The Hospital Association of South Africa (HASA) has confirmed the continuation of the majority of its previous Board of Directors following its Annual General Meeting, with Gale Shabangu from Mediclinic Southern Africa continuing as Chairperson and Mark Bishop from Lenmed continuing as Deputy Chairperson.
The continued composition of the Board provides stability and continuity as HASA builds on its work in policy engagement, sector collaboration and its contribution to South Africa’s healthcare priorities.
The Board brings together leaders from across the private hospital sector, with experience spanning healthcare operations, strategy, governance and stakeholder engagement.
HASA Chief Executive Officer, Dr Dumisani Bomela, welcomed the continuation of the Board and said:
“The continued leadership of the HASA Board provides an important foundation for the Association as we enter the next chapter of our work. We are fortunate to have a Board with significant sector experience, combined with fresh perspectives that will help us engage constructively on the opportunities and challenges facing healthcare in South Africa.”
He added: “Our focus remains on meaningful engagement and collaboration across the healthcare sector. HASA will continue to work with government, healthcare professionals and other stakeholders to support practical solutions that contribute to a stronger, more resilient and sustainable health system.”
HASA Board 2026/27
Gale Shabangu (Chairperson)
Mark Bishop (Deputy Chairperson)
Andre Joseph
Amrita Raniga
Bert von Wielligh
Dr Biancha Mentoor
Charles Vikisi
Hendrica Ngoepe
Dr Melanie Stander
Prathna Sookoo
Vishnu Rampartab
Alternate Directors:
Dr Ashley Chengadoo
Chantel Heyns
Mary Ann Nabbie
As HASA moves forward, the continued Board leadership will support the Association’s ongoing engagement with stakeholders across the healthcare sector and its role in contributing to national health priorities.
Johannesburg, South Africa – 2 October 2026 – Bonitas Medical Fund unveiled its 2027 product range, signalling a bold step forward in preventive healthcare, improved wellness, personalised support and long-term sustainability within the open scheme market.
Lee Callakoppen, Principal Officer of Bonitas Medical Fund, says: “Healthcare in South Africa is evolving rapidly, and members need more than traditional medical aid cover. They need proactive support, personalised health journeys and meaningful value at every stage of life.”
“Our 2027 product offering and plan enhancements are designed to reflect our commitment to keeping healthcare accessible, affordable and relevant for all our members.”
Earlier detection, better health outcomes
Bonitas has made preventive healthcare a strategic priority for 2027.
“It’s important that members are both enabled and encouraged to identify potential health risks earlier through preventive assessments and screenings,” says Callakoppen.
To support this, Bonitas has expanded access to wellness screenings through a growing provider network that now includes Clicks, Dis-Chem and Medirite pharmacies, bringing basic wellness screening access closer to members across South Africa.
Around 95% of Bonitas members are located within 10km of a health risk assessment provider. With the expanded network, members now have access to more than 1 245 pharmacies nationwide for basic wellness screenings.
The enhancement responds to growing demand. In 2025, health and wellness assessments increased by 138.6% compared to the previous year.
To close the gap between screening and treatment, Bonitas is introducing a GP Confirmation Benefit in 2027. When a potential health risk is identified, eligible members will have access to a risk-funded GP consultation within 14 days of the wellness screening, removing financial barriers to follow-up care and supporting a more connected wellness journey.
Enhancing member experience through more rewards and everyday value
The Benefit Booster, a hallmark of Bonitas innovation, is being expanded by 140% for 2027, offering families up to R12 000 in additional value. For the first time, it will also be available on the BonCap income-based plan.
Complementing this is B-Value, Bonitas’ lifestyle and wellness platform. More than a rewards programme, B-Value supports wellbeing through expert guidance, practical tools and rewards across fitness, nutrition, financial health and stress management. With new partners including Takealot and Checkers Sixty60, members can unlock even more rewards, discounts and lifestyle benefits through healthier behaviours.
Stronger plans, better benefits
Bonitas continues to refine its product range to balance affordability and sustainability for its members. Key enhancements across the product range include improvements to BonPrime, updates to the Standard option and the introduction of a Dental Emergency Benefit on selected plans.
Together, these changes are designed to improve accessibility, affordability and member value while simplifying the healthcare experience.
