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BHF360° JULY 2016

into healthcare

Transforming

healthcare in southern Africa

COVER: Dr Odwa Mazwai, General Manager – Gems Fund Management p. 16-17


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BHF360°

F O R E WORD

into healthcare

Editor in Chief: Zola Mtshiya Copy-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 the third annual edition of BHF 360o, which once again gives you a panoramic view of southern Africa’s healthcare landscape along with some predictions of what the future holds. I hope that you find it an informative read and that it complements your enjoyment of our annual conference. As I write this editorial, healthcare reform is the major topic on everyone’s radar. South Africa’s healthcare system is on the brink of a total overhaul, further to the release of the White Paper on National Health Insurance (NHI) for public comment in December 2015. Health systems in the Southern African Development Community (SADC), like many others globally, wrestle with the challenge of balancing the aspirations of providing equitable access and high-quality care with cost containment. Healthcare has a pivotal role to play in driving economic and industrial capacity development within the SADC region. It is therefore critical for all participants within the region to continue to share ideas, knowledge and expertise. I would like to urge everyone to participate in the process, to ensure we build an equitable healthcare system not just for ourselves, but also for our children and grandchildren. To achieve universal healthcare, each of us has to identify what we want in such a system and then commit to being part of the process that helps shape that future. I'm also excited about the 2nd annual Titanium awards. By recognising benchmarks for exceptional performance, the awards are geared to drive standards and service delivery which, in the long term, will help build a more effective healthcare industry overall. Zola Mtshiya Manager: Marketing, Branding and Communications – BHF

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IN THIS ISS UE

CONTENTS 4

DO WE NEED TO DISRUPT

the healthcare system to save it?

In order to answer the question, we should firstly be clear about what we mean by 'disrupt', and secondly decide on whether the healthcare system needs saving. – By Dr Farayi Chinyanga

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CHANGING THE FACE OF

healthcare in South Africa

The envisaged change in the delivery of healthcare will not be successful without structured collaboration among the various stakeholders. – By Dr Katlego Mothudi

10 GLOBAL PERSPECTIVES Universal healthcare – where are we at globally? . . . . . . 10 Lessons from 11 country studies . . . . . . . . . . . . . . . . . . . . 13 »»p.9

16 ON THE COVER

– Meet Dr Odwa Mazwai

He is committed to developing strategies focused on cost, quality and access to care and passionate about creating a sustainable healthcare system for South Africa’s children.

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Fraud in South Africa's healthcare . . . . . . . . . . . . . . . . . 22

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Compliance and risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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I N T HI S I SSUE

19 HEALTHCARE INSIGHTS The crisis in the private healthcare sector . . . . . . . . . . . . 19 The future role of medical schemes in an NHI environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Sustainability of NHI – does the economy adjust or does the health sector adjust? . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 »»p.25

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National health insurance and international experiences in universal health coverage . . . . . . . . . . . . . . . . . . . . . . . . 28

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17th ANNUAL BHF CONFERENCE

Conference programme . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Conference speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . 33 Listing of sponsors and exhibitors . . . . . . . . . . . . . . . . . . . 57

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REGIONAL UPDATES

Botswana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Lesotho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Namibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Zimbabwe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

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BHF MEMBERS

South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 »»p.25

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SADC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

ADVERTISER INDEX Universal Healthcare. . . . . . . . . . . . . . . . . . IFC, 12 FNB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Sizwe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Mandela Children's Hospital . . . . . . . . . . . . . . . 18 SAMWUMED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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MediKredit. . . . . . . . . . . . . . . . . . . . . . . . . . 24, OBC Mediscor . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38, 39 GEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Radisson Blu. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Medshield . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IBC

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DO WE NEED TO

disrupt the healthcare system to save it? One of the fathers of modern philosophy, Socrates, was renowned for answering a question with a question – a most successful approach. And so, in the spirit of success and ancient wisdom, I adopt the Socratic method to consider this matter.... in order to answer the question: ‘Do we need to disrupt the healthcare system to save it?’ we should firstly be clear about what we mean by ‘disrupt,’ and secondly decide on whether the healthcare system needs saving. By Dr Farayi Chinyanga EXECUTIVE MANAGER – MEDSCHEME

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he concept of disruption in business is widely attributed to Clayton Christensen, a Harvard professor who first coined the term ‘disruptive innovation’ in his book The Innovator’s Dilemma. As any student of linguistics knows, the meanings of words have a tendency to change over time and with use; think of Michael Jackson and the 1987 hit song Bad. When disruption is mentioned in a business context, more often than not, what is being referred to is the concept of ‘disruptive innovation’.

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As is the case with many business concepts, no single definition of the term suffices. Perhaps the definition that best captures Christensen’s intended meaning is the one penned by his close associate, Scott Anthony, who says: “At its core, disruptive innovation is something that creates a new market or transforms an existing one through simplicity, convenience, accessibility or affordability.”1 Sound familiar? Expressed differently, disruption in business is a process of transformation that leads to an industry operating in a completely different manner from the way it did before. Most significantly, this change often

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renders elements of the pre-disruption industry completely redundant. Disruptive innovation does not happen spontaneously. It is the product of carefully considered decisions and changes deliberately put in motion. It is therefore important to identify just what these agents of disruption are. A great variety of things impact on a system, but key instruments include legislation, the introduction of a novel business model or process, groundbreaking technology and the entry of a new player into a monopolistic market. However, more often than not, it is a combination of two or more of these elements that leads to


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sustained change. Consider the impact of email on the postal service, iTunes on the music and CD production industry, and flight on commerce, business, politics and even health. With this understanding of disruption, I now reflect on the somewhat philosophical question: ‘Does the healthcare system need saving?’

ENSURING SUSTAINABILITY THROUGH INNOVATION To best answer this, we need to ask another question: ‘What elements of the healthcare system does the average individual care about?’ While there are undoubtedly many, affordability and quality outcomes are two aspects likely to rank near the top. And so we need to consider whether healthcare systems in general deliver excellent healthcare outcomes at an affordable cost to the people they serve. The truth is that healthcare management systems around the world are struggling. The rapidly rising costs associated with the provision of quality health services to citizens is a major challenge, as is the implementation of measures to ensure that cost escalations are kept to a minimum. This dilemma is being researched and actively tackled in most countries where medical inflation is outpacing general inflation by several percentage points.2 In the South African context, this reality must be considered together with

KEY FOCUS AREAS Areas of focus identified by Christensen4 include: provider reimbursement,

TO THE RESCUE So, does the healthcare system need salvation? Simply put, yes it does, and disruption or disruptive innovation will undoubtedly play a role in this.

the manner in which healthcare providers are trained 30 per 1000.

Health systems in their entirety are incredibly complex. Like living organisms, they pulse with life, moving, reacting, growing and constantly changing in infinitesimal ways. Van Rensburg3 defines a total health system as ‘a system which includes the national healthcare system and all peripheral matters which are either directly or indirectly associated with health: specifically the surrounding environment of the healthcare system and the population served by the healthcare system concerned’.

the socio-economic landscape of the country. The social determinants of health (access to clean water, housing, education and meaningful employment) are exacerbated by a struggling public healthcare system. Viewed in its entirety, the healthcare picture appears bleak.

This broad definition encompasses everything from initiatives that positively impact social determinants of health, to technological innovation, to new ways of engaging with patients and empowering them to manage their lifestyle and chronic conditions better.

Within this totality, different health systems have different challenges and a key concern of health system administrators and policy-makers is how the provision of quality healthcare can remain sustainable.

Significantly it also includes new ways to empower healthcare providers to deliver value-based care through education, upskilling and information sharing, thus enabling strategic purchasing and coordination of care.

the role and integration of the pharmaceutical industry, the hospitals’ business model, the clinicians’ practice model, chronic disease management, the role and integration of medical technology companies, the political and civil will to drive change and, potentially,

No single ‘disruption’ exists that will eliminate all that ails the health system because there are just too many moving parts.

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ing processes and quite simply make the entire industry function better. There are many instances of such innovations and they emanate from different spheres. An excellent example is the potential impact that the use of health applications that are synchronised with electronic health records can have, and the predictive values of ‘big data’ that will result from this. A PricewaterhouseCoopers report released earlier this year highlighted the fact that developments such as bedless hospitals and virtual care centres have the potential to fundamentally change aspects of care delivery in the health system.

DR FARAYI CHINYANGA Executive Manager – Medscheme

The NHI White Paper articulates a clear focus on improved primary healthcare, which includes the promotion of health and disease prevention. This in turn embraces a myriad of opportunities within the sector which could be both disruptive innovations and sustaining ones. Sustaining innovations are those that improve exist-

For the disruption of the healthcare industry to be effective, however, it should not occur in isolation. Instead it requires that small disruptions occur in different parts of the broader system. Areas of focus identified by Christensen include: provider reimbursement, the role and integration of the pharmaceutical industry, the hospitals’ business model, the clinicians’ practice model, chronic disease management, the role and integration of medical technology companies, the

political and civil will to drive change and, potentially, the manner in which healthcare providers are trained.4 It is interesting to note that in the South African context, transformation has already begun in many of these areas (albeit that the changes are still in their early stages). No single disruption exists that will eliminate all that ails the health system because there are just too many moving parts. In addition, there are elements within the system that do not need to be changed, but rather supported or developed. So after ‘going around the mountain’ a few times we return to the original question: ‘Does the healthcare system need to be disrupted in order to save it? The simple answer is ‘yes’. It is clear that there are structural fault lines running through the healthcare system and that these need to be addressed through the reinvention of key elements. Innovative changes, correctly researched and implemented, can bring about the progressive improvement of patient-centred healthcare with quality outcomes at a cost that the system can afford.

REFERENCES 1. Anthony S. The Little Black Book of Innovation: How It Works, How To Do It. Brighton, MA: Harvard Business Press, 2013. 2. Aon Hewitt Ltd. Global medical cost increases in 2016 expected to be 2.5 times higher than inflation. Available at: http://www.aon.com/ unitedkingdom/employee-benefits/news/articles/medical-cost-increases-2016.jsp 3. Van Rensburg HCJ, ed. Health and Health Care in South Africa: Structure, Types, and Dynamics. Pretoria: Van Schaik, 2004. 4. Christensen C. The Innovator’s Prescription. New York: McGraw Hill, 2009.

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CHANGING THE FACE OF HEALTHCARE in South Africa CLINICAL EXECUTIVE, SIZWE MEDICAL FUND

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n 2016, most corridor and conference talks on healthcare are peppered with, if not dominated by, two major topics; the Competition Commission’s Health Market Inquiry (HMI) and the implementation of national health insurance (NHI). The latter, however, wins by several lengths. This is understandable as the topic immediately introduces more questions than answers and, along with these, a high level of anxiety and doubt.

Change is uncomfortable, because it forces a confrontation between our priorities and our values or principles.

By Dr Katlego Mothudi

There can be no argument against the intentions of the NHI from any perspective, least of all its social agenda which fulfils what Section 27 of our Constitution espouses. Discussions and arguments about how it would be achieved remain relevant as the White Paper released by the Minister of Health

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answered few of the existing questions. Almost every stakeholder in the South African healthcare sector battles with the certainty of change that is looming, as they ponder the implications of the Certificate of Need for health practitioners, the accreditation process for healthcare facilities or the complementary role assigned to medical aid schemes by the White Paper. Such is the nature of any major policy reform. The challenges in our healthcare system have been well articulated, and the HMI will provide additional insight. There are, however, a number of factors, which in my opinion will catalyse the change management process. These are as follows.

LEADERSHIP Strategic leaders have to guide organisations towards creating a vision and a mission. Thereafter, they have to ease the progress of appropriate strategic projects and ensure their timeous implementation. We have seen how government has directed healthcare reform through the


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perception from government, though, that these have resulted in parasitic relationships which foster corruption. There is no doubt that if these partnerships are properly structured their potential benefits would be immense. With appropriate risk mitigation and adequate attention paid to governance requirements when setting the parameters, the beneficiaries would get the best of both sectors. The envisaged change in the delivery of healthcare will not be successful without structured collaboration among the various stakeholders.

CLINICAL GOVERNANCE

DR KATLEGO MOTHUDI Clinical Executive, Sizwe Medical Fund leadership of the Minister of Health. Dr Aaron Motsoaledi has been consistent in communicating the 10-point plan and, subsequently, the four priorities his portfolio is expected to deliver. The shortcoming has undoubtedly always been the disconnect between the private and the public health sectors. As a result, initiatives on either side are often regarded with some mistrust and often disdain. There is a therefore a dire need for visibility and the articulation of firm positions from the leaders of various stakeholders in the private sector. Many would argue, though, that they require an enabling environment from the government.

TRANSPARENCY Early observations from the HMI proceedings have revealed a relatively low level of accountability, with most stakeholders abdicating their responsibility

for our current position. That may just be a symptom of the poor understanding of one another’s environment. The HMI is, however, forcing a muchneeded discourse about our processes and realities. This, in my opinion, will help the industry to unravel the complexities around pricing strategies, resourcing and also assist policy-makers to make betterinformed decisions with regard to the required changes. The much-required information and data exchange would then take place in an environment and spirit of trust.

COLLABORATION The public and private health sectors have, over time, collaborated on specific projects for some common purpose. The outcomes of these projects have been variable. There is a strong

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Clinical governance has been punted since the mid-1990s; however, it has not gained as much traction as its relative, corporate governance. Since the constitution of the King Commission in 1993, we have seen the latter transforming the governance culture of companies through the adoption of the various editions of the King report. In the clinical environment, we have instead seen uncoordinated discussions of the various pillars, but there has been no push to standardise our application or understanding of these principles. We should be thinking about establishing and empowering structures that will have the authority to pronounce on standards that will guide the delivery of healthcare. Change is uncomfortable, because it forces a confrontation between our priorities and our values or principles. We should, however, realise that we have most of the tools required to make this work.

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UNIVERSAL HEALTHCARE where are we at globally? By Zola Mtshiya MANAGER: MARKETING, BRANDING & COMMUNICATIONS, BHF

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he World Health Organization (WHO) recently released its first global monitoring report on Tracking universal healthcare coverage (UHC). The report aims to show how progress towards UHC can be measured. A majority of countries are already

generating credible, comparable data on both health service and financial protection coverage. Nevertheless, there are data blind spots on key public health concerns such as the effective treatment of non-communicable diseases, the quality of health services and coverage among the most disadvantaged populations within countries. One of the main challenges

faced in supporting UHCoriented reform is the perception on the part of some decision-makers that it is too diffuse a concept, and that UHC-related progress is unquantifiable. This report was produced partly to challenge that notion. There are three main challenges in tracking UHC: first, sourcing reliable data on a broad set of health service coverage and financial protection indicators; second, disaggregating data to expose coverage inequities; third, measuring effective coverage, which not only includes whether people receive the services they need but also takes into account the quality of services provided and their ultimate impact on health.

EIGHT CORE INDICATORS The report presents the global and regional situa-

tion with regard to eight core tracer health service coverage indicators for: reproductive and newborn health (family planning, antenatal care, skilled birth attendance); child immunisation (three doses of diphtheria, tetanus and pertussis (DTP) -containing vaccine); infectious disease (antiretroviral therapy (ART), tuberculosis (TB) treatment)); and non-health sector determinants of health (improved water sources and improved sanitary facilities). The indicators were chosen because they involve health interventions from which every individual in every country should benefit – no matter what the country’s level of socioeconomic development or epidemiological circumstances, and no matter what type of health system it may have – and because recent, compa-

Regional coverage in 2000 (baseline) and 2013 (endline; unless otherwise noted) for essential health servicesa a) ART coverage shown for 2003 and 2013; improved water and sanitation shown for 2000 and 2012.

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rable data are available for most countries. The picture they present is mixed. On the one hand more people have access to essential health services today than at any other time in history. In some cases, global population coverage already surpasses the 80% minimum proposed by the WHO/World Bank global monitoring framework. Substantial coverage gaps remain, however. For example, in spite of significant improvements in the coverage rates for ART, only 37% of people living with HIV receive ART treatment. Only 55% of new TB cases reported receive diagnosis and successful treatment. Access to sanitation is also a major concern, with 36% of the world’s population (nearly 2.5 billion people) lacking access to improved sanitation facilities, putting them at risk of several diseases including dysentery, cholera and typhoid. Equity is a matter of concern across nearly all indicators in many parts of the world, with at least 400 million people currently lacking access to one of seven

Country distributions of current coverage for essential health services essential services for Millennium Development Goal (MDG) priority areas. A key aim of UHC is protecting people from financial hardship. UHC achieves this by ensuring that most funds for the health system are prepaid, that there are few if any barriers to the redistribution of these funds (i.e. little if any fragmentation in pooling), and that services are purchased from these pooled funds in a way that limits the need for people to pay for services out-ofpocket (OOP). Using OOP payment to fund health systems has a number of disadvantages; among the most important is that it discourages people

(especially the poor) from seeking care. By focusing on the level of OOP payment it is possible to monitor the degree to which people lack financial protection. In 2013, globally 32% of total health expenditure came from OOP payments, down from 36% in 2000. While this is a move in the right direction, the 2013 figure is nevertheless indicative that in many countries OOP payments are still too high (below 20% of total health expenditure is usually a good indication of reduced risk of catastrophic health spending). The report utilises the two most commonly used indicators of financial hardship: catastrophic health expenditure and impoverishing health expenditure.

CONCLUSION Effective UHC tracking is central to achieving the global goals for poverty alleviation and health improvement set by the World Bank Group and the WHO. Without it, policy-makers and decision-takers cannot assess exactly where they are or set a course for where they want to go. They cannot know whether they are focusing their efforts in the right areas, or whether their efforts are making a difference. Monitoring is thus fundamental to the achievement of UHC objectives. It will also be vital to the realisation of the new Sustainable Development Goals.

