Category: Medical Industry

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 One of the most important, yet often overlooked, barriers is the outdated framework governing prescribed minimum benefits (PMBs).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 As a result, the outdated PMB framework has become one of the most significant contributors to medical scheme costs and thus an inefficient health policy.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.

Categories : Medical IndustryTags :

Momentum Health Calls for a Shift from Healthcare Cost to Prevention Investment

On By ModernMedia
Pexels Photo by Thirdman

As South Africans face rising inflation, pressure from the burden of chronic disease and financial strain, Momentum Health is advocating for a stronger national focus on the prevention dividend: the long-term value created when South Africans use preventative healthcare, wellness programmes, screenings, health assessments and digital tools to manage health risks before they become serious and costly.

This comes as households, employers and the healthcare system face increasing pressure from affordability constraints, chronic disease and mental health challenges. Research referenced by Stellenbosch Business School has estimated that health-related productivity losses cost South Africa around R161 billion a year, driven by absenteeism, presenteeism and untreated mental health challenges.

Momentum Health believes the conversation needs to move beyond healthcare as an expense that pays only when people are ill. Instead, medical aid should be seen as an investment in helping people stay healthier for longer.

“Rather than paying claims after someone becomes ill, modern healthcare needs to focus on helping people understand their risks earlier, take action sooner and build healthier habits that can improve quality of life over time,” says Damian McHugh, Chief Marketing Officer at Momentum Health. “Prevention is one of the most practical ways to support both better health outcomes and greater financial resilience for South Africans.”

Prevention is becoming more urgent

South Africa’s health and economic realities make prevention increasingly important. PwC’s South Africa Economic Outlook notes that South Africa’s real GDP per capita declined by a cumulative 4.2% over the past decade, a signal often associated with pressure on living standards and economic stability.

At the same time, the country continues to carry a significant disease burden. Government and World Health Organisation reporting show that South Africa has made progress in controlling tuberculosis, with TB cases declining significantly since 2015 and treatment coverage improving to 79% in 2023. However, more than half of TB-affected households still face catastrophic costs, showing how illness can deepen financial vulnerability when people are diagnosed late or struggle to access care.

Mental health is also placing pressure on individuals, employers and families. SADAG’s Working Life Survey found that 52% of surveyed employees had been diagnosed with a mental health condition, with depression, stress, anxiety and burnout among the commonly reported conditions.

These figures show why prevention must be personal, practical and accessible,” adds McHugh. “Every member’s health risks are different. The more people know about their own health, the easier it becomes to make informed choices, use the right benefits and take action before problems escalate.”

Healthy habits can create long-term value

Regular health checks, screenings, physical activity, digital healthcare tools and ongoing health management can help members detect risks earlier and make healthier decisions more consistently.

Preventative care can also support employers and the wider economy. When people are healthier, they are more likely to be present, productive and able to participate fully at work and in their communities. This matters in a country where affordability pressures mean many people are looking for healthcare solutions that deliver tangible value, not only financial protection after illness occurs.

Behavioural incentives can play an important role in this shift. When healthy choices are recognised and rewarded, members are more likely to build routines that support their physical, mental and financial wellbeing. This is the principle behind Momentum’s broader health and wellness approach- making it easier for members to take control of their health before problems arise.

Prevention is personal

The next phase of healthcare will be increasingly personalised. Data, health assessments and digital tools can help members better understand their individual health risks and choose the most relevant actions, whether that means completing a screening, increasing physical activity, accessing care digitally or managing a chronic condition more proactively.

“Prevention works best when it is simple, personalised and part of everyday life,” says McHugh. “Our role is to help members connect the dots between their daily habits, their health outcomes and their financial wellbeing. That is how healthcare becomes more than a monthly contribution. It becomes an investment in a healthier future.”

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

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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

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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 : Hospitals Medical IndustryTags :

SAMED Calls for Urgent Action as Gauteng Health Supplier Debt Crisis Reaches Critical Point

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The South African Medical Technology Industry Association (SAMED) has called for urgent and measurable action to resolve the escalating supplier debt crisis within Gauteng’s public health system, warning that continued delays in payments and procurement failures are placing both healthcare delivery and supplier sustainability at serious risk.