Expanded support across the care journey
Bonitas continues to invest in proactive healthcare support through initiatives such as Live Lean, the Ocular Health Programme, enhanced rehabilitation support through the new Back, Neck, Shoulder and Knee Rehabilitation programme and expanded mental health services. Together, these programmes are designed to help members manage health risks earlier, access support more easily and achieve better long-term health outcomes.
Smarter digital engagement
Bonitas continues to simplify healthcare through its Member App, Member Zone, WhatsApp support channel and other digital platforms. In 2027, the Fund will also expand digital engagement initiatives, including the Medical Aid Made Easy podcast hosted by Dr B, while enhancing support tools for both employers and brokers.
Balancing affordability with sustainability
“Against a challenging economic backdrop, affordability remains a key priority. Strategic purchasing and provider negotiations continue to help maximise value for members while supporting the long-term sustainability of the Fund,” Callakoppen adds.
Across all plans, the average contribution increase for 2027 will be 8.7%.
“We know that alongside all our updates, enhancements and new rewards, this will go a long way towards providing our members with additional value.”
“Our 2027 product range is about more than just useful medical aid benefits. Our enhanced offering is also about evolving healthcare to meet the needs of our members today and tomorrow. By focusing on prevention, wellness, personalised support and affordability, we are delivering meaningful value for our members, and building a stronger, more sustainable future for healthcare in South Africa,” concludes Callakoppen.
The potent antiretroviral medicine alimatravir is being evaluated in two ongoing clinical trials as a potential once-monthly HIV prevention pill. (Photo: Unsplash)
By Catherine Tomlinson for Spotlight
Aspen Pharmacare has announced that it will not be manufacturing the lenacapavir HIV prevention injection, and that it will instead focus on producing alimatravir, an experimental HIV prevention pill.
At the start of 2020, the only medicine approved to prevent HIV infection in people who are not living with HIV in South Africa was tablets containing the antiretroviral drug tenofovir. Apart from the tablets, ideally taken daily, HIV transmission could also be prevented by the correct use of condoms and reduced through medical male circumcision. Treating people living with HIV also helps a lot, since most people who are stable on antiretroviral treatment become non-infectious.
Since 2020, three more HIV prevention medicines have been registered in South Africa. Most prominent of these is the lenacapavir injection, which provides almost complete protection for six months at a time. The cabotegravir injection (CAB-LA) provides two months of protection and the dapivirine vaginal ring a month of partial protection. Several more products are in advanced clinical trials – including a new formulation of lenacapavir that may provide 12 months of protection and a tablet that could protect for a month.
Yet, despite the promise of new HIV prevention medicines, the rollout and uptake of these products in South Africa and globally has been slower than expected. Currently, only around 350 000 people are using HIV prevention tablets in South Africa, while in the region of 60 000 people have started taking the twice-yearly lenacapavir injections. At these levels, the number of people taking HIV prevention medicines in South Africa remains far too low to make a significant dent in the rate of new infections.
Cost has been a barrier
HIV prevention tablets cost the health department around $40 (roughly R700) per person per year. This price is considered to be affordable and the tablets are currently available at almost all public sector clinics in the country.
But modelling shows that long-acting injections can prevent more HIV infections than daily tablets, because their efficacy is less reliant on people taking the tablets every day. There is also evidence that many people prefer long-acting injections over daily tablets.
The cost of these newer, long-acting products has been a challenge. The health department has not procured CAB-LA injections, which was registered in the country in 2022. This was largely due to the price of around $160 per person per year. It also didn’t help that the current formulation of CAB-LA provides only two months of protection, compared to lenacapavir’s six.
In June, the health department started rolling out lenacapavir injections to around 10% of public sector facilities – for now the potential demand by far outstrips supply. The limited scale of the rollout is due to both supply and affordability challenges. The health department is paying $60 per person per year for lenacapavir through a Global Fund procurement arrangement that is allowing donors to pay an additional confidential top-up amount to Gilead Sciences above what the health department pays. For now, Gilead is the only supplier of the jab.
Supply should however improve over the next 12 months and prices are likely to come down. Gilead has licensed six companies to manufacture generic lenacapavir and is considering granting additional licenses, possibly to South African companies through a process coordinated by the South African National AIDS Council. Deals are in place with Indian pharmaceutical companies Hetero and Dr Reddy’s that should ensure a generic price of $40 per person per year. Hetero has already filed its product for registration with the South African Health Products Regulatory Authority – although it is expected to only get the green light early in 2027.
Is a new highly affordable option on the way?
