

Medical scheme solutions Sanlam’s scheme administration system is customised and presents an integrated solution for claims processing and client management functions, while our medical scheme risk management techniques are outcomes based and customized to our clients’ needs. We also pride ourselves in wellness solutions and a corporate wellness programme which includes early detection of health and lifestyle risk factors that drives key intervention strategies. Sanlam’s application of two Regulation 30 compliant investment vehicles assists with improved solvency rates and boosts stability of contribution increases. The Sanlam Investment Management (SIM) Enhanced Cash Medical Portfolio provides capital stability and high liquidity while offering competitive returns relative to bank deposits; whereas the Sanlam Investment Management (SIM) Absolute Return Medical Portfolio provides medical inflation beating returns to schemes, with an emphasis on capital protection. Sanlam provides a valuable asset consulting service. We, in partnership with medical schemes, assist to determine the most appropriate investment structure, portfolio objectives (and benchmarks) and investment manager mix for the schemes.


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A DVE R TOR IAL

A client-focused solution set Health advisory services CompleteMed is an independent healthcare brokerage that specialises in healthcare advice and service solutions, and assists medical schemes by sourcing quality new members.

Alternative healthcare funding Sanlam provides individual members top-up cover by way of a Hospital Cash Back Plan and Medical Gap Cover.

Value adding loyalty programme Sanlam Reality is a lifestyle, wellness and rewards programme available to Sanlam group clients. It serves to empower members by helping them to achieve the lifestyle they desire and gain financial wellness. Sanlam Reality members save money on travel, entertainment, health and fitness.

Corporate balance sheet solutions Sanlam assists corporates in closed schemes with high liability by removing post-retirement liability from their book. Ultimately, Sanlam’s respect for clients and their hard-earned money drives our healthcare division’s solutions orientated approach. It’s what makes us Wealthsmiths™.


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ANNUAL B H F C ON FE RE N C E

6

The

BHFI S OUTHERN A FRICA

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Annual Cape Town BHF Southern 26-29.07.15 African Conference Healthcare accountability “A luta Continua” Partnering for success

Leaders in healthcare

chart a course for the future FACILITATOR: Dr Humphrey Zokufa: BHF Managing Director This year’s conference aims to come up with practical strategies that will challenge the industry to take accountability and change the current status quo.

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hen the leaders of South Africa’s private healthcare industry get together for the Board of Healthcare Funders’ (BHF) annual conference at the Cape Town International Convention Centre from 26 to 29 July 2015, their focus will be firmly on the future sustainability of their industry. This year’s conference, with its overarching theme – Healthcare Accountability: Partnering for Success – aims to come up with practical strategies that will challenge the industry to take accountability and change the current status quo.

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We are going to collectively design a roadmap that plots our route to where we want to be in the future. We have listened to what our conference delegates have asked for. They represent over 300 major companies and institutions in the sector, including healthcare professionals, policymakers and regulators – the pillars of the medical industry – and we have changed the way we will engage with them this year.

goals of the event and distributed it to key members in every field for their input.

Working with ten major role-players, the BHF has prepared a positioning statement containing the overarching

The conference organisers have taken the decision not to focus on NHI this year, so right from day one delegates

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The aim for this year's conference is to engage with each other and determine what we can do together to contain these costs and ensure that providers are still satisfied with their remuneration. We need to get to a place where we can all work together for the greater good of the patient.


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A N N UA L BHF C O N F ERENCE

Coherent legislation and supportive policy framework

will start to look forward in time as they assess their industry and work to establish where they want to be – and what regulations are needed – in two, 10 and 20 years’ time.

showcase the first ever winners of the BHF’s recently launched Titanium awards for excellence in healthcare.

Hot topics at the conference include: transformation in healthcare, accountability, ethical leadership, health governance, the legal status of CMS Circulars and issues surrounding the regulatory environment.

On day two, delegates will be hearing from key speakers who have looked into new ways of addressing existing problems in the sector. Then, on day three, the BHF will present the first draft of the newly crafted road map to the industry – the culmination of the debates and discussions.

Also under the spotlight will be healthcare financing and service delivery, health information systems and technology, as well as co-ordinated care. In addition, the conference will

This document will be the starting point on the journey to create a realistic and sustainable future for the private healthcare industry in the region.

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The roadmap will take into account issues such as the need for a unified approach, greater alignment and a common purpose to ensure greater access, affordability and quality. The overarching goals are a coherent legislation and policy framework, the building of trust within the healthcare environment and reducing the burden of disease and trauma. We’re excited about what’s ahead. We know that our work on the document certainly won’t be over, but we also know that we will end the conference having taken the first steps towards real, sustainable change in the industry.

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Medical schemes – a vehicle to improve employee health? SPEAKER: Jane Ball | General Manager, Clinical Fund Management, Medscheme Disease management interventions offered by medical schemes, when appropriately targeted and aligned with best practice, improve productivity and the employee value proposition

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he massive cost associated with staff absenteeism and the resulting decline in productivity is a critical business dilemma, not merely a human resources one.

cost of treating the chronic diseases themselves. Disease management interventions offered by medical schemes, when appropriately targeted and aligned with best practice, thereby improve productivity and the employee value proposition; they are therefore of primary benefit to the employer. Disease management programmes are typically provided by medical schemes and, as such, medical schemes are a useful tool for reducing absenteeism.

According to research conducted last year by Occupational Care South Africa (OCSA) as well as Statistics South Africa, employee absenteeism reportedly costs the local economy between R12 billion and R16 billion annually. While many companies focus resources on attempts to alleviate this problem, clearly more needs to be done. WHAT MAKES A GOOD

A KEY CULPRIT IN THE PREVALENCE OF SICK DAYS While the reasons for absenteeism are multifactorial, many studies have shown that chronic medical conditions are a major drain on workplace productivity. A PwC research paper released last year indicated that productivity losses associated with workers who suffer chronic diseases are as much as 400% more than the

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DISEASE MANAGEMENT PROGRAMME? The questions are: what differentiates one disease management intervention from another and what should an employer be looking for in a disease management programme? Key is the ability of the disease manager to offer targeted, tailored healthcare programmes that effectively meet the needs of employees. Successful


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costs the South African economy between R12 billion and R16 billion annually

outcomes are achieved through the use of sophisticated data analytics to identify employee groups at risk and then allocate appropriate interventions to these groups. A programme that cannot integrate all of the relevant data for reporting and analysis purposes is of little use to the employer. At Medscheme, we have undertaken comprehensive research and analysis to determine the best use of medical scheme and employee data. Combining clinical, statistical and actuarial insights into these data has helped identify opportunities to improve product offerings to employers. Medscheme's analytical abilities have been recognised through awards such as the inaugural Barbara Starfield Award, created by Johns Hopkins University in the United States, for understanding the health needs of scheme populations using Adjusted Clinical Groupers (ACG). Further recognition includes

SERVICE DELIVERY Tuesday, 28 July 2015 11h00-12h30: Session Two

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Employee absenteeism reportedly

the Accenture Innovation Index Top Concepts Awards (2015) for groundbreaking work conducted to identify individuals with ‘emerging risks’.

WORKING TOGETHER TOWARDS A COMMON GOAL The employer is a fundamental stakeholder in the entire employee well-being process and is often a major contributor to medical benefit packages. As a key decision-maker on the medical schemes that employees have access to, the employer plays a significant role in how employees will experience medical scheme membership and the value derived from the scheme. Working together towards common goals that positively demonstrate, through analysis, improved employee health and a reduction in absenteeism (e.g. effective viral load suppression for HIV-positive employees, targeted influenza vaccination campaigns, improved adherence to treatment for chronic diseases) can significantly improve the value that employees and employers derive from their medical scheme. As such, partnering with a medical scheme that can deliver on this should be a critical business imperative.

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2015 Conference Objectives Co-ordinate the industry in developing a roadmap for a healthcare system for the next generation to meet growing demand for high-quality healthcare.

DAY ONE OBJECTIVES Day one will focus on the current status quo and the challenges of the present. Further to presentations on hot topics like ethical leadership, health governance, the legal status of CMS circulars and the issues surrounding the regulatory environment, the afternoon will see workshops focused on the future characteristics of a sustainable healthcare system, adapted to the WHO’s ‘six building blocks, which include; (i) leadership and governance; (ii) health information systems; (iii) healthcare financing; (iv) service delivery; (v) human resources and (vi) medicines and technologies. The aim is to reach consensus on the way forward.

DAY TWO OBJECTIVES To spotlight possible solutions to the problems and challenges identified on day one. It will have a decidedly futuristic bent with the aim of defining the characteristics of a newly envisioned healthcare system – one that is less fragmented and which will ensure superior healthcare for more, while keeping the medical schemes environment sustainable.

DAY THREE OBJECTIVES Presentation and distribution of the consolidated feedback collated during the conference. Committees to be set up to monitor the industry’s progress towards the goals identified on day one.


