Healthcare access in South Africa is increasingly shifting towards prevention, early intervention and more accessible primary healthcare. Yet for many communities, accessing healthcare can still mean long waiting times, travel and delays in receiving care.
As pressure on the healthcare system continues, there is an opportunity to make better use of healthcare professionals who are already accessible within communities.
For many people, the pharmacist’s role has traditionally been associated primarily with dispensing medication. But the profession has evolved significantly. Pharmacists are increasingly contributing to medicine optimisation and adherence, chronic disease support, health screening and other primary healthcare services within their scope of practice.
According to Tanya Ponter, Pharmacy Director at Dis-Chem, pharmacists are equipped with skills that extend well beyond the dispensing of medicines.
“Pharmacists are trained to interrogate symptoms, review evidence and metrics that identify risk and make life saving decisions under pressure. Their expertise places them in a unique position to support patients beyond the traditional dispensing function and contribute to earlier intervention and better health outcomes.”
This evolving role is particularly important as South Africa looks for ways to improve access to primary healthcare. Pharmacists are often accessible within communities and can provide guidance, identify potential health risks and, where appropriate, refer patients to other healthcare professionals. What’s more, they are the most accessible clinical touchpoint for consumers and are always available to provide expert advice at no cost to patients.
“Expanded pharmacist-led services have the potential to reduce existing pressure on the healthcare system, with these professionals often being a first point of contact for patients in communities. Their presence can help address appropriate healthcare needs earlier and potentially reduce unnecessary demand on higher levels of care,” says Ponter.
With rising rates of chronic conditions like diabetes, hypertension, and HIV, pharmacists play an ongoing role in long-term wellness. To support complex patients who often take multiple pills, they offer guidance and medication reviews to simplify regimens and eliminate unnecessary or duplicate treatments.
As South Africa marks World Pharmacists Day, Ponter states that the profession should increasingly be viewed as an integral part of the country’s primary healthcare ecosystem.
“Pharmacists should not simply be seen as the final step between patients and prescriptions. They can help bridge the gap between communities and healthcare by supporting prevention, identifying risks earlier and helping patients navigate the healthcare system, particularly when barriers make accessing other healthcare services more difficult,” Ponter concludes.
By Dianne Boyd – Chief Operating Officer Frail Care at Allmed
Photo by Kampus Production on Pexels
There is a quiet shift happening in homes across South Africa. As the population ages and hospitals grapple with packed wards and immense strain, families are looking closer to home for answers. More seniors are choosing to stay right where they are, surrounded by their own memories, familiar furniture, and beloved pets, rather than moving into frail care or assisted living facilities. At the same time, because hospitals are discharging patients much faster following surgery, strokes, or cancer treatments, expert recovery support right in the living room has never been more important.
For most people, the thought of healing or growing older in a familiar space brings an unmatched sense of comfort and dignity. But for someone navigating the fog of dementia or the daily weight of a chronic illness, holding onto familiar routines is life changing. It reduces anxiety, keeps confusion at bay, and gives patients a deep-seated feeling of control that a clinical institution simply cannot match.
The hidden trap of doing it alone
As the need for home care grows, it becomes easy to see why some families turn to online platforms or informal word-of-mouth recommendations to find help. On the surface, hiring a caregiver directly feels simpler, quicker, and perhaps cheaper. But it often masks a maze of hidden responsibilities and risks that families are rarely prepared for.
Society tends to think of home care as simple companionship or a helping hand with daily tasks. In reality, caring for a vulnerable loved one safely requires a tremendous amount of unseen work. When individuals hire someone independently, they suddenly step into the role of an employer. Managing contracts, payroll, UIF contributions, and leave becomes an immediate reality. Worse still, what happens when a caregiver wakes up sick or resigns unexpectedly? Without a reliable agency behind the household, finding cover at 4am in the morning falls entirely on the family.
Even more concerning are the clinical visibility gaps in such an arrangement. Without professional oversight, missing the subtle early warning signs of trouble is remarkably easy; a tiny pressure sore starting to form, the early stages of dehydration, a missed medication, or a silent infection.
Why professional care changes everything
Treating home-based care as a true healthcare partnership rather than a domestic arrangement completely changes the experience for a family. Reputable, registered providers shoulder the heavy burden of care, so relatives do not have to carry it alone.
Instead of crossing fingers and hoping for the best, a professional approach brings real clinical governance into the home. Experienced clinical facilitators step in to assess patient needs, create tailored daily care plans, and check in regularly. They ensure that caregivers are thoughtfully matched to the individual, such as pairing someone with specialised dementia training with a patient who needs calm, skilled behavioural guidance.