To read the full report, visit: http://apps.who.int/iris/bitstream/10665/174536/1/9789241564977_eng.pdf

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ADVERTO RIA L

Dedicated to the creation of a seamless healthcare value chain Universal Healthcare is one of South-Africa’s fastest growing, leading-edge healthcare brands. Our end-to-end, patient-centric service offering touches the lives of more than three million people, some well beyond the borders of our country. Not every healthcare management company has that special quality that sets it apart, and places it head and shoulders above the rest. But we do. We call it the Universal FACTOR. It is that sought after quality that has helped us perfect the balance between cost, access and excellence of care for over four decades. The health of the medical schemes under our management remains central to our ability to ensure appreciable value for our clients. We are dedicated to improving the lives and wellbeing of each individual under our care, placing clients and their members at the centre of our Universe. Because we are totally focused on creating a seamless healthcare delivery model, underscored by service excellence for medical scheme members, healthcare providers, employers and healthcare consultants alike, we have never lost a medical scheme client to a competitor in our 40-year history. We are committed to extending access to world-class healthcare services, supported by robust, leading-edge technological solutions. Universal Healthcare’s caring, high-touch, forward-thinking approach makes it easy for stakeholders to interact with us. Our results, which are reflected in our medical scheme clients’ continuously improved benefits, low contribution rate increases, excellent solvency ratios and low non-healthcare expenditure, speak for themselves. Our services include the administration of open and closed medical schemes, managed care, corporate health, occupational health and wellness solutions. In addition, companies look to us for local and international healthcare insurance, healthcare-related IT and switching solutions. 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, scheme members and providers.

There’s nothing quite like the Universal FACTOR Universal, the difference between merely good and positively excellent

Tel: 011-208-1000 Fax: 011-208-1128 Email: info@universal.co.za Web: www.universal.co.za


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MOVING TOWARDS UNIVERSAL HEALTH COVERAGE

Lessons from 11 country studies By Dr Rajesh Patel HEAD OF BENEFIT AND RISK, BHF

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n recent years, many countries have adopted universal health coverage (UHC) as a national aspiration. In response to increasing demand for a systematic assessment of global experiences, the government of Japan and the World Bank collaborated on a two-year multi-country research programme to analyse the processes of moving towards UHC. Their findings were published in The Lancet earlier this year.1 The programme included 11 countries (Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey and Vietnam), representing diverse geographical, economic and historical contexts. The study identified common challenges and opportunities and useful insights for how to move towards UHC. The goals of UHC are typically defined by three dimensions: the population that is covered by pooled funds; the proportion of direct health costs covered by these funds; and the health services covered by these funds. These dimensions help to de-

Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey and Vietnam have all committed to UHC as a key national aspiration, but are at different points in the process fine where a country seeks to move its health system, and many reports about this subject have been published. However, prior to this study comparatively little information existed about how a country can move its health system towards UHC. The study’s main objective was to identify common challenges and opportunities and useful insights into how to move towards UHC. The 11 countries were selected intentionally to represent a range of income levels and health systems. All selected countries have committed to UHC as a key national aspiration, but are at different points in the process. Some are still setting the national policy agenda for moving towards UHC; others have made substantial progress toward UHC but still face substantial gaps in coverage, while those in a third group have recently achieved many UHC policy goals but face new challenges in deepening and sustaining cover-

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age. Those in yet a fourth group have mature health systems with UHC, but still need to adjust their national policies to meet changing circumstances. The study analysed each country with a common analytical framework and focused on three themes: the political economy and policy process for the adoption, expansion and maintenance of UHC; health financing policies to enhance health coverage; and policy approaches for meeting the human resources requirements for UHC. These themes were selected because financing and human resources represent two essential inputs for a health system, and because political economy has a key role in shaping policy decisions.

EXPANSION OF HEALTH COVERAGE All 11 countries used an incremental approach to the expansion of health coverage. This step-by-step approach

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One core lesson of this study is that countries need to match their commitment to UHC with their capacity to deliver health services depended on efforts to gain political support from (and sometimes confront) specific interest groups, and relied on developing institutional and technical capacities to move towards universal coverage.

HEALTH FINANCING The study reviewed national experiences in three areas of health financing: mobilisation of revenues to expand and sustain coverage; establishment of effective pooling and redistributive mechanisms to ensure equity and financial protection; and building of capacities to manage expenditures. All the countries have faced challenges in finding sufficient government finances to support UHC policies and programmes, since expansion of coverage calls for a significant increase in public spending. Countries found different approaches to securing the necessary budgetary allocation to implement UHC. The study shows that providing universal coverage for the entire population needs different forms of crosssubsidisation, both from rich to poor and from low-risk groups (e.g. the young) to high-risk populations (e.g. the elderly).

Management of expenditures is essential at all stages of UHC. Even countries that achieved UHC a long time ago still face ongoing cost pressures and must make difficult decisions on issues such as which drugs to include and exclude in benefit packages. All of the study’s 11 countries face substantial resource constraints in achieving or maintaining UHC. The study showed that open-ended fee-for-service payment systems typically lead to cost-escalation. Many countries respond by introducing measures to contain costs. However, these measures can erode coverage and undermine financial protection.

HUMAN RESOURCE CHALLENGES All 11 countries have faced major challenges in the production, performance and distribution of health workers in relation to UHC goals. One core lesson of this study is that countries need to match their commitment to UHC with their capacity to deliver health services, which in turn depends on the availability of a qualified and motivated health workforce. The shortage of health workers is a global challenge, but this problem is

especially acute for countries in early stages of UHC adoption and implementation. These countries need to rethink traditional models of health worker education and their deployment in service delivery. Expansion of the production of health workers needs to be accompanied by appropriate governance and regulatory reforms to ensure their quality and that they have appropriate skills. This is especially important for countries in the early stages of moving towards UHC. That said, all 11 countries continue to grapple with a maldistribution of health workers.

CONCLUSION This study shows that movement towards UHC needs both technical knowledge and political know-how. Countries need political leaders with vision and commitment who are ready to invest in the development of solid institutional foundations, administrative capacity and good governance. Overall, countries have a better chance of moving forward if they have leaders who show political commitment to reform, a clear understanding of the political economy challenges, and a willingness to learn from experience and adapt. This combination of factors supports national leaders in their efforts to design and implement coverage-enhancing reforms that are inclusive and sustainable in the long run.

REFERENCE 1. Reich MR, Harris J, Ikegami N, et al. Moving towards universal health coverage: lessons from 11 country studies. Lancet 2016; 387: 811-816.

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A DVE R TO RIAL

A healthy society is a productive society Few can deny that South Africa’s healthcare system needs radical reform. As things currently stand, only 16% of our population have access to medical aid cover, and there is also much debate about whether the various medical scheme options still offer value for money. From the vantage point of its 30-odd years of operation, Sizwe Medical Fund can proudly claim its relevance to and impact on the lives of its members and their families. Sizwe’s entire ethos is predicated on “CARE” – genuine concern for the wellbeing of its members. This effectively drives every facet of operation, from access to healthcare for those on a really tight budget, to crafting healthcare options which are simple to understand with rich benefits, to developing excellent healthcare networks. Sizwe’s concern stretches beyond its immediate members. Principal Officer Neo Khauoe states, “A medical fund should be looking well beyond just covering today’s health crises. We believe it has a vital role to play in the overall wellbeing of the whole of society. In fact, our mission states it plainly: we strive to provide a better future for our nation in making quality healthcare accessible and affordable through sustained growth for generations to come. “As South Africa seeks to reform the healthcare system, we welcome collaboration and cooperation with all parties involved, sharing our experiences and the vast expertise we have garnered. The healthcare landscape is highly complex, and combined skills, wisdom and abilities will be essential if the proposed reforms are to be implemented successfully. “We strongly encourage inclusive public debate from all stakeholders, including the ordinary citizens, so that all advantages and disadvantages can be properly aired and the wisest decisions are made.”

Tel: 0860 100 871 Fax: 011 221 5198 Email: queries@sizwe.co.za Web: www.sizwe.co.za


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O N T HE C OV E R

Getting to know

Dr. Odwa Mazwai General Manager – Gems Fund Management BHF360° spent some time with Dr. Odwa Mazwai to chat about his contributions to business, life experiences and lessons learnt along the way. You are a medical doctor. Do you still practise?

A

Yes, I am a medical doctor. I am no longer in clinical practice, but I maintain my keen interest in emergency medicine and aviation medicine. I stay current on my ACLS and PALS courses so that my clinical skills are not completely dusted over. You are the general manager for GEMS fund management. What is the connection here with Medscheme?

A

The GEMS fund management is a business unit within Medscheme. Medscheme, in turn, is GEMS’ largest managed care organisation service provider. Medscheme itself is a great company to work for. The GEMS business unit within Medscheme has the most phenomenal people, people driven by a passion for caring and who empower other people to thrive in everything they do. What are some of your key contributions at Medscheme?

A

Healthcare provider relations is one of my key contributions at Medscheme. I came into a managed healthcare services role that spanned interactions with healthcare providers. It’s been exciting to develop strategies to be implemented in both the private and public sectors that focus on cost, quality and access to care.

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O N T HE C OV ER

What are you currently reading?

A

I’ve just finished Mindset: The New Psychology of Success, by Carol Dwek. It’s a personal development book that shows how mindset drives every aspect of our lives. I found it fascinating how mindset shapes our goals, our attitude toward work and relationships, and how we raise our kids. The last part is important to me and I’ve already changed my approach to some things I think will help my boys become great. Tell us about your family.

A

I’m from Lusikisiki in the Transkei – okay, Eastern Cape then. I’m the youngest of four brothers. I have three boys myself: Yanga, Nemo and Theo, and a gang of nephews and nieces whom I adore. I treasure family and I would never be where I am without their love and support. I grew up with lots of cousins, friends and neighbours so I enjoy my extended family too. I now live in Jo’burg, as do my brothers, and I have to say my whole family continues

to inspire me. My parents are both doctors and I’ve always been in awe of how they touched the lives of the people they served. Gcwanini, MaSkhosana. In closing, what are some of the teachings from your upbringing that you still carry with you?

A

An experience that stays with me comes from when I was at university in the USA. A college professor who’d lived through the American civil rights movement took a particular interest in me, given that I was from a now post-apartheid South Africa. He called me into his office one day and told me something like this: “Young man, you are very privileged to be getting the education that you are. You may not realise this now but a lot of people in your country who have nothing and no voice will look to bright men like you to help them rise. It is your duty to be the best and the brightest that you can be to help those people out of the conditions they were forced into.” We therefore cannot fail to create a sustainable healthcare system for South Africa’s children.

Thoughts about the next 5-14 years How has your experience in both the public and private sectors influenced your vision for the South African healthcare system in the next 5-14 years?

1 23 My passion lies in the

I had the added privilege of

I remain excited about the

public sector and it was

working in the office of the

changes that are on the ho-

from my experience there

Director-General at the Na-

rizon for healthcare in our

that my interest in public

tional Department of Health

country. There is no doubt

health and health policy

in a technical advisory role

that there will be a seismic

was born. Working in public

and this experience shaped

shift in the status quo over

health introduced me, quite

my passion into a vision. I did,

the next 5-14 years, but

unapologetically, to the real

however, feel that there was

without it healthcare will

issues that face healthcare

a lot to be learned in health

undoubtedly fail in both

delivery in South Africa.

administration in the private

sectors.

sector, where I am now. Perhaps it’s no surprise that I’ve gravitated towards GEMS.

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ADVERTO RIA L

Nelson Mandela Children's Hospital to alleviate dire paediatric need The Nelson Mandela Children’s Hospital will be the newest dedicated paediatric hospital in South Africa Conceived by the late Nelson Mandela, championed by CEO

to develop a pool of highly specialised medical professionals and

Sibongile Mkhabela, and built entirely from the donations from

inject much needed capacity into paediatric medicine.

corporates, philanthropists and ordinary people, the hospital will help to alleviate the dire paediatric need, especially in areas of Cardiology and Cardiothoracic surgery, Haematology, Oncology, Nephrology, Pulmonology, Craniofacial Surgery, Neurosciences and General Paediatric Surgery; when it opens in December 2016. The 200-bed hospital will be a world-class, specialist academic and tertiary referral hospital providing child-centred services to the children of Southern Africa, regardless of their

Contributions of the National Skills Fund and other partners have enabled the Nelson Mandela Children’s Hospital Trust to award 70 under-and-post graduate nursing bursaries, and accept 11 doctors to become super-specialist Paediatricians in 2015; with a further 9 candidates on-boarding later in 2016. The hospital aims to further build capacity in the southern African region through telemedicine, exchange programmes and research. To date R800 million of R1 billion required to build and equip the

socio-economic status. Located close to Charlotte Maxeke Johannesburg Academic Hospital, adjacent to Wits University’s Medical School and within the Gauteng medical circuit, the hospital will allow for paediatric academic teaching access and capacity building. The development of a high-care facility created an opportunity

hospital, and train professionals and staff, has been raised. The construction of the shell was completed in June 2016, and the building is currently being fitted out – yet another milestone in the journey of creating a hospital that will ensure that every child’s life counts.

www.nelsonmandelachildrenshospital.org


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THE CRISIS

in the private healthcare sector! Dr Brian Ruff CEO – PPO SERVE

T

he private healthcare sector is experiencing a worsening crisis of access and affordability. Scheme premiums are increasingly unaffordable to most South Africans. Costs are driven by an aging population and a poorly performing healthcare system. Despite a growing middle class and a weak public sector, membership is static. System ‘production’ is characterised by unnecessary hospitalisation; this soared even higher in 2016. Serious gaps in cover drive hospitalisation, patchy quality of care and outcomes, particularly for older patients with multi-morbid, complex problems.

four private beds per 1000 members whereas well-functioning systems with competent community services now use under two per 1000. The case mix of our admissions suggests that many patients don’t need to be in hospital.

Misaligned incentives and competition drive weak production. There is no organised, coherent care system. Clinicians work in isolation in a fragmented system where processes are chaotic and where individuals fend for themselves.

REASONS FOR THE CURRENT STATUS

In addition to the aging risk pool, the schemes’ purchaser role is weak. National coverage requirements and absent health outcome performance information mean that local factors and relative production are ignored. Schemes compete on benefits and price, rather than on value for members.

As long as clinical professionals are remunerated per service as individuals and not in teams accountable for populations, they will remain trapped in hamster wheels of income sustainability targets, with suboptimal and vulnerable practice missing the scale and support infrastructure to pursue evidence-based practice.

Absent structures underpin suboptimal performance. There are too few funded members for system capacity in respect of hospital beds and clinicians, which could easily serve double the number of people they currently do. There are around

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Industry ‘band aid’ solutions aren’t able to counter these issues. Managed care interventions, alternative reimbursement arrangements, scheme coordination projects and well-meaning but small-scale voluntary improvement efforts can’t fix fundamental structural and process issues. Stand-alone hospitals are also not systems and represent national oligopolies. Ultimately, quality of care suffers while costs increase. There is a lack of regulatory control and a lack of information standards. State oversight failure to create a functioning market is now evident for member demand and finance as well as for the performance of the supply side. There are neither clear policy aims for the sector nor iterative regulations to drive continual improvement. Credentialling, while important, is not enough to enable healthy competition based on value.

OUR RECOMMENDATIONS A ‘managed’ market is a better alternative than a centralised model that lacks incentives for productivity and customer service. Patients are not ‘normal’ consumers because catastrophic costs require a third party payer and they don’t have the information or often the opportunity for informed choices. Extraordinary steps are needed for a competitive market model. Competition between healthcare delivery systems that are made up of organised multidisciplinary clinical teams with economies of scale and

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Proposed steps to create a high-functioning market that produces value for South Africans on both the supply and demand side effective management leads to high standards and reliability. Because healthcare is delivered locally, and issues and production vary significantly, markets for both delivery systems and for schemes should operate and be regulated regionally (not necessarily within provinces) and not nationally, which blunts focus and entrenches oligopolies.

STEPS FOR A COHERENT POLICY FRAMEWORK We propose steps to create a highfunctioning market that produces value for South Africans on both the supply and demand side. The state undertakes iterative regulation to ensure continuous market investment and responsiveness. Formula-driven licensing of hospital beds and continual production standard evaluation (health outcomes

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and costs) by a new regulator are key. An expanded Council for Medical Schemes brief includes mandatory cover and risk equalisation. Because ‘not-for-profit’ schemes with ‘forprofit' administrators have failed, new ‘for-profit’ self-administered schemes with minimum loss ratios are an alternative. Serious attention to and investment in healthcare information is needed, including mandatory data standards and generation, and routine informed reporting at every level of the industry. The pursuit of universal healthcare is a noble one. Tactically, it should recognise the existing income and wealth strata of our population. Efficient, lower-cost provision models, which are built on scale, teamwork and competition to produce value, can promote affordable access.


We are pulling up our socks, are you? We are re-committing to service excellence by honest introspection and more improved methodologies. Our challenge to the medical aid industry is to commit to service excellence, in pursuit of responsibly meeting member and service provider expectations. We care about what our members think. Make it your business to care too.

www.samwumed.org


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INDUSTRY P E RS PE C T IVE S

FRAUD in SA healthcare Keeping abreast of the evolution of new modus operandi trends in healthcare fraud trends is as big a challenge as providing affordable, quality healthcare By Connie Bakkes RISK MANAGER, POLMED

I

t is unfortunate that only a few stakeholders are responsible for South Africa’s overall healthcare fraud statistics. However, it is this small number of fraudsters who are costing the industry billions in losses per annum and they have been identified as a rising threat, especially in light of our coming NHI. It is important to note that these fraudulent activities occur at all levels of the industry and may involve medical scheme members, healthcare service providers, medical scheme employees and/or their administrators. Fraud is not only limited to a specific group within the healthcare industry.