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ANNUAL B H F C ON FE RE N C E

Low-cost options – how do we bring more members into the schemes environment? SPEAKER: Dr Johan Pretorius | CEO, Universal Healthcare

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lmost 10 years after the lowincome medical schemes (LIMS) survey was carried out in 2006, the predicament remains: how do we provide affordable, private healthcare for salaried, low-income workers? This is a question Dr Johan Pretorius, CEO of Universal Healthcare, will be posing and attempting to answer in his presentation at the forthcoming Board of Healthcare Funders’ (BHF) conference. “We know that only 16% of South Africans are covered by private healthcare – around 8.5 million people – and that they are paying an average cost per life insured of R1000 per month. We also know that there are another seven million people who are economically active, but who cannot afford even the most basic cover currently available,” he says. He believes that LIMS and other research shows that there is an overwhelmingly clear indication that lower-income employees would pay between R200 and R300 a month for the convenience of having access to private service providers for their primary or essential healthcare needs, thereby avoiding a day of

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queuing at a state clinic. “But how can we achieve this?” Dr Pretorius’ view is that the only way to make such affordable medical cover possible will be to relax the prescribed minimum benefit (PMB) regulations for this category of cover. Currently schemes are legally obliged to pay in full for PMBs, which is an extremely onerous requirement, particularly where hospital-based PMBs are concerned. Some of the issues are: • Unlimited PMB liability costs an average of R500 per life per month • Administration fees can be as high as R300 per life per month • Is it possible to develop a more affordable solution within the regulations of the Medical Schemes Act and the National Health Act? • Should there be a different dispensation for low-income earners to avoid buy-downs? • Should membership of a low-cost medical scheme be compulsory?

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SERVICE DELIVERY Tuesday, 28 July 2015 11h00-12h30: Session Two

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The legal status of CMS circulars SPEAKER: Paul Midlane | General Manager: Legal Governance Risk Compliance, Medscheme

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irculars from the Council for Medical Schemes (CMS) are being regarded by the regulator as legally binding, but CMS circulars are not law and the CMS needs to stop trying to govern by circular. This is the view of Paul Midlane, General Manager of Legal Governance and Risk Compliance, AfroCentric Healthcare. Medical schemes who do not comply with CMS circulars are being declared in contravention and face punitive action from the CMS. This can include losing their registration or facing the removal of their Board, which would have a detrimental effect on the scheme’s members. “Some circulars have a vast impact, especially when medical schemes find themselves having to comply with a circular that is contrary to the regulations and contrary to the requirements of the Medical Schemes Act,” he says. Prescribed minimum benefit (PMB) payments are a very topical case in point. According to a CMS circular, PMBs must be paid ‘in full’. But Midlane says that PMBs are not even part of

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the Act and that medical schemes should be bound by their own rules, most of which prescribe that only a percentage of PMB costs should be paid. The CMS currently interprets the ‘in full’ requirement as ‘pay at provider cost’, regardless of what that is, rather than requiring schemes to pay a specified maximum in terms of their own rules and limits. “The bottom line is that a circular from the CMS has the same legal standing as a recommendation in King III – it is not the law. The trustees of a medical scheme are responsible for the guidance of the scheme and its compliance with its own fit and proper laws,” he says. “The Medical Schemes Act demands public comment and input from the Department of Health about any proposed changes. The CMS must create other mechanisms if it has comments to make.”

SERVICE DELIVERY Monday, 27 July 2015 11h00-11h25: Session Two

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A prescription for access FACILITATOR: Dr. Konji Sebati, Chief Executive Officer | IPASA

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he much debated and talked about issue of rising healthcare costs in South Africa is generally accompanied by finger pointing and the blame game. This is a reflection of poor dialogue between local healthcare service providers and reminds one of the age-old adage: ‘the pot calling the kettle black’.

healthcare systems, pharmacists, the innovative research-based and generic pharmaceutical companies and, our most important stakeholder, the Department of Health – are linked by one goal: to ensure the best, most efficient, effective and high-quality healthcare for all South Africans.

We won’t move beyond the current reality until all healthcare stakeholders can sit around the table and acknowledge that we are all links in the healthcare value chain. Further to that, we need to collaborate to create an ecosystem that is nurturing and sustainable, but which, most importantly, has the patient at its centre.

Finally, we need transformation of the care delivery system on a scale that will generate the cost savings necessary to revitalise it. This will require a myriad of initiatives, many partners and, importantly, empowered patients whose experiences and voices are heard. Patients will not only demand the best innovations, but also drive the way diseases are measured and medical advances are made. This will move patients closer to ‘the true centre of healthcare’.

Ultimately, all healthcare service providers – health practitioners, medical schemes, the public and private

The 17th Annual Southern African Conference dates and venue will be announced soon. For more information please contact us. EMAIL: marketing@bhfglobal.com WEB: www.bhfglobal.com

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MEDICINES AND TECHNOLOGY Monday, 27 July 2015 13h45-14h45: Session Five


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The Finalists 2015 Award Nominees T

he Board of Healthcare Funders (BHF) is recognising and celebrating excellence at its conference this year, with the announcement of the finalists of the first annual Titanium awards.

“It is particularly appropriate to announce the winners of the Titanium awards at this year’s BHF conference,” says Zola Mtshiya, BHF Manager: Marketing, Branding and Communications. “Our theme is ‘Partnering for Success’, and the finalists are leading the way, having formed successful partnerships with the people they serve and the organisations with which they interact.” The Titanium awards recognise excellence in the public and private sectors on the part of medical schemes, administrators, managed healthcare organisations, hospital groups, the pharmaceutical industry, healthcare practitioners and the industry at large. The 10 awards, which are divided into seven categories, are designed to: • Improve the quality of health services; • Create a platform that unites the healthcare industry; • Demonstrate best practice; and • Recognise application of best practice in action – with an emphasis on initiatives that are well rounded, sustainable, holistic and responsible. “The awards are a unique initiative, based on the fact that BHF has a wide footprint across the whole healthcare industry,” explains Mtshiya. “We have hospitals, specialists, pharmacists, doctors, government facilities, medical schemes, managed care companies and administrators that all converge around the Practice Code Numbering System (PCNS). So it is under that umbrella we opened this up to the entire industry,” she says. BHF feels that the Titanium awards’ recognition of excellence will drive standards and service delivery, with benchmarks for exceptional performance leading to a more effective healthcare industry overall in southern Africa.

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CATEGORY 1 Titanium Award for Service to Membership OPEN Medical Schemes BOMaid – Botswana Medical Aid Society Botswana Medical Aid Society, commonly known as ‘BOMaid’, is the oldest and largest open medical aid scheme in Botswana and to date has over 38 000 lives and about 83 000 total lives. BOMaid exists for the sole purpose of giving its members access to private healthcare at affordable contributions and through comprehensive benefit options.

CompCare Wellness Medical Scheme CompCare Wellness provides unique and innovative solutions to ensure our members always receive complete and quality healthcare when crucial treatment is needed, while maintaining affordability of contributions. Registered in 1978, the Scheme has grown by more than 40% over the last three years and its profile has been engineered to support efficient risk distribution. CompCare Wellness Medical Scheme has proved its sustainability, maintaining significant growth and currently covering more than 27 000 beneficiaries through six options.

Titanium Award for Service to Membership CLOSED Medical Schemes Bankmed Registered as a closed scheme under the Medical Schemes Act 131 of 1998, Bankmed was established in 1914 by bankers for bankers. With more than a century of experience in the provision of healthcare insurance, Bankmed has accumulated an unrivalled specialist insight into the management of health in this sector. Bankmed covers more than 100 000 principal members within South Africa’s financial institutions. This translates to providing over 200 000 South Africans with access to quality healthcare services.

Massmart Health Plan Massmart was founded in 1990 and listed on the JSE Limited on 4 July 2000 at R12.50 per share. Massmart employs over 45 000 permanent and flexi-time staff, and achieved annual sales of R78bn for the year ending December 2014. Massmart is the leading retailer of general merchandise, liquor, home improvement equipment/supplies and basic foods.

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CATEGORY 1 [Continued] Titanium Award for Service to Membership CLOSED Medical Schemes The Government Employees Medical Scheme (GEMS) The Government Employees Medical Scheme (GEMS) was registered on 1 January 2005 and actively started enrolling members in January 2006. The necessity for GEMS stemmed from the imperative of Government as employer to protect, improve and support the health and well-being of its workforce in a manner, and at a cost, that is affordable. GEMS serves public service employees exclusively.

Libcare Libcare was established over 50 years ago to provide funded healthcare to the employees and retirees of the Liberty Group and their dependants. Libcare’s tagline and ethos is ‘Libcare Cares’. Libcare forms an integral part of the suite of benefits that provide employees, retirees and their families with essential social protection against the financial shocks related to health issues, loss of income, ageing, etc. Libcare has been a member of the Board of Healthcare Funders for over 20 years. 

CATEGORY 2

Titanium Award for Service Excellence ADMINISTRATORS Universal Healthcare Administrators Not every healthcare management company has that special quality that sets it apart from other companies, that makes it stand out head and shoulders above the rest. But we do. We call it the Universal Factor. It is this unique quality that has helped us perfect the balance between cost, access and excellence of care for nearly four decades.

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CATEGORY 2 [Continued] Titanium Award for Service Excellence MANAGED HEALTHCARE Centre For Diabetes And Endocrinology (CDE) We believe that the Centre for Diabetes and Endocrinology (CDE) epitomises the true value of managed healthcare. The programmes of care that the CDE runs with client medical aid schemes focus on the provision of best practice care for patients with diabetes.