In light of these pricing and supply concerns, news from the 2026 International AIDS Society Conference about a monthly HIV prevention tablet under development has made waves. Health economists presented research showing that the monthly tablet, alimatravir, could be profitably produced for a price tag as low as $3 per person per year (a $15 price was indicated in a conference abstract and previously quoted by Spotlight, but the price presented in the conference session was $3).
Not only is this a fraction of the cost of long-acting injections, but it is also substantially cheaper than the cost of daily tablets.
“Alimatravir for $3 per year could be the cheapest HIV prevention drug the world has ever seen, affordable worldwide,” Dr Samuel Cross of Christchurch Hospital told delegates.
He told conference delegates that the methodology used to calculate the $3 per person per year price is the same methodology that has previously been used to predict the manufacturing cost of several medicines. He said that “[o]ver the past decade, this methodology has correctly predicted production costs for [several] drugs,” including drugs for HIV, TB, Hepatitis B and C, and other conditions.
Some caution would however be prudent, given that alimatravir’s safety and efficacy hasn’t been definitively proven. The final verdict will come from two ongoing Phase 3 clinical trials, called EXPrESSIVE-10 and EXPrESSIVE-11 – both expected to report in 2027. Regulators typically approve medicines only after positive findings from such phase 3 trials.
Alimatravir is already influencing the market
Despite the absence of phase III data, alimatravir is already making waves and affecting the market for HIV prevention products.
The most stark example of this is the recent announcement by Aspen Pharmacare that it will no longer pursue a license to locally manufacture lenacapavir and focus instead on developing its capacity to manufacture alimatravir.
Aspen, along with six other companies, are already licensed to produce generic versions of alimatravir. The unusually early licensing of these companies by MSD (known as Merck in the US and Canada) is a key factor as to why this product is expected to be affordable right out of the gate, if it is shown to be effective in preventing HIV.
No generic companies have yet indicated what price they will charge for alimatravir – but the $3 reference price will no doubt exert some downward pressure.
Why Aspen is no longer pursuing lenacapavir manufacturing
Stavros Nicolaou, senior executive for strategic trade at Aspen Pharmacare, this week told Spotlight that Aspen halted its pursuit of a license to manufacture generic lenacapavir because the South African government’s current pharmaceutical procurement policies and practices provide insufficient assurance that the company will be able to recoup its investments.
The absence of guaranteed procurement by the health department, the lack of a local preference procurement policy, and the existence of competitive products – such as alimatravir – coming down the pipeline all factored in Aspen’s decision, said Nicolaou.
He said that developing manufacturing capacity for tablets, such as alimatravir, is less costly than developing manufacturing capacity for injectables, such as lenacapavir.
“We need greater certainty before we make these investments,” Nicolaou told Spotlight.
He added that the early licensing of alimatravir to enable accelerated generic registration of the product following Phase III trials also made the product an attractive candidate for the company to pursue. He said it was premature to comment on the price they might charge for alimatravir.
Aspen’s decision comes against a broader debate regarding the obligations of the health department to support local pharmaceutical manufacturers, while also delivering on its obligations to maximise the benefits derived from the country’s constrained health budget.
What’s next?
A cheap monthly HIV prevention pill could be a game changer in the fight against HIV in the coming years. However, while data on alimatravir are awaited, its potential arrival has complicated the investment decisions facing pharmaceutical companies, governments, and donors regarding new HIV prevention medicines. It has also raised questions over how the state is, or is not, incentivising local production and procurement of locally produced pharmaceuticals.
The prospect of a monthly pill costing around $3 per year is undeniably exciting. Yet scientists have repeatedly shown that offering a range of prevention medicines—allowing people to choose the option that best suits their needs and lives—improves overall uptake. Even if alimatravir works as well as hoped, there will still be a role for six-monthly lenacapavir, let alone the potential 12-monthly version of the jab that is currently being evaluated in a phase 3 clinical trial.
Either way, while the health department must keep a close eye on the products in the pipeline as it plans for the future, it cannot afford to slow the rollout of the products already available.
“South Africa’s diabetes epidemic will not be solved by the next pharmaceutical breakthrough. It will be solved by fundamentally reshaping how healthcare is organised and paid for”
– Lungile Kasapato, CEO of PPO Serve.