Partnering with an established provider also puts a safety net around the entire household. Professional agencies cover personnel with medical liability insurance while handling all statutory requirements like workmen’s compensation, keeping families legally and financially protected from unforeseen accidents.
Finding peace of mind and financial relief
One of the greatest barriers families face with home care can be the financial weight. This is where working with a registered provider can make a profound difference. Because established agencies hold an official practice number, families can often submit claims directly to their medical aid schemes, subject to scheme rules and a specialist’s clinical motivation. This can be a powerful way to ease the financial strain of long-term support.
Bringing care into the home should bring peace of mind rather than sleepless nights. Leaning on a professional team for the vetting, the legalities, and the clinical oversight allows relatives to step back from being managers and return to being sons, daughters, or partners. That leaves space to focus on what truly matters: sharing meaningful, comfortable moments with a loved one, right where they belong.
“South Africa’s diabetes epidemic will not be solved by the next pharmaceutical breakthrough. It will be solved by fundamentally reshaping how healthcare is organised and paid for”
– Lungile Kasapato, CEO of PPO Serve.
Diabetes is now South Africa’s leading killer, accounting for more deaths than HIV and TB combined. Global headlines celebrate GLP-1 receptor agonists (RAs) as a breakthrough for metabolic disease and obesity. But this narrative ignores a fundamental reality: for most South Africans, these drugs are inaccessible. Priced between R3 000 and R6 000 per month, they remain unaffordable. Even as cheaper generics become widely available, they won’t solve the problem alone. Without the clinical infrastructure to support treatment, and the social support to access healthy food, access means little.
“We’re pushing an incomplete solution,” says Lungile Kasapato, CEO of PPO Serve, a healthcare management company implementing value-based care in South Africa for over a decade. “GLP-1 RAs offer real benefits – sustained weight loss, reduced inflammation, lower cardiac risk, protection against comorbidities. For someone facing diabetes, these outcomes matter. But we’re acting as if a drug alone can solve a system failure. It can’t. A medication prescribed into a broken healthcare system is just a product. It’s not a national health strategy.”
The scale of the crisis is staggering. Forty percent of low-income South Africans’ diet consists of ultra-processed foods. Across the broader population, nearly 30% have undiagnosed hypertension. Most discover their condition only after complications like strokes or heart attacks emerge. By the time they reach treatment, the system can only manage disease with medications, never addressing what caused it in the first place. When a GLP-1 RA is prescribed in this fractured environment, initial sustained progress stalls because the infrastructure to maintain results was never built.
“This fragmentation isn’t accidental,” says Kasapato. “It’s structural. Fee-for-service rewards volume, not health. A provider, working alone, gets paid for each visit, test, or procedure – regardless of whether the patient’s health improves. With no teamwork or incentive to coordinate, follow-ups become inconsistent and inadequate. Every encounter is transactional, continuity is impossible, and no one is accountable for the patient actually getting better. As long as we pay for activity instead of results, we won’t fix the system or build the infrastructure these medications need.”
PPO Serve’s The Value Care Team, implemented in partnership with the Government Employees Medical Scheme (GEMS), demonstrates what a different payment structure creates. GPs, nurses, dietitians, and care coordinators work together, sharing accountability for patient outcomes rather than billable procedures. Coordination becomes the norm, and prevention becomes profitable, meaning early intervention can stop complications before they escalate. Medication works better because the system supports it, including addressing the social issues that drive obesity in the first place. This is what reshaping incentives creates.
“The real choice isn’t just about drug access,” says Kasapato. “It’s about payment models, and the system it creates. Cheaper GLP-1 RAs could be available tomorrow – generics are already arriving. But availability achieves little without the organisation to deploy them. The conversation must progress from funding medications to funding the teams and systems that make them work. South Africa’s diabetes epidemic will not be solved by the next pharmaceutical breakthrough. It will be solved by fundamentally reshaping how healthcare is organised and paid for.”
For generations, corporate South Africa treated water like as an abundant utility. Facility managers turned on the tap, paid the monthly municipal bill, and gave the resource little further consideration. That luxury is gone. Today, deteriorating municipal infrastructure, frequent water cuts, and declining water quality have transformed water security from an operational concern into a strategic business risk. It is no longer an issue confined to factory floors or facilities departments, but it demands attention at board level. For modern companies, water stewardship is no longer a corporate social responsibility initiative. It is a core leadership duty that directly affects business survival, legal compliance, and long-term success.
Caught between strategic expectations and operational reality
Business leaders are under pressure from both ends of the value chain. From the top down, investors, banks, and strict environmental standards demand complete openness about how much water companies use and how they protect the environment. From the ground up, operational teams face mounting challenges as unreliable municipal supply, infrastructure failures, and water quality concerns disrupt daily activities.