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Recent investigations have shown that healthcare service providers, in collusion with medical scheme members, are more willing to risk their ethical standards in order to increase their illegal profit margins. This behaviour in turn makes prevention and detection strategies more challenging and substantially increases the industry’s risk exposure to fraud. The biggest challenge for the industry is therefore not just to ‘...provide affordable, quality healthcare to all...’ but to keep abreast of the evolution of new modus operandi trends in healthcare fraud. It is pertinent to the industry to ensure the development of efficient detection and prevention strategies to preserve medical scheme funds for the

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long-term benefit of members. Medical schemes pursue these ‘specialised’ offenders through a collaborative approach, which entails partnerships with entities like the HPCSA, BHF Healthcare Fraud Management Unit, South African Police Service, National Prosecuting Authority as well as networking relationships with administrators, private insurance groups, associations and other private investigative firms. Several medical schemes and/or their administrators have enhanced their prevention and detection strategies to include improved healthcare fraud, waste and abuse software applications – this unfortunately comes at a high cost.

SOUTHERN AFRICA

Nevertheless, many of these programmes assist medical schemes to reduce healthcare fraud, waste and abuse expenditure, and improve claims payment efficiency. Successful prevention of fraud using this technology is essential, as returns on the investment need to surpass the cost of expenditure. Even though the road ahead seems daunting, awareness of and education about healthcare fraud will help to ensure that everyone grasps the scope and impact of fraud on the sustainability of medical schemes and the quality of healthcare services available to members. Every rand lost through fraud means that someone who is sick is not getting the treatment they need.


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I N D U S T RY P E R S P E C TIV ES

COMPLIANCE & RISK The activities undertaken by the HFMU and the compliance and risk unit are part of a cohesive approach to manage medical aid fraud, waste and abuse By Janine Keeler SECTION HEAD: COMPLIANCE AND RISK

O

ne of the key service offerings of the Board of Healthcare Funders (BHF) is the healthcare forensic management unit (HFMU). This forum, established by BHF in 2003, is an information and resource sharing committee comprising representatives from medical schemes, administrators and insurers. BHF has developed a fraud risk management standards document, which outlines a cohesive approach to understanding and examining fraud in the healthcare industry. This standards document was launched at the 16th annual BHF conference. BHF’s board of directors set the key strategic objective to lead a cohesive approach to manage medical aid fraud; this is aimed at

achieving an accessible, affordable and accountable health system transformation. The compliance and risk unit, established in 2015 under the auspices of BHF’s operations department, is tasked with achieving this strategic objective. The practice code numbering system (PCNS) is a unique database of healthcare professionals and institutions from both the public and private sectors. The compliance and risk unit holds a vetting function and also identifies and mitigates risks associated with practice code number. On the road to universal healthcare, the compliance and risk unit has embarked on various activities to discover what can be learned from other countries and industries. The aim of this research is to identify the key elements for risk miti-

gation. The compliance and risk unit engages with various national and international organisations. Head of operations, Lamees Scholtz, and overseer of compliance and risk, Janine Keeler, recently attended a strategic session in McLean, Virginia, in order to develop a framework for international antifraud cooperation. The USA, the UK, Canada, Europe and South Africa participated in this strategic session, the aim of which was to establish a framework on how best to engage on healthcare fraud, waste and abuse. The BHF is fostering relationships to facilitate the sharing of information with national and international law enforcement agencies through both its fraud unit and compliance and risk

JANINE KEELER unit. The activities undertaken by the HFMU and the compliance and risk unit are part of a cohesive approach to manage medical aid fraud, waste and abuse.

For further information on the compliance and risk unit and the HFMU, contact Janine Keeler on +27-11-537-0200 or email janinek@bhfglobal.com

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ADVERTO RIA L

Technology before its time MediKredit is the pioneer of online real-time claims processing in South Africa. Established as a clearing-house for pharmacy claims 75 years ago, MediKredit continues to dominate the South African healthcare industry as a leader in pharmaceutical benefit management, claims processing and online real-time connectivity. Our impressive track record and global expertise have taken us to the pinnacle of healthcare innovation in South Africa, with MediKredit evolving into an innovative, leading-edge organisation and acknowledged leader in the field of provider network management and connectivity, processing more than four million claims every day. The locally developed, flexible, internationally patented IT systems of MediKredit impact the lives of more than 7.8 million South Africans while the fully integrated end-to-end service offering is used by more than 3 500 pharmacies, 194 private hospitals, 91 public sector hospitals, 4 700 doctor practices – all of which are connected to more than 77 medical schemes. MediKredit seamlessly and reliably connects and processes healthcare claims and transactions for members, medical schemes and healthcare service providers. Our technology can integrate with all practice management and medical scheme administration systems. The service offering of MediKredit includes pharmacy benefit management, doctor claims processing, hospital claims processing (both public and private), provider network management and real-time connectivity through our ability to switch claims for healthcare providers to a number of medical schemes, managed care organisations and administrators. 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, thereby affording its vast client base customised technological solutions with a uniquely patented rule stacking capability.

MediKredit – Smart data, healthy decisions

Tel: 011-770-6000 Fax: 011-770-6001 Email: enquiries@medikredit.co.za Web: www.medikredit.co.za


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HE A LT H C A R E I N S I GH TS

The future role of medical schemes in an NHI environment By Dr Vusi Memela PRINCIPAL OFFICER – HOSMED MEDICAL SCHEME

T

he private medical aid industry is engaging in serious dialogue regarding its role in the NHI environment. Major discussions focus on the effect of NHI on the currently insured and what the impact will be within the industry. Various views on NHI involvement are still being defined, based on the facts and anxieties associated with NHI execution. The industry supports the point in the NHI White Paper that medical aid schemes will play an important role alongside or within NHI in South Africa. Currently, medical aids provide care to over 8.7 million beneficiaries. The skill and expertise amassed in the industry over the years can play a crucial part in NHI management. Clinical, actuarial and finance interfacing within the risk management and application of risk tools for demand and supply balance forms the basis of any medical insurance system. The risk pool management of 8.7 million lives could easily be devolved to cover

over 50 million lives within the NHI environment. Even though the role of medical schemes is not clearly defined in the NHI White Paper, the industry is taking an active role in defining itself within the NHI environment. Member contributions management, which includes billing and receipting appropriately, is an administrative feature unique to the industry. Benefits management with suitable quality of care is pivotal to measurement of outcomes.

both NHI and the role of medical aid schemes. The provision of affordable healthcare to all South Africans is the goal of both the medical aid industry and government. To realise this goal, the industry and government have to co-exist on a platform where tailored amenities and sustained brilliance are progressively offered in order to sustain the healthcare offering to all.

Schemes have over time developed the necessary infrastructure, which includes tried and tested interventions to achieve measurable outcomes. A wide range of benefit and contribution options has been developed in order to cater for medical needs at affordable levels. Robust investment, provider and governance strategies always inform the industry’s management approach and systems. Claims administration platforms are flexible, stable and vigorous, with built-in clinical rules. Contributions in the form of proficiency, direction and advisory roles will be a constructive element for a practical environment that supports

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HE ALTHCAR E IN S IG H T S

Sustainability of NHI – does the economy adjust or does the health sector adjust? By Elias Masilela COMMISSIONER – NATIONAL PLANNING COMMISSION

T

he policy discourse on the implementation of the NHI is one of the most topical in South Africa today, both as a fiscal consideration and because of the socio-economic need to deliver a better quality of life for all. The BHF’s choice of conference theme can therefore only be commended. However, as we ponder this programme, we need to be conscious of the context within which the debate and planning are taking place. It is also important to appreciate that whatever policy we consider as a country, we need to do so with a long-term view. We are therefore reminded of an old principle and idiom, which goes: ‘The quality of any policy is as good as its implementability’. What this means is that whatever policy we pursue, it ought to pass the tests of: Acceptance and buy-in from society Being transparent and predictable Being efficient Being sustainable, which makes the affordability test paramount.

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The NHI also has to pass these tests. If it does not, it will be difficult to implement. This is in line with the underlying philosophy of the NDP, which is: Optimising within existing resources Efficiency gains invested towards strengthening delivery and new programmes. It is instructive to note that South Africa is spending about 8% of GDP. This is in line and in many cases higher than its peers, for a lower return or service quality. The NDP calls for better use of resources and improved management, rather than throwing money at the problem. Finally, cognisance needs to be given to the fact that this discussion takes place at a time when South Africa is experiencing its tightest economic and fiscal conditions since 1994, as well as in the context of gaping economic inequalities. This state of the economy and social imbalances force dire policy choices. A balance of need and efficient resource allocation will prevail.

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CANONS OF THE NHI The key objective of the NHI ought to be that of giving South Africans healthcare access in a predictable and sustainable manner. This noble objective relies on key characteristics of access being in place at all times: price affordability, appropriate quality and quantity, as well as geographic reach. In principle, it is easy to reach consensus on these characteristics and how we understand access. But it is more difficult to agree on ‘whose responsibility it is to deliver on them’. This is where the policy starts being challenged, as society grapples with issues of: Supply and demand of health services Efficiency of the delivery mechanism in both private and public sectors. The irony of the policy consideration is that NHI will give effective demand to members of public who never had effective demand. If this is not matched by supply increases, we will be back to square one.


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HE A LT H C A R E I N S I GH TS

NDP TARGETS Raising life expectancy to 70 Ensuring that the generation of under 20s is HIV free Significantly

reducing

the

burden of disease Reducing infant mortality to less than 20 deaths per 1000 live births Delivering an under-five mortality rate of less than 30 per 1000.

A relevant question that follows from the above observation is: ‘How have we fared?’ Work that has been done by the NPC reveals that we have fared poorly; where we record health outcomes that are worse relative to South Africa's expenditure levels and experience of peers. This is by all indicators, in the areas of namely, TB, HIV, infant/ meternal mortality as well as life expectancy. These are partly ascribed to: Suboptimal public sector delivery, which is in turn explained by: Centralised & top-down management; Poor governance & quality control; Feeble accountability; Marginalisation of clinicians; Low staff morale. Increased reliance on the private sector: Which gives pricing power to the sector While optimality of private sector delivery is difficult to test for, it seems better than public delivery However, it fails society by being

concentrated in urban centres, over-capitalised and supply-driven. These imbalances have had far-reaching consequences, among which are: High cost of services, owing to poor demand/supply conditions Poor access for rural and poor communities.

POLICY RESPONSE If not well managed, NHI may worsen these imbalances. Therefore, it is essential that the policy design and implementation be aimed at bettering rather than cementing the status quo. This design should take the following into account: An emphasis on efficiencies in both sectors; That public service delivery needs to be prioritised and precede full implementation; The role of an effective health standards office; That funding ought not be the only focus, but also management of the health service. There is substantial evidence that health outcomes are only partly explained by spending levels. In the absence of other integral interventions, higher spending remains ineffective. The need to change attitudes.

WHAT THE NDP SAYS? Health is not just a medical issue. We need to deal with all its facets in a bal-

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anced and equitable manner. Human capacity and its deployment are key. Governance and the undoing of infrastructure backlogs across the health system need to be strengthened. NHI needs to be implemented in phases, complemented by a reduction in the relative cost of private medical care. Failure to adhere to this will create huge bottlenecks for economic growth and the improvement of quality of life. The NDP then challenges us with a vision against which we should test all our decisions. It sets aspirational targets of: Raising life expectancy to 70 Ensuring that the generation of under 20s is HIV free Significantly reducing the burden of disease Reducing infant mortality to less than 20 deaths per 1000 live births Delivering an under-five mortality rate of less than 30 per 1000.

CONCLUSION To deliver on the vision and dreams of South Africa, we need an NHI that is premised on: Meaningful public private partnerships Prioritisation of management over simply throwing money at the problem Enhanced public sector capacity Focus on complementing the implementation of the NDP, as well as the private sector using its power for good.

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National health insurance and international experiences in universal health coverage By Sarah Barber WHO REPRESENTATIVE: SOUTH AFRICA

G

lobal support for universal health coverage (UHC) is gathering momentum. Last December, the world celebrated Universal Health Coverage Day in commemoration of the unanimous adoption of a 2012 United Nations resolution calling for countries to provide affordable, quality healthcare to all citizens of the world.1 In September 2015, governments established the Sustainable Development Goals (SDGs), which set forth the commitment to achieve UHC through country-level action by 2030.2 A global coalition of actors among countries, civil society, academics and international organisations has formed to support countries in achieving UHC.3

The concept is simple. Healthy people are a pillar of sustainable economic and social development. The goal of UHC is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them. In middle- and high-income countries, well-designed healthcare re-

forms have been able to control escalating healthcare costs – thus contributing to stronger economic growth. In practice, this means that countries across the world have embarked on a series of reforms to UHC – to reorganise the financing of health services, improve access to essential medicines and technologies, and ensure that health workers are available and motivated.

PROGRESSIVE REALISATION There is no one blueprint for achieving UHC. But there are a few principles that guide countries to action. One is progressive realisation. No country has set forth all the details of UHC implementation, which can take decades or longer to realise. Most countries initiate their roadmap, such as South Africa’s national health insurance (NHI) White Paper, to gain political commitment in recognition that a process is needed. Such a process requires negotiation with a wide range of stakeholders, sequenced implementation, and careful monitoring and evaluation to make adjustments along the way and correct for any unintended consequences.

REFERENCES

In terms of financing, critical policy choices have to be made. No country has achieved UHC through voluntary contributions to insurance schemes.4 Mandatory prepayment or public financing is required to achieve UHC. Pooling arrangements are needed to redistribute prepaid resources to individuals with the greatest health needs. And it is essential that efficiencies are built into the system and used to promote better health. A critical principle is equity. Health insurance schemes can improve health service utilisation and financial protection for their members. But what is the effect of any one scheme on the broader health system and the population as a whole? Expanding health coverage that benefits a few but takes resources away from others may compromise equity and overall UHC policy objectives. UHC is now a global movement in response to unprecedented demand. While there is no blueprint, stakeholders need to work together to set forth the pathways enabling the whole population to benefit.

1. Global Health and Foreign Policy, 67th Session UNGA 6 December 2012; A/67/L.36 http://www.un.org/ 2. Sustainable Development Goals: Goal 3: http://www.un.org/sustainabledevelopment/health/ 3. Global Coalition for Universal Health Coverage http://universalhealthcoverageday.org/partners/ 4. Kutzin J. Anything goes on the path to universal health coverage? Bulletin of the World Health Organization 2012; 90: 867-868.

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A N N UA L BH F C O N F E R ENCE

Conference

Programme SATURDAY, 16 JULY 2016 07h00-24h00

Exhibition Build-up

Exhibitors only

15h00-17h00

Registration

Delegates

CTICC HALL 4 CTICC REGISTRATION AREA

SUNDAY, 17 JULY 2016 07h00-24h00

Exhibition Build-up

CTICC HALL 4

10h00-15h00

BHF Golf Challenge 2016

PEARL VALLEY GOLF COURSE

Shotgun start

13h00-17h30

Delegate Registration

CTICC REGISTRATION AREA

15h00-18h00

Meet the leaders in healthcare

Closed Session for BHF Members ONLY

An opportunity for BHF members to engage and network with leaders across the healthcare sector.

18h30-20h30

OPENING CEREMONY

Facilitator: Grace Khoza: Executive Director, Group Marketing & Corporate Affairs – AfroCentric Health

AUDITORIUM 1

OFFICIAL OPENING ADDRESS The constitutional obligation the state has to enable the right to access healthcare services for all Albie Sachs: Former Justice of the Constitutional Court KEYNOTE ADDRESS The role of business and civil society in saving our democracy and economy Professor Mcebisi Ndletyana: Associate Professor: Political Science – University of Johannesburg

Entertainment by: Africa Umoja – the Spirit of Togetherness

20h30-22h30

RE-CONNECT

Networking Cocktail

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ANNUAL BH F C ON FE RE N C E

MONDAY, 18 JULY 2016 07h00-08h00

TEA ON ARRIVAL

SESSION 1

DISPELLING NHI MYTH – IT WON’T HAPPEN?

08h00-08h05

OPEN AND WELCOME

Facilitator: Clem Sunter

08h05-08h40

KEYNOTE ADDRESS

Universal healthcare coverage – What have we learnt so far?

Dr Adam Wagstaff: Research Manager, Human Development and Public Service team in the

Development Research Group – World Bank (USA)

08h40-09h15

“Transforming our World – the 2030 Global Agenda for Sustainable Development”

Dr Sarah Barber: WHO Representative in South Africa

09h15-09h45

CTICC HALL 4 BALLROOM EAST & WEST

The long road to universal healthcare In South Africa Professor Robert van Niekerk: Director – Institute of Social and Economic Research, Rhodes University

09h50-10h20

TEA BREAK & EXHIBITION

CTICC HALL 4

SESSION 2

DISPELLING NHI MYTH – WE DON’T HAVE THE MONEY?

10h20-11h00

Sustainability of NHI – does the economy adjust or does the health sector adjust?

Elias Masilela: Commissioner – National Planning Commission

11h00-11h40

Striking a balance in NHI funding – requirements and implications on the inter-governmental system

Bongani Khumalo: Acting Chairman and CEO – Financial & Fiscal Commission (FFC)

11h40-12h30

Options for financing the NHI – an overview of the fiscal capacity and instruments

Amanda Jitsing: Director: Public Economics – DNA Economics

Fouche Venter: Health Economist – DNA Economics

12h30-13h30

LUNCH & EXHIBITION

SESSION 3

DISPELLING NHI MYTH – WE CAN’T GET INVOLVED?

13h30-14h15

In search of the perfect healthcare system

Ballroom East & West

CTICC HALL 4 BALLROOM EAST & WEST

Dr Mark Britnell: Chairman & Partner – KPMG Global Health Practice (UK)

14h15-16h00

PANEL DISCUSSION: INDUSTRY CAPTAINS

Short-term strategic imperatives: Investing in an efficient health system

16h00- 17h00

67 Minutes: Making the world a better place

Calling on all delegates to pledge 67 minutes of the day supporting a local institution/initiative.