Diabetes is now South Africa’s leading killer, accounting for more deaths than HIV and TB combined. Global headlines celebrate GLP-1 receptor agonists (RAs) as a breakthrough for metabolic disease and obesity. But this narrative ignores a fundamental reality: for most South Africans, these drugs are inaccessible. Priced between R3 000 and R6 000 per month, they remain unaffordable. Even as cheaper generics become widely available, they won’t solve the problem alone. Without the clinical infrastructure to support treatment, and the social support to access healthy food, access means little.
“We’re pushing an incomplete solution,” says Lungile Kasapato, CEO of PPO Serve, a healthcare management company implementing value-based care in South Africa for over a decade. “GLP-1 RAs offer real benefits – sustained weight loss, reduced inflammation, lower cardiac risk, protection against comorbidities. For someone facing diabetes, these outcomes matter. But we’re acting as if a drug alone can solve a system failure. It can’t. A medication prescribed into a broken healthcare system is just a product. It’s not a national health strategy.”
The scale of the crisis is staggering. Forty percent of low-income South Africans’ diet consists of ultra-processed foods. Across the broader population, nearly 30% have undiagnosed hypertension. Most discover their condition only after complications like strokes or heart attacks emerge. By the time they reach treatment, the system can only manage disease with medications, never addressing what caused it in the first place. When a GLP-1 RA is prescribed in this fractured environment, initial sustained progress stalls because the infrastructure to maintain results was never built.
“This fragmentation isn’t accidental,” says Kasapato. “It’s structural. Fee-for-service rewards volume, not health. A provider, working alone, gets paid for each visit, test, or procedure – regardless of whether the patient’s health improves. With no teamwork or incentive to coordinate, follow-ups become inconsistent and inadequate. Every encounter is transactional, continuity is impossible, and no one is accountable for the patient actually getting better. As long as we pay for activity instead of results, we won’t fix the system or build the infrastructure these medications need.”
PPO Serve’s The Value Care Team, implemented in partnership with the Government Employees Medical Scheme (GEMS), demonstrates what a different payment structure creates. GPs, nurses, dietitians, and care coordinators work together, sharing accountability for patient outcomes rather than billable procedures. Coordination becomes the norm, and prevention becomes profitable, meaning early intervention can stop complications before they escalate. Medication works better because the system supports it, including addressing the social issues that drive obesity in the first place. This is what reshaping incentives creates.
“The real choice isn’t just about drug access,” says Kasapato. “It’s about payment models, and the system it creates. Cheaper GLP-1 RAs could be available tomorrow – generics are already arriving. But availability achieves little without the organisation to deploy them. The conversation must progress from funding medications to funding the teams and systems that make them work. South Africa’s diabetes epidemic will not be solved by the next pharmaceutical breakthrough. It will be solved by fundamentally reshaping how healthcare is organised and paid for.”
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12–13 September 2026
Career clarity. Practice power. Financial freedom.
Join one of South Africa’s leading gatherings of women healthcare professionals for two days focused on leadership, career growth, entrepreneurship, financial empowerment and well-being.
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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.
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.”
By Brian Harris, CEO at Turnberry Management Risk Solutions
28 July 2026 – Medical aid remains essential for accessing private healthcare in South Africa, but it does not always cover the full cost of treatment. While regulations such as Prescribed Minimum Benefits (PMBs) ensure that members have access to a defined level of care for certain conditions, medical schemes still apply tariff limits, treatment protocols, co-payments and other funding rules that can leave members exposed to out-of-pocket costs. At the same time, healthcare costs continue to rise, placing additional pressure on how schemes fund treatment. As a result, medical expense shortfalls are becoming increasingly common, making gap cover an essential part of helping clients manage their healthcare costs and protecting them against unexpected expenses.
Protection within limits
PMBs are a clear example of how scheme rules and funding limits influence what medical schemes ultimately pay for. They are designed to ensure that all medical scheme members have access to treatment for a defined list of emergencies, chronic, and life-threatening conditions. However, they do not provide unlimited funding for every treatment option, and there is often a misunderstanding about this.
When it comes to PMBs, cover is still subject to scheme rules, treatment protocols, formularies, and designated service provider requirements. In many cases, cover is also aligned to the level of care that would ordinarily be available in the public healthcare system. This becomes particularly important in areas such as oncology, where newer or more specialised treatments may fall outside what a scheme is required to fund in full.
As a result, members may still face co-payments, sub-limits, or shortfalls that need to be paid for out of pocket, even when the condition itself qualifies as a PMB.
