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Opinion Piece: Medical Aid Cover is Changing – Are South Africans Prepared for the Gaps?

On By ModernMedia
Photo by Alex Green on Unsplash

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.

Categories : Expert Opinion Medical IndustryTags :

Reforming Prescribed Minimum Benefits Is the First Step to Affordable Medical Cover

On By ModernMedia
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.

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Breast Cancer Screening in South Africa: Balancing Early Detection with Appropriate Care

On By ModernMedia

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.

Categories : Expert Opinion Medical IndustryTags :

Opinion Piece: How Medical Aid Regulation Changes Are Shaping the Future Demand for Gap Cover

On By ModernMedia

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.

Categories : Expert Opinion Medical IndustryTags :

Rethinking Success in Primary Healthcare

On By ModernMedia
Dr David Sekete

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.”

Categories : Expert Opinion Medical IndustryTags :

Opinion Piece: Why Gap Cover Has Become a Non-negotiable Conversation for Advisers

On By ModernMedia
Photo by Alex Green on Unsplash

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.

Categories : Expert OpinionTags :

Why Rehabilitation is a Core Pillar of Managing Occupational Injuries and Improving Wellness and Healthcare Outcomes for Workers

On By ModernMedia
Photo by Towfiqu barbhuiya

The new dawn of managing occupational injuries as prescribed in the recently enacted Compensation for Occupational Injuries and Diseases (COID) Amendment Act 10 of 2022 puts at the forefront the need to rehabilitate injured workers. This ensures that their potential for reintegration into the world of work is maximised. Rand Mutual Assurance argues that rehabilitation must move from the margins to the centre of national workforce health strategies.

Speaking on the sidelines of the 25th Annual Board of Healthcare Funders (BHF) Conference, which took place in Cape Town from 4–8 July, Kyle Fredericks, Managing Executive: Social Insurance at RMA, emphasised that rehabilitation, reintegration and return to work were not simply clinical services, but strategic enablers of economic resilience, worker wellbeing and long-term productivity.

“Rehabilitation in the healthcare value chain has historically been treated as a downstream intervention – something that happens after an injury, after a claim, after a disruption. But the evidence is clear that rehabilitation is most effective when it is prioritised, integrated and supported from the very beginning of the occupational healthcare journey,” says Fredericks.

Rehabilitation as a driver of workforce resilience

South Africa’s labour market is undergoing rapid transformation, with new technologies, new models of employment and shifting workforce demographics reshaping how people work and the pressures they face. In this environment, the cost of prolonged recovery, delayed treatment and fragmented care pathways is becoming increasingly unsustainable.

“A resilient workforce can recover quickly, safely and sustainably from injury or illness. Rehabilitation is the engine of that resilience. It restores function, supports reintegration and protects workers from long‑term disability. When rehabilitation is integrated, the entire healthcare ecosystem strengthened,” notes Fredericks.

RMA’s position reflects a growing global consensus that rehabilitation is not an optional add‑on, but a core pillar of modern occupational healthcare. Countries that invest in structured rehabilitation programmes consistently report improved recovery outcomes, reduced compensation costs and higher return‑to‑work rates.

The consequences of fragmented rehabilitation pathways

Despite its importance, rehabilitation in South Africa remains unevenly prioritised across sectors. Workers often face delays in accessing appropriate care, limited coordination between healthcare providers and insufficient support for community or work reintegration. These gaps prolong recovery, increase the risk of complications and reduce the likelihood of successful return‑to‑work.

“Fragmentation is one of the biggest barriers to effective rehabilitation. When clinicians, therapists, employers, administrators and social insurers operate in isolation, workers fall through the cracks. Rehabilitation must be part of a connected ecosystem – one where every stakeholder understands their role in supporting recovery,” explains Fredericks.

Fredericks adds that strengthening rehabilitation requires more than clinical expertise; it requires collaboration, shared standards and a commitment to worker‑centred care. “Rehabilitation is a team effort. It succeeds when everyone is aligned around the same goal, which is restoring the worker to full participation in life and work.”