19h00-24h00

GALA DINNER

2nd Annual Titanium Awards: Recognising Excellence in Healthcare

Entertainment by: MiCasa

MC: Zola Mtshiya

Theme: Black Tie

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A N N UA L BH F C O N F E R ENCE

TUESDAY, 19 JULY 2016 SESSION 1

A ROADMAP TO A PATIENT-CENTRIC HEALTHCARE SYSTEM

BALLROOM EAST & WEST

Facilitator: Dr Ali Hamdulay – Director & Head of Clinical Risk Solutions, Metropolitan Health Risk Management 09h00-10h00

PANEL DISCUSSION

Health market inquiry – what have we learnt?

Advocate Hasina Cassim

Why are medical scheme members complaining? Member experience: past, present and future

Thembekile Phaswane: Senior Manager: Complaints Adjudication – CMS

The rise of an empowered patient – transforming the member experience

Bella Mfenyana: Executive: Contracts and Operations – GEMS

SESSION 2

CREATING ACCESS THROUGH INNOVATION

BALLROOM EAST & WEST

Facilitator: Dr Ali Hamdulay 10h00-10h30

Personalised healthcare enabling patient-centric care

Kuldeep Singh Rajput: Founder and CEO – Biofourmis (Singapore)

10h30-11h00

What does healthcare innovation look like in the context of NHI?

Dr Farayi Chinyanga: Executive Manager – Medscheme

11h00-11h15

TEA BREAK & EXHIBITION

SESSION 3

MITIGATING RISK

11h15-11h35

Defining healthcare fraud in the context of NHI: Is it a victimless crime?

Alanna Lavelle: Program Manager, Healthcare Fraud – MITRE (USA)

11h35-12h10

New frontier: Fraud risk mitigation

Lamees Scholtz: Manager Operations – BHF

Dr Hleli Nhlapo: MD – DENIS

12h10-12h30

Cyber and IT risk for healthcare organisations: no longer just a “what if”. But a “when”.

Alex Muller: Partner – PwC

12h45-13h30

LUNCH & EXHIBITION

SESSION 4

COST DRIVERS: ENOUGH TALK: WHAT ARE THE SOLUTIONS?

CTICC HALL 4 BALLROOM EAST & WEST

CTICC HALL 4 BALLROOM EAST & WEST

Facilitator: Dr Mangaliso Mahlaba: CEO – Thebe ya bophelo Administrators 13h30-14h00

Drivers of hospital prices in South Africa – where to focus to contain costs

Tomas Roubal: Health Economist – World Health Organisation (WHO)

14h00-14h20

Drivers of expenditure on pathology costs

Chris Adams: Director – Verirad

14h20-14h40

Improving access to medicines in South Africa

Professor Praneet Valodia: Independent Healthcare Consultant

14h40-15h30

What are the drivers of utilisation?

Dr Jonathan Broomberg: CEO – Discovery Health; Dr Guni Goolab: Principal Officer – GEMS

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ANNUAL BH F C ON FE RE N C E

TUESDAY, 19 JULY 2016 [CONTINUED] 15h30-15h45 TEA BREAK & EXHIBITION CTICC HALL 4 PARALLEL SESSIONS VENUE: MEETING ROOM 1.6 CTICC MEETING ROOM 2.6 CTICC FOCUS: REGIONAL DEBATE: SADC FRAUD, WASTE AND ABUSE IN HEALTHCARE FACILITATOR: Selikane Motseko: Director – Mamoth Lamees Scholtz: Operations Manager – BHF Health Benefits (Lesotho) 15h40-16h00

Learning from ourselves – African perspective on health Dr Anuschka Coovadia: Head of Health Africa – KPMG

Big data vs little data – what we can learn from other industries? Michelle Beeter: MD – Experian South Africa

16h00-16h30

Finding solutions to the student visa impasse – call to action Duncan Thela: MD – Associated Fund Administrators (Botswana) Dr Lorato Mangadi: Fund Administration Manager - Southview (Botswana) Callie Schafer: CEO (Namibia)

Does healthcare fraud inhibit access to healthcare services? Ishmael Mogapi: HFMU Member

16h30-17h00

Pathology trends in South Africa Chris Adams & Paul Horn: HFMU Members

17h00

BHF AGM (Members Only)

Venue: Ballroom East & West

21h00-01h00

MEDIKREDIT PARTY The Two Oceans Aquarium, V & A Waterfront, Cape Town

WEDNESDAY, 20 JULY 2016

THE ROAD AHEAD

09h30-11h50

PANEL DISCUSSION | INDUSTRY CAPTAINS

Facilitator: Dr Tebogo Phaleng: Executive Director – Coalesce

Where to from here? Action plans to actualise universal healthcare

PANELLISTS Dr Rajesh Patel: Head Benefit and Risk – BHF Dr Tony Behrman: CEO – IPA Foundation Dr Brian Ruff: CEO – PPO Serve Vishal Brijlal: NHI Coordinator – National Department of Health

12h00

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A N N UA L BH F C O N F E R ENCE

Conference

Speakers DR ADAM WAGSTAFF

Research Manager, Human Development and Public Service Team in the Development Research Group – World Bank (USA) Adam Wagstaff is research manager of the human development and public services team in the Development Research Group of the World Bank. He holds a DPhil in economics from the University of York, and before joining the bank was a professor of economics at the University of Sussex. He was an associate editor of the Journal of Health Economics for 20 years, and has published extensively on a variety of aspects of the field. Much of his recent work has been on health insurance, health financing, vulnerability and health shocks, and provider payment reform. He has extensive experience of China and Vietnam, but has worked with countries in Africa, Latin America, Europe and south, east and central Asia. Outside health economics, he has published on efficiency measurement in the public sector, the measurement of trade union power, the redistributive effect and sources of progressivity of personal income tax, and the redistributive effect of economic growth.

ALANNA MARIE LAVELLE

Programme Manager, Healthcare Fraud – MITRE (USA) Alanna Marie Lavelle has several decades of executive level expertise in managing complex healthcare fraud investigations through legal or negotiated remedies in civil and criminal prosecution in both public and private sectors. She is currently director of the healthcare fraud programme for the Council for Medical Schemes’ Healthcare Fraud Prevention Partnership (HFPP) at MITRE Corporation. For over 10 years she was director of the special investigations unit for Anthem Blue Cross Blue Shield, Inc., with an established track record of successful recoveries and savings. She spent 25 years as a Federal Bureau of Investigation (FBI) special agent, including nine years in management. She has received five national awards from Blue Cross Blue Shield Association for ‘Investigation of the Year’ and an investigative excellence award from the National Healthcare Anti-Fraud Association. She is a nationally respected speaker on healthcare fraud issues within both private and public sectors to a wide variety of stakeholders, including the US Congress and law enforcement agencies.

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ANNUAL BH F C ON FE RE N C E JUSTICE ALBIE SACHS

Former Justice of the Constitutional Court Justice Albie Sachs started practice as an advocate at the Cape Bar, aged 21. The bulk of his work involved defending people charged under racist statutes and repressive security laws. In 1966 he went into exile. After spending 11 years studying and teaching law in England he worked for a further 11 years in Mozambique as law professor and legal researcher. In 1988 he was blown up by a bomb placed in his car in Maputo by South African security agents, losing an arm and the sight in one eye. During the 1980s, working closely with Oliver Tambo, he helped draft the organisation's Code of Conduct, as well as its statutes. After recovering from the bomb he devoted himself full-time to preparations for a new democratic Constitution for South Africa. In 1990 he returned home and as a member of the Constitutional Committee and the National Executive of the ANC took an active part in the negotiations which led to South Africa becoming a constitutional democracy. After the first democratic election in 1994, he was appointed to serve on the newly established Constitutional Court. In addition to his work on the Court, he has travelled to many countries, sharing the South African experience in healing divided societies.

DR ALI HAMDULAY

Director & Head of Clinical Risk Solutions – Metropolitan Health Risk Management Dr Ali Hamdulay holds a number of qualifications, including a Master’s in Family Medicine from Stellenbosch University. He is currently the head of clinical risk services for Metropolitan Heath. He joined Metropolitan Health Risk Management as clinical advisor in the clinical best practice unit in 2007. In 2009, he was appointed executive manager: disease risk management and was responsible for the design and management of the company’s various healthcare programmes. In 2010, he was appointed executive manager: provider networks to enhance Metropolitan Health Risk Management’s value-based clinical offering to members of medical schemes and employer groups by increasing access to quality care networks and by steering the integration of managed care programmes with healthcare providers. In 2012, he was appointed general manager: health provider and policy unit to take on the challenge of ensuring that Metropolitan Health Risk Management is the leading provider of strategic health provider management and policy services and products in the industry. In 2014 he attended the Harvard Business School (HBS) Executive Education: Value Measurement for Health Care Programme, which has further influenced his thinking on health outcomes models and value-based healthcare. He has also served as a director of Metropolitan Health Risk Management and is a currently a director of BHF.

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A N N UA L BH F C O N F E R ENCE ALEXANDRA MULLER Partner – PwC

Alexandra Muller is a qualified chartered accountant and a partner: ICT and risk management at PwC with over 15 years’ experience at the firm. She leads its risk and controls assurance practice for medical schemes with her main areas of expertise being governance, controls, IT risk services and risk management. She has been extensively involved in these areas since the end of 2002 and is a member of the Institute of Internal Auditors. She has travelled and worked internationally for large ICT clients and has also managed a large internal audit outsourcing client that operated in 12 countries across Africa. In 2009, she was responsible for creating the ‘integrated internal audit solution’ for PwC. Since 2012 she has focused on medical schemes, administrators and managed care organisations, consulting with them and reviewing their ICT governance structures, helping trustees manage their risk frameworks and assisting with crisis control interventions related to data breaches.

AMANDA JITSING

Director: Public Economics – DNA Economics Amanda Jitsing holds a Master's in Commerce from the University of KwaZulu-Natal and leads the public economics practice at DNA Economics. She has experience in public finance, monitoring and evaluation and policymaking. Over the past 10 years, she worked on the national budget, reviewing and analysing estimates of national expenditure. More recently, she has been involved in conducting performance expenditure reviews on institutions in the public sector. These performance expenditure reviews are methodologies that aim to analyse expenditure in detail and determine the unit costs of government services to inform policy-making. Amanda has a broad range of experience in the health sector. She led a team that costed the district health implementation strategy. She was also involved in developing the regulatory framework for the Office of Health Standards Compliance. Over her career, she has led and been involved in over 50 research projects, working closely with national and provincial government.

DR ANNA MOKGOKONG

Chairperson – AfroCentric Group Dr Anna Mokgokong is chairperson of AfroCentric Holdings. Her qualifications include a BSc and an MB ChB. She is also the chairperson of the Tsoseletso Consortium which will oversee the upgrading of the Tshwane WesPrecinct area – which represents an investment of over R6 billion by the Tshwane municipality, a board member of Shoprite Holdings and a board member of Adcock Ingram. She is a former president of the South African Women Entrepreneurs’ Network and of the International Women’s Forum of South Africa, and the founding member and group executive chairman of Community Investment Holdings. She is also a recipient of honorary doctoral awards and international awards. One of her most recent awards is the Lifetime Achievement award of the Department of Trade and Industry. She is the chairperson of the US SA Trade Commission and currently serves with the Bill Clinton Global Foundation. She is also a board member of the American University (Nigeria) and a member of Leading Women of the World.

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ANNUAL BH F C ON FE RE N C E ALLAN SWEIDAN CEO – Akeso Clinics

Allan Sweidan studied for a degree in commerce before qualifying as a clinical psychologist in 1998. After a stint working at SANCA and then as head psychologist at the children’s unit at TARA/Alexandra Clinic, he joined the private sector in 2004, establishing an addiction programme at Crescent Clinic in Randburg. He is a co-founder and current managing director of the Akeso Psychiatric Group of Hospitals, which now has 13 inpatient sites and one outpatient site in South Africa, with two more hospitals currently being commissioned. Akeso is the largest provider of inpatient psychiatric services within the private sector and is a member of the National Hospital Network.

DR ANUSCHKA COOVADIA Head of Health Africa – KPMG

Dr Anuschka Coovadia holds an MB ChB and a Master's in Economics. She is head of healthcare, KPMG Africa, and has over 21 years of healthcare experience in strategy and operations, monitoring and evaluation, financial modelling, market access and clinical due-diligence assessments, feasibility studies, private equity transaction services, health risk management, good clinical practice and health services performance audits. She has participated in a number of major public forums on investing in healthcare in Africa (most recently at the World Economic Forum in Davos 2015) and has written numerous articles on healthcare systems, the business of healthcare, leadership, and key economic and social issues. She has successfully hosted mentorship and development programmes, international conferences and round-table discussions and is a sought-after speaker and facilitator on strategy, governance, strategic risk planning, leadership and healthcare systems reformation/transformation. In addition, she mentors young leaders within KPMG and externally and is passionate about economic growth implementation strategies and youth development.

BELLA MFENYANA

Executive: Contracts and Operations – GEMS Bella Mfenyana holds a BCom in Economics, MBA, Leadership Best Practices Programme from Harvard Business School and multiple acreditations. She is executive: contracts and operations at GEMS, tasked with the integration of the scheme’s business requirements so as to mitigate financial risk, including fraud management and legal exposure of the scheme. She is also in charge of service delivery by all contracted providers, mitigating financial risk and managing contracted operational business units and their performance. Her department is basically the engine of the scheme, with an extensive scope of responsibility, proven success and track record of delivering optimal results in high-growth environments through initiatives that exceed operational performance targets and yield measurable outcomes. She loves seeing tangible results in the health sector and knowing that she’s playing a part in this makes her proud. One of her career highlights was increasing the number of people who now have access to quality healthcare, which she did by introducing innovative solutions in the insurance industry, particularly with regard to quality and efficient healthcare.

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A N N UA L BH F C O N F E R ENCE BONGANI KHUMALO

Acting Chairman and CEO – Financial & Fiscal Commission (FFC) Bongani Khumalo holds a Bachelor of Science Honours in Economics, Master's of Science Economics, and a certificate of good leadership & Governance (Australian Habitant Studies). He is acting chairperson and chief executive of the Financial and Fiscal Commission (FFC RSA). He was previously the programme manager for fiscal policy in the Secretariat of the Commission. He has worked on a variety of areas within the South African intergovernmental fiscal relations system, including the design of revenue-sharing formulae, the financing of education, healthcare and social assistance programmes, subnational borrowing and taxation issues and the design of conditional grants. He lectured in economics and public finance at the University of Zimbabwe (Harare) and at Rhodes University (Grahamstown) prior to joining the FFC as a researcher. He serves as ex-officio commissioner in the Presidential Remuneration Review Commission and also chairs the Forum of Institutions Supporting Democracy. He has published extensively and his professional accreditations include a certificate of achievement from the Andrew Young School of Policy Studies at Georgia State University (USA) after he successfully completed a World Bank institute training programme (for professionals) on Fiscal Decentralisation in Developing and Transitional Countries. He has interacted regularly with various stakeholders of the FFC, among them the budget council and budget forum, parliamentary portfolio committees and National Council of Provinces select committees and the Presidential Co-ordination Committee.

DR BRIAN RUFF CEO – PPO Serve

Dr Brian Ruff, MB BCh (Wits 1983), FCP (SA 2002), Rheumatology D HM E FP (UCT 2002), CPMD (Wits 2006), is the CEO of Professional Provider Organisation Services (PPO Serve). PPO Serve helps clinicians organise structured healthcare systems with technical support for local, commercial Integrated Clinical ConsortiaTM that serve defined communities - this is ‘population medicine’. Their remuneration is related to good outcomes in a population value contract with medical schemes. Proactive patient care is supported by shared staff, health IT and detailed clinical information. Until March 2015, he was head of strategy at Discovery Health. He managed various divisions including the risk intelligence and the integrated care unit. His work included a macro-economic model of the South African private healthcare sector.

CARL (CALLIE) SCHAFER

CEO (Namibia) – Corporate Propserity Group Callie Schafer started working for Afrox Namibia in 1975, resigning as its regional manager for Namibia in 1997 when he joined the healthcare industry. Since joining that industry, he has gained extensive experience as principal officer of both closed and open schemes and in senor senior management positions in medical aid administration in Namibia. He has also served as president of the Namibian Association of Medical Aid Funds (NAMAF) and served for several terms as a director of the Board of Healthcare Funders of Southern Africa between 2002 and 2013.

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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  The Single Exit Price (SEP) of a Mediscor is an independent managed care organisation 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 27 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 from 54.5% in 2013 to solution in our market and to set the benchmark. One 55.6% in 2014.

of the areas where we have achieved this, is with our Mediscor Medicine Review (MMR). This report has been published on an annual basis since 2002 and 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 2015 results and findings: Ÿ

Overall medicine expenditure measured as the cost per beneficiary per annum increased by 5.9% for 2015 compared to 2014. This increase was mainly driven by a 7.0% increase in item cost.

Medicine expenditure increased by

Ÿ

The Single Exit Price (SEP) of a basket of medicine available in the market during 2013 to 2015 increased by 4.6% from 2014 to 2015.


solution in our market and to set the benchmark. One of the areas where we have achieved this, is with our BHF360° Mediscor Medicine Review (MMR). This report has been

| J U LY 2 0 1 6

A DVE R TO RIAL

published on an annual basis since 2002 and is highly regarded and used as a reference by industry. A sneak preview of the MMR 2015 results and findings: Ÿ

Overall medicine expenditure measured as the cost per beneficiary per annum increased by 5.9% for 2015 compared to 2014. This increase was mainly driven by a 7.0% increase in item cost.

Medicine expenditure increased by 5.9% from 2014 to 2015

Ÿ

The Single Exit Price (SEP) of a basket of medicine available in the market during 2013 to 2015 increased by 4.6% from 2014 to 2015.

Ÿ

Generic utilisation increased to 56.2% in 2015, while the generic uptake increased from 74.6% in 2014 to 76.5% in 2015.