The call comes ahead of the Gauteng Department of Health’s hospital-level engagements with suppliers on 27 May, following MEC for Health and Wellness Faith Mazibuko’s recent acknowledgement that approximately R8 billion is owed to suppliers.

SAMED’s latest member data shows that R245 517 666.12 is owed to 27 medical technology suppliers, with a significant portion overdue well beyond the public sector’s 30-day payment requirement. Many affected suppliers are South African SMEs now operating under severe financial strain, forced to absorb the consequences of systemic procurement and payment failures while continuing to supply essential medical devices, diagnostics, consumables, and other critical technologies needed for patient care.

While SAMED welcomes the Department’s willingness to engage directly with suppliers, the association stresses that these discussions must lead to concrete commitments and operational action.

For SAMED and its members, this crisis is not new.

The association has spent more than a decade raising concerns about systemic procurement dysfunction, delayed payments, weak supply chain controls, and administrative failures that continue to undermine the effective functioning of the public healthcare system.

Today, those longstanding failures have evolved into a critical risk for both the healthcare sector and the businesses that support it.

In some cases, suppliers are delivering urgently needed products to hospitals while administrative bottlenecks make timely payment structurally impossible. This is particularly acute where delayed purchase orders, including for consignment stock arrangements, create a mismatch between supply delivery and budget allocation.

Monica Lucas, SAMED Board Member said, “SAMED members have continued supporting public healthcare under extraordinary financial strain because patient care cannot simply pause. But suppliers cannot indefinitely act as the financiers of a dysfunctional system. This is no longer just a debt issue; it is a structural operational failure that requires urgent executive intervention.”

Following the Department’s engagement with service providers on 23 May, SAMED has formally written to MEC Mazibuko requesting greater transparency on the Department’s debt reduction plans, and stronger accountability across finance, supply chain management, and hospital leadership.

SAMED will participate constructively in the upcoming hospital engagements and remains committed to finding practical solutions in partnership with government.

However, the association cautions that engagement without accountability will not restore supplier confidence.

After years of repeated commitments and limited progress, the sector requires clear timelines, written commitments, and measurable implementation.

“Direct engagement with leadership is welcome, but suppliers need more than reassurance. We need transparency, accountability, and a credible plan to resolve both the immediate debt burden and the underlying operational failures that continue to create it. Without that, the risks to healthcare continuity will only deepen.” – Scott de Oliveira, SAMED Chairperson

SAMED is calling for immediate action, including:

  • Publication of a verified and transparent debt position
  • A time-bound repayment plan for outstanding supplier debt
  • Executive oversight of hospital procurement and payment failures
  • Improved responsiveness from finance and supply chain leadership
  • Structured follow-up engagements with measurable progress reporting

SAMED remains committed to constructive engagement but warns that the public healthcare system cannot continue relying on suppliers to absorb systemic dysfunction indefinitely.

This week’s engagements must mark the beginning of real corrective action, not another cycle of discussion.

Categories : Expert Opinion Medical IndustryTags :

Why Medical Schemes Must Own Healthcare Reform

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“Medical schemes have an enormous amount of power to change the trajectory of healthcare in this country – but only if they are willing to use it,” Lungile Kasapato, CEO of PPO Serve.

South African medical schemes have long borne the brunt of public frustration. Contribution increases have outpaced both wages and inflation, forcing many members to choose between healthcare cover and basic needs. But according to Lungile Kasapato, CEO of PPO Serve, a healthcare management company that has been implementing value-based care in South Africa for more than a decade, rising premiums and shrinking benefits are symptoms, not causes. The real problem is structural: the industry has been operating as a passive payer when it should be commissioning a better functioning healthcare system.

“The conversation we keep having – about contribution levels, affordability, and who is to blame – is only half the conversation,” says Kasapato. “What is missing is the question of why costs keep escalating and what schemes are actively doing about it.

The World Health Organisation is clear on what that answer should look like: schemes purchasing value for their members, managing the quality and cost of care, and correcting the incentives that keep a poorly functioning system in place. “Until that happens, we will be back here next year, at a higher number, with the same grievances,” she says.