When poor municipal water supply stops production lines or dirty wastewater breaks environmental laws, the financial hit is immediate. Businesses are constantly forced to choose between paying massive fines or spending large sums of money on emergency repairs. Because of this constant pressure, water has permanently shifted from a minor monthly expense into a top business risk.
Knowing your true water footprint
One of the biggest challenges for large organisations is the lack of accurate, consolidated water data. Many organisations operate without a comprehensive understanding, unified view of how much water they consume, where losses occur, how water quality changes across facilities, or what is ultimately discharged into the environment. Without this basic information, setting realistic reduction goals or meeting modern Environmental, Social and Governance (ESG) reporting requirements becomes exceptionally difficult.
To take back control, boards need to know exactly which of their facilities sit in water-stressed areas or depend on fragile local water supplies. Executive leaders must connect with site managers to truly understand how water shortages impact everything from daily manufacturing output to employee health and community relations.
Testing business resilience for a drier future
Protecting a business for the future requires serious planning at the executive level. Boards can no longer assume that municipal water services will remain reliable. Leadership teams must prepare for a range of scenarios, including long municipal outages, water quality that drops below safe working levels, and sharp increases in water tariffs and fines. As South Africa works to fix its national water infrastructure, factoring these rising costs and risks into financial planning is a basic duty for any director.
Forward-thinking companies are discovering that active water stewardship creates real business advantages beyond just avoiding risks. Moving toward a circular water model allows businesses to grow without relying entirely on fresh water. Investing in on-site water recycling, greywater systems, and advanced treatment technology is what enables companies to insulate themselves from municipal supply problems while turning environmental responsibility into operational strength.
Bridging the gap between policy and practice
Protecting a company’s right to operate means connecting high-level company goals with everyday actions on the ground. Effective water stewardship takes a holistic view of the entire water cycle, examining how water enters a facility, how efficiently it is used, how losses are managed, and how responsibly wastewater is treated and discharged.
Partnerships with specialised environmental service providers can help organisations implement advanced filtration systems, optimise treatment processes, improve wastewater management, and deploy innovative water-efficiency solutions. When the private sector takes responsibility for its water use, the benefits go far beyond individual company profits and reputations.
By taking stress off municipal systems, businesses actively help secure water for the surrounding community. Water stewardship is no longer an act of corporate philanthropy. It is a fundamental requirement for organisations seeking to remain competitive, resilient, and sustainable in an increasingly resource-constrained world.
By James White, Director: Sales and Marketing at Turnberry Management Risk Solutions
Medical aid remains essential for accessing private healthcare in South Africa, but it is no longer safe to assume it will cover the full cost of treatment. In 2026, industry regulators recommended that scheme contribution increases be capped at around 6-7% (CPI plus 3%), roughly in line with inflation, yet several major schemes have raised contributions well beyond that, with healthcare cost inflation broadly running at 9 – 11% against consumer inflation of about 3%. Medical aid options have also introduced growing numbers of co-payments, sub-limits, penalties and benefit restrictions. As a result, the role of gap cover has changed. What was once seen as an optional extra has become a critical safeguard against medical expense shortfalls, and it is now imperative that advisers and clients understand where medical aid cover may fall short and how those risks can be managed.
Healthcare cover is not what it used to be
The biggest change over the past decade is that medical aid has become far more complex. In the past, it was fairly simple to understand, and many routine healthcare costs were covered. Today, most day-to-day expenses are paid from medical savings or out of a client’s own pocket, and members must weigh up co-payments, sub-limits, designated service providers, network restrictions and benefit limits, all of which affect what a scheme will ultimately pay. At the same time, healthcare costs have continued to climb, and specialists often charge well above scheme rates. This means that having medical aid and being fully financially protected are no longer the same thing.
Every registered medical scheme is still required to cover Prescribed Minimum Benefits (PMBs) in full, a defined list of around 270 conditions, the Chronic Disease List, and emergency care, regardless of a member’s savings or threshold status. But PMBs are a floor, not a ceiling: outside of them, members are far more exposed than many realise.
Despite this, many people still believe they are adequately protected, without fully understanding the limitations of their medical aid. The reality often only becomes apparent when they need treatment. A claim subject to a co-payment, a specialist charging above the scheme rate, or a treatment subject to benefit limits can result in significant and unanticipated out-of-pocket costs.
Advice needs to evolve with the healthcare system
As the healthcare landscape has changed, the role of the adviser has changed with it. Recommending a medical aid option is no longer enough. Advisers also need to help clients understand how that option works, what it covers, where medical expense shortfalls may still arise, and how concepts such as co-payments, penalties, and designated service providers could affect them.