Dental Information Systems (Pty) Ltd DENIS is a Business Unit of EOH Health, which is a division of JSE-listed EOH. The company is proud that it has achieved an AA BEE rating and is a Level 2 contributor.

Performance Health (Pty) Ltd Performance Health (Pty) Ltd is the wholly owned subsidiary of MediKredit Integrated Healthcare Solutions (Pty) Ltd and is an unconditionally accredited managed care organisation.

PPN Managed Care PPN is the first managed care organisation of its kind, specifically centred on the management of optical benefits, in the healthcare arena. Established over 22 years ago we have grown our client base to currently include 22 medical aids covering 2.1 million lives.

Universal Healthcare Administrators Not every healthcare management company has that special quality that sets it apart from other companies, that makes it stand out head and shoulders above the rest. But we do. We call it the Universal Factor. It is this unique quality that has helped us perfect the balance between cost, access and excellence of care for nearly four decades.

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CATEGORY 3 Titanium Award for Health Facilities (Hospitals, Clinics, etc.) PUBLIC SECTOR Witrand Hospital Witrand Hospital, as it is known within the North-West Province, is one of the institutions with a rich history of specialised services dating back to the early 1800s, currently serving as a referral hospital while rendering a comprehensive hospital based mental health and rehabilitation services to other institutions within the province (Total population – 2011 Census: 3 509 952). The hospital is situated in Potchefstroom within the Dr Kenneth Kaunda District. Witrand Specialised Hospital renders level 1, 2 & 3 services.

Potchefstroom Hospital Potchefstroom Hospital is in the North-West Province’s Dr Kenneth Kaunda District, located in the centre of Tlokwe. It is an access point for Tlokwe Sub-district and Ventersdorp Municipality. The population the hospital serves includes that of Ventersdorp. Potchefstroom Hospital was established in 1914 and initially named Kalie De Haas.

Queen Mamohato Memorial Hospital Within a year of opening, the Queen Mamohato Memorial Hospital and filter clinics were listed in 2012 by global professional services firm KPMG as one of the 100 most innovative and inspiring urban infrastructure initiatives in the world. The Queen Mamohato Memorial Hospital (QMMH), named after the Queen mother of the Mountain Kingdom, was officially opened in Botšabelo by his Majesty, King Letsie III of Lesotho, on 1 October 2011.

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CATEGORY 4 Titanium Award for Excellence in Corporate Social Investment Clicks Founded in February 2011, the Clicks Helping Hand Trust is a public benefit organisation that aims to redue the burden on state facilities by extending a ‘helping hand’. It has offered FREE clinical services to mothers and babies since September 2014.

Sanofi – Ikhaya Lethu In 2005 Sanofi South Africa’s senior management team adopted a rural Zulu village in KwaZulu-Natal.

Sanofi – Mental Health Initiative This Sanofi Mental Health Initiative and Patient Access to Care progamme seeks to build leadership capacity in the public mental health sector in South Africa. The express aim is to equip healthcare professionals with the requisite skills to more effectively advocate for their patients.

GEMS Within the Government Employees Medical Scheme (GEMS) a special employee committee is tasked with looking beyond matters related to staff to identify how GEMS can contribute to society at large and to its members. An action plan was developed during 2008 and implemented comprehensively in 2009. The mandate was to promote health and wellness in underprivileged communities by investing time, skills and expertise.

Lilly Through collaboration with Eli Lilly & Company as a part of their generous NCD Partnership Program, Project HOPE, a global NGO whose mission is to improve the quality of life of the world’s most vulnerable people by improving healthcare delivery and building local capacity, is changing the lives of people living with non-communicable diseases in South Africa.

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CATEGORY 4 [Continued] Titanium Award for Excellence in Corporate Social Investment EOH EOH is honoured and humbled to be part of one of the most ambitious health screening projects ever undertaken between government and the private sector, co-ordinated by SABCOHA and implemented by EOH Workplace Health and Wellness and various stakeholders.

PPN Masibonisane The Masibonisane campaign was launched in 2011, realising PPN’s vision of assisting previously disadvantaged children in South Africa by coordinating access to a professional optometric evaluation. Subsequent correction of refractive errors thus enhances their sight and their education.

Aspen Aspen is a home grown South African company established in a two-bedroomed house on the Berea in Durban, 18 years ago. Without losing sight of its humble beginnings, Aspen has grown into a multinational pharmaceutical company headquartered in South Africa with an active presence in over 70 markets and selling its products in over 150 markets. Corporate Social Responsibility (CSR) and contributing towards a sustainable country and continent have been key business imperatives for Aspen since inception and continue to enjoy the same importance as they did when the company was first established. Aspen’s CSR initiatives have in many respects changed the face of South Africa and were instrumental in saving the so called 'lost generation' of HIV-infected youth.

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CATEGORY 5 Titanium Award for Young Achiever Sonja Malan Subsequent to completing her BA (Law) degree, Sonja commenced employment with Nammed medical aid fund in Namibia from 1 July 2009 until 30 April 2013. She was employed as business development officer responsible for all marketing, advertising and fund development strategies/activities under direct leadership and supervision of principal officer, Gert Grobler. During this time she was exposed to all spheres of the Namibian medical aid industry and acquired knowledge, skills and insight on the country’s healthcare industry, its operations and legal requirements. Sonja believes in continuous personal development and during her employment with Nammed she completed a marketing certificate. This allowed her personal growth and a broader understanding of the industry while the acquired skills equipped her with additional marketing abilities. During 2013 she applied for a position as principal officer of Renaissance Health Medical Aid Fund (RHMAF), the third-largest open fund/scheme in Namibia with approximately 13 500 principal members and an estimated 27 000 lives. She was awarded the position at the age of 29 in 2013, becoming the youngest principal officer in Namibian medical/healthcare history (if not in the SADC region), which is a remarkable achievement that recognises her excellent qualities and abilities. During her tenure, the RHMAF experienced exceptional growth over two consecutive years, accompanied by an extreme escalation in claims costs. The fund therefore faced financial challenges. The reserve level (total accumulated funds divided by total contributions) declined below the required 25% reserve benchmark set by the Namibian Financial Institutions Supervisory Authority (NAMFISA) - registrar and Namibian regulator. Addressing this and implementing a turn-around strategy in 2013 was both demanding and challenging, requiring dedication and effort. The fund managed to turn around its financial position in a two-year period (2013-2015) from a 20% audited reserve level in 2013 to 28% (preliminary audit) in 2014. This achievement in itself confirms and displays her knowledge, skills, leadership and management abilities. Since taking up the position, she has established herself as a worthy and key participant in the Namibian healthcare industry. Her involvement at such a young age, consequent on her leadership, dedication, loyalty and passion for the industry and within the RHMAF, have been recognised by all stakeholders. Her attributes therefore merit her nomination as a ‘Young Achiever’, both in Namibia and regionally.

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CATEGORY 5 [Continued] Titanium Award for Young Achiever Dr Lungi Nyathi Lungi has represented Medscheme, Afrocentric, and Aid for AIDS, as well as clients like Sasol and GEMS, at several industry forums including: • International Health Funders Conference in 2011; • International AIDS conferences in 2013 and 2014, as an exhibitor at both of these conferences; • Several South African National Aids Council (SANAC) projects and a SANAC plenary as a special guest; • As a presenter at a public-private partnership project at the Mpumalanga Local AIDS Council; • As an active participant in the Gert Sibande Business Collaboration; and • As a speaker/delegate at several specialist forums. In all public spheres where Lungi is requested to represent an organisation, she is a fantastic brand ambassador for the organisation in question, finding synergies and collaborations between industry players for the benefit of all. In her role as director of Aid for AIDS, she showed great leadership ability in the way she kept clients and staff engaged and devoted to the brand, especially during the transition phase of the organisation. Apart from her already demanding roles at Medscheme, leading both the GEMS managed care business unit and AfA simultaneously, Lungi was also involved in several Medscheme exco committees (employment equity forums; risk committee; think tank/strategy; team leader in leadership development programme for leaders below exco level). She also represented Afrocentric at various thought leadership and CSI events. It was partly because of her leadership role in Medscheme and in the industry as a whole that Insight asked Lungi to present at the CMS Indaba and OSSA conference, both of which were well received by the industry. She is involved in provider client engagements at Insight. Lungi is a great ambassador for healthcare and is passionate about the South African health system.