South Africa’s healthcare system rewards providers for the volume of services delivered, not patient outcomes achieved; “More tests, more procedures, more bed days: each generates revenue regardless of clinical necessity. The Health Market Inquiry identified this as a structural failing – schemes, unable to control what providers charge, absorb the pressure by eroding the benefits members thought they were paying for,” says Kasapato.

On average, schemes are currently spending three cents more for every rand they collect; “Even the best-capitalised ones are drawing down their historical reserves. Without meaningful intervention, that gap does not close on its own – it widens. And yet the industry continues to treat this as a pricing problem rather than the systemic one it actually is,” she says.

PPO Serve’s The Value Care Team programme, implemented in partnership with the Government Employees Medical Scheme (GEMS), demonstrates what a different approach looks like in practice. The programme segments members by clinical need – from high-risk complex cases to those currently healthy – and aligns care accordingly. GPs are equipped with real-time data, including visibility of planned admissions from other providers, enabling early intervention before costs escalate. Clinicians are rewarded for measurable patient outcomes rather than the volume of services delivered.

“When patients are well-managed at primary care level, unnecessary hospital admissions fall – and that is exactly what we are seeing,” says Kasapato. “Early pilot data shows a 29% reduction in hospitalisations over three years.  Those savings can then be reinvested into better care. That is what purchasing value looks like in practice.”

For lower-income members, who have historically faced benefit structures favouring hospital care over preventative and primary care, The Value Care Team operates outside discretionary benefit allocations. This preserves out-of-hospital benefits while ensuring members receive coordinated care throughout the year.

“The evidence is already there, globally and in our own programme: investing in primary healthcare costs more today but far less tomorrow. A scheme that cannot absorb the short-term cost of prevention will not survive the long-term cost of inaction. Medical schemes have an enormous amount of power to change the trajectory of healthcare in this country – but only if they are willing to use it. At PPO Serve, we are not waiting for the system to fix itself – we are doing the work,” says Kasapato.

Categories : Medical IndustryTags :

From Hospital Wards to Clinic Ownership, SA Nurses Are Becoming Their Own Bosses

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“Mpathy Clinics are nurse-led, low-fee primary healthcare facilities with a vision of transitioning from nurse-led to nurse-owned clinics, creating opportunities for nurses to own and operate clinics in their own communities,” said Rhiza Ventures managing director Linda Dunkley.

For decades, nurses were the backbone of South Africa’s healthcare system, present in every ward, every emergency and every recovery room, but rarely in positions of ownership and leadership.

Now, as South Africa marks International Nurses Day on May 12 under the global theme “Empowered Nurses Save Lives”, a growing network of township clinics is transforming nurses from employees into entrepreneurs while helping to ease pressure on overcrowded public healthcare facilities.

Affordable Healthcare and Building Local Economies

In communities where patients often endure long queues at public clinics or cannot afford private healthcare, nurse-led Mpathy Clinics are emerging as an accessible and affordable alternative rooted in empowerment, dignity and community-based care.

The model, driven by NPO Rhiza Babuyile, currently operates 11 clinics in township areas including Umlazi, Naledi, Gugulethu, Tembisa and Diepsloot. Beyond expanding primary healthcare access, the initiative is creating something rarely seen in South Africa’s nursing

“South Africa’s public sector serves roughly 80% of the population, yet clinics routinely face long queues, staff shortages and medicine stockouts. Most primary healthcare services fall within the legal scope of a Professional Nurse and policies like NIMART (Nurse Initiated Management of Antiretroviral Treatment) – leaning on nurses is the only way to scale primary healthcare capacity at a cost the country can afford,” says Rhiza Ventures, Managing Director Linda Dunkley.

For Mpathy, this means helping the Department of Health extend healthcare services into underserved communities while aligning with the Ideal Clinic Realisation programme and supporting the long-term National Health Insurance (NHI) rollout, where accredited primary healthcare facilities serve as the first point of entry.

“Nurse-led PHC clinics like Mpathy are where early detection is possible, response rates are highest, and the cost to both the patient and the public system is lowest,” said Dunkley.

Dunkley added that the clinics were designed to complement, rather than compete with, the public healthcare system. “Mpathy is positioned explicitly as an extension of the Department of Health rather than a parallel system,” she said.