Ÿ

New chemical entities constituted 1.9% of total medicine expenditure.

Ÿ

Utilisation of speciality medicines continues to increase, due to increases in both prevalence and item cost.

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


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ANNUAL BH F C ON FE RE N C E CHRIS ADAMS Director – Verirad

Chris Adams is a registered medical technologist who trained at the SAIMR (1978-1981) and was laboratory manager for Lancet Laboratories (1981-1998). He holds a number of qualifications in fields such as health economics, clinical pathology, chemistry and microbiology and is currently director of Verirad (Pty) Ltd and Verimed Africa (Pty) Ltd – Botswana, where he serves as health risk manager in the spheres of pathology and radiology expenditure.

CLEM SUNTER Author

Clem Sunter is a top-selling business author and one of the few specialists in the world on scenarios and their use in corporate strategy. He spent much of his career with Anglo American in the gold and uranium division, serving as its chairman and CEO from 1990 to 1996. He was until recently chairman of the Anglo American Chairman's Fund, which in a recent survey was rated the premier corporate social responsibility fund in South Africa. During the early 1980s he helped set up a scenario-planning function at Anglo, and later was one of the driving forces behind the South African ‘High Road/Low Road’ scenarios that helped pave the way towards the country’s peaceful transition to democracy. Since 1987, he has authored 17 books including the best-selling Fox Trilogy with fellow scenario strategist, Chantell Ilbury. He was recently awarded an honorary doctorate by the University of Cape Town for his work in the field of scenario planning, and was also voted by leading South African CEOs as the speaker who has made the most significant contribution to, and impact on, best practice and business in the country.

DUNCAN THELA

MD – Associated Fund Administrators (Botswana) Duncan Thela holds a Bachelor of Pharmacy from the University of Nottingham (UK) and an MBA from the University of Botswana. He has more than 30 years’ experience of working in various spheres of healthcare (both public and private sectors), including hospital, community pharmacy, wholesale and drug manufacturing, procurement, selection, regulation and registration, as well as implementation and management of disease management programmes and health insurance/medical aid administration, mostly in leadership/management positions. He is currently managing director of AFA Botswana (Pty) Ltd and is a member of its board of directors. He also works with or serves on various other advisory committees and boards. His previous positions include: chief operations officer at AFA; director of programmes (Botswana office) – International Training and Education Centre for Health (I-TECH); disease management programme manager (later managed care advisor) at AFA Botswana (Pty) Ltd; principal pharmacist: Ministry of Health – Botswana Essential Drugs Action Programme (BEDAP); managing director and production pharmacist – Pulo Pharmaceuticals (Pty) Ltd (own company); production pharmacist: Caps Botswana (Pty) Ltd and member of the board of directors of Caps Botswana Industries (Pty) Ltd and Caps Botswana Trading (Pty) Ltd.

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A N N UA L BH F C O N F E R ENCE ELIAS MASILELA

Commissioner – National Planning Commission Elias Masilela is currently executive chairman of DNA Economics, a position he has held since July 2014. In addition, among other responsibilities, he is commissioner, 1st & 2nd National Planning Commission (NPC), April 2010-May 2015 & September 2015-August 2020; independent advisor, Gerson Lehman Group, New York, July 2014; chairman, Economic Research Southern Africa (ERSA), November 2014-October 2019. His previous responsibilities include his being a steering committee member, DST-NRF Centre of Excellence in Human Development, May 2015-February 2016; member, UN Global Compact Board & Chairman, SA Local Network, NY, March 2012-June 2015; an independent advisor to DaMina Advisors, New York, July 2014-June 2015; CEO, Public Investment Corporation (PIC), February 2011-June 2014; head of policy analysis, Sanlam, July 2005-January 2011; member, board of the South African Reserve Bank (SARB), May 2008-January 2011; and a member of the board of the Government Employees Pension Fund (GEPF), August 2008-January 2011. His many qualifications include a Master of Sciences in Economic Policy and Analysis, Money, Banking and International Economics from Addis Ababa University, Ethiopia. He has a deep understanding of policy environment, grounded in sectoral and international matters.

DR FARAYI CHINYANGA

Executive Manager – Medscheme Dr Farayi Chinyanga holds a Bachelor of Medicine and Surgery, Honours in Biochemestry, postgraduation certificate in Law, and a Postgraduate Diploma in Health Economics from, inter alia, the University of Liverpool, Yale University and the University of Cape Town. He is currently executive manager of the Government Employees’ Medical Scheme (GEMS) business unit at Medscheme. Two months after being appointed to the role, the tender for the company’s largest contract (providing managed care services to over 1.8 million lives) was up for renewal. As head of the business unit, he was responsible for bringing the highly coveted contract back to the business. This was achieved and the contract was awarded to Medscheme for another five years. Prior to this, he was advanced specialist – clinical risk management at Medscheme from 2013 to 2015. He was the primary liaison between Medscheme and its largest client, GEMS. He also served as a member of the advisory team that sits on numerous key strategic executive committees within GEMS. He was responsible for reviewing statistical data relating to the client’s clinical risk parameters and advising on ways to minimise risk. As project champion he was responsible for providing innovative managed care solutions to the client, including disease management programmes, claims containment interventions and fraud mitigating measures. Earlier in his career he was casualty officer at Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, from 2011 to 2013, and deputy head of the casualty department at Parirenyatwa Academic Hospital, Harare, Zimbabwe, from 2008 to 2009.

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ANNUAL BH F C ON FE RE N C E FOUCHE HJ VENTER

Health Economist – DNA Economics Fouche Venter is an economist at DNA Economics, Pretoria, and has a specific interest in public policy and systems within the health and education sector. His qualifications include a Postgraduate Diploma in Public Health, University of Pretoria, 2015 and an M Com Economics, University of Pretoria, 2012. During his time at DNA Economics, and as a member of the public economics team, he has worked on a wide range of projects, specialising in the costing of public service provision, public finance and strategic planning. He was on the consulting team that developed and costed the South African District Health System Implementation Plan and he is currently completing a project in which he is costing primary healthcare services at two clinics in Gauteng. During a recent colloquium hosted by the Fiscal and Financial Commission he also presented on the international experience of other countries that have implemented a national health insurance system.

GRACE KHOZA

Executive Director, Group Marketing and Corporate Affairs – AfroCentric Health Grace Khoza is responsible for group marketing and corporate affairs, transformation and strategic relations activities across the AfroCentric Health Group. She has a wealth of experience at executive level in both the private and public sector. She holds a Master’s degree in media policy, communication and economics from the London School of Economics and a BA (Hons) in journalism from Rhodes University. Prior to joining AfroCentric Health, she was public relations and marketing manager at Bain Management Consulting. She has also served as the head of strategic communications and marketing within the Department of International Relations and Cooperation for a number of years, overseeing the communication, branding and marketing of the country across 126 embassies.

DR GUNVANT (GUNI) GOOLAB Principal Officer – GEMS

Dr Guni Goolab is a qualified medical practitioner, who graduated from the University of the Witwatersrand in 1985 and later completed an MBA at the University of Cape Town. He has extensive executive experience, having led AstraZeneca, a multinational healthcare company. Dr Goolab also has an extensive public and private healthcare background spanning nearly three decades. Under his leadership, AstraZeneca was one of the fastest growing pharmaceutical companies in South Africa. During that period, three flagship products were launched, which featured in the top 10 brands. From 2008 to 2013, he led the expansion of AstraZeneca into sub-Saharan Africa, with a particular focus on Nigeria, Ghana, Kenya and Angola. Since 1 August 2013, he has been principal officer of the Government Employees Medical Scheme (GEMS). Since his appointment, GEMS has implemented its third three-year strategy with some key achievements during this period, including the scheme’s new product development and benefit design process,

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A N N UA L BH F C O N F E R ENCE ADVOCATE HASINA CASSIM

Member of the Johannesburg Bar and Advocate of the High Court After completing her BPharm degree in 1990, Hasina Cassim did her internship at Brenthurst Clinic and continued to practise in hospital pharmacy as a pharmacist and manager. While part of the Presmed Group, she set up a home-based care company, the first of its kind, called SA Home Patient, before establishing an independent home-based care company, Careways, which thereafter expanded its services to include employee assistance programmes. She subsequently joined the pharmaceutical sector as an access and reimbursement manager and pursued studies in pharmaco-economics. After completing a certificate course in medicine and law through UNISA, she completed her LLB in 2011. She joined Discovery Health in 2005 as a risk manager, focusing on medicine and medical devices. She then added risk management of the Key Care plan to her portfolio. While with Discovery, she completed an executive leadership programme at the Said Business School, Oxford University. In 2015, Hasina left Discovery and joined the Johannesburg Bar as a pupil. Having passed the Bar exam, she is now a full member of the Johannesburg Bar and an admitted advocate of the High Court.

DR HLELI NHLAPO MD – DENIS

Dr Hleli Nhlapo qualified with a BChD from MEDUNSA in July 1991. He obtained a Postgraduate Diploma (Forensic Dentistry) and MSc Dent Sc (Forensic Dentistry) from Stellenbosch University in 1999 and 2001, respectively. He is registered with the HPCSA as a general dental practitioner and is a member of the South African Dental Association (SADA), where he has served on the private practice committee. He is currently a managing director of the medical schemes division at Dental Information (Pty) Ltd. He practised as a dental surgeon for 14 years before joining Denis in January 2005. He has attended various postgraduate courses within the dental specialties. He has served as the dental advisor for Medscheme (1998-2004), Managed Health Systems (2002-2004) and a local area manager for Bankmed under MHS. He was part of the SAMDP yearly tariff increase negotiation team with the then RAMS and also involved in the negotiations with the Dental Technicians Council that made it possible for dental technicians to claim directly from medical aid schemes. The University of the Western Cape's Dental Faculty invites him to speak annually to its final- year students on the subject of private health funding in South Africa.

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ANNUAL BH F C ON FE RE N C E ISHMAEL MOGAPI

Senior manager: operations risk at the Government Ishmael Mogapi has over 20 years of law enforcement and risk management experience in both the public and private sector. He is currently a senior manager: operations risk at the Government Employees’ Medical Scheme (GEMS), a medical scheme established to help public service employees and their families get the best possible healthcare at the most affordable rate. He holds various legal qualifications from some of South Africa’s leading academic institutions. Before joining GEMS, he held various strategic managerial positions in the health administration business, where he advised and coordinated the fraud risk management activities of several medical schemes. He lives by the motto ‘fun with a serious intent’ and it is with this belief that he combines a professional learning experience with fun.

DR JONATHAN BROOMBERG CEO – Discovery Health

Dr Jonathan Broomberg is CEO of Discovery Health, South Africa's largest health insurer, which manages 17 health funds, comprising over 3.2 million members. He is a medical doctor and health economist. He studied medicine at the University of the Witwatersrand, South Africa, and then read PPE at Balliol College as a Rhodes Scholar. He subsequently completed MSc and PhD degrees in health economics at the University of London. His career in healthcare includes a period serving as special advisor to the Minister of Health of South Africa in the first post-apartheid administration. Prior to joining Discovery Health 11 years ago, he was a founding director of a private equity and venture capital business investing in healthcare and education. Alongside his private sector interests, he maintains a strong engagement with South African and global health policy affairs.

DR JUDY DLAMINI

Executive Chairman – Mbekani Group Dr Judy Dlamini is the executive chairman of the Mbekani Group, which she founded 20 years ago, and recently stepped down as non-executive chairman of Aspen Pharmacare Limited (Aspen) after serving on the board for 10 years. She qualified as a medical doctor in 1985 but changed careers after obtaining her MBA in 1999. She worked for HSBC Investment Bank in corporate finance before leaving in 2003 to pursue a career as an entrepreneur. She recently (2014) obtained a doctorate in business leadership from UNISA. She initially founded Mbekani Health & Wellbeing (Pty) Ltd as an occupational health business, which offered executive medical screening, work policies on health and occupational assessments in business. Subsidiary companies were added within four years. She has resigned from most of her non-executive director positions in order to focus on her business and the family’s philanthropy work but remains a non-executive director for Anglo American Plc. She and her husband are the founders and trustees of Mkhiwa Trust, a family public benefit organisation with a focus on rural development and education. Through Umthombo Youth Development Fund, Mkhiwa funds students pursuing a career in medicine; through Thuthuka Bursary Fund, the trust funds students pursuing chartered accountancy. The trust has increased the number of students funded to include engineering and ICT with students at Wits, UKZN, UJ and UCT.

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A N N UA L BH F C O N F E R ENCE KULDEEP SINGH RAJPUT

Founder and CEO – Biofourmis (Singapore) Kuldeep Singh Rajput is the founder and CEO of Biofourmis Pte Ltd, a Singapore-based data analytics company working around a singular challenge: to personalise healthcare. Its revolutionary health programmes tackle remote, home-based management of various conditions such as cardiovascular disease in the most engaging, effective and personalised way possible. He is an active member of the healthcare innovation and entrepreneurship community in Singapore, with a specific interest in technology-enabled healthcare innovation. He is also a visiting research scholar at the National University of Singapore, where he focuses on building bioelectronics medicines, which aim to control biological processes and treat diseases by modulating electric impulses. Prior to moving to Singapore, he held a research position at MIT Media Lab’s Camera Culture group, where he worked on designing wearable technologies and biosignal analytics for cardiac health monitoring. He believes in pushing out working prototypes and closing the gap between engineering and medicine. He is a part of Google’s Solve for X community and has been invited to speak at various prestigious platforms like TED, HiMSS and EMBC on biomedical technologies. He and his team at Biofourmis have begun their journey towards unlocking the potential of biosensors to give deeper and meaningful insights into health, through data. He seeks to connect ideas and people to spark innovation.

LAMEES SCHOLTZ

Manager: Operations – BHF Lamees Scholtz is a self-motivated driven professional with a proven track record in management and administration. She joined the BHF in 2006 overseeing the managing director’s office and company secretariat administration functions, and currently holds the position of BHF manager: operations. Her qualifications include a Bachelor of Business Administration (Regenesys) and Certificate in Project Management (Wits Plus). She underwent pension fund trustee training at Meritor Consulting in 2008. Her current responsibilities include oversight and management of the Practice Code Numbering Unit, the Risk and Compliance Unit and the Health Forensics Management Committee. As a business-oriented professional, her core competencies include strategic planning, project management, staff management and risk management. Her result-driven competencies have been demonstrated by her Improving efficiencies through identifying strengths and weaknesses in systems and processes; designing, developing and implementing new systems, policies, standards and processes; optimising and motivating staff productivity through regular ongoing engagements and engagement with various external stakeholders to manage risk. A recent career highlight was her participation in the GHCAN strategic planning session in Washington DC in June this year.

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ANNUAL BH F C ON FE RE N C E DR LORATO MANGADI

Fund Administration Manager - Southview (Botswana) Dr Lorato Mangadi is currently head of fund administration at Southview (Pty) Ltd, the administrators of the Botswana Medical Aid Society (Bomaid). She obtained her medical degree from the University of Newcastle, New South Wales, Australia. Her work experience includes positions as a medical officer at Princess Marina Hospital in Botswana and as a senior medical officer at Gaborone City Council outpatient-based clinics. Her career in the funding industry started at Bomaid in 2009, where she served as a medical advisor until 2011. In 2012, following a restructuring exercise that led to the formation of Southview (Pty) Ltd, she was appointed as a managed care manager in charge of pharmacy, wellness and chronic disease management services. She took up her present position in 2014. She studied part time at the University of Botswana and graduated with an MBA in 2014.

DR MANGALISO MAHLABA

CEO – Thebe ya Bophelo Administrators Dr Mangaliso Mahlaba holds a BSc Hons from Rhodes University, an MB ChB from MEDUNSA and a Master's in Health Economics and Pharma-economics from Pompeu Fabra, Spain. He is currently the CEO of Thebe Ya Bophelo Administrators (TYB). Prior to this, his positions included being COO and medical director at TYB, network manager at Prime Cure and director and co-founder of Philani Healthcare. He is a former deputy chairperson of BHF and served for four years on the board.

MARK BRITNELL

Chairman & Partner – KPMG Global Health Practice (UK) Mark Britnell is chairman and partner of the Global Health Practice at KPMG. Since 2009, he has worked in over 60 countries, helping governments, public and private sector organisations with operations, strategy and policy. He has a pioneering and inspiring global vision for healthcare in both the developed and developing world and has written extensively on what works around the world (for more information, visit kpmg.com/whatworks). He has dedicated his professional life to healthcare and has led organisations at local, regional, national and global levels. He was CEO of high-performing University Hospitals in Birmingham and masterminded the largest new hospital build in the NHS. He also ran the NHS from Oxford to the Isle of Wight before joining the NHS management board as a director-general. He developed ‘High Quality Care for All’ with Lord Darzi and published his first book, In Search of the Perfect Health System, in October 2015.

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A N N UA L BH F C O N F E R ENCE PROFESSOR MCEBISI NDLETYANA

Associate Professor: Political Science – University of Johannesburg Mcebisi Ndletyana is an associate professor of political science at the University of Johannesburg. Before joining UJ, Professor Ndletyana worked at the Mapungubwe Institute, where he headed the political economy faculty. He has also held research positions at numerous other institutions, including the Human Sciences Research Council, Centre for Policy Studies and the Steve Biko Foundation. Professor Ndletyana is an author of 27 publications. His latest book is entitled Institutionalising Democracy: The Story of the Independent Electoral Commission of South Africa, 1993 – 2014. His next book, due to be published next year, will be on the 100-year history of Fort Hare University.