A call for stronger partnerships with healthcare professionals (and beyond)

RMA is using the BHF Conference as a platform to call for deeper collaboration with healthcare practitioners, rehabilitation specialists and allied health professionals. The organisation believes that building a robust rehabilitation ecosystem depends on strong clinical partnerships and shared ambition.

“We want healthcare professionals to understand our commitment to rehabilitation and reintegration. We are scaling our rehabilitation function significantly, and we are inviting clinicians, therapists and specialists to partner with us and recognise community-based mechanisms that make reintegration possible” says Fredericks.

“Together, we can build a rehabilitation ecosystem that is responsive, evidence‑based, and centred on the needs of workers.”

Fredericks points out that rehabilitation must be recognised as a specialised discipline that requires dedicated investment, continuous learning and integrated care pathways. “Rehabilitation is not a single event; it is a journey. And that journey must be supported by skilled professionals who understand the complexities of recovery”

Rehabilitation and the future of occupational healthcare

RMA’s advocacy for rehabilitation is part of a broader shift in the sector, which is seeing a move from reactive compensation models to proactive, integrated healthcare ecosystems. This evolution recognises that worker wellbeing cannot be achieved through compensation alone. It requires prevention, early intervention, coordinated care and structured rehabilitation.

“The future of occupational healthcare is holistic. It begins with prevention, continues through injury management and culminates in rehabilitation and return‑to‑work. Rehabilitation is the bridge between injury and recovery – without it, the system cannot deliver the outcomes workers deserve,” says Fredericks.

Fredericks adds that rehabilitation also plays a critical role in strengthening national productivity. “Healthy workers build healthy industries. When rehabilitation is strong, businesses benefit from reduced downtime, improved morale and greater long‑term stability.”

Categories : Expert Opinion Lab Tests and ImagingTags :

Provinces Owe the NHLS Billions, Patients Could Pay the Price. It’s Time to Crack the Whip

On By ModernMedia
Through its countrywide network of quality-assured diagnostic laboratories, the NHLS is the sole provider of diagnostic pathology services to over 80% of the South African population. Photo by National Cancer Institute on Unsplash

Comment & Analysis

By Faith Muthambi

Provincial debt to the National Health Laboratory Service is not just a financial governance matter, but also a public healthcare service delivery risk that affects diagnoses, treatment, disease surveillance, and government’s ability to protect vulnerable patients, writes Faith Muthambi, chairperson of the Portfolio Committee on Health in the National Assembly.

When *Lungile Mbonambi, a hypothetical healthcare user, waits for a blood test at a public hospital, she is not thinking about all the zeros in provincial budgets or intergovernmental disputes. She is thinking about her health. Like some 80% of people in South Africa, she places her trust in the public healthcare system, the inner workings of which she will never see, and in laboratory professionals she will likely never meet. However, in using the system, she experiences its impact.

For her blood test, a nurse will draw the sample, seal the vial and send it to the closest National Health Laboratory Service (NHLS) facility. For patients, waiting for the results often feels uneasy and ridden with dread. In addition to the immediate health concern, patients also find themselves in the hands of a system that needs to function well, not only on paper and in policy, but also in the concrete reality of their particular case.

The NHLS plays a big role in public health in South Africa through epidemiology, surveillance and responding to public health outbreaks. Among other things, it is involved in HIV and TB programmes, conducting diagnostic tests for non-communicable diseases, and the screening for cervical cancer. In essence, contemporary healthcare would grind to a halt without the robust laboratory infrastructure that the NHLS provides.

Ballooning debt

Just recently at the end of May, the Portfolio Committee on Health in Parliament, which is tasked with overseeing the National Department of Health, met with representatives from the NHLS and all nine provincial health departments. The meeting revealed that outstanding debt to the NHLS had climbed to an imposing R11 billion as of March this year. Most of this debt stemmed from KwaZulu-Natal with around R3.94 billion, and Gauteng with roughly R3.3 billion, both of which include debt from previous years.