The clinics also contribute to local economic development, not only creating jobs for administrators and community health workers, but   enabling non-nursing entrepreneurs to own clinics and employ qualified nurses, broadening community-based healthcare investment and expanding access to care.

This month alone, a new Mpathy Clinic will open in Orange Farm on 21 May, led by nursepreneur Sister Mbalenhle, and on 19 May an entrepreneur will be inducted into the model in  Zithobeni, Bronkhorstspruit.

‘It’s My Answered Prayer’ — A Nurse Returns Home as Nursepreneur

For professional nurse and nursepreneur Sindiswa Nhlabathi, the model has become deeply personal.  Nhlabathi will this week open the  Mpathy Clinic in Naledi, Orange Farm on 14 May, serving the same community where she was born and raised.

“I was born at Zola, right across from where the Naledi clinic is based. I grew up in a family where no one was formally employed but they were ‘business people’,” she said. Her mother and grandmother sold cakes and goods to support the family. “It wasn’t easy as there was no money for university,” she said.

Before nursing, she worked at a government hospital as a personal assistant manager. Until a friend changed everything. “One day my friend came to me with nursing application forms and persuaded me to apply. I refused telling her that ‘you know I don’t like nursing’ but she insisted. I was accepted and the minute I was exposed to clinical experiments I knew I was born for this.”

After years in public healthcare, including at Zola Clinic, Nhlabathi resigned from her permanent post and was later offered the opportunity to run the Naledi clinic. “When I was studying it never crossed my mind that one day I might own a clinic. It’s my answered prayer. I feel empowered and I don’t even have the words to articulate my heart but one thing I know is that I intend to take this opportunity and make the best out of it,” says Nhlabathi.

At the clinic, children can receive treatment for under R200, while adult consultations with medication cost up to R350.

“Our clinic is private but very affordable,” Nhlabathi adds that “Our community relies on social grants and low incomes, while public clinics remain overwhelmed. Mpathy Clinics are a bridge between private and public healthcare and our priority is to build trusted relationships with the community.”

Visit https://mpathyclinic.co.za/ to find out more.

Categories : Medical IndustryTags :

Opinion Piece: Medical Aid Out-of-pocket Healthcare Expenses are the Highest Ever

On By ModernMedia

14 April 2026

Photo by Towfiqu barbhuiya on Unsplash

By James White, Director: Sales and Marketing at Turnberry Management Risk Solutions

Many South Africans assume that belonging to a medical scheme means their hospital treatment will be fully covered. In practice, this is often not the case. Patients are increasingly encountering co-payments, specialist shortfalls and benefit sub-limits that leave them responsible for part of the bill. This happens because medical schemes pay according to their own tariff structures, while specialists often charge significantly more than those tariffs, sometimes as much as 500% of the scheme rate.

The difference between the scheme tariff and the provider’s invoice is then billed to the patient, and it can amount to tens of thousands of Rands. Gap cover exists specifically to address these shortfalls by covering the gap between what medical schemes pay and what healthcare providers charge, offering peace of mind and greater financial certainty.

Healthcare costs are rising faster than household incomes

Medical inflation in South Africa has consistently outpaced general inflation. While many employees receive annual increases of around four or five percent, healthcare costs often rise by nine or ten percent. Hospital tariffs, specialist fees and the cost of advanced medical technology continue to increase each year.

Medical schemes therefore face a difficult balancing act: keeping contributions affordable while managing rising provider costs. To do this, schemes increasingly rely on co-payments, tighter benefit limits and reimbursement based on scheme tariffs. For members, this means that belonging to a medical scheme does not always guarantee that every medical expense will be fully covered.

The shortfall between tariffs and specialist fees

One of the most common out-of-pocket expenses occurs when a healthcare provider charges more than the scheme rate. Medical schemes reimburse treatment according to their own tariffs, while specialists may charge several times that amount. This can create confusion for members, because policies often state that they pay “100% of the scheme rate”. In practice, this means the scheme pays up to its tariff limit, not the full amount charged by the provider.

From a gap cover perspective, this tariff shortfall accounts for the majority of claims. In many cases it represents roughly 78% to 80% of claims, making it one of the most common funding gaps patients experience.