How scheme rules create shortfalls
PMBs are only part of the picture when it comes to medical expense shortfalls. Even where treatment is covered, medical schemes reimburse according to their own tariffs and funding rules, while healthcare providers may charge significantly more. The difference between what the scheme pays and what the provider charges is the member’s medical expense shortfall.
At the same time, medical schemes use co-payments, benefit limits, Designated Service Providers (DSPs) and authorisation requirements to manage rising healthcare costs and keep contributions affordable. If these rules are not followed, or if treatment falls outside the approved funding structure, members may still need to pay part of the cost themselves.
This means that having medical aid does not always guarantee that treatment will be covered in full. Even where treatment is approved, members can still face significant out-of-pocket expenses.
Advice is essential
As funding rules become increasingly complex, advisers need to take on a more proactive role in helping clients understand and navigate the healthcare landscape. Many clients do not fully understand how PMBs, DSPs, funding rules and scheme tariffs affect what their medical aid will ultimately pay. The reality often only becomes clear at the claims stage, when members discover that they are responsible for part of the cost themselves.
Explaining these rules clearly, together with where medical expense shortfalls may arise, is therefore becoming an increasingly important part of the healthcare funding discussion. Regular reviews and clear guidance also help ensure that changes to scheme rules, benefits, and healthcare costs do not leave clients exposed to unnecessary or unexpected out-of-pocket expenses.
Future-proofing healthcare advice
Medical aid and gap cover should not be treated as once-off decisions. Scheme rules, pricing structures and healthcare costs continue to change, which means healthcare advice needs to be reviewed regularly to ensure that cover remains appropriate.
Helping clients understand how their medical aid works, where medical expense shortfalls may arise, and how gap cover can be structured forms an important part of responsible advice. Regular reviews also help ensure that changes to benefits, family circumstances or healthcare needs do not leave clients exposed to unnecessary costs.
As regulation continues to shape how healthcare is funded in South Africa, gap cover is becoming an increasingly important part of managing healthcare costs. Brokers and financial advisers play an essential role in ensuring their clients have medical aid and gap cover that together provide the right level of protection.
Turnberry Management Risk Solutions (Pty) Ltd is an authorised Financial Services Provider (FSP no. 36571). Underwritten by Lombard Insurance Company, an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.
The single greatest threat to South African primary healthcare isn’t a lack of resources or medical expertise – it’s how doctors are paid. That’s the consensus of a growing number of doctors, including Dr David Sekete, who has practised medicine in Katlehong for more than four decades. The traditional funding model, he argues, is systemically flawed, with consequences that ripple through every stage of a patient’s care.
“Many of the people I see live on modest incomes and struggle with the cost of care. Those covered by medical schemes face the same pressure from a different angle – benefits exhausted by mid-year, out-of-pocket costs remain high, and when cover runs out, GPs are left to choose between turning patients away or treating them at their own cost,” says Dr Sekete. “Over time, a doctor’s incentives and their patients’ interests drift apart. It is tempting to blame geography or poverty for these failures, but the barrier was never only location or scarcity. It is the payment model.”
In response, Dr Sekete restructured his practice entirely. Through The Value Care Team (TVCT), a programme powered by healthcare management company PPO Serve, he now receives a guaranteed, risk-adjusted monthly fee for every enrolled GEMS member, rather than billing for each consultation or procedure. Out-of-pocket costs fall away, patients can return throughout the year regardless of their benefits status, and the administrative burden of chasing schemes for payment is eliminated. The practice now operates as a single multidisciplinary facility, bringing together an optometrist, dentist, physiotherapist, psychologists, social workers, a mother-and-child unit, a dialysis centre, and on-site imaging and pathology under one roof.
This shift has fundamentally changed what the practice delivers, and nowhere is that more evident than in prevention. TVCT Care Coordinators follow up on diabetic, hypertensive and mental-health patients at home, educating entire families along the way. Weekly health talks cover diabetes, hypertension, and prostate and breast cancer; a mammography team visits monthly; and the wider team regularly takes its work into schools and churches across the community.
“Care stops being a series of emergencies and becomes something managed before it reaches crisis point,” says Lungile Kasapato, CEO of PPO Serve. “Patients who once arrived only when illness had become unavoidable now come in early, when problems are still simple and affordable to treat. This holistic approach creates a support system around the patient that simply does not exist in traditional fee-for-service models.”