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CATEGORY 6 Titanium Lifetime Achievement Award Professor Praneet Valodia My journey towards this ‘lifetime achievement award’ began in 1976, my matric year. This was the year of the uprising that is commemorated on 16 June every year in South Africa. During this time black schools were non-functional because their teachers were arrested and imprisoned. Because of this, I only attended school for six months that year and prepared for the final matric examination using self-study methods. Unfortunately, during this period, students were unable to attend school because it was closed; neither were they allowed to study in groups because these were regarded as illegal gatherings. In an act of selflessness, I secretly arranged for my fellow matric scholars to enter the school premises at night where I taught them mathematics and physical science. This marked the beginning of my journey to support others to achieve their life goals, despite any hurdles they might face. After completing high school in 1976, securing a place at a university was a challenge. As an Indian the only university that I could freely attend was the University of Durban-Westville, which was the only designated Indian university in South Africa. However, under protest and with a special permit, I was permitted to attend the University of the Western Cape (UWC). After completing my first year of a BSc degree, I competed with about 700 applicants (mostly graduates) and fortunately was accepted for one of only 15 seats in second-year dentistry at the UWC. Interestingly, at that time an additional five seats were allocated for students from the University of Durban-Westville to study dentistry at UWC. I regret that I wasted this seat and deprived someone else of it as after a year, I decided dentistry was not for me and moved on to study pharmacy with the intention of pursuing a career in pharmacology. My educational challenges continued during my studies for a master’s degree. In 1983, I became the first full-time student in pharmacology at UWC. After enrolling, I realised that the university had minimal equipment and accordingly funding had to be sourced for the purchase thereof, e.g. a liquid scintillation counter to measure radioactivity. As a student I was involved in arranging for a laboratory to be certified for radioactive work before I could perform my studies. However, against all odds and through continued perseverance I achieved a master’s degree in 1989 which was of the highest standard as reflected herein. I obtained it at a time when few black people achieved such a qualification and the applause from the audience at my graduation ceremony still remains vivid in my mind. I then pursued a PhD on a full-time basis. In order to pursue my passion for postgraduate research, I sacrificed six years of full-time employment (for master’s and PhD studies) to achieve this. I was greatly disadvantaged in terms of career progression by attending a historically disadvantaged institution. However, the lessons and life skills learnt at that institution made me determined to grow from strength to strength. Although my quest to gain an education of the highest standard was not an easy path, I pursued my ambition with conviction. The success that I achieved should be viewed against the background I have sketched. I bring a unique perspective to the managed health care environment. The combination of my in-depth research and clinical experiences has allowed proper design, evaluation of projects and good decisions to be made, based on available information. I have been in the forefront of innovation in the managed health care industry in South Africa. .

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CATEGORY 6 [Continued] Titanium Lifetime Achievement Award Dr Laubi Walters – Medscheme Medical doctor, professor of clinical pharmacology, past director of primary healthcare at the Department of Health, author, innovator and instrumental architect of managed healthcare initiatives in this country, as well as esteemed teacher and mentor, Dr Laubi Walters has made a truly significant and meaningful contribution to the healthcare sector in South Africa. At the age of 70, Dr Walters shows no signs of slowing down and still plays an active role in the healthcare space, co-ordinating and driving the strategic advisory process at Medscheme, South Africa’s largest health risk management services provider and second-largest medical aid administrator. As group functional specialist and, previously, executive manager: strategic support, Dr Walters steers health risk management, an area for which Medscheme is widely recognised for innovation and industry firsts. Dr Walters’ 20 years of service to Medscheme have seen him drive pioneering industry developments such as the Chronic Medicine Management programme, one of the first chronic drug utilisation programmes in South Africa, Aid for AIDS, the first HIV disease management programme and the internationally recognised Beneficiary Risk Management programme, which focuses holistically on high-risk beneficiaries – all in order to ensure the sustainability of private healthcare and improve the quality of healthcare funding. Evidence of this is the lower than expected healthcare inflation of our client schemes when compared with the industry norm. Dr Walters continues to drive managed care strategies in an attempt to further control escalating costs while ensuring highquality healthcare for scheme members. A key current focus is enhancing population health and a drive towards greater primary healthcare within our client schemes – in line with NHI objectives.

Professor Jan van der Merwe - Universal Healthcare In 2009, Jan joined Universal Healthcare (Pty) Ltd as a joint founder member and non-executive chairman. Together with business partners Dr Johan Pretorius (CO) and Catharina Sevillano-Barredo (CFO), Universal acquired Status Medical Aid Administrators (Pty) Ltd, an accredited medical scheme administrator, and QA Care Plus (Pty) Ltd, an accredited managed care organisation. Universal is a well-established healthcare organisation, with a long-standing track record spanning more than four decades, and provides services within the medical schemes environment, corporate and occupational health, wellness services, INSETA accredited training and related health insurance services. Under the chairmanship of Jan, Universal has grown its client base from five medical scheme clients to 13, and increased the total number of lives under its administration and managed care services combined from 85 000 to some two million. Jan’s influence at Universal, arguably part of the reason for the group’s success, stems from his philosophy of ‘evidencebased care with a caring approach’. He still serves as chairman of the board of directors of Universal.

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CATEGORY 8 Titanium Award for Advisory Services Excellence KPMG Services The next half-century will witness a more holistic approach to improving health, as systems move toward preventative as well as curative care. Improving access to and equity within health systems requires multisectoral interventions. It also means engaging the cooperation and participation of all stakeholders, including national and provincial governments, the private sector, and local communities. The international community and regional development institutions also have a role to play in assisting to build the capacity of national health systems, as well as in mobilising financial support.

Alexander Forbes Alexander Forbes Group is a leading provider of financial and risk services internationally. The company was founded in South Africa in 1935 and is one of the top ten largest providers of risk and benefit services in the world. A significant network of subsidiaries and partners ensure we provide an outstanding level of service to our customers internationally. Alexander Forbes’ clients include small, medium and large organisations, specialist groups, funds and individuals. We focus on our customers to deliver an efficient and innovative service by empowered people wherever we operate.

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16 Annual Conference Sponsors & Exhibitors

I6 The

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Annual Cape Town BHF Southern 26-29.07.15 African Conference Healthcare accountability “A luta Continua” Partnering for success

South Africa’s undisputed leader in providing modern ICT business solutions to the insurance sector – 2Cana Solutions – brings broad experience and deep technical expertise to clients in Healthcare funding / Medical Aid Administration, risk management, life and general / short-term insurance. Clients include Private Health Administrators, TopMed Medical Scheme, Momentum Health, Hollard Insurance Company, Zurich Financial Services, Old Mutual, MiWay Insurance, Altfin Health Insurance. The Health information Platform (HiP) is a modern, innovative, real-time, fully integrated, cloud enabled solution for efficient and reliable administration of medical schemes incorporating policy and claim administration, managed care, disease management and more. The HiP Solution enables you to dynamically and rapidly adapt to the changing market conditions and compliance requirements with innovative products and superior service levels. 2Cana Solutions currently supports more than 20 insurers in 15 countries across 4 continents with over 740,000 policy holders and a total premium yield of more than US$880 million (over R10bn). Come and visit us at BHF 2015 in Cape Town In to find out more.

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Allegra’s software solutions are built around the philosophy of TOTAL PATIENT CARE. Allegra provides one integrated effective customised business process solution that enables the healthcare provider to adapt to current and future customer care challenges. The Allegra solution allows integration between healthcare stakeholders such as medical aids, insurance companies and healthcare providers. This results in the opportunity of one shared patient health record across the Southern African healthcare network for those who are a part of the Allegra Healthcare community. The Allegra Healthcare Management product suite, that will assist the healthcare community in this task of TOTAL PATIENT CARE, consists of the following solutions: Allegra Connect provides seamless clinical, biometric, pharmaceutical and financial data interchange. WellScreen is a preventative health risk assessment solution; ClinicPro is a primary healthcare patient record keeping solution; CarePro is a retail pharmacy management solution and the Allegra eCademy offers training to healthcare professionals. Allegra and its partners aim to create a healthier society through the provision of Integrated Healthcare Business Solutions.

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At AstraZeneca we believe the best way we can help patients is to focus on breakthrough science in order to uncover disease mechanisms and develop novel, targeted therapies that interact with them. We invest in distinctive science in three main therapy areas where we believe we can make the most meaningful difference to patients: oncology; cardiovascular and metabolic disease; and respiratory, inflammation and autoimmunity. In Africa AstraZeneca has been successful in positively impacting communities by introducing products, providing patient support programmes and strengthening healthcare capabilities. Our Phakamisa partnership brings together organisations to help raise breast cancer awareness, increase early diagnosis, and improve access to treatment and effective support networks. AstraZeneca’s Healthy Heart Africa programme is a sustainable programme that aims to improve the lives of hypertensive patients across Africa by increasing awareness of the symptoms and risks of hypertension. Through leading in science, we are confident that we can transform the lives of patients around the world.

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The Healthcare Forensic Management Unit (HFMU) was formed to ensure a unified approach in the reduction of fraud, waste and abuse within the medical schemes environment. The platform is used to share information relating to behaviour and modus operandi to assist its members in the detection, response and prevention of fraud, waste and abuse.

As a pioneer in network provider management CareCross Health, a member of MMI Holdings offers sustainable healthcare solutions through its extensive networks of General Practitioners, Specialists and other healthcare providers throughout Southern Africa. Through these networks CareCross ensures access to healthcare services from primary care to specialised and in-hospital care.

The HFMU has recently developed a set of standards with key principles to change the lack of policing of fraud as an industry. The HFMU has already made a difference in that they have identified that the majority of those committing fraud are not hardened criminals but commit fraud because the environment is conducive. It is estimated that the industry has saved hundreds of millions as a result of the efforts of the HFMU.

CareWorks is a South African managed care company that specialises in HIV disease management, HIV /AIDS prevention and employee wellness services.