Advice also needs to be more personalised than in the past. Medical scheme options differ significantly, and the right level of cover depends on a client’s healthcare needs, affordability and family circumstances. A younger family with children, for example, may require very different cover from someone approaching retirement, even if both belong to the same medical scheme.
It’s also worth noting that gap cover itself isn’t unlimited. Under the Demarcation Regulations, gap cover claims are capped at an aggregate annual limit per beneficiary, a figure adjusted each year for inflation. Most claims fall comfortably within it, but very large shortfalls can still exceed the cap, which is one more reason the underlying medical aid plan needs to be right in the first place, not just the gap cover sitting on top of it.
This advice is no longer a once-off conversation either. Medical scheme benefits change, family circumstances shift over time, and healthcare needs evolve. Regular reviews help ensure that both medical aid and gap cover continue to provide the level of protection clients need.
A critical part of healthcare planning
The healthcare system has changed significantly over the past decade, and the way advisers approach healthcare cover needs to change with it. Medical aid remains essential, but it no longer provides the level of protection many people still expect. As a result, gap cover has evolved from an optional extra to a core part of protecting against medical expense shortfalls. Helping clients understand how their medical aid works, where shortfalls may arise, and how gap cover can address them has become an important part of modern healthcare advice.
As medical aid benefits, healthcare costs, and client needs continue to change, regular reviews are essential. By ensuring cover continues to reflect a client’s circumstances, and by explaining potential shortfalls before they arise, advisers can help clients make informed decisions and avoid unexpected medical expenses. Clients should speak to their broker or financial adviser regularly, to make sure their medical aid and gap cover continue to meet their healthcare needs.
Turnberry Management Risk Solutions (Pty) Ltd is an authorised Financial Services Provider (FSP no. 36571). Underwritten by Lombard Insurance Company, an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.
Dr Katlego Mothudi is the Managing Director of the Board of Healthcare Funders, an industry representative body for medical aid schemes, administrators and managed care providers.
By Katlego Mothudi
With plans in motion to roll out universal health coverage in South Africa, Dr Katlego Mothudi, of the Board of Healthcare Funders, argues that revising the compulsory prescribed minimum benefits that medical schemes must provide can be a tool to deliver meaningful improvements today while laying the foundations for a more sustainable healthcare system.
South Africa’s journey towards universal health coverage will not be defined by a single policy or piece of legislation, but by the practical reforms that make quality healthcare more accessible and affordable for more people. Achieving this goal requires, among other things, tackling structural barriers that continue to drive up the cost of medical scheme cover and place private healthcare beyond the reach of millions of people in South Africa. One of the most important, yet often overlooked, barriers is the outdated framework governing prescribed minimum benefits (PMBs).
PMBs are the set of conditions and services that every medical scheme is legally required to cover, regardless of the plan a member chooses. Their existence is critical, created with the intention of ensuring scheme members do not lose access to catastrophic care in the event of serious illness. PMBs ensure that members are not reliant on an over-burdened public sector during medical emergencies. And although this principle remains important, the framework has not kept pace with South Africa’s changing disease burden, evolving models of care, or the cost of delivering healthcare.
20 years of PMB limbo
Regulations made under the Medical Schemes Act require PMBs to be reviewed every two years. This must be carried out by the Department of Health together with the Council of Medical Schemes, provincial health departments and other stakeholders. In practice, this has happened only once, more than 20 years ago.
The current review process has been underway for close to a decade without conclusion. As a result, the outdated PMB framework has become one of the most significant contributors to medical scheme costs and thus an inefficient health policy. Actuaries advise that roughly 60% of a scheme’s budget goes towards funding PMBs before any other benefit is considered. This used to be approximately 40% when the PMB was amended in 2003.
The consequences of this laborious review process directly impact household budgets. The most basic scheme cover now costs a single beneficiary in the region of R1 600 a month, with a family of three facing around R4 000. For most working people in South Africa, that is simply unaffordable, and it is a significant reason why medical scheme membership has stagnated even as the population has grown. Furthermore, South Africa’s healthcare “missing middle” has grown to an estimated 8 million people who access private healthcare, paying out-of-pocket, without belonging to a medical scheme.
An out-of-date framework
If the PMB list were redesigned today, using current clinical evidence, the country’s evolving disease burden, and the realities of healthcare affordability, many of its benefits would likely look very different. The current framework no longer reflects what the system can sustainably provide. And because it consumes such a large portion of every scheme’s budget, it crowds out the very things that would make cover more affordable and more useful – primary care, early intervention and prevention.