The practice in Katlehong has since been awarded 100% accreditation by the Office of Health Standards Compliance, a rare achievement that proves value-based care can meet the highest quality standards. Yet adoption remains limited. Many GPs continue to favour fee-for-service, drawn by the prospect of higher individual billing, even as the system deteriorates around them: schemes cannot absorb rising claims, patients cannot afford increasingly expensive care, and healthcare moves further out of reach for ordinary South Africans.
“What Dr Sekete has built, proves that value-based care is not a theoretical ideal – it is a practical, replicable model that delivers better outcomes for patients, better sustainability for practitioners, and a more viable future for the sector,” says Kasapato. “Our ambition is to see this replicated in communities across the country.”
For GPs considering the transition, Dr Sekete is direct: get the foundations right first – a proper facility, the right staffing, a genuine multidisciplinary team, strong IT systems, and reliable laboratory and diagnostic support – then coordinate closely with the community. “What I want now is replication: pockets of excellence across the country, each one a working example others can build from. The only real question is whether the profession – and the system around it – is ready to adopt it.”
By James White, Director: Sales and Marketing at Turnberry Management Risk Solutions
Medical aid is essential for accessing private healthcare in South Africa, but it does not always cover the full cost of treatment. Shortfalls related to specialist fees, co-payments, and sub-limits, are an ongoing reality, leaving many medical aid members exposed to significant out-of-pocket expenses. This is why gap cover is no longer an optional conversation for advisers. As these shortfalls become increasingly common, clients rely on advisers to identify where cover may fall short and to explain how these risks can be managed. Gap cover plays an important role in addressing this challenge by covering the difference between what medical schemes pay and what providers charge, making it an integral part of the advice process.
Making gap cover part of the conversation
As medical expense shortfalls become increasingly common, addressing them is becoming part of a financial adviser’s responsibility. When recommending or reviewing medical aid, it is not enough to focus only on contributions and benefits. Advisers also need to ensure that their clients are fully aware that their medical aid may not cover the full cost of treatment, particularly where specialist fees, co-payments and sub-limits apply.
Areas where clients are likely to face out-of-pocket costs need to be explained clearly, together with how gap cover can reduce them. Advisers need to position gap cover not as an optional extra, but as an essential part of ensuring that clients are not left exposed to avoidable out-of-pocket costs.
The cost of not addressing shortfalls
If financial advisers do not discuss gap cover with clients, the impact is typically not felt immediately. However, the problem becomes clear when a claim arises. If a member receives treatment expecting their medical aid to cover the full cost, and then ends up with a large bill for the shortfall, or has to pay a large co-payment upfront, this can result in significant dissatisfaction.
The reality is that medical expense shortfalls are no longer unusual, and both the size and frequency of these costs are increasing. Specialists may charge several times the scheme rate, while co-payments and benefit limits are increasingly used by medical aids to manage costs and keep premiums affordable. Without additional cover, patients must pay these costs out of pocket, and they can run into tens or even hundreds of thousands of rands.
This is why it is important that these gaps be raised upfront. Clients rely on their advisers to explain how medical aid works and what costs may arise, so they can make informed decisions before a claim happens, rather than being caught off guard by costs that place pressure on their finances.
What advisers should be explaining
Gap cover should form part of every discussion around medical aid, rather than being treated as an optional extra. When recommending or reviewing medical aid, it is important for advisers to highlight where out-of-pocket costs may still arise, including specialist tariff gaps, co-payments, sub-limits and network restrictions.
These risks need to be explained clearly, together with how gap cover can reduce them. Discussing this upfront helps clients understand what their medical aid will and will not pay, so they are not surprised by costs when they claim. It also ensures that decisions around cover are based on a clear view of the full healthcare funding picture, not only the monthly premium.
Over time, this approach builds trust and reinforces the adviser’s role in helping clients manage healthcare costs, rather than reacting to them after the fact.
Complete advice requires a complete view of healthcare risk
Medical aid remains essential, but it does not remove the risk of medical expense shortfalls, co-payments, or sub-limits. These are now a routine part of private healthcare and need to be addressed as part of the advice process.
Advisers have a responsibility to identify and explain these risks clearly, and to make them a consistent part of every client conversation.
Helping clients understand how their medical aid works, where shortfalls may arise, and how gap cover can address those gaps ensures that their cover reflects a complete view of their healthcare costs and is genuinely aligned to their needs.