For more information, please visit www.bhfglobal.com or call Chelesile Mtshiya on 011 537 0244 or email hfmu@bhfghlobal.com.

We deliver superb treatment adherence outcomes through optimising patient experience with data driven disease management processes.

H E A LT H C A R E f U N D E R S

CareWorks is a level 1 BEE contributor.

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Voted South Africa’s leading specialist health and beauty store for the past four years, Clicks is the country’s largest retail pharmacy chain with a national footprint comprising over 340 in-store dispensaries and over 150 instore clinics, and is devoted to making professional primary healthcare services more accessible to all. Clicks’ compliant and transparent network with monthly reporting, no hidden costs and administration fees and opportunities to collaborate on marketing initiatives is the reason that we are a preferred service provider for most medical schemes. Speak to our dedicated key accounts team to find out how we can provide outstanding value to your scheme and your members.

The cost impact of the high rate of C-sections in South Africa and the exponential increase in HIV-related pregnancies in the past 24 months have medical schemes concerned. How are you addressing your care of the young family-to-be? Identifying risky pregnancies earlier, ongoing pregnancy education, regular interaction and enlisting medical support for mothers-to-be are elements that assist in cost reduction for schemes and facilitate a better birthing outcome. The longer medical schemes continue to pay for elective C-sections, the more the practice continues. It’s time to rewrite benefits and support holistic approaches to natural childbirth! For over 14 years, DLA Group has provided comprehensive, schemecustomised maternity and toddler healthcare programmes in South Africa and Botswana. Each year enhancements are added, through various education and communication platforms to ensure your programme is uniquely tailored to young families. Contact Deryse on +27 11 704 4646 or e-mail deryse@dlagroup.co.za

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EOH is one of the largest ICT service providers in Africa and a leader in technology and business services. One of our key business areas Business Process Outsourcing (BPO) currently serves over 2,5 million people throughout Africa with a range of consulting, benefit risk management, ICT, workplace health, learning and development, legal and Human Capital competencies. EOH Health, a division of EOH BPO, specialises in providing employers, medical schemes and administrators with a variety of services including wearable and medical device technologies, electronic patient records, hospital, dental and primary care benefit risk management and network services. It also offers a comprehensive range of workplace health, wellness and intermediary services. We’re connected to an extensive provider network across Africa, allowing us to offer an essential risk management resource to local and international insurance carriers operating across the continent. With this range of competencies, and our dedicated public and private sector consultancies, EOH Health is also well placed to participate in public private collaborative initiatives that strengthen the country’s healthcare delivery system and improve overall resource utilisation.

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The Day Hospital Association represents registered day hospitals throughout South Africa. Day hospitals offer distinct quality, comfort and cost advantages to patients, medical practitioners and medical funders, being designed, equipped and staffed for specific specialities. Some 60% of surgical procedures can be safely performed in a day hospital.

We aspire to relentlessly improve customer service and operational excellence to ensure Firstcare Courier Pharmacy’s position as one of the leading providers of HIV medication in South Africa. Our client centric call centre’s prime objective is to promote compliance and an uninterrupted treatment plan. We will address patients’ unmet needs and provide them with access and assistance in healthcare wherever and whenever they may need it. We believe we can unlock additional value for patients without compromising their integrity and confidentiality.

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Health24, South Africa’s leading digital health company, has recently launched an upgraded version of YourHealth, its bespoke employee wellness and disease management platform. Packed with up-to-date content, eTutorials and interactive selfassessment tools, YourHealth is a powerful tool to assist medical schemes, managed care organisations, pharmaceuticals and corporates with change-oriented communication to its patients, members and employees. The white-label closed platform will feature your logo and corporate colours. Included are: • 12-week eTutorials on chronic conditions, complete with comprehension tests • Comprehensive A-Z databases of diseases, symptoms, medication, tests & procedures and wellness content • Weekly diet & fitness programmes with tracking graphs • Wearables integration • Quizzes, calculators and risk assessment questionnaires • An innovative point-based rewards system • And many more powerful instruments Please visit our exhibition stand. We promise to enthral!

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Helios IT Solutions (Pty) Limited was established in July of 2012 as an independent Information and Communication Technology (ICT) company within the AfroCentric Health Group. Helios ITS specialises in delivering inno vative technology solutions and creating efficiencies for its clients. Technology is an enabler to creating the ideal environment in which the business thrives and remains sustainable. At the core of Helios’ strategy is a commitment to align with each client’s strategic objectives in order to deliver solutions that meet and exceed expectations. FICO Insurance Fraud Manager FICO IFM is a robust solution that detects fraud, waste and abuse at claim and provider levels. It uses an automated data driven method that pulls proven, advanced analytic models and workflows that are integrated in purpose-built software to rapidly and effectively enhance a scheme’s ability to identify and address existing and emerging losses. The solution can detect up to 47% of fraud, waste and abuse before or after payment of claims.


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The Health Professions Council of South Africa is a statutory body and is committed to protecting the public and guiding the professions.

Insight Actuaries & Consultants have the expertise to ensure we gain a deep understanding of the issues faced by our clients.

The HPCSA’s vision is to enhance the quality of health by developing strategic policy frameworks for effective coordination and guidance of 12 Professional Boards.

Over time we have developed a deep understanding of the complexities in healthcare systems and insurance markets and have developed the tools and capabilities to address these complexities.

The mission of the HPCSA is quality healthcare standards for all. The Council is mandated to regulate the health professions in the country in aspects pertaining to registration, education and training, professional conduct and ethical behaviour, ensuring continuing professional development, and fostering compliance with healthcare standards. Tel: 012 338 9300/1 Fax: 012 328 5120 Web: www.hpcsa.co.za Email: info@hpcsa.co.za and servicedelivery@hpcsa.co.za

Our advice is distilled to succinct, understandable and relevant recommendations that speak directly to our clients’ needs, operating across the health, insurance and employer sectors. Our business intelligence solutions enable clients to successfully manage and navigate their data. Insight’s core purpose is to assist our clients to identify and mitigate their risks; and to reveal and take advantage of key opportunities. By leveraging our hand-picked team, unique expertise and desire to innovate, we are able to help our clients realise their potential and achieve excellence.

Iso Leso is a national provider network of optometrists that administers optical benefits for over 1 200 000 beneficiaries in South Africa. The administration office and Call Centre is based in Northcliff, Johannesburg and has ample capacity and experience to deliver all the requirements needed by any healthcare funder. The Iso Leso Practitioner Enhancement Programme (PEP) is the most advanced provider accreditation system in Optometric Management. This is designed to provide audited superior clinical and product delivery via an enhanced network. This unique approach is designed to improve the Quality Outcomes for your members. Our Fraud Management is industry leading as it includes comprehensive individual provider analysis by Insight Actuaries. Once you make the choice to switch to Iso Leso as your optometric partner, you will be assured of a provider relationship that promotes successful delivery, sophisticated management structures and a holistic approach to optical benefits for funder/provider relationships that ensures stability in the market.

Web: www.insight.co.za For more information call us on 011-340-9300 or send an email to janie@ isoleso.co.za.

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Investment Solutions is South Africa’s leading provider of multi-managed investment-related services. Min 45mm wide

Started in 1997, the company now has R320 billion in assets under stewardship (at 31 March 2015). It provides a range of investment services to institutional and private investors. There are 40 000 individuals invested in the company’s discretionary range of portfolios and 2 000 institutional clients have entrusted it with their pension and retirement savings. Investment Solutions has a proven track record in managing specialist Medical Schemes Act-compliant portfolios, and in constructing assetliability models to assist asset consultants in managing fund objectives for medical and pension funds. Vision: to protect and grow the wealth of clients by providing world-class investment-management services to help them achieve investment success. Mission: to continue to be a successful investment-management and solutions organisation that helps clients achieve certainty, simplicity, clarity and peace of mind.

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KPMG has an excellent track record of successful engagements and strong relationships in the health sector. Its dedicated health team has delivered more than 100 projects successfully over the last 16 years, working with central and provincial governments, private-sector and public hospitals, large global private equity houses and a range of payers. The company has an in-depth understanding of the local context and issues facing the health sector. KPMG’s multidisciplinary South African healthcare team can support its clients with a broad range of challenges. Its competencies range across advisory, audit, tax and legal arenas. It has expertise and a strong track record in various roles, including: support through the whole transaction process, developing organisational and clinical strategy, working on performance improvement projects and undertaking both internal and external audits. The local team is backed by global expertise. They have world-class experience and an unparalleled understanding of all aspects of the health sector. KPMG’s global network of health teams regularly share experience, thought leadership and best practice.

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Liberty Health provides industry leading pan-African healthcare solutions, servicing over 1 million lives across 15 African countries, including South Africa. Its reputation for providing advanced IT healthcare systems, comprehensive disease management, administration and insurance solutions has made Liberty Health a trusted brand throughout the continent.