At a recent Board of Healthcare Funders conference, Dr Fatima Hoosain, a specialist breast and endocrine surgeon, set out the numbers plainly: a mammogram and ultrasound cost in the region of R2 500. Left undetected until the disease has progressed, that same patient may require R100 000 in radiation therapy, R200 000 in chemotherapy, and, for HER2-positive cancers which typically can quickly spread from the breasts to other areas of the body, roughly R7 000 every three weeks for a year in targeted biological therapy. Early detection does not only save lives, but it is also, by a wide margin, the cheaper pathway. From a cardiology perspective, Dr Martin Mpe, president of the South African Heart Association, made the same point at the conference. He argued that the cheapest way to treat a heart attack is to prevent it, and that the system needs to start rewarding prevention rather than paying only for treatment after the fact.
Rather than expanding access, an outdated PMB framework has unintentionally limited it.
A PMB framework anchored in 1999-era diagnosis-and-treatment logic has little room for rewarding the prevention and early detection that would keep patients out of the expensive end of the system altogether. Importantly, reform does not mean stripping away protection. It means modernising the list so that mandatory cover reflects today’s clinical realities. It also means rethinking how the package is defined. The current approach is built around a long, condition-by-condition diagnostic list, a modern framework could instead focus on the essential health services people need most, including preventative care, primary healthcare services, medicines on an essential medicines list, and diagnostics on an essential diagnostics list. It could also emphasise the areas where the disease burden is greatest.
A core service package
This aligns closely with the Board of Healthcare Funders’ (BHF) recent commitment to explore a Core Service Package as a practical step towards universal health coverage. By focusing on the services that deliver the greatest health benefit within available resources, such an approach would place prevention and patients at the centre of the health system while creating greater flexibility to expand affordable access.
The BHF has previously worked to operationalise South Africa’s national Essential Medicines List (EML) within the private funding environment, partnering with MediKredit in 2021 to launch a NAPPI-coded mapping tool that helps funders align benefit design and claims systems with the EML, improve medicine access, and reduce out-of-pocket costs. This existing groundwork offers an affordable, prevention-oriented foundation on which a modernised PMB package could be built.
The evidence of where the current framework falls short is already available. Annually, the Council for Medical Schemes reports on out-of-pocket expenditure, which exceeded R40 billion last year. When people spend that much of their own money on healthcare, over and above their contributions, they are pointing directly to where their cover is failing.
A broader set of changes
PMB reform does not stand alone, and it will not by itself fix affordability. It is the entry point to a broader set of changes that reinforce one another. The most important of these is regulated tariff reform. South Africa currently lacks a transparent, predictable mechanism for setting provider prices, and this absence has driven costs upward for years. Allowing schemes and willing providers to negotiate fair tariffs, within a properly regulated framework, published for transparency, would bring discipline and predictability to pricing and give members clarity on what they are paying for.
Alongside this, permitting schemes to offer low-cost benefit options, a subset of the proposed revised PMBs and based on services rendered in the public sector clinics, would extend affordable, primary-care-based cover to millions of people in South Africa who currently fall outside the system and pay out-of-pocket for private care.
None of these reforms require new legislation or a wholesale restructuring of the health system. They can be pursued within the existing regulatory framework, and PMB modernisation is the logical place to begin, because it addresses the highest single cost in every member’s contribution and unlocks the room to fund better, more preventive care.
For members, this shift would be felt less as a change to their PMB entitlements and more as a change in what their contribution actually buys before a crisis ever occurs. Money currently locked into funding late-stage, high-cost treatment for conditions that could often have been caught earlier could instead support routine age- and risk-appropriate cancer screenings, cardiovascular risk assessments and blood pressure checks, diabetes screening and management support, and the kind of primary care consultations that catch problems while they are still cheap and simple to treat. None of this is about giving members less. It is about intervening earlier, so that fewer members ever need the R100 000 radiation course, the R200 000 chemotherapy regimen, or the cardiac admission that better screening or blood pressure control could have prevented.
There is an understandable reluctance to reopen the PMB framework, given how long the review has already taken and how contested the terrain can be. The longer reform is delayed, the greater the affordability pressures on households and the greater the strain on the broader health system.
Reforming prescribed minimum benefits is ultimately about far more than updating a list of conditions. It is about creating the flexibility to expand access, strengthen prevention and make medical scheme cover affordable for more people in South Africa.
*Mothudi is the Managing Director of the Board of Healthcare Funders, which represents around 45 medical aid schemes in South Africa, including GEMS and Bonitas.