This meeting confirmed what many in the public health system have warned about for years. This outstanding debt is not merely a matter of the numbers not adding up, but is symptomatic of a serious failure in financial governance. Failing to pay or delaying payments for critical services already rendered to the public health system also reflects poor coordination among government departments and entities.

The consequences of this can be dire.

For the NHLS, without these funds, the institution cannot sustain research, do proper disease surveillance, detect outbreaks or monitor antimicrobial resistance, or upgrade equipment. When a laboratory cannot replace ageing instruments on time, fill critical posts, modernise information technology or plan procurement with certainty, it is felt in hospitals and clinics.

For patients, it means delayed diagnoses and disrupted care, and those living in rural and under-resourced communities often bear the brunt.

Time to act

Listening to presentations from all nine provincial health departments showed that this crisis can be prevented. There are provinces that are getting this right and paying their invoices to the NHLS within the required 30-day period. This shows that, even with budget constraints, laboratory services can be prioritised.

As Chairperson of the Portfolio Committee on Health, I have made it clear that it is now time to shift our oversight from concern to action that leads to actual consequences for those provinces that fail to pay their NHLS debts.

There had been instances in the past where National Treasury intervened by withholding or redirecting funds when provinces failed to fulfil their responsibilities. The committee may need to engage the National Treasury on ways to protect funding for laboratory services, including the possibility of direct transfers or ring-fenced funding where provinces fail to prioritise their obligations to the NHLS. The message is clear: We cannot allow a situation in which a province destabilises another public institution by failing to pay for services central to healthcare provision.

Our next step cannot be to just accept more vague commitments and assurances that the debt will be paid. Provinces with outstanding debt must provide clear repayment plans linked to strict timelines, while continuing to pay current invoices within the required period. The committee will request quarterly progress reports on payments made to reduce the debt, as well as on actions taken against officials involved in this non-payment.

We live in an era marked by emerging health threats and increasing demands on health services. It is therefore important to remind ourselves that health systems do not collapse overnight. They deteriorate gradually through deferred payments and normalised delays, among other things. By the time patients experience the full impact, the horse may have already bolted because we ignored the warning signs.

To be clear – this, here, is a serious warning sign.

Yet notwithstanding these pressures, laboratory professionals continue to demonstrate extraordinary commitment. Samples are being processed, and results are verified. I commend these public servants who work beyond ordinary expectations to protect the service. However, we cannot bank on this devotion to become a permanent substitute for responsible governance.

The decision before us is whether we allow patients’ experience of the public health value chain between health facilities and NHLS laboratories to continue to be determined by delay and uncertainty, or by a public health system that understands the seriousness of its responsibilities and acts accordingly.

Patients like Mbonambi are placing their trust in the state. We must do better.

*Muthambi is a Member of the National Assembly and Chairperson of the Portfolio Committee on Health.

Note: 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.

Republished from Spotlight under a Creative Commons licence.

Read the original article.

Categories : Expert Opinion Healthcare Politics and RegulationsTags :

Inside The Box with Dr Andy Gray | How Should the Compounding of Medicines Be Regulated?

On By ModernMedia
Photo by National Cancer Institute on Unsplash

By Andy Gray

The South African Health Products Regulatory Authority, with the South African Pharmacy Council, recently announced what was described as a crackdown on a compounding pharmacy. They allege “critical regulatory non-compliance” in relation to the compounding of unregistered medicines. In his latest Inside The Box column, Dr Andy Gray provides some background to the issues at stake, while recognising that some key elements remain contested.

Until the 20th century, medicines dispensed by pharmacists were all compounded (mixed) from raw ingredients, most of which were inorganic chemicals and herbal products. The gilded majolica jars displayed in pharmacies and museums depict the names of those common ingredients, often in Latin. Hence, a jar labelled as “Paraf mol alb” would contain “paraffinum molle album”, or white soft paraffin (white petroleum jelly), more commonly known as Vaseline.

The market for finished pharmaceutical products, in the form of modern tablets, capsules and the like, has grown dramatically over the last century. Even so, the need for the preparation of medicines in a pharmacy, from either raw ingredients or existing products, has not entirely disappeared.