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With its proud 74-year track record as leaders in healthcare innovation in South Africa and acknowledged global expertise, MediKredit has carved a niche for itself in the field of medicine management, provider network management and real-time connectivity. At present the locally developed, flexible internationally patented IT systems of MediKredit touch more than 7 million lives. The fully integrated end-to-end MediKredit service is used by more than 2900 pharmacies, 187 private hospitals, 5500 doctor practices, 80 medical schemes as well as 121 public sector hospitals in five provinces. As the only electronic benefit management company with its own switch MediKredit can guarantee its clients 99.9% real time provider connectivity and flexible information technology systems that cross boundaries with the aid of smart switching. MediKredit affords its clients customised technological solutions with a uniquely patented rule stacking capability. In 2014, MediKredit received and processed more than R12.4 billion general healthcare claims saving customers close on R496 million through its accredited electronic managed care interventions. On the medicine benefit front more than R1.6 billion worth of claims were processed resulting in a R270 million saving for clients.

Medipost Pharmacy, South Africa’s first and leading courier pharmacy is an affordable and convenient chronic, HIV and oncology medication provider which dispenses right to the doorstep of chronic medication users. At 24 years old, Medipost has grown and maintained an unparalleled track record and currently an average of 400 000 prescriptions are dispensed monthly. We have a unique in-house developed software system that can be adapted to accommodate scheme or client requirements. Furthermore we have comprehensive, factual, customised yet simplistic and relevance-based reporting capabilities. A superior call centre infrastructure integrated with capabilities to facilitate clear communication between the partners and also enhances the scheme and member experience. As part of our patient-centric service offering, we provide personal telephonic clinical consultations through our friendly and qualified pharmacists and pharmacists’ assistants. Delivery is free of charge to your destination of choice. Hereby please accept your personal invitation for a guided tour through our Head Office facility based in Gezina Pretoria. Contact us on email at rentia@medipost.co.za or call + 27 12 426 4007. www.medipost.co.za BOARD

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Medscheme is a wholly owned subsidiary of AfroCentric Health Limited and part of JSE listed AfroCentric Investment Corporation. The company is the largest health risk management services provider and among the leading medical scheme administrators in South Africa with over three million lives under management. Its clients include two of the country’s largest open medical schemes, Bonitas and Fedhealth, as well as several closed schemes. Medscheme has over four decades of experience in the healthcare industry and currently employs 3 200 employees. Medscheme’s vision is ‘Creating a World of Sustainable Healthcare’. Medscheme’s Health Risk Management Division received the Starfield Award from Johns Hopkins University in the United States in April 2014. The Starfield Award acknowledges the organisation that makes the best use of the university’s ACG® System which improves both accuracy and fairness in evaluating provider performance, identifying patients at high risk, forecasting healthcare utilisation and setting equitable payment rates. Medscheme received the award in recognition of the project entitled “A comprehensive care management programme focused on emerging and high risk individuals”. Medscheme was awarded 14 Professional Management Reviews (PMR) awards for excellence in medical scheme administration in 2014.

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MIP is one of the few software companies globally to deliver solutions across all the financial service verticals. Our systems are diversified to accommodate the specialised administration needs of medical aids; employee benefits; life insurance; lending; collective investments; wealth management and short-term maintenance and warranty. Also unique to MIP is our billing model. There is no upfront capital outlay for MIP's financial administration systems, and no hidden billing. Instead, we share your risk while helping you to grow your business. By creating partnerships with our clients, your success is in our best interest, which is why some companies have been with MIP for over 21 years. Because MIP understands the business of financial administration, we offer more than technical knowledge to our clients. Our services include over two decades of experience, ingenuity, perception and a distinctive way of dealing with your individual needs. All our administrative systems come with fully integrated workflow, document management, standard communications interfaces, and integrated mobile apps. Our roots in emerging markets give us the advantage of delivering cost-effective solutions that meet the current financial conditions across the globe.

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myCARE Health Solutions (Pty) Ltd is an innovative and dynamic majority female black-owned managed healthcare organisation established in 2012.

At Old Mutual Wealth, we believe our clients’ long-term goals shouldn’t come at the cost of sacrificing what they enjoy doing today.

As an accredited managed healthcare organisation myCARE renders chronic medicine- and disease management services, and offers a fully-fledged clearinghouse facility.

That’s why we help clients determine how much is enough – for now, for life and their legacy.

Its disease management services focus on: • Asthma • Coronary heart disease • Diabetes mellitus • HIV • Hyperlipidaemia • Hypertension The myCARE clearinghouse specialises in: • Medicine claims • Pathology claims • Radiology claims As a customer-driven organisation, myCARE aims to deliver turnkey solutions to its clients. myCARE enhances your business through the provision of committed, transparent and uncompromising service. myCARE – your partner in healthcare Web: www.mycaresolutions.co.za.

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As part our fully integrated offering, Treasury and Advisory Services provide medical scheme trustees with an investment consulting service, using a single point of engagement. We build long-term partnerships and gain a thorough understanding of your medical scheme’s unique needs and circumstances. Our highly qualified and experienced team then ensures that trustees receive the best advice and service.


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C O N F E R E N C E S P ONSORS

“I haven’t seen you for ages, how are you doing?” “Great thanks, we’ve just been so busy”. Isn’t this one of the most common things we say these days? Time is precious and despite all our technological inventions to make life easy, people are just getting busier. With this in mind, the last thing you want your members to waste their precious time doing is queuing in a pharmacy. That’s where we step in. At Optipharm we know that living a healthy life is about more than just getting the right medicine. So skip the pharmacy visit and make time for that cup of coffee with someone special because life is too short to stand in queues. Optipharm is a preferred pharmacy provider of chronic medicines to the majority of Medical Schemes in South Africa and has been “dispensing health with care” door to door countrywide for more than a decade. Contact us today for your dose of time-saving care! Customer Care Centre: 0860 90 60 90 Email: info@optipharm.co.za Web: www.optipharm.co.za

Private Health Administrators (PHA) is a fully independent managed care and medical scheme administrator. PHA was established more than 20 years ago and currently provides administration services to a number of open and restricted medical schemes. PHA has successfully developed and implemented a concept known as “Demand Management” using our experience in the healthcare industry as well as the clinical knowledge and insights gained. The Demand Management concept adds to the underlying PHA business model by creating a unique member informed and clinically appropriate consumer driven healthcare delivery approach ensuring a high level of patient advocacy.

FACT Excellent service record for the last 22 years as verified by HULBRIT FACT The most sophisticated and effective fraud controls FACT The most effective basic benefit design – so good that it is now being adopted by competitors. FACT New innovative benefit improvements that competitors don’t have. FACT Cost effective optical and cataract management. FACT If you haven’t asked us to quote you may be missing out.

This approach is implemented through our nurse-based member interaction programme, which is supported by our centralised health risk management system. This identifies and targets members with the highest burden of disease and greatest need for intervention, who present the highest potential risk to the scheme and employer. This concept is exceptionally useful in a corporate environment where the opportunity to integrate this approach with HR strategies, corporate occupational and primary health offerings ensures that the synergies of an organisational health strategy are realised and issues such as absenteeism addressed.

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Patient Focus Africa – leaders in supplying innovative, cutting edge technology, “Point of Care” equipment and consumables.

Engaging the future – with innovative mobile technology – to meet the needs of the employed uninsured market.

Long term partnerships with global companies – long term customers – the preferred supplier to the World Health Organisation.

Prior has re-invented health delivery, for a time such as this, to launch our unique Mobile Health voucher product.

Always focusing on the patient, ensuring we provide the best products at the best price

Low cost of entry, and simplicity are the hallmark of this amazing comprehensive, authentic solution – for access to health – crafted for a target market that knows how to use cell phones! Web based portal provides ease of registration for: brokers, employers, health practitioners, our major retail store outlets nationally, etc – for all participants to gain access to using our Mobile Health vouchers, which can be redeemed via IPAF family practitioners. System also provides informative activity reports for all parties, real time live - 24/7. Full process of employer voucher purchases, issues to staff, broker fees, redemption by doctor – and payments to ALL Parties, fully automated via our web portal. View our interactive web portal at www.priormobile.co.za Healthcare for everyone made simple …

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Rx Health (Pty) Ltd is a registered managed healthcare organisation that is accredited with the Council for Medical Schemes. It has been providing integrated health risk and clinical management services since 2006. It is accredited to assist medical schemes to attain clinical and financial outcomes by properly and efficiently assessing and managing their risk, and ensuring the cost-effective management of benefits. Patients receive a standardised and coordinated set of evidence-based interventions, and have access to a client-friendly authorisation centre with consultants who are equipped to provide individualised personal support. Rx Health operates a days a year call centre with clinically qualified driven personnel who what they do.

24 hour, 365 that is staffed and customer take pride in

Rx Health is accredited to render healthcare management services: - Hospital benefit management services - Disease management - Pharmaceutical benefit management services Contact us: (012) 845 0000 info@rxhealth.co.za


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C O N F E R E N C E S P ONSORS

The South African Medical Association (SAMA) is an independent, non-profit, professional association for over 17 000 medical practitioners, making it the largest organisation of its kind in the country. Our mission is: • To empower doctors to bring health to the nation • To represent doctors with authority and credibility in all matters concerning their interests in the healthcare environment • To promote the integrity and image of the medical profession • To develop medical leadership and skills • To promote medical education, research and academic excellence • To encourage involvement in health promotion and education • To provide doctors with knowledge relevant to the demands of medical practice • To influence the healthcare environment to meet the needs and expectations of the community by promoting improvements to health reform and policy Junior Doctors Association of South Africa

SADAG’s Speaking Books are truly a cost effective “edutainment tool”, giving people access to critical, life-saving information they never dreamed of having access to previously. Each book actually speaks to people in their own language, often through the voice of a local celebrity, arming individuals with important information while also empowering communities to live a better life. Today, companies and organisations simply do not have the resources or the right tools to communicate effectively with illiterate populations. Traditional tools such as pamphlets and brochures are useless to those who cannot read and community workers are too few and far between to reach large populations. We therefore created a ‘one-stop shop’ tool to help organisations overcome the barriers presented by illiteracy. Our mission is simple: We exist to help organisations reach communities that previously seemed unreachable, by delivering critical messages that empower, educate and save lives.

