The growing cost of medical aid puts the spotlight on the need for a more realistic approach to healthcare policy in South Africa. While NHI is intended to offer universal health-care, questions have long been raised about how the country’s constrained fiscus can afford it and whether an already strained tax base can bear the additional burden. xacerbating the situation is the fact that the public health-care sector, particularly many tertiary hospitals, are largely dysfunctional, requiring significant investment and repair before NHI can be implemented.
Health insurance products are a viable solution, providing access to healthprimary-care providers such as nurses,prageneral andctitioners dentists, along with medication
In one example, the health ombud found that Helen Joseph Hospital in Johannesburg was so under-resourced and poorly managed that it was not fit for purpose. Another, separate investigation by the office of health standards compliance came to a similar conclusion, reporting that the hospital was in a state of decay.
Jessica Bates Integrated health executive: Dis-Chem
The private health-care industry believes that instead of reducing the role of private health-care funders, it should be expanded to cover more people, reducing pressure on the over-burdened public health-care sector.
While medical schemes are struggling to grow their membership bases, they argue that they should be able to compete with low-cost benefit options (LCBOs) to compete with the proliferation of health insurance products currently in the market.
Health insurance products are not subject to the same regulatory burden as medical schemes and are able to position themselves as a more affordable alternative to medical aid.
In April, the medical schemes regulator gave companies selling health insurance products a
two-year extension, pending government’s final decision regarding the future of LCBOs.
There is growing interest in health insurance products which provide affordable solutions covering basic primary medical care, such as day-to-day consultations with general practitioners, dentistry, optometry, acute and chronic medication as well as defined hospital events. The key difference between medical aid and health insurance lies in their coverage. The former offers comprehensive health benefits including prescribed minimum benefits, while the latter pays a fixed amount for specific health events outlined in the policy.
Jessica Bates, integrated health executive at Dis-Chem, points out that medical insurance plays an important role in helping consumers who are not members of a medical aid scheme have access to quality health care, including primary health care. “Medical aid membership isn’t affordable for all South Africans. Health insurance products are a viable solution, providing access to primary health-care providers such as nurses, general practitioners and dentists, along with medication,” says Bates.
The World Health Organisation (WHO) says more than 1-billion people globally are at risk of falling into poverty due to out-ofpocket health spending of 10% or more of their household budget, and that scaling up primary health-care interventions across low- and middle-income countries could save 60-million lives and increase life expectancy by 3.7 years by 2030. The WHO says primary health care is the most inclusive, equitable and cost-effective way to achieve universal health coverage and is key to strengthening the resilience of health
BONITASWINS4TH TITANIUMAWARD
systems to prepare for, respond to and recover from crises.
In partnership with Kaelo and licensed non-life insurer Centriq Insurance, Dis-Chem Health branded medical insurance products provide access to affordable and quality private primary health care including doctors, dentists, optometrists, counselling, tests, scans and screenings, among others.
Dis-Chem Health policyholders qualify for Dis-Chem extraRewards which provides additional savings, which can be used to fund the insurance premium.
Bates says health insurance products are ideal for corporates wanting to ensure that all their employees’ primary health-care needs are covered. “At Dis-Chem we require our employees to join a medical aid scheme or be covered by medical insurance, based on relative affordability. Among our employee base and their beneficiaries, we have around
3,000 individuals who are covered by medical aid while 20,000 are covered by medical insurance products. There is a misperception that insurance products don’t offer sufficient value. Our experience with our own employees proves otherwise. Of the 20,000 medical insurance members, 7,000 (33%) are voluntary dependents where employees have chosen to add family members out of their own pocket.
“We see significant utilisation of general practitioners, nurses, medication and dentistry. In 2024, 70% of members utilised their benefits during the year, with the insurance paying for almost 17,000 GP consults, while 1,500 employees utilised their dental benefits. There is a notable shortage of dentists in the public sector, with the result that some of our employees had never seen a dentist before being covered by these policies.”
Lee Callakoppen, principal officer of Bonitas Medical Fund; adv RT Monene, member of the Bonitas board of trustees; OJ Komane, chairof the Bonitas board of trustees); and MG Netshisaulu, member of the Bonitas board of trustees, at the Titanium Awards.