#InsideTheBox is a column by Dr Andy Gray, a pharmaceutical sciences expert at the University of KwaZulu-Natal and Co-Director of the WHO Collaborating Centre on Pharmaceutical Policy and Evidence Based Practice. (Photo: Supplied)

There has always been a need for the preparation of particular products for individual patients in cases where a commercial product does not exist or is not suitable. For example, a pharmacist may be asked to produce an eye drop when no commercial products exist, using an injection as the starting material. Similarly, where a patient is unable to swallow tablets or capsules, an oral liquid preparation may be compounded. In many cases, the preparation is done extemporaneously, meaning that it is done specifically for that patient at a point in time. Such medicines are compounded by pharmacists as part of their usual professional practice in community and hospital pharmacies.

Exceptions, limitations and contestation

Modern medicines regulatory practice is based on the concept of registration or marketing authorisation. This is where a manufacturer is required to provide evidence to the national medicines regulatory authority of the quality, safety and efficacy of a medicine, before it can be sold. However, an exception has been created, allowing for compounding of medicines. In the South African medicines legislation, this is provided by section 14(4) of the Medicines and Related Substances Act (Act 101 of 1965).

The usual approach is described in section 14(1) of the Act, which states that “no person shall sell any medicine … which is subject to registration by virtue of a declaration published in terms of subsection (2) unless it is registered”. The declaration in this regard refers to the call-up notices issued for different pharmacological classifications of medicines since 1967, when the Act came into operation. All pharmacological classifications have now been made subject to registration.

The exception is provided by section 14(4), which states that subsection 14(1) will not apply when a medicine is “compounded in the course of carrying on his or her professional activities by a pharmacist”. A similar exception applies to licensed dispensing and compounding practitioners and veterinarians. Two scenarios are envisaged: compounding a preparation in accordance with a prescription for a particular patient, or compounding by a pharmacist for the retail trade.

However, there are three critical additional restrictions: a compounded medicines shall “not contain any component the sale of which is prohibited by this Act or any component in respect of which an application for registration has been rejected”, the compounded medicine “is not or has not been advertised”, and the “the active components of such medicine appear in another medicine which has been registered”. Thus, unless declared undesirable or never before registered, an active ingredient may be compounded and sold without being registered. A compounded medicine may also not be advertised to the public or to health professionals.

Further details were provided by the General Regulations to the Medicines and Related Substances Act, which were published in 2017. The initial version of those regulations added some additional restrictions, for example restricting the quantity to be compounded to the “quantity that is intended to be used by a patient for not more than 30 consecutive days from the date of compounding”. More importantly, sub-regulation 3(3)(a) prohibited compounding that was intended “to circumvent the provisions of section 14 of the Act”, the requirement for registration.

Legal challenge

In December 2021, the North Gauteng High Court in Pretoria ruled in a case brought by The Association of Compounding Pharmacists of South Africa, challenging the regulations. While noting that “[w]hat constitutes pharmacy compounding is not well defined”, Judge Norman Manoim ordered that the regulations be redrafted and that a draft guideline on good compounding practice be published. In particular, the judgment recognised the need to clarify what was needed for “anticipatory compounding”, where medicines were compounded in anticipation of a prescription or for sale by a pharmacist.

In accordance with the court judgment, amended regulations were published for comment and finalised in 2022, deleting sub-regulation 3(3)(a), and recognising that a pharmacist could “based on the amount of medicine compounded previously for a particular period, compound such medicine in anticipation of supply thereof within such particular period”. Lastly, the regulations required that draft guidelines on good compounding practice be published within 6 months, for public comment. These draft guidelines were published for comment in June 2023, but have not been issued in final form. The draft guidelines are no longer accessible on the South African Health Products Regulatory Authority (SAHPRA) website.

Compounding pharmacies

While the extemporaneous compounding of medicines for individual patients is routinely performed in most community and hospital pharmacies, “anticipatory compounding” has emerged as a speciality practice.