*This piece was published by Spotlight – health journalism in the public interest. Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
By Dr Fatima Hoosain, specialist surgeon and Principal of Apffelstaedt, Hoosain & Associates, with a clinical focus on breast and endocrine surgery.
Photo by National Cancer Institute on Unsplash
When people think about breast cancer screening, the conversation often begins and ends with one message: screen more women.
As clinicians, we know it is not quite that simple.
There is no question that screening saves lives. Regular mammography reduces breast cancer mortality and gives us the opportunity to diagnose disease when it is smaller, more treatable and associated with significantly better outcomes. Few interventions in medicine demonstrate such a clear benefit.
The challenge is that good breast care is not defined simply by how many mammograms we perform. It is defined by the quality of the decisions that surround them.
This was the focus of my presentation at the recent Board of Healthcare Funders (BHF) Conference, where we explored how clinicians can balance the burden of breast cancer with evidence-based screening decisions while remaining mindful of both underdiagnosis and overdiagnosis.
Those competing risks are encountered by every clinician involved in breast care.
We all worry about the patient whose cancer is diagnosed later than it should have been. Earlier diagnosis frequently means less extensive surgery, more treatment options and, ultimately, better outcomes. The survival difference between early-stage and advanced disease is substantial, making timely diagnosis one of the most important contributors to long-term prognosis.
At the same time, screening is not without consequences.
Not every abnormality detected on imaging will become life-threatening, yet every suspicious finding understandably creates anxiety. Additional imaging, biopsies and sometimes treatment may follow. Our responsibility is therefore not simply to detect abnormalities, but to interpret them appropriately within the context of each patient’s overall clinical picture.
This is why breast screening should never be approached as a uniform process. Risk matters.
A woman with an inherited genetic mutation or a strong family history should not necessarily follow the same screening pathway as someone at average risk. Likewise, imaging should answer a clinical question. Mammography remains the cornerstone of breast screening, but dense breast tissue, patient age and individual risk factors may require supplementary investigations such as ultrasound or MRI. More imaging is not automatically better medicine. Appropriate imaging is.
These decisions have become even more complex within the South African healthcare environment. International guidelines provide an excellent evidence base, but they do not remove the practical realities we face every day. Access to imaging differs between regions. Advanced investigations may not always be readily available. Medical scheme funding, co-payments and affordability inevitably influence what is possible for many patients. These factors cannot be ignored when discussing best practice because they form part of the reality in which clinical decisions are made.
Fortunately, the treatment landscape continues to evolve.
Advances in oncoplastic surgery, targeted therapies, immunotherapy and modern radiation techniques have transformed outcomes for many patients diagnosed with breast cancer. These developments are encouraging, but they should not distract us from one fundamental principle: the earlier we diagnose clinically significant disease, the greater the opportunity to offer patients treatments that are both effective and less invasive.
Diagnosis, however, is only the beginning of the journey.
Long-term follow-up remains an essential part of breast cancer care. Ongoing surveillance, adherence to endocrine therapy where appropriate, management of treatment side effects and supporting patients through the psychological and financial impact of a cancer diagnosis all influence outcomes. Good breast care extends well beyond the operating theatre or oncology unit.
As our healthcare system continues to face increasing clinical and financial pressures, I believe we need to move beyond simplistic conversations about screening uptake alone.
The more important discussion is whether we are making consistently good clinical decisions. Are we identifying the patients who stand to benefit most? Are we investigating appropriately? Are we avoiding unnecessary intervention when the evidence suggests it is unlikely to improve outcomes?
Those are not easy questions, but they are the ones that matter.
Ultimately, breast cancer screening is not about doing more. It is about doing what is right for the patient sitting in front of us. That remains the most important clinical judgement we make.
By Brian Harris, CEO at Turnberry Management Risk Solutions
28 July 2026 – Medical aid remains essential for accessing private healthcare in South Africa, but it does not always cover the full cost of treatment. While regulations such as Prescribed Minimum Benefits (PMBs) ensure that members have access to a defined level of care for certain conditions, medical schemes still apply tariff limits, treatment protocols, co-payments and other funding rules that can leave members exposed to out-of-pocket costs. At the same time, healthcare costs continue to rise, placing additional pressure on how schemes fund treatment. As a result, medical expense shortfalls are becoming increasingly common, making gap cover an essential part of helping clients manage their healthcare costs and protecting them against unexpected expenses.
Protection within limits
PMBs are a clear example of how scheme rules and funding limits influence what medical schemes ultimately pay for. They are designed to ensure that all medical scheme members have access to treatment for a defined list of emergencies, chronic, and life-threatening conditions. However, they do not provide unlimited funding for every treatment option, and there is often a misunderstanding about this.