Picture: SUPPLIED
One of the biggest challenges for medical schemes is delivering on brand promise and consistent customer service. Bonitas Medical Fund recently secured a Titanium Award for Service to Membership: Operational Performance at the Board of Healthcare Funders Titanium Awards. Considered a benchmark for excellence in the health-care funding industry, the awards honour medical schemes, administrators and managed care organisations that consistently deliver outstanding value and service. This is the fourth consecutive win for Bonitas at the Titanium Awards. The fund also won the medical aid category at the 2024 Ask Afrika Orange Index Awards, the largest and longest-standing customer experience benchmark in South Africa. Lee Callakoppen, principal officer of Bonitas Medical Fund, says: Our goal has always been to deliver real value to our members. This means providing health care that is not only affordable but also underpinned by solid governance, smart risk management and a proactive focus on prevention.
PARTNERSHIP
BROADENINGACCESS TO PRIMARY HEALTH CARE
licks offers an affordable health insurance product called Flexicare in partnership with Discovery Health and Auto&General Insurance.
“Flexicare is not a medical scheme nor is it intended to be a substitute for medical scheme membership,” says Dr Melanie van Rooy, chief marketing officer at Clicks Group. “It offers quality, affordable access to primary health care for consumers who are unable to access medical scheme benefits, providing cover for medication, specialist consultations, maternity benefits as well as in-person and online doctor consultations through a primary health-care network of 12,000 providers.”
Flexicare is not a medical scheme nor is it intended to be a substitute for medical scheme membership
DR MELANIE VAN ROOY Chief marketing officer:
Clicks
Medical and health-care insurance products are governed by either short-term or long-term law rather than medical aid regulations. In addition to not being
required to include prescribed minimum benefits, they can impose different waiting period criteria as well as a maximum entry age limit.
To keep the products affordable, they are primarily focused on out-of-hospital primary care expenses such as GP consultations, prescribed medication, basic dentistry and some optometry cover with their benefits subject to strict network provider rules. They may also include a defined limit for emergency hospitalisation stabilisation or illness.
Maria Makhabane, chief growth officer at Discovery Health, says that Flexicare provides unlimited GP consultations with network doctors. It also covers medication, preventative care, health checks, dental checks and eye tests. Moreover, it provides members with information on when and where health checks should be conducted as well as a suite of digital tools to help manage and access benefits on the go.
“What makes Flexicare particularly impactful is its role in broadening access to private health care for many South Africans for the first time. For example, a member may receive their first pair of spectacles or gain critical insight into an undiagnosed chronic condition through a wellness screening. This level of access enables earlier interventions and fosters a more proactive approach to personal health which is both empowering and transformative,” Makhabane says, adding that nearly 1.2-million South Africans have opted for such primary health insurance products.
A unique feature of the product is a 10% premium cashback and loyalty benefit for Clicks ClubCard members who purchase Flexicare using a simple four-step Clicks digital purchasing process. For an average
family of four, this amounts to R123.80 in cashback earned monthly that can be used
“Flexicare forms part of Clicks’ strategy to make private health-care cover easily available and affordable for everyone, with the added benefit of cashback in your pocket,” says Van Rooy. “This forms part of our continued commitment to providing great value, convenience and rewards for our customers.”
Makhabane says Flexicare reflects Discovery Health’s commitment to expanding cover to millions more South Africans. “This is made possible by the strengths of excellent partners who share this vision. We look forward to making even more of a significant impact on people’s lives through Flexicare and through our network of dedicated healthcare providers.”
Feel the Personally Yours promise with Bestmed.
Bestmed Medical Scheme has been awarded the BHF Titanium Award for Service to Membership: Category A for a second time. This means you get award-winning medical aid with a human touch. Join Bestmed Medical Scheme. Contact 086 0333 838 or visit www.bestmed.co.za for Personally Yours medical aid.