Compounding pharmacies are not recognised as a specific category of pharmacies licensed by the Department of Health and recorded as such by the South African Pharmacy Council (SAPC). The current regulations to the Pharmacy Act only recognise community, institutional (hospital), wholesale, manufacturing and consultant pharmacies. The services that each category of pharmacy can deliver are regulated, with both community and institutional pharmacies enabled to perform “compounding, manipulation or preparation of any medicine or scheduled substance”. Specialist compounding pharmacies are thus licensed as community pharmacies.

SAHPRA licenses manufacturers and wholesalers of medicines, not community pharmacies. Section 22C(1)(b) of the Medicines and Related Substances Act states that the Authority “may … issue to a … manufacturer, wholesaler or distributor of a medicine … a licence to manufacture, import, export, act as a wholesaler of or distribute, as the case may be, such medicine … upon such conditions as to the application of such acceptable quality assurance principles and good manufacturing and distribution practices as the Authority may determine”.

Whether a compounding pharmacy, licensed as a community pharmacy, can import active pharmaceutical ingredients (APIs) for the purposes of compounding, is contested. It is the API which is responsible for the desired medicinal effect but can also be the cause of adverse events. Inactive excipients are added to produce the final dosage form administered to patients.

The question of quality

As was outlined in a previous column in this series, patients are assured of the quality of medicines on the South African market by virtue of their registration by SAHPRA and compliance with Good Manufacturing Practice (GMP) standards by licensed manufacturers. Compounded medicines are an exception to the rule – they are unregistered, and their preparation is not subject to GMP.

In the case of medicines compounded for individual patients, the risk is more manageable. Where larger quantities are prepared in anticipation of demand, and in particular where sterile preparations such as injections are made, the risks may be greater.

Equally, there is a need to ensure that APIs used for manufacturing or compounding medicines are of acceptable quality. A draft guideline on post-importation testing, published by SAHPRA for comment in May 2026, applies to all imported APIs.

Following a major incident in the United States, where contaminated compounded corticosteroid injections resulted in a number of serious fungal infections, US law was amended in 2013 to create a new category of outsourcing facilities regulated by the Food and Drug Administration (FDA), not by state pharmacy boards. State pharmacy boards were not considered to have the capacity to effectively regulate large scale compounding, especially for higher risk sterile preparations.

In South Africa, while the Good Pharmacy Practice standards issued by the SAPC cover the usual services delivered by community and hospital pharmacies, they are insufficient to cover larger scale anticipatory compounding or outsourcing services.

Ongoing contestation

Existing South African law may well be deficient in the way in which it regulates compounding pharmacies. How the current legal provisions are applied and interpreted is contested and will be the subject of a number of court challenges.

Patient safety must remain the key animating feature of any future regulatory process that is fit for purpose and effective.

*Dr Gray is a Senior Lecturer at the University of KwaZulu-Natal and Co-Director of the WHO Collaborating Centre on Pharmaceutical Policy and Evidence Based Practice. This is part of a series of columns he is writing for Spotlight.

Disclosure: Gray serves on three technical advisory committees at the South African Health Products Regulatory Authority.

Note: 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.

| Republished from Spotlight under a Creative Commons licence.

Read the original article.

Categories : Expert Opinion IT in HealthcareTags :

Opinion Piece: Healthtech is Only as Strong as the Hands that Shape It

On By ModernMedia

By Vishal Barapatre, Group Chief Technology Officer at In2IT Technologies

| 17 June 2026

Healthcare is investing heavily in technology, but outcomes do not always improve at the same rate or deliver the desired effect. The issue is rarely a lack of tools. More often, it comes down to the way those tools are designed, connected, and maintained. Health technology, often referred to as Healthtech, delivers real value not just when systems exist, but also when expert IT partners shape them to turn health data into meaningful, useful intelligence throughout the entire care journey.

In many healthcare environments, technology has accelerated rapidly over the past decade. Hospitals and clinics have introduced electronic medical records, diagnostic platforms, and telehealth systems, with enormous potential, the benefits are often uneven when systems operate in isolation or fail to align with the realities of clinical workflows. The difference between technology investment and measurable clinical improvement often lies in the design and integration that happens behind the scenes.