Sanlam has a way about it… a determination and resoluteness, supported by a legacy of ‘safe hands’. Ours is a rollup-your-sleeves readiness, pragmatic approach to providing client-focused solutions. As managed healthcare provider and medical scheme administrator, our clients and members enjoy easy access to information, regular updates, as well as Sanlam’s vast knowledge in wealth and health management underpinned by a wellstructured rewards programme. We proudly provide the following services to add value to your scheme: • Distribution and new member administration • Contribution and claim management • Scheme marketing • Governance and compliance management • Financial and actuarial management • Corporate wellness programmes. Our investment solutions for medical schemes include two funds that are Regulation 30 compliant: • SIM Medical Aid Domestic Absolute Return Fund • SIM Enhanced Cash Medical Fund Continuous recognition of our investment credentials is testimony to the fact that you can trust us with the prudent investment of your scheme’s funds. We simply call it: The Sanlam Way

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As the fourth largest administrator in the industry, Strata’s innovative solutions are underpinned by vast experience in developing systems and services to suit the varied requirements of medical schemes – whether individualised or as a complete, integrated solution. Our commitment to excellent service is demonstrated through a focus on the voice of the customer, accurate administration and empathetic customer service. This makes Strata a trusted partner offering innovation and value through solutions such as custommade smartphone applications, and an online wellness programme promoting a healthy lifestyle and offering tangible value in every life stage while seamlessly integrating with the medical scheme benefit offering. Strata is committed to an uncompromising adherence to the principles of good governance and the practice of fairness, openness, integrity and accountability in all dealings with our stakeholders. Strata has extensive legal, compliance and organisational secretariat experience. We arrange and manage boards of trustees’ meetings, directors’ meetings and annual general meetings for clients, offering a user-friendly, secure online voting system that allows eligible members to vote and get confirmation of their voting in a few minutes. This system can be adapted to suit clients’ needs.

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Transpharm (Pty) Ltd is the pharmaceutical distributor and wholesaler of the Shoprite Group. Our vision and mission is to become the biggest pharmaceutical wholesaler in South Africa, and this commitment is evident in the quality of our service delivery and offerings. - We offer an extensive range of frontshop items as well as wide hospital and ethical ranges, and have a dedicated surgical division serving more than seven thousand clients ranging from doctors, pharmacies and hospitals. - Transpharm offers FREE DELIVERIES to all clients with NO MINIMUM ORDER QUANTITY - Deliveries twice daily in all major metros of Gauteng and Western Cape - Overnight courier deliveries to all outlying areas - Great savings to our clients through our weekly and monthly promotions. For more information please contact our client service team on: Gauteng: 012 377 9000 W. Cape: 021 929 2120 Or visit www.transpharm.co.za

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Not every healthcare management company has that special quality that sets it apart from others, and which makes it stand out head and shoulders above the rest. We at Universal Healthcare call it the Universal FACTOR, and in our vocabulary this means, the difference between being merely good and positively excellent. Whether it be corporate health services, healthcare administration or managed care, it is this unique quality that has helped us perfect the balance between cost, access and excellence of care for over four decades. With 13 medical schemes and healthcare funds under our management, Universal Healthcare is able to cater to the diverse healthcare needs of around two million individuals whose lives we touch on a daily basis. By paying close attention to every aspect of the healthcare delivery chain, we are able to offer unparalleled healthcare funding solutions to medical schemes, employer groups, members and providers. We provide our clients with a Universal Solution by putting them at the centre of our universe.


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C ON F E R E N C E S P O N S O R S

2015 ANNUAL CONFERENCE

Conference Theme Healthcare Accountability: UDoTest empowers people in the area of disease prevention and screening through the use of technology. Our FDA and CE approved tests, along with our self-collection service, make screening easy and reduce future medical claims. UDoTests are available online, from pharmacies, doctors, and wellness days. Web: www.udotest.com

The challenge A rapid increase in chronic conditions fuelled by lifestyle choices necessitates an increased focus on preventative strategies to counteract the negative effects on disease profiles and – most importantly – organisational productivity. The active participation in a Personal Health Risk Assessment as well as other preventative screenings is a starting point to create awareness amongst participants of their own health status. Prevention is better than cure! Wellness Odyssey conducts real-time clinically based, preventative Personal Health Risk Assessments that contribute to healthcare cost reduction in the short and long term. Our efficient onsite participant-centric experience benefits both the funder of care and the patient. Our customisable rules-based referral platform identifies and refers participants to their designated managed care provider for individual disease management interventions. The population risk profile quantifies risk factors relevant to the specific population, which can then be addressed through population-based preventative interventions.

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Partnering for Success

CPD Accreditations 10 Ethics Points 6 Clinical Points

Conference Objectives Coordinate the industry in developing a roadmap for a healthcare system for the next generation to meet growing demand for high-quality healthcare.


1 Represent Member Interests

Lobbying and advocating policy position on behalf of our members Assist members with regulatory compliance Provide legal advice to membership on industry issues Assist in containing healthcare costs Identify and monitor trends impacting our members Protect the image of the industry

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2 Create Platforms for Member Engagement

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Promote unity and collaboration by creating platforms that enable our members to engage with BHF and participate in industry issues Create networking opportunities Engage and develop relationships with key stakeholders

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3 Develop Industry Standards

Promote best practice in the healthcare funding industry Promote healthcare quality Identify and recognise key role players in the industry

4 Facilitate Education and Training

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Provide stewardship and facilitate thought leadership exchange on industry issues Enhance skills and knowledge within our membership Provide guidance Progress tracking reports on industry issues Promote stakeholder, consumer awareness and medical scheme member education

5 Transformation through Development

Identify opportunities to drive transformation in the industry Graduate programme development

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Provide and Identify Opportunities Profile our members and our industry

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R E G I O N A L UPDATE

BOTSWANA

Advancing access to healthcare in Botswana Botswana continues to do well in respect of advancing access to healthcare. The country maintains a pluralistic healthcare system with the public sector being the predominant provider (83%) of services. The current situation and recent milestones

receiving earlier treatment.

About 95% of the population lives within 15 km of a health facility. Early childhood immunisation coverage above 90% has been maintained.

The country has maintained its commitment to the prevention of mother-to-child transmission of HIV, putting the nation on track to achieving a target of less than 1% transmission by 2015. To date, about 30% of the eligible population has taken advantage of the safe male circumcision programme.

The availability of medicines has improved to about 88% across all public facilities. Government has rolled out an HPV vaccine and continues to increase access to early cervical cancer screening and treatment. In addition, government has invested in revolutionary technology for accelerated confirmation of diagnosis of tuberculosis. While ARV therapy coverage has been maintained at above 95%, the CD4 threshold for initiating therapy has been increased from 250 to 350, resulting in individuals

Key health indicators Life expectancy is estimated at 68 years with crude birth and death rates per 1000 being 25.7 and 12.7, respectively (CSO 2014). Both infant mortality rates and maternal mortality ratios continue to remain a concern at 17 per 1000 live births and 148 per 100 000 live births, respectively (CSO 2014). While HIV prevalence BOARD

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rose to 18.5% (BAIS 2013), the incidence dropped to 1.35%. Tuberculosis remains a challenge despite a reduction in notification rates and improved treatment outcomes, and the incidence of malaria has dropped to 0.23%. In view of this achievement, the country is targeting elimination of malaria by 2018. The prevalence of non-communicable diseases (NCDs) is on the rise and these conditions are estimated to account for approximately 35% of all deaths nationwide.

Challenges At the moment, the country is going through a dual epidemic of both communicable diseases and NCDs. Through the STEPS survey, the Ministry of Health (MOH) H E A LT H C A R E F U N D E R S

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aims to get a better measure of the growing challenge of NCDs. Other challenges that continue to face the public health system are shortage of skilled manpower, service delivery and performance challenges, weak supply chain management systems, weak health information management systems and the declining capability of the government to fund health services and key programmes.

Private healthcare The private sector remains relatively small with nine medical schemes, about 400 independent medical practitioners and two main private hospitals catering for approximately 350 000 lives. Key industry challenges continue to be a slowly SOUTHERN AFRICA

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R E GIO NAL UPDAT E

which identifies priority areas to be addressed going forward to 2020. Key to this plan is an Essential Health Services Package (EHSP), which seeks to offer universal coverage – in the form of a high-quality package of essential services - to the population in an equal and integrated manner.

high-quality and low-cost models of service delivery and is encouraging the private sector to develop such models for the use of both public and private patients. Government continues to call for private sector participation in order to improve the overall performance of the health system.

towards commissioning its first teaching hospital which is expected to uplift medical education, clinical training and research.