Having medical aid cover is essential for those wanting to access private health care. It ensures that members and their beneficiaries are covered for at least a portion of their medical bills while also providing members with access to a network of doctors, hospitals and specialists. Selecting the right medical scheme plan is an essential part of managing your health- care needs. Consider your overall health, available budget and specific health-care needs before deciding on the most suitable plan, says Weatherton Nyambeu, sales manager at Bestmed Medical Scheme.
There are two main types of medical aid plans to consider.
A hospital plan is the most basic option and focuses on in-hospital care for both planned and unplanned hospital stays.
A planhospital is ideal for young,healthy individuals, who only want cover for life’s big emergencies, but don’t anticipate many GPvisits
WEATHERTON NYAMBEU Sales manager: Bestmed
It covers members for major medical expenses such as surgeries and specialist treatments. It does not, however, cover outof-hospital expenses, such as GP visits and medications.
A hospital plan is ideal for young, healthy individuals, who only want cover for life s big emergencies, but don t anticipate many GP visits and don t mind paying for these out of pocket, says Nyambeu.
A comprehensive plan, on the other hand, provides coverage for both inhospital and out-of-hospital expenses including GP visits, specialist consultations and medication, among others.
Nyambeu explains that the monthly contributions for comprehensive plans are higher because they cover so much more.
The majority of comprehensive plans also include a savings component.
Nyambeu says, It s a good idea to familiarise yourself with the specifics of your chosen plan, including what is paid for from your savings and what limits of copayments apply to specific treatments, practitioners or medications
For a more affordable comprehensive plan, he suggests considering a network plan.
Medical schemes negotiate better tariffs with particular providers such as specialists, GPs and hospital groups. The benefit of a network plan is a lower contribution, but bear in mind that you will have a smaller list of providers to choose from. Should you decide to visit an out-of-network provider, you will have to pay for it yourself. To avoid potentially large out-of-pocket expenses, only make use of medical practitioners within your network.
PARTNERSHIP
AHEALTHIERSOUTHAFRICAREQUIRESACCESSIBLE
HEALTHCARE ANDGOODLIFESTYLE HABITS
Studies reveal that nearly 30% of adults suffer from chronic health conditions, significantly affecting their productivity and quality of life.
According to Stats SA, deaths due to chronic health conditions such as cardiovascular disease, cancer, diabetes and chronic lower respiratory disease have increased 58.7% over 20 years.
While health is often viewed through the lens of physical wellbeing, financial instability can lead to poor health choices, exacerbating existing issues.
Damian McHugh, chief marketing officer at Momentum Health, points out financial stress affects over 40% of the population, increasingly contributing to mental health issues. “These alarming statistics underline the essential connection between financial wellbeing and overall health,” he says.
Understanding your health, says McHugh, is a crucial first step because it allows you to take proactive measures in empowering yourself through lifestyle choices that promote wellbeing.
A sustained, proactive approach to health is key. For example, investing in regular health check-ups and preventative care can mitigate the risk of serious health problems, mitigating serious and costly illnesses in the long term. Simple lifestyle changes such as prioritising rest and recovery, making time to connect with loved ones, maintaining balanced nutrition, practising mindfulness and engaging in regular exercise not only promote physical and mental health, but can
also lead to significant long-term savings in health-care costs.
“Wellbeing is about more than the absence of disease; it encompasses the interplay of physical, mental, emotional and social health factors,” says McHugh.
“Prioritising our health through financial wellbeing allows us to invest in preventative care and maintain a fulfilling life.”
Given South Africa’s economic challenges, many households are under financial pressure. In the current environment, comprehensive health and financial support systems are indispensable.
“To address the needs of financially
constrained and stressed consumers, the medical scheme sector needs to evolve to ensure quality health care and preventative measures are accessible to all,” he says.
population. An insurance product, Health4Me allows policyholders to choose the combination of benefits most suitable to their needs and available budget, including how they want to engage with doctors. Members get free and unlimited access to Hello Doctor, a mobile phone-based service that provides 24/7 access to doctors.
In addition, incentivised health and wellbeing programmes such as Momentum Multiply enable a guided approach to healthy habit stacking that rewards members for knowing and improving their health.