MICHELLE BEETAR

MD – Experian South Africa Michelle holds a Bachelor of Commerce (Economics) degree from the University of the Witwatersrand. She joined Experian in May 2011 as director: decision analytics, marketing and sales for Experian South Africa and progressed to her current position in December 2011. Her role entails taking accountability for setting the business’s overall strategy and ensuring the South African team achieves its goal of becoming the most respected information services player in the local market. She is also a member of the EMEA executive leadership team. Prior to joining Experian, she enjoyed 16 years in the South African software industry including director-level positions at well-known local and multinational companies such as MWeb and Oracle. Her most recent position was as managing director of Novell South Africa, during which time she is very proud to have been honoured as the Workgroup Businesswoman of the Year in 2009. She currently holds positions on the boards of Experian SA (Pty) Ltd and Who Owns Whom (Pty) Ltd and was previously a board member at Novell SA (Pty) Ltd.

NHLANHLA MUSA NENE

Resident Advisor – Thebe Investment Corporation Nhlanhla Nene holds the following qualifictions: B Com (Honours) (University of the Western Cape), Certificate in Micro- and Macroeconomics (University of London), Certificate in Economics (UNISA), Advanced Diploma in Economic Policy (University of the Western Cape) and Diploma in Marketing Management (DMS). He was a sales representative and later branch administrative manager at Metropolitan Life from 1985 to 1999 and served as a local government councillor from 1996 to 1999. He was a member of Parliament from 1999 to 2015 and co-chairperson of the Joint Budget Committee from 2002 to 2004. He chaired the Portfolio Committee on Finance from 2004 to 2008 and was deputy Minister of Finance from 2008 to 2014. He also chaired the Public Investment Corporation (which manages the funds of the State pension funds) from 2008 to 2014. He was a member of the local organising committee for the FIFA World Cup in South Africa, Confederation of Football Association and African Nations Championship from 2009 to 2013. He was South Africa’s Minister of Finance from 2014 to2015. He is currently a non-executive director of Allan Gray and resident advisor at Thebe Investment Corporation.

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ANNUAL BH F C ON FE RE N C E PROFESSOR PRANEET VALODIA Independent Healthcare Consultant

Extraordinary Professor Praneet Valodia is a healthcare consultant in strategy, innovation, health policy, managed healthcare, business efficiency and technology. His qualifications include a PhD (Pharmacology) from UCT. He serves on the Ministerial Medicines Pricing Committee and has worked in the managed healthcare and medical scheme environment for 19 years as an executive: innovation and development, executive: research and development, director: medicines management, clinical executive, head: product development, chairman: drugs and therapeutics committee, chairman: formulary committee (oncology), advanced specialist in medicines and beneficiary management and as a business consultant. He supervises postgraduate research in health economics and in 2015, he was a finalist for the BHF Titanium Lifetime Achiever’s award for significant contributions to the healthcare industry. In 2015, he also started his own business offering consultancy services in innovation in disease and medicine management, health outcomes measurements, health policy, clinical trial and pharmacoeconomic evaluation, and medicines pricing.

DR RAJESH PATEL

Head: Benefit and Risk – BHF Dr Rajesh Patel is head of the Benefit and Risk Department, Board of Healthcare Funders (BHF). He is a specialist family physician and worked as one from 1987 to 1995. After leaving private practice he joined the medical schemes industry. His roles in the industry have included medical advisor, scheme manager and clinical risk manager. Prior to joining the BHF in 2005 he spent two and a half years in the pharmaceutical industry. His special interests are quality assurance, value-based medicine and application of public health principles in health risk management. During the period 2001-2003 he was a teaching assistant in the Department of Health Systems Management of the National School of Public Health (MEDUNSA). He assisted with postgraduate training of FCFP (SA) candidates. He was a non-executive director of the Council for Health Service Accreditation of Southern Africa (COHSASA), and is a non-executive director of Health Quality Assessment (HQA) and a past chairman of the Clinical Review Committee of HQA. He is a member of the Ministerial Health Data & Advisory Committee. He was a member of the Ministerial ICD10 Advisory Committee.

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A N N UA L BH F C O N F E R ENCE REG MAGENNIS

Managing Director – EOH Health Reg Magennis is a chartered accountant with a Master’s in Business Leadership and an international qualification in managed healthcare. He has held directorship, CEO and head of department positions at a number of healthcare organisations in South Africa, including Glaxo, the Medical Association of South Africa, the Representative Association of Medical Schemes (forerunner of the Board of Healthcare Funders), Medscheme, Network Healthcare Holdings Limited (Netcare) and Deloitte & Touche Human Capital Corporation. In 2003, he and two partners acquired the healthcare consulting business from Deloitte and over time developed a suite of healthcare firms that offered strategic consultancy, intermediary, wellness and occupational health and logistics services to large employers and organisations in the medical scheme funded sector. These businesses were sold to EOH, an ICT, business process management and building technology company listed on the Johannesburg Stock Exchange. He is the managing director of the EOH Health Division.

PROFESSOR ROBERT VAN NIEKERK

Director of the Institute of Social and Economic Research, Rhodes University Robert van Niekerk is professor of social policy and director of the Institute of Social and Economic Research at Rhodes University, Grahamstown. He holds a BA (Hons) (UCT), MSc Sociology (LSE), MPhil, DPhil (Oxon). Professor van Niekerk’s area of research, teaching and publication is the institutional history, ideologies and understandings of social policy and social change in South Africa, with a special focus on the struggle to achieve universal healthcare. He also has an interest in social policy in a postapartheid South Africa – particularly polices aimed at overcoming inequality and developing social rights of citizenship and the ‘good society’, and looking at the factors that account for success and failure in policy implementation.

SANDILE ZUNGU CEO – ZICO

Sandile Donald Muziwenkosi Zungu completed a BSc (Mechanical Engineering) degree at the University of Cape Town (UCT) in 1988, as well as a Master’s in Business Administration (MBA) at the UCT Graduate School of Business in 1995. He is a member of the BRICS Business Council, vicepresident (business) of the Black Business Council and also serves on the BBBEE Presidential Advisory Council. He is the chairman of the UCT Graduate School of Business advisory board. He currently serves as a non-executive director of Grindrod Ltd, non-executive director of Novus Holdings and nonexecutive chairman of EOH Holdings, all listed on the JSE Securities Exchange. He is executive chairman of Zungu Investments Company (Pty) Ltd (Zico), which is the holding company of his business interests. He is also non-executive director of the Qhubeka Forensic Services Board.

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ANNUAL BH F C ON FE RE N C E SARAH LOUISE BARBER

Senior Policy Adviser, Regional Director's Office, WHO Regional Office for Africa Sarah Louise Barber holds a post-doctorate in economic evaluation from the Haas School of Business, University of California, Berkeley, and a doctorate of public health: health economics from the School of Public Health at the same university. She is currently the senior health policy advisor, office of the regional director, African Regional Office of the World Health Organization (WHO). From 2012 to 2016, she was the WHO representative to South Africa. She is a health economist and policy specialist. She holds a master’s degree in epidemiology in addition to her doctoral and post-doctoral qualifications. She has published widely on diverse topics, including health economics and policy research, healthcare reform, quality of care, hospitals, medicines quality, monitoring and evaluation, and tobacco economics. During the past 20 years, she has lived and worked in China, Indonesia, Cambodia, Thailand, the USA, Europe and Mexico, and has conducted research in Africa, Asia and Latin America. Before she came to South Africa, she was working with the WHO in China on the design and implementation of their national health reforms; this work built on experiences in working on healthcare reforms in the USA, Mexico and Indonesia.

DR TEBOGO PHALENG

Executive Director – Coalesce Dr Tebogo Phaleng holds an MB ChB from the University of Natal. He is a medical doctor and current managing director of Coalesce, an independent advisory agency that provides strategy, risk management and related advisory services to health institutions and organisations in the private and public healthcare sectors. He has over 17 years of experience within the health industry and has held senior clinical and management roles in various healthcare and clinical research institutions locally and in the UK. He was a senior member of the strategy and risk management division at Discovery Health for seven years, prior to founding Coalesce in 2013. At Coalesce, Tebogo has led a number of major consultancy assignments, among others, curator and acting principal officer of Medshield Medical Scheme, where he was responsible for operating and restoring the scheme’s governance, internal controls, risk management structures and processes; and strategy advisor to BHF, currently as an independent member of BHF’s Think Tank and NHI Working Group.

THEMBEKILE PHASWANE

Senior Manager: Complaints Adjudication – CMS Thembekile Phaswane is a senior manager in the complaints adjudication unit at the Council for Medical Schemes (CMS) and has 16 years of experience there. After obtaining her BA degree and LLB (postgraduate) degree from the University of the Western Cape and University of Cape Town, respectively, she worked in the legal department of the South African Human Rights Commission before joining the CMS in 2000. A lawyer by profession, she is responsible for the overall management, administration and strategic leadership of the team of lawyers handling complaints lodged with the CMS. The role of the complaints adjudication unit is to investigate and resolve complaints lodged with the CMS against entities registered or accredited by the CMS in terms of the Medical Schemes Act.

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A N N UA L BH F C O N F E R ENCE TOMAS ROUBAL

Health Economist – World Health Organization (WHO) Tomas Roubal holds qualifications in economics and public policy from Charles University in Prague, Czech Republic. He gained his experience in health systems at the Czech Ministry of Health advising the minister of health on the long-term sustainability of the social health insurance system and reform of payment mechanisms. He was responsible for regulation of health insurance funds in the Czech Republic. He co-authored several decrees regulating prices in the Czech healthcare sector. During his consultancy at the Organisation for Economic Co-operation and Development (OECD) in 2012 he prepared guidelines for measuring overthe-counter pharmaceuticals as part of the System of Health Accounts 2011. Since 2013 he has been working for the World Health Organization in South Africa as a health economist. He has been supporting the national Department of Health on the introduction and institutionalisation of national health accounts and has been advising on health system reform. In cooperation with the OECD he prepared an international price comparison report, which was presented to the Healthcare Market Inquiry in February 2016.

DR TONY BEHRMAN CEO – IPA Foundation

Dr Tony Behrman holds an MB ChB and a Diploma in Occupational Health, both from the University of Cape Town. He is a Foundation Fellow of the Faculty of Forensic and Legal Medicine (Royal College of Physicians) and an accredited DISAC mediator, UCT Law @ work. His current positions include chairman of the South African Managed Care Cooperative (since 2013); CEO and treasurer of the IPA Foundation of South Africa (since 2013); chief executive officer of Cape Primary Care / Qualicare IPA, Western Cape (since 1990); coard member of Profmed (since 2009); and private medicolegal consultant (since July 2012).

VISHAL BRIJLAL

NHI Coordinator – National Department of Health Vishal Brijlal trained as a health economist and has over 20 years of experience in various aspects of health and financing policy in many countries, including South Africa and India. After completing his postgraduate studies at the University of Durban-Westville (now the University of KZN), he joined the Health Economics and Financing Unit at the Centre for Health Policy (University of the Witwatersrand). In 1998, he left to join the Health Economics and Finance Directorate at the national Department of Health (NDOH) as a deputy director. In 1999, he was appointed to the post of director: health financing and economics. After leaving the NDOH in late 2003, he joined the Board of Healthcare Funders (BHF) as executive for research and advocacy. In 2006 he was appointed country director for the CHAI programme in India. He was instrumental in the introduction and implementation of a paediatric ART programme in partnership with the National AIDS Control Organisation (NACO). In 2008, he established the CHAI programme in South Africa and currently serves as country director. In 2012, he was seconded to the office of the director-general: health at the NDOH as technical advisor on health financing and national health insurance (NHI). In December 2015, he was appointed to lead Workstream 4: The Future of Medical Schemes, one of the six NHI workstreams. In May 2016, the Minister of Health appointed him NHI coordinator.

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ADVERTO RIA L

How medical schemes can better serve the needs of their members When the Government Employees’ Medical Scheme (GEMS) first opened its doors for business in 2006, few expected it to be the success that it turned out to be. To its credit, GEMS took swift and incisive measures to make the most of a golden opportunity. With the aid of a rigorous tender process and watertight contractual agreements, we have contracted with best-ofbreed service providers, who are providing the appropriate infrastructure and skills to serve the needs of our members.

Snapshot of recently introduced customer-centric innovations from GEMS

A recent advance in our continuous efforts to enhance our service saw the introduction of GEMS self-help kiosks. These interactive tools provide personalised service to members and prospective members at the touch of a button. With a dedicated GEMS ambassador on hand to assist, members can access a range of services, including logging of queries and requests, viewing their claims and benefits, and printing their GEMS documentation.

In a bid to help protect members against lifestyle diseases and proactively promote health and productivity, the GEMS fitness programme was piloted late last year and implemented at the beginning of 2016. This initiative offers members guidance and support on exercise and nutrition, as well as access to the GEMS ‘fitness journey’ portal, which allows them to measure their progress and challenge their colleagues.

GEMS has introduced a number of client liaison officers (CLOs) to serve members throughout South Africa, including those residing in remote areas. The specially trained CLOs serve as a vital link between the scheme, the service provider network and the members, whom they are able to assist in the member’s language of choice.

Extensive research was conducted into the development of an innovative product range, options specifically designed to suit members’ medical usage patterns. In-house campaigns focused on an ethos unique to GEMS, boosting staff morale and rewarding productivity. The results have been encouragingly positive but we have not stopped there. We conduct regular surveys to assess our service on an ongoing basis. We research the opinions of each individual government department, member and service provider. These research results are not simply filed away. We take active measures to address each issue highlighted as problematic or potentially challenging.

VALUE FOR MONEY – FIRST AND FOREMOST GEMS has always made an effort to deliver the finest possible healthcare benefits to its members at the most affordable rates. Contribution rates on GEMS benefit option plans are maintained at 19% below those of similar benefit plans offered by other medical schemes, while offering similar or better benefits. At GEMS we understand that if you put your members at the heart of everything you do and focus on making a difference in their lives, others will be encouraged to join your medical scheme and existing members will become your brand ambassadors. This belief is at the core of everything we stand for within GEMS.

Tel: 0860 00 4367 Fax: 0861 00 4367 Emergency number: 0800 44 4367 (available 24-hours) Confidential fraud line: 0800 21 22 02 Email: enquiries@gems.gov.za Website:www.gems.gov.za


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T I TA N I U M AWARD S

The 2016 Titanium Awards W

e are excited to host the 2nd Annual Titanium awards. Adjudicated by a panel of well-respected health professionals, the awards recognise and honour top performers in the public and private healthcare sector in southern Africa, and those delivering superior service to their customers and members. By recognising benchmarks for exceptional performance, we aim to drive standards and service delivery, which, in the long term, will help build a more effective healthcare industry overall. The 10 awards are divided into seven categories. By recognising service excellence and celebrating the success of both individual and business contributions to the healthcare industry in southern Africa, the awards have the following objectives:

Improve the quality of health services. Create a platform that unites the healthcare industry. Demonstrate best practice. Recognise application of best practice in action – with an emphasis on initiatives that are well rounded, sustainable, holistic and responsible.

For the Titanium awards to achieve their goals, the industry needs to engage pro-actively with them. BHF is therefore issuing a call to action to all those involved in healthcare in South Africa. “We want to hear from you. Do you have a dynamic youngster on your team who’s eligible for our Young Achiever award? Is there someone who’s devoted their entire career to improving the quality of healthcare in our country? Nominate them for our Lifetime Achievement award. We also want to know about what the industry is giving back to the community – and potentially recognise such initiatives with a Titanium award for Corporate Social Investment.” The adjudication process for this year’s awards was still under way at the time BHF 360o went to press. All winners will be announced on 18 July 2016.

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The Judges 2016 Awards DR ANUSCHKA COOVADIA Dr Anuschka Coovadia holds an MB ChB and a Masters in Economics. She is head of healthcare, KPMG Africa, and has over 21 years of healthcare experience in strategy and operations, monitoring and evaluation, financial modelling, market access and clinical due-diligence assessments, feasibility studies, private equity transaction services, health risk management, good clinical practice and health services performance audits. She has participated in a number of major public forums on investing in healthcare in Africa (most recently at the World Economic Forum in Davos 2015) and has written numerous articles on healthcare systems, the business of healthcare, leadership, and key economic and social issues. She has successfully hosted mentorship and development programmes, international conferences and round-table discussions and is a sought-after speaker and facilitator on strategy, governance, strategic risk planning, leadership and healthcare systems reformation/transformation. In addition, she mentors young leaders within KPMG and externally and is passionate about economic growth implementation strategies and youth development.

DR CAROL MARSHALL Dr Carol Marshall holds an MSc in Mother and Child Health from the University of London and an MSc in Community Medicine from the University of the Witwatersrand, among other qualifications. She is currently the national coordinator of district clinical specialist teams responsible for clinical governance in relation to mothers and children at district level, and is a visiting lecturer for quality healthcare at the University of the Witwatersrand. She has worked extensively in Mozambique and South Africa as a paediatrician, a health service manager and an academic. Starting in 2008 she managed the Office of Standards Compliance in the national Department of Health, guiding the development and monitoring the implementation of quality programmes. She supported the parliamentary process for the promulgation of the National Health Amendment Act establishing a new public entity, the Office of Health Standards Compliance (OHSC) and was its interim CEO until her retirement in 2015.

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T I TA N I U M AWARD S

PROFESSOR AMES DHAI Professor Ames Dhai, MB ChB, FCOG, LLM, PhD, is the director of the Steve Biko Centre for Bioethics at the Faculty of Health Sciences, University of the Witwatersrand. She is an ethicist of international standing who can be credited with entrenching bioethics as an integral aspect of health sciences in South Africa. She established the centre, which runs Master's and PhD programmes in bioethics and health law, in 2007 and it has gained local and international recognition as a leading centre in these disciplines. Professor Dhai serves on several policy-making bodies. She also serves regularly as a consultant/expert advisor for the World Health Organization, is on the WHO’s African Advisory Committee for Health Research, and serves on the World Medical Association’s (WMA) working group on health databases and biobanks. She also participated in the WMA’S working group on amendments to the current Declaration of Helsinki.