Co-payments and sub-limits add further pressure

Shortfalls are not the only challenge patients face – medical schemes increasingly rely on co-payments and sub-limits to manage rising healthcare costs.

A co-payment is a fixed amount that the member must pay before treatment takes place. Depending on the procedure and scheme rules, these amounts can range from around R5,000 up to R30,000, and in some cases even higher. For many households, being asked to produce this amount upfront can create significant financial strain.

Sub-limits can create a similar problem. Even when a procedure is covered, schemes may limit how much they will pay for certain treatments, scans or specialist services. Once the limit is reached, the remaining cost falls to the patient.

Why adviser education matters

Because the system is complex, many clients only discover these gaps when they receive a bill after treatment. They assume their medical aid will cover the full cost of care, only to find that co-payments, benefit limits or specialist shortfalls still apply.

This is why it is important for advisers to explain clearly how medical schemes pay claims, particularly the difference between scheme tariffs and provider fees. When clients understand how these shortfalls arise, the role of gap cover becomes easier to understand. Rather than being seen as an optional extra, gap cover becomes part of the overall structure of healthcare cover alongside medical aid.

Understanding your healthcare cover before you need it

Healthcare funding in South Africa is unlikely to become less complex in the near future. As costs continue to rise, it is essential to understand how your medical scheme operates and where potential shortfalls may arise.

Many people only learn how their cover works when a claim is processed and an unexpected bill appears. Understanding the difference between scheme tariffs, provider fees, co-payments and benefit limits can help prevent these surprises.

Gap cover plays an important role in addressing these shortfalls by covering the difference between what medical schemes pay and what healthcare providers charge. Speak to a broker about what your medical aid covers, where shortfalls may occur, and how gap cover can help protect you from unexpected medical bills.

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 : HIV Medical IndustryTags :

Cipla Confirms Continued Support for ARV Supply Following Changes in Supplier Landscape

On By ModernMedia
Photo by Towfiqu barbhuiya

Cipla Medpro South Africa reaffirmed its commitment to ensuring the uninterrupted supply of critical antiretroviral (ARV) medicines to the Department of Health. It is essential that people living with HIV have uninterrupted access to these life-saving medicines. Any disruption of supply puts patients at risk of developing resistance to the drugs or adversely affecting health outcomes. According to Statistics South Africa, the number of people living with HIV in the country is estimated to be approximately 8 million (12,7% of the population)[1].

Recently, two suppliers who were awarded the current antiretroviral (ARV) tender, Barrs Pharmaceuticals Industries (Pty) Ltd and Innovata Pharmaceuticals (Pty) Ltd (subsidiaries of Avacare Health), have entered business rescue.

Cipla acknowledges the uncertainty this may create within the ARV supply chain and underscores its readiness to assist in maintaining stability and continuity.

Cipla has been manufacturing tenofovir/lamivudine/dolutegravir (TLD) for the government for the past 7 years, and has been one of the main suppliers of ARVs to the government for more than 12 years. Cipla has made significant investments in its local manufacturing facility, upgrading the capacity of the ARV production line with the installation of a new Countec bottle line and have increased its tablet filing capacity by 190%. The company is able to locally produce 475 million tablets annually and has upscaled its manufacturing capabilities to ensure sufficient capacity to meet current demand and support near‑term growth, while reinforcing Cipla’s commitment to secure and reliable ARV supply.

“We have mobilised resources to help maintain equitable access to quality, affordable critical medication. Cipla confirms its willingness to support national requirements under the current tender agreement and, if needed, contribute meaningfully to any supplementary procurement processes to safeguard patient access to essential treatment. We want people to live a long and healthy life as part of our commitment to caring for life,” said Paul Miller, CEO of Cipla Africa.

“In addition, we believe this tender presents an opportunity to further advance government’s commitment to strengthening local manufacturing capacity. By ensuring greater support for locally produced medicines, future allocations could meaningfully contribute to South Africa’s industrial development agenda while maintaining continuity of supply,” said Miller.

The total ARV tender is for a period of three years, and is worth an estimated R15.5bn, of which the TLD component comprises R12.6bn.