Wellbeing is about more than the absence of disease; it encompasses the interplay ofmentalphysical, , emotional and social health factors
Recognising the complexities within South Africa’s health-care sector and the diverse factors affecting the overall health of the nation, Momentum Health has expanded access to health care by improving and introducing more low-cost benefit options, including its Health4Me offering, to cater to a larger segment of the
DAMIAN MCHUGH Chief marketing officer: Momentum Health
McHugh reveals that the programme not only contributes to improving members’ health, which lowers medical costs, but also allows medical scheme members to earn returns, deposited into their health savings accounts, that can be used to pay scheme contributions turning their health efforts into a financial asset.
“Our aim is to make quality health care more accessible, while enabling and rewarding healthy, preventative habits that can lead to complete physical and mental health and wellbeing. Investing in access and wellbeing, we believe, is a powerful pathway to realising more wealth and more health for more South Africans.”
THE CHALLENGE IS TO ATTRACT YOUNGPEOPLE TO MEDICAL SCHEMES
South Africa’s two-tiered health system has never been a simple one. Only 14.7% of South Africans are covered by medical aid schemes, down from 16% in 2000.
Kevin Aron, principal officer at Medshield Medical Scheme, says the health-care landscape is undergoing significant shifts and challenges. “It’s a complex landscape requiring a nuanced understanding of the interplay between regulatory frameworks, economic pressures facing households, rising health-care provider costs and government’s intention to implement NHI, which was signed into law in 2024.”
In recent years, medical scheme contribution rates in South Africa have consistently exceeded consumer inflation, creating significant affordability and industry sustainability challenges.
“Annual contribution increases which exceed inflation raise concerns about the long-term viability of the medical schemes industry, particularly for financially strained consumers,” says Aron. “One of the biggest challenges that medical schemes face is attracting young adults entering into the formal job market.
Given that the existence of a medical scheme is based on the principle of cross-subsidisation, the reality is that an ageing population in a medical scheme will result in high health-care costs, which in turn requires a higher than CPI contribution increase.”
Economic pressures are forcing many members to downgrade to more affordable options not designed for their health-care needs.
Aron says this misalignment leads to higher claims costs and necessitates further contribution increases, creating a vicious cycle that threatens the viability of these options.
“Medshield designs benefit options based on life stages with the aim of providing appropriate cover as members’ needs evolve. In the current environment, however, older members are often compelled to opt for low-cost plans due to financial constraints.
This disrupts the cross-subsidisation model, resulting in higher claims and economic strain on these options. There is sufficient evidence to support the conclusion that as people age, their health deteriorates, leading to higher claims costs. These higher claims costs need to be balanced by a young population that has a
healthier health profile, with a lower claims ratio profile.”
Aron says regulatory reform is required to allow medical schemes to offer low-cost benefit options which can compete with the proliferation of health insurance products on the market today.
Medshield resisted the temptation to impose steep contribution increases this year, instead utilising some of its reserves to ease the financial strain on its members, many of whom have been experiencing severe financial challenges from rising inflation and low employment growth.
“While this approach had a positive impact on our members, it’s not a sustainable long-term strategy,” says Aron. “Medical schemes cannot continually underprice their products without eventually compromising their financial health. This delicate balance highlights a critical issue: the need for a more supportive regulatory environment that allows for flexibility and innovation, especially in pricing and benefit structuring.”
Medshield has maintained a robust solvency ratio in the last few years, despite the economic challenges that plagued many sectors. This stability, says Aron, is a testament to good governance, strong risk management strategies, and a conservative and responsible management approach.
The scheme has proactively explored various initiatives to enhance sustainability and affordability, including introducing specialist networks across 15 disciplines and has optimised its existing hospital networks to reduce costs and improve the level of care.
Hospital expenses account for nearly 50% of medical scheme costs, and by negotiating better rates and ensuring better quality care, we can pass savings on to members.
Medshield has also expanded its disease management programmes and is refining its network of general practitioners. Targeted marketing efforts have also helped to attract younger members, lowering the scheme s average age and risk profile.
marketiTargetedng efforts have also helped to attract younger members, loweringschemethe ’s average age and risk profile