The promise of healthtech lives in the data

At its core, healthtech is about data. This includes how data is captured, stored, presented, and analysed to support better patient care. Every interaction between a patient and the healthcare system generates information that can guide more informed decisions. From recognising early signals for preventive care, tracking progress during rehabilitation, to ensuring complete and accurate information during operative procedures, effective use of data underpins every stage of the healthcare journey.

Yet data alone is not enough. Without systems designed to bring clarity to complexity, information becomes fragmented, inconsistent, and largely underused. This is where expert IT partners are essential. They do not just implement platforms; they create the right conditions for data to support better patient care.

Another challenge lies in the diversity of healthcare data sources. Clinical records, laboratory results, imaging systems, wearable devices, and patient engagement platforms, all generate valuable information. However, without thoughtful integration and governance, these data streams can quickly become disconnected. When aligned, they allow clinicians to see a more complete picture of a patient’s health, enabling earlier intervention and more personalised treatment decisions.

Intuition does not happen by accident

There is a growing expectation that healthtech should feel intuitive, where insights emerge naturally without creating additional friction in already demanding clinical environments. However, intuitive technology does not happen by chance. It results from thoughtful choices about structure, integration, and user experience.

What needs to be understood is that a system’s value is not determined by its technical features but by how well it fits into clinical workflows. The data must be available at the right time, in the right context, and in a way that supports judgment instead of overwhelming it. Without this insight and expertise, even the most advanced systems may become obstacles instead of assets.

This is particularly important in high-pressure healthcare environments where time is limited, and decisions are critical. If systems require excessive navigation, duplicate data entry, or complicated interfaces, clinicians may spend more time interacting with technology than with the patients. Well-designed systems quietly support decision-making rather than compete for attention, ensuring that technology strengthens clinical practice of disrupting it.

Continuity of care requires continuity of systems

To add, preventive, rehabilitative, and operative care are often treated as separate areas, yet they are part of a single patient journey. The true value of healthtech emerges when data flows smoothly across these stages, creating continuity instead of hand-offs.

This continuity does not happen on its own. It relies on systems that preserve data integrity over time, integrate seamlessly across different care settings, and evolve as patient needs evolve. Without it, technology investments risk becoming isolated solutions rather than truly transformative tools.

When healthcare providers can access consistent patient information across departments and care phases, they gain a more holistic understanding of health outcomes. This continuity helps reduce redundant tests, prevent information gaps, and support coordinated treatment plans. Over time, it contributes to a healthcare environment where patients’ experiences feel more connected and less fragmented.

Trust is built behind the scenes

To truly be transformative, healthcare must rely on trust between patients and clinicians, as well as between clinicians and the systems they depend on. Yet, this trust is fragile, as a single system failure, data inconsistency, or security issue can erode confidence across a healthcare facility.

Trust is built on reliability, resilience, and strong governance. Systems must perform well under pressure, safeguard sensitive information, and evolve safely over time. Although this foundation work often goes unnoticed, its impact is felt every time clinicians use technology with confidence and ease.

The growing digitisation of healthcare has also made cybersecurity and data protection essential pillars of trust. Healthcare data is among the most sensitive information an organisation can manage. Protecting it requires robust security architecture, continuous monitoring, and governance practices that evolve as threats emerge. When these safeguards are embedded into the system architecture, healthcare organisations can innovate confidently without compromising patient privacy.

The real differentiator is partnership, not platforms

As healthtech continues to evolve, access to tools will be less of a significant differentiator. What will matter more is how those tools are shaped, connected, and sustained. Technology alone cannot provide better care. It requires partners who understand both the technical and human aspects of healthcare.

This is where an IT partner can navigate and guide healthcare organisations through complexity, turning possibilities into practice and ambitions into results. Their role is not just supportive but foundational in demonstrating the true value of healthtech. The future of healthcare will belong not to those who adopt the most technology, but to those who build it wisely.