The MOH remains committed to improving the health status of the nation. Through the National Health Policy, government continues on its path towards ‘A Healthier Botswana’.

Various options for funding the EHSP continue to be explored, one of them being a national health insurance scheme which will allow participation of medical schemes.

Botswana Public Officers Medical Aid Scheme (BPOMAS)

The policy is implemented through the Integrated Health Services Plan (IHSP),

In order to arrest the escalating cost of care, government is calling for

Efforts are ongoing to adopt a sector-wide approach in order to improve collaboration and coordination of the health sector as well as to strengthen harmonisation and alignment of goals and objectives of all health partners.

saturating market, the increasing cost of private healthcare, decreasing purchasing power, limited specialist care within the country (leading to referral of complex cases to neighbouring South Africa) and lack of a regulatory framework for the sector.

Future outlook

The country is still looking

BHF MEMBERS Pula Medical Aid Fund (PULA) +267 71313035 duncant@afa.co.bw

+267 71313035 duncant@afa.co.bw

Botswana Medical Aid Society (BOMaid) +267 71300035 dalexander@bomaid. co.bw

We have moved! We have! moved

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Lower Ground Floor South Tower 1Sixty Jan Smuts Avenue Cnr Tyrwhitt Ave Rosebank, Johannesburg


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R E G I O N A L UPDATE

MOZAMBIQUE

Private healthcare is slowly gaining ground Mozambique, one of the fastest growing economies in Africa, is experiencing extraordinary growth in all sectors. With such rapid expansion comes the expected task of a ‘quick catch up’ to other countries in order to meet the demands of first world foreign investors. Private healthcare is no exception. In fact, this sector has been under the spotlight recently and has caught the eye of some serious investors. Applications for new private hospitals, clinics, pharmacies and other medical service providers are streaming in to the Department of Health. As one of the largest medical schemes in Mozambique, Mediplus noticed the expected implications of supply and demand.

Government healthcare facilities are improving nicely, but not fast enough to accommodate the needs of the influx of foreign workers and expatriates. This means that although Mediplus has contracts in place with these provincial facilities, its members are forced to use private facilities. Unfortunately the costs of these facilities are exorbitant. The average cost of claims for chronic medication has increased by an average of 2% per month. The lack of tariff regulation in Mozambique makes it an administrative nightmare. However, there is light at the end of the tunnel. Mediplus has established a strong negotiating team called APROSAP, which

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consists of various roleplayers in the private insurance industry. The team is successfully engaging with the government of Mozambique to begin implementing some basic regulations. Government sees the value of this and is participating keenly. In the meantime, Mediplus continues to overcome the cost challenges. Owning its own medical service division, including ambulances and paramedic services, is a huge cost saving. The company has also established excellent network service providers as far north as Pemba, which enable its members to be treated locally instead of being transported all the way to Maputo.

still not been overcome is the reintegration of South Africans back onto South African medical schemes once their contracts in Mozambique end. Mediplus is still hoping to find a willing South African medical scheme to partner with in order to provide its South African members with a form of interchangeability when they return home. “At this stage, it seems the South African schemes do not have enough faith in our underwriting capabilities; however, I am confident that the right, forward-thinking scheme will take the plunge at the right time,” said a spokesperson.

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The only challenge that has

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An industry beset by challenges In 2014, medical aid funds collectively incurred claims costs of over US$400 million, over and above the national health budget of almost US$340 million. Over the years medical aid societies in Zimbabwe have supported government in providing healthcare services in the country. Eighty percent of the income for service providers in private practice comes from medical schemes. In 2014, medical aid funds collectively incurred claims costs of over US$400 million, over and above the national health budget of almost US$340 million. The industry is plagued by falling membership numbers, high claims costs, late remittance of contributions and high default rates. In more recent years, errant behaviour by some service providers has been reported in respect of fraudulent claims, which

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ultimately erode member funds and increase claims costs. Annually more service providers come on board and currently there are 5 714 service provider payee numbers in the Association of Healthcare Funders of Zimbabwe (AHFoZ) database. These providers are taking a share of a member base (‘pie’) that is not growing. Expectations from service providers continue to grow and have not been moderated in line with the economic constraints affecting the entire country in which the funders operate. The value of total claims paid annually continues to increase. This is as a result

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of the growing number of providers coming on board and the increased number of claims submitted. AHFoZ has members who have been providing services since 1985 at the invitation of medical service providers. At that time AHFoZ members came to the rescue of a laboratory whose future was uncertain following the withdrawal of some of its shareholders. In 2004 an AHFoZ member was forced to open new clinics as general practitioners declined to serve its members as hyperinflation escalated. At that time

services at public health institutions were in decline and members could not access those institutions either. Public health institutions are operating below capacity and certain categories of members therefore still have limited choices. The facilities of one health funder attended to over 1 300 000 patients in the last five years. Another funder has, in spite of lack of member contributions in the last six years, miraculously delivered healthcare services to its 800 000 membership through its facilities. The funders employ permanent staff.

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SOUTHERN AFRICA


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BH F AT A GLANCE

Members South Africa

MEDICAL SCHEMES

ADMINISTRATORS

Alliance Midmed Medical Scheme

Holcim SA Medical Scheme (previously Alpha)

Anglo Medical Scheme

Horizon Medical Scheme (previously Moremed)

Barloworld Medical Scheme BIMAF (Eastern Cape) BIMAF (Western Cape) BMW Employee Medical Aid Society

Hosmed Medical Scheme Imperial Group Medical Plan Libcare Medical Scheme Liberty Medical Scheme

Remedi Medical Aid Scheme Rhodes University Medical Scheme SA Breweries Medical Aid SABC Medical Aid Scheme SAMWUMED Sasolmed SEDMED

Bonitas Medical Fund

Malcor Medical Aid Scheme

BP Medical Aid Society

Makoti Medical Scheme (previously Good hope)

Sisonke Health Medical Scheme (previously Gold Fields Medical Scheme)

Massmart Health Plan

Sizwe Medical Fund

Cape Medical Plan

Medipos Medical Scheme

Spectramed

Chartered Accountants (SA) Medical Aid

Metropolitan Medical Scheme

Suremed

Community Medical Aid Scheme (COMMED)

Medimed Medical Scheme

Building & Construction Industry Medical Aid Fund

Compcare Wellness Medical Scheme Engen Medical Benefit Fund Fedhealth Medical Scheme Fishing Industries Medical Aid (Fishmed) Glencor (previously Xstrata ) Golden Arrows Employees’ Medical Benefit Fund Grintek Electronics Medical Aid Scheme

TGF Medical Scheme (previously Foschini)

Sanlam Health Administrators Private Health Administrators Sechaba Medical Solutions Thebe Ya Bophelo Healthcare Administrators Medscheme Holding (Pty) Ltd Metropolitan Health Universal Health Administrators

MANAGED CARE ORGANISATIONS EOH Health

Thebemed

Nedgroup Medical Aid Scheme Netcare Medical Scheme

Tiger Brands Medical Scheme

Old Mutual Staff Medical Aid Scheme

Topmed Medical Scheme (merged with Pharos)

Opmed

Umvuzo Health Medical Scheme

P G Group Medical Scheme Pick n Pay Medical Scheme Polmed Medical Scheme

University of Witwatersrand Medical Scheme

Profmed

Witbank Coalfields Medical Aid Scheme

Rand Water Medical Scheme

Wooltru Healthcare Fund

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Members SADC

BOTSWANA

ZIMBABWE

Pula Medical Aid Fund (PULA)

AHFoZ

Botswana Public Officers’ Medical Aid Scheme (BPOMAS) Botswana Medical Aid Society (BoMaid)

Altfin Medical Aid Scheme Blanket Mine Medical Aid Society Calm Health Medical Scheme Cellmed Health Medical Fund

LESOTHO

Cimas Medical Aid Society

Mamoth Health

EMF Medical Aid Society

MOZAMBIQUE Mediplus

NAMIBIA Namdeb Napotel

Fidelity Life Medical Aid Society First Mutual Health

Harare Municipality Medical Aid Society (HMMAS) Heritage Health Fund Kwekwe City Council Medical Aid Society Liberty Health Medical Aid Society Masvingo Municipal Medical Aid Society Medical Aid Society Of Central Africa (MASCA) Municipality Of Bulawayo Medical Aid Society

Galaxy Medical Aid Society

National Social Security Authority (NSSA)

Generation Health Medical Fund

Northern Medical Aid Society

Grainmed Agricultural Medical Aid Society (GAMAS)

Premier Service Medical Aid Society (PSMAS)

RCC Medical Scheme RHMAF Namaf

SWAZILAND Medscheme

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Railmed Regency Employees Medical Fund TN Medical Benefit Fund Ultracorporate Medical Aid Varichem Limited Medical Fund Zenith Medical Benefit Society Zimpapers Medical Aid Society


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2015/06/19 5:13 PM

BHF360 INTO HEALTHCARE 2015  

Annual publication of the Board of Healthcare Funders of Southern Africa

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