ADJUNCT PROFESSOR SHAN NAIDOO Professor Shan Naidoo is chief specialist and head of the Department of Public Health Medicine at the Wits School of Public Health. He has over 15 years of health services experience in addition to his 15 years in academia. He holds a joint post with the Gauteng Department of Health, where he is involved in strategic planning, policy development, monitoring and evaluation. He is the immediate past president of the College of Public Health Medicine of the Colleges of Medicine of South Africa. He has extensive research interests and has published over 40 publications in the last 10 years. He is also an associate editor of the Southern African Journal of Epidemiology and Infectious Diseases. He reviews for many international journals including the UK’s Journal of Public Health. He has received many awards including the Transformation Award and the Vice Chancellor’s Academic Citizens award of the University of the Witwatersrand.

PROFESSOR STUART WHITTAKER Stuart Whittaker, BSc, MB ChB, FFCH (CM), MMed, MD, is the founder and former chief executive officer of the Council for Health Service Accreditation of Southern Africa. He pioneered the concepts of a facilitated accreditation programme and graded recognition to assist disadvantaged hospitals to comply with professional standards. He also conducted research on and the testing of adverse event monitoring systems. He has published widely and has presented at numerous conferences. As a temporary consultant to the World Health Organization he participated in projects to assess the impact of accreditation on national health systems. He was appointed by the Minister of Health in 2013 to serve on the board of directors for the Office of Health Standards Compliance (OHSC). He is a visiting professor at the School of Public Health and Medicine, Faculty of Health Sciences, University of Cape Town and extraordinary professor in the School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria.

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The Winners 2015 Awards Congratulations to the winners of the inaugurial Titanium Awards 2015

CATEGORY 1 | Titanium Award for Service to Membership OPEN Medical Schemes – CompCare Wellness Programme CLOSED Medical Schemes – Massmart Health Plan

CATEGORY 2 | Titanium Award for Service Excellence MANAGED HEALTHCARE Entities – Universal Care ADMINISTRATORS – Universal Administrators

CATEGORY 3 | Titanium Award for Health Facilities (Hospitals, Clinics, etc.) PUBLIC SECTOR – Witrand Hospital

CATEGORY 4 | Titanium Award for Excellence in Corporate Social Investment Clicks Helping Hand Trust

CATEGORY 5 | Titanium Award for Young Achiever Dr Lungi Nyathi

CATEGORY 6 | Titanium Lifetime Achievement Award Professor Jan van der Merwe

CATEGORY 7 | Titanium Award for Advisory Services Excellence Alexander Forbes Health

CATEGORY 8 | Titanium Award for BHF Member of the Year – 2015 SAMWUMED

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17 Annual Conference th

Sponsors & Exhibitors GROUP 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, administration, managed care, disease management and life and general insurance. 2CANA’s clients include Bestmed Medical Scheme, Momentum Health, Private Health Administrators, TopMed Medical Scheme, First Mutual Health, Alliance-Midmed, Hollard Insurance Company, Alexander Forbes, Old Mutual, MiWay Insurance, Cellmed Health and Altfin Health. 2CANA’s HiP system is regarded as the premier solution in southern Africa for efficient and reliable administration of medical schemes, incorporating policy and claims 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.

AfroCentric Investment Corporation Limited (‘AfroCentric’) is a black-owned, diversified investment holding company established in 2008 and listed on the JSE. AfroCentric has specifically invested in businesses that demonstrate favourable prospects for growth while actively contributing to the upliftment of South Africa’s people in a meaningful and sustainable manner. Through its operating subsidiaries, AfroCentric provides health administration and health risk management solutions to the healthcare funding industry. In addition, AfroCentric provides a range of complementary services to its traditional medical scheme clients as well as a portfolio of healthcarerelated enterprises. These services include IT solutions, transactional switching and specialised disease management. www.afrocentrichealth.co.za Email: judyb@afrocentrichealth.com

2CANA Solutions currently supports more than 20 insurers in 15 countries across four continents with over 740 000 policy holders and a total premium yield of more than US$880 million (over R10bn). www.2cana.co.za Tel: 031-583-3200 BOARD

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CO NFE R E NC E S PON S ORS

Agility Health, a subsidiary of Agility Holdings, a global healthcare solutions company, operates predominantly in South Africa and has successfully concluded projects across a broad spectrum of clients throughout Africa. As one of the 10 largest open medical scheme administrators in the South African healthcare industry, Agility Health’s delivery model is built around a boutique, integrated offering to medical schemes and health funders. As a result, the company is able to ensure customised service centres, executive involvement in delivery and assistance with the development and roll-out of healthcare strategies. Based in Johannesburg, Gauteng, Agility Health’s ownership encompasses a combination of institutions, executive management and strategic stakeholders, while partnering with local players who add invaluable expertise, resources, capital and local knowledge to ultimately ensure a holistic, worldclass delivery model. www.agilitychannel.co.za Tel: 021-918- 6210

Aid for AIDS was launched in 1998 and has since expanded its services across Africa. With our modular treatment programmes we’ve been able to take on clients of all sizes, in all business sectors, locally and internationally. We are the most experienced, knowledgeable and furthest-reaching HIV/ AIDS management partner, ensuring members have access to the best care throughout their life. We also play a leading role in collaborating with and participating in government-led task teams involved in HIV/AIDS projects. Our approach is to act as a care-coordinator between the funder, doctors, pathology laboratories, pharmacies and patients. Supported by a team of world-respected clinicians in the field, we enable the optimal care of patients with an end-to-end solution, backed by a customised IT system that has become the gold standard in HIV disease management. Our programmes understand the needs of patients and equip them with the treatment and tools to lead normal, fulfilled lives. We empower funders to guard against the financial risk posed by unmanaged HIV in their employee or member populations. Website: www.aidforaids.co.za Tel: 011-671-2538

Allegra’s software solution enables total patient care through technology. 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 product suite is a sharp instrument in the hands of agile, progressive thinking healthcare businesses and consists of different modules, which can be combined or used as standalone solutions to fit your business requirements. The Allegra platform allows integration between healthcare stakeholders such as medical aids, insurance companies and healthcare providers. The Allegra product suite offers: • Allegra Connect, a real-time electronic data interchange. • Allegra Synergy, a software suite that consists of WellScreen (a health risk assessment solution), ClinicPro (a primary care practice management solution), CarePro (a retail pharmacy management solution) and ScriptPro (a management solution for courier pharmacies). • Allegra Synapse, a real-time clinical information exchange solution between medical aids, administrators and their members. www.allegra.co.za Tel: 012-329-5911

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ALUWANI Capital Partners is an independent owner-managed investment management business, registered with the Financial Services Board (FSB) and is an approved investment manager in terms of the Financial Advisory and Intermediary Services Act (FAIS). Our core offering is investment management with research and product capabilities across all asset classes. With over 20 years of investment management experience, we manage approximately R67 billion on behalf of institutional clients, which include retirement funds, medical schemes, treasuries, state-owned, enterprises, corporates and insurers. ALUWANI, meaning ‘to prosper or to grow’, was created to play a transformational role within South Africa, while positively contributing towards the prosperity of all our stakeholders, including clients, staff, shareholders and communities. www.aluwanicapital.co.za Tel: 021-204-3817

The Healthcare Forensic Management Unit (HFMU) was formed to ensure a unifi ed 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. The HFMU has also 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 eff orts of the HFMU. www.bhfglobal.com Tel: 011 537 0244 Email: hfmu@bhfghlobal.com.

Bonitas Marketing Company (Pty) Ltd (BMC) is a sales and marketing firm appointed by Bonitas Medical Fund to ensure the optimal marketing of Bonitas with the aim of ensuring sustainable growth. In essence, we are the engine through which Bonitas’ growth strategy initiatives are driven and we provide unique and expert strategic guidance. BMC possesses the competencies required to carefully consider the economic conditions in South Africa and their impact on the medical schemes industry. We monitor the industry closely on a continuous basis to identify trends, something that enables us to prepare and respond adequately to the needs of Bonitas Medical Fund and its members as stated in the scheme’s strategic intent. We advise the scheme on the emergence of media; the way in which consumers interact, research and buy products; the internet and evolving distribution models; the growing number of sales and service touch points; and the fragmentation of member segments. With time, we aim to emerge as the ‘voice of the member’ for the Scheme as it responds to any significant changes in the marketplace. www.bonitas.co.za Tel: 011-671-2538

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Council

a division of

Cape Town is one of the leading cities in Africa. It is an economic powerhouse with a good climate, spectacular natural beauty and a fine academic legacy. With arguably the best infrastructure on the continent and a business hub that constantly outperforms the rest of the country, there is no better place to choose for hosting a business event. The city is set within the unique Cape floral kingdom and is surrounded by the historic winelands of the Western Cape, which have earned the city its reputation as a gastronomic destination. Add to this natural beauty, interesting cultural diversity and a creative spirit, and you’ll discover why Cape Town inspires meeting planners to explore a wide variety of unforgettable attractions. Cape Town and the Western Cape are the number one conference destination in Africa and the Middle East (ICCA 2015). With custom-built centres designed to top international specifications, a diverse range of facilities at hotels, educational institutions and theatres, visitors can be guaranteed a world-class experience.

for Medical Schemes

Clicks is the country’s pharmacy chain with a print comprising over dispensaries and over ‘feel good clinics’.

largest retail national foot380 in-store 170 in-store

Clicks is devoted to making professional primary healthcare services more accessible to all; our compliant and transparent pharmacy network, which charges no hidden costs and additional administration fees, and offers opportunities to collaborate on marketing initiatives, is one of the key reasons why we are the preferred service provider to most medical schemes.

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Speak to our dedicated key accounts team to find out how we can be your strategic primary healthcare partner. www.clicks.co.za Tel: 021-460-1359

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

Day hospitals are centres of excellence, developed and equipped for same-day surgical procedures. They play a major role in reducing the cost of healthcare. In fact, seventy-five percent of all surgical interventions can today be performed in day hospitals, thanks to technological innovations. The Day Hospital Association promotes ‘cost-effective quality services’.

Email: hello@wesgro.co.za www.capetownconventionbureau. org

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The Council for Medical Schemes (CMS) promotes vibrant and affordable healthcare cover for all. It ensures protection for medical scheme members and informs them of their rights. Furthermore, the CMS keeps an eye on medical schemes’ financial performance and ensures their compliance with the Medical Schemes Act of 1998.

www.dhasa.co.za Tel: 082-776-1186

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Documentation Based Care (DBC) is the global leader in musculoskeletal rehabilitation. For over 20 years we have pioneered a growing global network of advanced specialist centres with a definite goal: to provide better results, more efficiently, with greater cost benefits. We have developed the industry’s best protocols to successfully and effectively promote functional ability and work capability to the chosen target group. The company’s mission is to deliver these services for the benefit of the working community and individual patient, while continuously developing the protocols in order to advance the functional ability and work capability of the individual.

DENIS, Africa’s leading dental funder, has been providing innovative dental solutions for the past 20 years. We are passionate about everything dental and strive to exceed all our clients’ expectations. As part of EOH Healthcare, we have the scale and support of the JSE’s leading technology provider in EOH.

EOH provides the technology, knowledge, skills and organisational ability critical to Africa’s development and growth. Following the consulting, technology and outsourcing model, we provide high-value, end-to-end solutions to our clients in all industry verticals. Listed in 1998, EOH attributes its 45% compounded annual growth to a culture of remaining prudent and not just meeting, but exceeding, customer expectations. EOH strives to be an ethical, relevant force for good and to play a positive role in society, beyond normal business practice.

www.denis.co.za Tel: 021-528-5300

The focus at EOH Health is on improving healthcare delivery fluently, which is done by drawing on the consulting, technology and outsourcing competencies within the broader EOH Group to strengthen and enhance health systems delivery. EOH Health spans a variety of inter-related areas, including health sector consulting, health facility operation management and engineering, claims processing management, workplace health solutions, information systems development and business modelling.

We build a central database containing baseline and outcome data from over 100 000 treated patients. These data, together with new findings from ongoing research, are used to continuously improve the efficacy of treatments. We offer collective experience from clinic instillations implemented in more than 20 countries. www.dbcklinikka.fi Tel: 011-671-2538

Email: derry.heron@eoh.co.za.

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Care

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 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. www.firstcarecourier.co.za Tel: 011 952 4000

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The mission of the Government Employees’ Medical Scheme (GEMS) is to provide all public service employees with equitable access to affordable and comprehensive healthcare benefits.

Health Management Digest (HMD) was launched two years ago, primarily to serve as a unique monthly non-clinical inter-stakeholder communications medium across the full healthcare spectrum.

GEMS is centred on the principles of: equity, efficiency and differentiation equity, where employees have equal access to the most extensive set of equal basic benefits under equitable remuneration structures, subject to affordability; efficiency in terms of the costs and delivery of benefits; and differentiation, where employees choosing more extensive cover have equal access to higher benefits, subject to their needs.

As the country’s only business-tobusiness healthcare management publication in digital format, HMD’s content has been structured to be of collective interest and importance to the country’s healthcare professionals, medical scheme executives and administrators, key pharmaceutical industry and medical device marketers, practice management consultants and suppliers, associated IT operators, and related service organisations.

www.gems.gov.za Tel: 0860- 004-367

Articles and reports therefore include legislative updates, related business and financial issues, reports, interviews and commentary on medicopolitical matters and industry reviews, as well exclusive illustrated coverage of pertinent seminars and conferences.

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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 innovative technology solutions and creating efficiencies for its clients. Technology is an enabler to create the ideal environment in which a 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 analytical models and workflow, which are integrated into 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.

The HPCSA is a statutory body and is committed to protecting the public and guiding the professions. 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. 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.

Insight Actuaries & Consultants have a deep understanding of the issues its clients face. We have developed the tools and capabilities needed to address the complexities of the healthcare system and insurance markets. Our advice is succinct, understandable and relevant. Insight’s services include: actuarial consulting, healthcare provider benchmarking (family practitioners, specialists, hospitals and pharmacists), patient risk classification, DRG-based hospital analysis, business intelligence, optimised investment strategies and alternative reimbursement model development. www.insight.co.za Tel: 011- 541- 0900

www.hpcsa.co.za Email: info@hpcsa.co.za and servicedelivery@hpcsa.co.za Tel: 012-338-9301 Fax: 012-328-5120

www.heliosits.com Tel: 011-671-2538

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CO NFE R E NC E S PON S ORS Iso Leso Exhibition Stand FA 25%_Front Podium.pdf

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As South Africa’s largest multi-manager, we aim to be the most trusted financial guardian to our clients, helping them achieve consistent outcomes and peace of mind when it comes to investment matters. We manage risk through every step of the process so that our clients achieve a more predictable investment outcome. As part of the Alexander Forbes group, we seek investment opportunities that will give sustainable and dependable outcomes. sa.investmentsolutions.co.za Tel: 0860-333-316

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Iso Leso Optics Ltd is a South African optometric network that is broadly owned by the majority of practising optometrists. Iso Leso enjoys an enviable demographic representation that allows peace of mind to medical funders. Our practitioner enhancement programme (PEP) and our telemedicine development with the Africa Vision Institute (AVI) are groundbreaking initiatives in introducing advanced clinical interventions at a primary care level. The Iso Leso VisionPartner Programme is designed to deliver world-class quality to patients via strategic alliances with global leaders in prescription lens manufacture. We are proud of our fraud mitigation programme which uses analytical matrices developed by Insight Actuaries to identify and root out deviant behaviour. In addition, our software-driven claims processing and laboratory verification process adds depth to a robust programme.

With its proud 75-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 healthcare claims management, including pharmacy benefit management, doctor claims processing, hospital claims processing (both public and private), provider network management and real-time connectivity through our ability to switch claims for healthcare providers to a number of medical schemes, managed care organisations and administrators. At present the locally developed, flexible internationally patented IT systems of MediKredit touch more than seven million lives. The fully integrated end-to-end MediKredit service is used by more than 3 500 pharmacies, 194 private hospitals, 4 700 doctor practices, 80 medical schemes as well as 95 public sector hospitals in five provinces.

We are excited about the opportunity to deliver clinically sound and innovative eye care to all patients. Please visit our stand at the BHF conference where we invite you to ‘Share our View’!

Known as a healthcare benefit management force to be reckoned with MediKredit not only pioneered on-line real time claims processing within the South African healthcare industry but is also the custodian of the NAPPI® Price File and an industry expert in medicine and clinical database management.

www.isoleso.co.za Tel: 011-340-9000

www.medikredit.co.za Tel: 011-208-1275

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Patient Focus

Africa

empowering prevention

Medipost is South Africa’s largest courier pharmacy and has 25 years of experience in the courier pharmacy industry. Medipost’s main business function is the provision of chronic, HIV, oncology and other specialised medication and pharmaceutical support services to registered patients of various medical schemes. Medipost offers a reliable, specialised, fast and nationwide service to all patients and clients. Medipost specialises in seamless take-on processes, delivery of chronic medication, HIV medication, oncology medication and other specialised products to any destination in South Africa. In order to achieve this, Medipost utilises stateof-the-art information technology, which includes electronic document routing, automated claim adjudication, SMS communication tools and parcel tracking facilities.