When it comes to PMBs, cover is still subject to scheme rules, treatment protocols, formularies, and designated service provider requirements. In many cases, cover is also aligned to the level of care that would ordinarily be available in the public healthcare system. This becomes particularly important in areas such as oncology, where newer or more specialised treatments may fall outside what a scheme is required to fund in full.
As a result, members may still face co-payments, sub-limits, or shortfalls that need to be paid for out of pocket, even when the condition itself qualifies as a PMB.
How scheme rules create shortfalls
PMBs are only part of the picture when it comes to medical expense shortfalls. Even where treatment is covered, medical schemes reimburse according to their own tariffs and funding rules, while healthcare providers may charge significantly more. The difference between what the scheme pays and what the provider charges is the member’s medical expense shortfall.
At the same time, medical schemes use co-payments, benefit limits, Designated Service Providers (DSPs) and authorisation requirements to manage rising healthcare costs and keep contributions affordable. If these rules are not followed, or if treatment falls outside the approved funding structure, members may still need to pay part of the cost themselves.
This means that having medical aid does not always guarantee that treatment will be covered in full. Even where treatment is approved, members can still face significant out-of-pocket expenses.
Advice is essential
As funding rules become increasingly complex, advisers need to take on a more proactive role in helping clients understand and navigate the healthcare landscape. Many clients do not fully understand how PMBs, DSPs, funding rules and scheme tariffs affect what their medical aid will ultimately pay. The reality often only becomes clear at the claims stage, when members discover that they are responsible for part of the cost themselves.
Explaining these rules clearly, together with where medical expense shortfalls may arise, is therefore becoming an increasingly important part of the healthcare funding discussion. Regular reviews and clear guidance also help ensure that changes to scheme rules, benefits, and healthcare costs do not leave clients exposed to unnecessary or unexpected out-of-pocket expenses.
Future-proofing healthcare advice
Medical aid and gap cover should not be treated as once-off decisions. Scheme rules, pricing structures and healthcare costs continue to change, which means healthcare advice needs to be reviewed regularly to ensure that cover remains appropriate.
Helping clients understand how their medical aid works, where medical expense shortfalls may arise, and how gap cover can be structured forms an important part of responsible advice. Regular reviews also help ensure that changes to benefits, family circumstances or healthcare needs do not leave clients exposed to unnecessary costs.
As regulation continues to shape how healthcare is funded in South Africa, gap cover is becoming an increasingly important part of managing healthcare costs. Brokers and financial advisers play an essential role in ensuring their clients have medical aid and gap cover that together provide the right level of protection.
Turnberry Management Risk Solutions (Pty) Ltd is an authorised Financial Services Provider (FSP no. 36571). Underwritten by Lombard Insurance Company, an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.
The single greatest threat to South African primary healthcare isn’t a lack of resources or medical expertise – it’s how doctors are paid. That’s the consensus of a growing number of doctors, including Dr David Sekete, who has practised medicine in Katlehong for more than four decades. The traditional funding model, he argues, is systemically flawed, with consequences that ripple through every stage of a patient’s care.
“Many of the people I see live on modest incomes and struggle with the cost of care. Those covered by medical schemes face the same pressure from a different angle – benefits exhausted by mid-year, out-of-pocket costs remain high, and when cover runs out, GPs are left to choose between turning patients away or treating them at their own cost,” says Dr Sekete. “Over time, a doctor’s incentives and their patients’ interests drift apart. It is tempting to blame geography or poverty for these failures, but the barrier was never only location or scarcity. It is the payment model.”
In response, Dr Sekete restructured his practice entirely. Through The Value Care Team (TVCT), a programme powered by healthcare management company PPO Serve, he now receives a guaranteed, risk-adjusted monthly fee for every enrolled GEMS member, rather than billing for each consultation or procedure. Out-of-pocket costs fall away, patients can return throughout the year regardless of their benefits status, and the administrative burden of chasing schemes for payment is eliminated. The practice now operates as a single multidisciplinary facility, bringing together an optometrist, dentist, physiotherapist, psychologists, social workers, a mother-and-child unit, a dialysis centre, and on-site imaging and pathology under one roof.
This shift has fundamentally changed what the practice delivers, and nowhere is that more evident than in prevention. TVCT Care Coordinators follow up on diabetic, hypertensive and mental-health patients at home, educating entire families along the way. Weekly health talks cover diabetes, hypertension, and prostate and breast cancer; a mammography team visits monthly; and the wider team regularly takes its work into schools and churches across the community.