At Old Mutual Wealth, we believe in integrated wealth planning – a structured holistic advice process – to manage true wealth. Our approach shifts the focus from planning for the money to planning for the individual and their goals and aspirations. Whether your clients’ priority is growth, income or capital preservation, we fully understand this and are here to support them in achieving their dreams. www.omwealth.co.za Tel: 0836-761-508

Patient Focus Africa is the leading point-of-care company focused on preventative care. We offer quality, accredited, connected point-of-care solutions across the value chain. Connected point of care creates meaningful information from loose data, allowing funders direct access to early identification of risk. Our primary focus is putting prevention first! www.patientfocusafrica.gov.za Email val@patientfocus.co.za

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. www.medipost.co.za Tel: + 27-12-426-4007, Cell: + 27-82-373-3981 Email: rentia@medipost.co.za,

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Pharmacy Direct is a premier courier service pharmacy that has been in operation for the past 10 years and has since its inception proven to be a major and leading role-player in the dispensing and delivery of chronic medication. In January 2004, Pharmacy Direct was appointed the designated service provider (DSP) for a number of medical schemes. Under this appointment we supply chronic medication to patients in accordance with prescribed minimum benefit (PMB) regulations. We currently deliver medication to 75 000 patients nationally. We are currently the biggest provider of antiretroviral therapy to patients living with HIV/AIDS in the private market. Pharmacy Direct also provides medication that is not approved as chronic medication but which is viewed as acute medication used by a patient over a longer period. Our current clients include Bonitas, Liberty, Polmed, Topmed, Medshield, Medihelp, Discovery Health, Commed, Pro Sano and private members. In addition, Pharmacy Direct also provides services to some US aid programmes. We do, however, service most medical schemes.

PPN is the largest optometry network with 4.3 million lives under administration. We constantly re-engineer our systems, knowing that it takes investment and innovation to stay ahead of the game. Our unique philosophy and methodology of managing optical claims provides both value-added and effective solutions for our clients. Our anti-fraud systems reduce claims values by up to 20%. The year 2017 will see PPN launching another new and unique anti-fraud measure to assist both schemes and their members. FACT: Excellent service record for 22 years FACT: The most sophisticated and effective fraud controls FACT: The most effective basic benefit design FACT: New innovative improvements FACT: Cost-effective optical and cataract management FACT: If you haven’t asked us to quote, you may be missing out – allow us to demonstrate the effectiveness of using our initiatives by emailing us on management@ppn.co.za

www.pharmacydirect.co.za Tel: 011-671-2538

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Qhubeka Forensic Services, a subsidiary of Zungu Investments Company, is a level 2 B-BBEE operation and has established itself as a forensic investigation service dealing with commercial crime. It has a reputation for integrity, impartiality and accuracy. Investigations are professionally and sophisticatedly addressed via a project management approach. We have associations with relevant specialists in the legal, forensic auditing and project management training sectors. All our investigators have extensive knowledge and experience gained within the SAPS and subsequent involvement in disciplinary, civil and criminal cases. We are registered with the Association of Certified Fraud Examiners and the Institute of Commercial Forensic Practitioners. Qhubeka undertakes its investigations across all provinces. www.qforensic.co.za Tel: 086-111-1956


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

From conception to creation, RISKAFRICA is produced entirely in Africa, offering insightful articles, interviews with industry leaders, news, events and analysis from across the continent. It can be found in the boardrooms of the largest financial services companies right down to the reception areas of the smallest independent brokerage. We bring the African financial services industry to you.

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 to low-income medical schemes since 2006. We are accredited to offer hospital benefit management and disease management as well pharmaceutical benefit management services.

RISKAFRICA is not only available in print; it offers a multi-platform solution for your brand and is available as a digital magazine, online, via social media as well as events.

www.rxhealth.co.za Tel: 0760-522-901

The South African Medical Association (SAMA) as we know it today was formally constituted on 21 May 1998 as a unification of a variety of doctors’ groups that had represented a diversity of interests. Today, SAMA is a non-statutory, professional association for public and private sector medical practitioners. It functions as a non-profit company registered in terms of the Companies Act as well as a public sector entity registered in terms of the Labour Relations Act. SAMA is a voluntary membership association, existing to serve the best interests and needs of its members in any and all healthcare-related matters. https://www.samedical.org/ Tel: 012-481-2000

Partnering with RISKAFRICA means you will associate your company with an award-winning publication.

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2016 ANNUAL CONFERENCE

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

Conference Theme A Roadmap to Universal Healthcare

CPD Accreditations 17th July = 4 Ethics Points 18th July = 6 Clinical 19th July = 6 Clinical & 2 Ethics 20th July = 6 Ethics

Conference Objectives

UDoTest have a range of self-sample medical tests along with a complete start-to-end process that is attracting medical experts, medical aids and pharmacies worldwide. Our selfsample colon cancer, cervical cancer, gluten intolerance and STD tests make screening easy, and are saving medical aids money. UDoTests are available online, from pharmacies, from doctors and at wellness days. www.udotest.com Tel: 011-507-4660

Coordinate the industry in developing a roadmap for a healthcare system for the

Building on a proud track record of more than four decades, Universal Healthcare is one of South-Africa’s fastest growing, leading-edge healthcare brands. Our patient-centric services enhance the lives of more than three million people, including some beyond our borders as we expand our presence internationally. We are committed to extending access to world-class healthcare services, supported by robust, highly advanced technological solutions. We provide medical schemes, corporates, healthcare service providers and individuals with a galaxy of outcomes-based, yet cost-effective, healthcare solutions. We are dedicated to improving the well-being of each individual under our care, placing clients and their members at the centre of our Universe.

next generation to meet growing demand for high-quality healthcare.

Our services include the administration of open and closed medical schemes, managed care, and corporate health and wellness solutions. In addition, companies look to us for employee wellness and occupational health solutions, healthcare insurance as well as healthcare-related IT and switching solutions. Our star-studded healthcare provider network is among the largest and fastest growing in South Africa. www.universal.co.za Tel: 011-208-1275

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BOTSWANA

Steady progress towards in Botswana

universal health coverage

Botswana continues to do well in advancing access to healthcare. The country maintains a pluralistic healthcare system with the public sector being the predominant provider of services By Dr Lorato Mangadi FUND ADMINISTRATION MANAGER – SOUTHVIEW (PTY) LTD

Current situation Botswana, like most countries, continues to face challenges with regard to the provision of accessible, quality and yet affordable healthcare services to the nation. The country aspires to achieve universal health coverage so as to ensure that all citizens obtain healthcare services without suffering financial hardship. The country's healthcare system is of a pluralistic nature with the public sector being the predominant provider of services. The private sector, on the other hand, caters for around 17% of the population, mainly individuals in the formal sector. Botswana has done well in

recent years in scaling up access to healthcare services, especially towards priority areas such as maternal and child health, HIV/AIDS, tuberculosis and malaria. About 95% of the population lives within eight kilometres of a health facility. Healthcare services are almost free with citizens (except vulnerable groups and the poor) paying a nominal out-of-pocket user fee of BWP 5.00 at the point of service. All Batswana are entitled to free antiretroviral therapy and the country has recently implemented the 'treat all strategy' for HIV/AIDS, aiming to further improve coverage for antiretroviral therapy. Botswana’s level of health spending per capita is above average compared to similar countries. Of the total health expenditure, BOARD

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Dr Lorato Mangadi: Fund Administration Manager - Southview (Pty) Ltd

government contributes around 57% whereas the private sector contributes 34%. With this level of spending, the country H E A LT H C A R E F U N D E R S

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has adequate resources to fund a minimum package of basic and essential health services for better health outcomes. However, SOUTHERN AFRICA

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The private healthcare system also has its own set of structural and regulatory challenges.

57% Of total health expenditure, government contributes around 57%

When compared to other middle-income countries it is clear that Botswana could do better, even just through small-scale interventions to improve efficiencies within the system.

Milestones whereas Botswana has comparatively better health outcomes than the average for sub-Saharan countries, it has worse outcomes compared to most uppermiddle-income countries.

The country has long set the agenda for universal health coverage and as reflected in the revised National Health Policy (2011), factors that limit coverage are identified and addressed.

This is as a result of challenges that still remain within the healthcare system which include resource allocation, procurement of services and use of technologies.

Through the Integrated Health Services Plan (IHSP), government outlines the strategy that will transform the healthcare sector.

Despite improvements that continue to be made, there are still inefficiencies that threaten the sustainability of services in the long run. It has now become apparent that there is declining capability of the government to fund health services and key programmes under the current financing model.

This strategy focuses on priority areas to be addressed going towards 2020. A key component of the strategy is the Essential Health Services Package (EHSP), which aims to offer universal coverage of high quality essential services to the population in an efficient, equitable and integrated manner. This package is set to be

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the standard package of essential and basic services and is to be the core of service delivery in all primary health facilities, both public and private. Although the framework of this package has been outlined, government is yet to cost the package and to define the vehicle that will deliver equitable services to the citizens. A multi sector stakeholder process involving technical experts has been in place since 2012, the task at hand being to review the current health financing model, in order to advise government on a health financing strategy that will be the best fit for Botswana. It is anticipated that the new health financing strategy will increase efficiency, ensure financial sustainability and promote an effective mix of public and private mechanisms for health financing and service provision. Discussions are highly advanced and progress to date includes a holistic scan of the current health financing landscape and its sustainability, as well as a critical review of the current

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health delivery structure for identification of sources of inefficiency. The final task, which is currently underway, is exploration of possible options to help the country achieve its universal health coverage aspirations. A national health insurance scheme is being considered as a possibility. Funding options for such a dispensation are being looked into as well as the role the private health sector will play under such an arrangement.

BHF MEMBERS Botswana Public Officers' Medical Aid Scheme (BPOMAS) +267 71313035 duncant@afa.co.bw

Botswana Medical Aid Society (Administered by Southview) +267 71306466 mmokgosana@bomaid. co.bw

PULA Medical Aid +267 71313035 duncant@afa.co.bw

Southview (Pty) Ltd +267 71300035 dalexander@southview. co.bw


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LESOTHO

The heavy burden of chronic illnesses Lesotho faces an increasing burden of non-communicable diseases. Hypertension and diabetes, in addition to HIV/AIDS, are among the most common conditions seen in outpatient departments. By Mamoth Health Plan

Poor lifestyles over many years are the cause of most chronic illnesses in Lesotho. These can be attributed to, among others, poor diet, lack of physical activity, overuse of alcohol and smoking. Poor lifestyle

Recent admissions and deaths

habits result in arthritis, heart attacks, stroke, cancer, diabetes, epilepsy, seizures, tuberculosis, obesity and hypertension, to mention a few examples. Lesotho faces an increasing burden of non-communicable diseases. Hypertension and diabetes, in addition ADMISSIONS Male

Female

All types of tuberculosis

1003

711

HIV and AIDS

968

Hypertension

to HIV/AIDs, are among the most common conditions seen in outpatient departments. Cervical cancer is one of the most common cancers in Lesotho, and the leading cause of cancer deaths among women – particularly women living with HIV.

Total

DEATHS

Total

Male

Female

1714

314

212

526

1117

2085

398

388

786

265

646

911

43

82

125

Diabetes mellitus

249

635

884

30

76

106

Cancer

65

291

356

6

52

58

Respiratory infection

196

184

380

67

40

107

The Lesotho government educates people about chronic illnesses and, primarily, it encourages them to improve their diets, quit smoking and to engage in physical activity. Secondarily the government helps to treat those people who already have chronic diseases and encourages people to undergo screening tests. Chronic medication is provided cheaply at government healthcare centres and medical aid schemes provide their clients with chronic benefits on top of consultation benefits, encouraging them to take their medication so that their consultation benefits are not exhausted before the end of the year.

BHF MEMBERS' LISTING ON PAGE 76

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NAMIBIA

On the road to achieving

universal healthcare in Namibia Providing a broader percentage of the population with equitable access to quality health services By Callie Schafer CEO – CORPORATE

challenge facing the private healthcare industry.

PROSPERITY GROUP The Namibian healthcare industry is facing many challenges, among them ensuring access to healthcare for a broader portion of Namibia’s population. Less than 50% of employed Namibians belong to any of the private/public service medical aid funds. Approximately 18% of the population enjoys private cover, which underscores the big

Namibia has a unique political history and these challenges will be best addressed through constructive engagement among all stakeholders. Learning from regional/international experience with the formation of national health insurance (NHI), social health insurance (SHI) and national medical benefit funds is likewise a guide. The Namibian authorities have embarked on the process of extending coverage to provide a broader percentage of the population with equitable access to quality health services. The identification of sustainable health financing options is a priority of the government’s agenda Callie Schafer, CEO, Corporate Prosperity Group

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and the Ministry of Health & Social Services Health (MoHSS) has the key objective to ensure the existence of a well-functioning and sustainable health financing system. Internationally this is best achieved by universal health coverage (UHC) and the provision for a national medical benefit fund. The MoHSS and the Social Security Commission (SSC) are working in close collaboration to explore the way forward towards achieving UHC. The Universal Health Coverage Advisory Committee of Namibia (UHCAN) was established for this purpose from among all stakeholders. The SSC has prepared a concept of a national medical benefit fund that is currently under review. The objective of UHCAN is to provide guidance to the MoHSS on the devel-

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opment of sustainable systems and policies for achieving UHC in Namibia. UHCAN also has to advise on approaches to expand coverage of the population in terms of access to and quality of health services, equitable distribution of services and to identify the allocation and financing of a sustainable model from available finance sources. The government of Namibia is the biggest contributor to health spending in the country. It is responsible for over 50% of the total health spend. The increase in government health expenditure is currently 13% of the government’s overall spend, marginally short of the Abuja target. This reflects the government’s strong commitment to invest in improving the health of the population and private healthcare should join this healthcare reform process.


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ZIMBABWE

Medical aid societies in Zimbabwe:

covering the gap in service provision By Shylet Sanyanga CEO – ASSOCIATION OF HEALTHCARE FUNDERS OF ZIMBABWE The concept of national health insurance (NHI) as a vehicle to achieve universal healthcare in Zimbabwe is currently under discussion by the government. It has been on the country’s agenda for many years but there have been renewed calls for such a scheme recently. The challenge is chiefly how to fund it in a manner that would universally benefit everyone, not just those who contribute directly to it, given that many more people are employed in the informal sector than the formal sector. Huge strides were made towards universal healthcare in the 1980s, with the emphasis on making primary healthcare widely available. However, the issue of how to make expensive medical procedures available to those who cannot afford them

has remained a challenge. Medical aid societies have played a part in this regard by introducing packages for lower-paid workers, who were previously unable to afford medical aid. Some medical aid societies have also established healthcare facilities of their own. Their services are provided as a benefit for members but are also available to non-members. The number of healthcare facilities operated by medical aid societies has expanded over the years, due to demand. These

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include primary healthcare clinics, hospitals, haemodialysis centres, a chemotherapy unit, clinical laboratories, dental clinics, rehabilitative institutions, radiology facilities, conventional ambulance services and an air ambulance service. These investments are contributing significantly towards making healthcare services widely available, accessible and affordable. The various services were introduced to fill in gaps in areas that were lacking or

inadequate in the health sector. For instance, a haemodialysis centre was established by one medical aid society at a time when, during a period of economic crisis, there were no working dialysis machines in Zimbabwe’s hospitals. The services provided by medical aid societies complement those offered by public and private healthcare institutions, making a substantial contribution to the provision of affordable quality health services.

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Members South Africa

ADMINISTRATORS

MEDICAL SCHEMES Alliance Midmed Medical Scheme

Hosmed Medical Aid Scheme

SA Breweries Medical Aid Society (SABMAS)

Barloworld Medical Scheme

Imperial Group Medical Scheme

SABC Medical Aid Scheme SAMWUMED

Private Health Administrators

Libcare Medical Scheme

SEDMED

Sanlam Health

Bonitas Medical scheme

Makoti Medical Aid

Sizwe Medical Fund

Sechaba Medical Solutions

BP Medical Aid Society

Massmart Health Plan

Building & Construction Industry Medical Aid Fund

Medimed Medical Scheme

POLMED – South African Police Service Medical Scheme

Southview (Pty) Ltd (BOTSWANA)

Cape Medical Plan

Medshield Medical Scheme

Sisonke Health Medical Scheme

Chartered Accountants (SA) Medical Aid Fund (CAMAF)

Metropolitan Medical Scheme

Suremed Health

Community Medical Aid Scheme (COMMED)

Nedgroup Medical Aid Scheme

Thebemed

Compcare Wellness Medical Scheme

Netcare Medical Scheme

BIMAF EC BIMAF WC

Medipos Medical Scheme

TFG Medical Aid Scheme

Tiger Brands Medical Scheme

De Beers Benefit Society

Old Mutual Staff Medical Aid Fund

Engen Medical Benefit Fund

Opmed

Fishing Industry Medical Scheme (FISH-MED)

PG Group Medical Scheme

Governmenment Empoyees Medical Scheme (GEMS)

Rand Water Medical Scheme

Grintek Electronics Medical Aid Scheme Horizon Medical Scheme

Topmed Medical Scheme (includes Pharos)

Pick 'n Pay Medical Scheme

Remedi Medical Aid Scheme Rhodes University Medical Scheme

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Medscheme Holding (Pty) Ltd Metropolitan Health Group

Thebe Ya Bophelo Healthcare Administrators Universal Healthcare Admin (Pty) Ltd Associated Fund Administrators (BOTSWANA)

MANAGED CARE ORGANISATIONS EOH Health

University of The Witwatersrand – Johannesburg Staff Medical Aid Scheme Witbank Coalfields Medical Aid Scheme Wooltru Healthcare Fund

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Members SADC

BOTSWANA

NAMIBIA

ZIMBABWE

Botswana Public Officer's Medical Aid Scheme

Heritage Health Medical Aid Fund

Association of Healthcare Funders of Zimbabwe

Botswana Medical Aid Society (Administered by Southview)

NAMAF

Altfin Medical Aid Scheme

Namdeb Medical Scheme

Cimas Medical Aid

Napotel Medical Aid Fund

Engineering Medical Fund

Southview (Pty) Ltd

Renaissance Health Medical Aid Fund

First Mutal Health

LESOTHO

SWAZILAND

Mamoth Employee Benefits

Swaziland Medical Aid Fund

PULA Medical Aid

Municipality of Masvingo Medical Aid Society

MediPlus Lda

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Harare Municipal Medical Aid Society Kwekwe City Council Medical Aid Society

MOZAMBIQUE

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SOUTHERN AFRICA


Embracing

Advertorial

MEMBERS SINCE

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1968

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2016 BHF360 Annual Magazine  

Board of Healthcare Funders of Southern Africa annual conference magazine

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