“Care stops being a series of emergencies and becomes something managed before it reaches crisis point,” says Lungile Kasapato, CEO of PPO Serve. “Patients who once arrived only when illness had become unavoidable now come in early, when problems are still simple and affordable to treat. This holistic approach creates a support system around the patient that simply does not exist in traditional fee-for-service models.”
The practice in Katlehong has since been awarded 100% accreditation by the Office of Health Standards Compliance, a rare achievement that proves value-based care can meet the highest quality standards. Yet adoption remains limited. Many GPs continue to favour fee-for-service, drawn by the prospect of higher individual billing, even as the system deteriorates around them: schemes cannot absorb rising claims, patients cannot afford increasingly expensive care, and healthcare moves further out of reach for ordinary South Africans.
“What Dr Sekete has built, proves that value-based care is not a theoretical ideal – it is a practical, replicable model that delivers better outcomes for patients, better sustainability for practitioners, and a more viable future for the sector,” says Kasapato. “Our ambition is to see this replicated in communities across the country.”
For GPs considering the transition, Dr Sekete is direct: get the foundations right first – a proper facility, the right staffing, a genuine multidisciplinary team, strong IT systems, and reliable laboratory and diagnostic support – then coordinate closely with the community. “What I want now is replication: pockets of excellence across the country, each one a working example others can build from. The only real question is whether the profession – and the system around it – is ready to adopt it.”
By James White, Director: Sales and Marketing at Turnberry Management Risk Solutions
Medical aid is essential for accessing private healthcare in South Africa, but it does not always cover the full cost of treatment. Shortfalls related to specialist fees, co-payments, and sub-limits, are an ongoing reality, leaving many medical aid members exposed to significant out-of-pocket expenses. This is why gap cover is no longer an optional conversation for advisers. As these shortfalls become increasingly common, clients rely on advisers to identify where cover may fall short and to explain how these risks can be managed. Gap cover plays an important role in addressing this challenge by covering the difference between what medical schemes pay and what providers charge, making it an integral part of the advice process.
Making gap cover part of the conversation
As medical expense shortfalls become increasingly common, addressing them is becoming part of a financial adviser’s responsibility. When recommending or reviewing medical aid, it is not enough to focus only on contributions and benefits. Advisers also need to ensure that their clients are fully aware that their medical aid may not cover the full cost of treatment, particularly where specialist fees, co-payments and sub-limits apply.
Areas where clients are likely to face out-of-pocket costs need to be explained clearly, together with how gap cover can reduce them. Advisers need to position gap cover not as an optional extra, but as an essential part of ensuring that clients are not left exposed to avoidable out-of-pocket costs.
The cost of not addressing shortfalls
If financial advisers do not discuss gap cover with clients, the impact is typically not felt immediately. However, the problem becomes clear when a claim arises. If a member receives treatment expecting their medical aid to cover the full cost, and then ends up with a large bill for the shortfall, or has to pay a large co-payment upfront, this can result in significant dissatisfaction.
The reality is that medical expense shortfalls are no longer unusual, and both the size and frequency of these costs are increasing. Specialists may charge several times the scheme rate, while co-payments and benefit limits are increasingly used by medical aids to manage costs and keep premiums affordable. Without additional cover, patients must pay these costs out of pocket, and they can run into tens or even hundreds of thousands of rands.
This is why it is important that these gaps be raised upfront. Clients rely on their advisers to explain how medical aid works and what costs may arise, so they can make informed decisions before a claim happens, rather than being caught off guard by costs that place pressure on their finances.
What advisers should be explaining
Gap cover should form part of every discussion around medical aid, rather than being treated as an optional extra. When recommending or reviewing medical aid, it is important for advisers to highlight where out-of-pocket costs may still arise, including specialist tariff gaps, co-payments, sub-limits and network restrictions.
These risks need to be explained clearly, together with how gap cover can reduce them. Discussing this upfront helps clients understand what their medical aid will and will not pay, so they are not surprised by costs when they claim. It also ensures that decisions around cover are based on a clear view of the full healthcare funding picture, not only the monthly premium.
Over time, this approach builds trust and reinforces the adviser’s role in helping clients manage healthcare costs, rather than reacting to them after the fact.
Complete advice requires a complete view of healthcare risk
Medical aid remains essential, but it does not remove the risk of medical expense shortfalls, co-payments, or sub-limits. These are now a routine part of private healthcare and need to be addressed as part of the advice process.
Advisers have a responsibility to identify and explain these risks clearly, and to make them a consistent part of every client conversation.
Helping clients understand how their medical aid works, where shortfalls may arise, and how gap cover can address those gaps ensures that their cover reflects a complete view of their healthcare costs and is genuinely aligned to their needs.
