PHUMELELE MAKATINI: Medical schemes want to work with SA to bring access to healthcare to all

National Health Insurance (NHI) has the potential to make or break SA healthcare, depending on the strength of its foundation. With the extensive world-class skills and experience in medical funding on offer within SA’s private sector, the NHI will require working together to develop universal health coverage that will best serve society.

Fundamentally we all want the same thing — a functional, high-quality healthcare system that is within reach for all. The Health Funders Association (HFA) shares government’s commitment to health. Establishing an adequately resourced and sustainable universal health system is a complex challenge that even developed countries grapple with.

During 2021, medical schemes collected R225bn in membership contributions and paid out more than 91% of this for members’ medical treatment. This efficiency in private healthcare funding is fulfilling a nonprofit social solidarity mandate to care for members' health on a large scale. 

This closely mirrors the aims envisaged by NHI, and the medical scheme industry can bring this experience and capacity to a collaborative effort to build the NHI we all want for our children and grandchildren. The cover currently provided by medical schemes has much in common with this social security framework as prescribed minimum benefits ensure members never run out of cover for in-hospital care, chronic conditions, or life-threatening emergencies. 

A medical scheme member on a diabetes programme or who has asthma, for example, cannot run out of benefits for these conditions and any member who has an emergency is fully covered regardless of how much they have claimed. The availability of these benefits contributes to the fact that South Africans pay only 5% of all health expenses out of their own pockets. By comparison, upper-middle-income countries pay 31%, according to World Bank data.

Considerable inroads have been made in establishing quality healthcare access, which will be further enabled with the long-awaited finalisation of a low-cost benefit option framework.

Stats SA’s General Household Survey of 2021 reports that roughly half of those surveyed belonging to a medical scheme live in households with a monthly income of less than R30,000, and the majority of respondents with healthcare cover surveyed were from previously disadvantaged groups.

We fully support the need for universal health coverage and believe there is no time to lose in harnessing the extensive experience and expertise of public and private stakeholders so that we can contribute together to the design of the best possible version of NHI. Even when the NHI is functional it may be decades before it is equipped to offer the comprehensive quality care we would all want for our families.

In the meantime, medical schemes are relieving pressure on public health facilities by providing unlimited cover for chronic conditions and some 300 common health conditions in the private sector. Health funders will continue to broaden and fine-tune healthcare access mechanisms to benefit more South Africans as far as possible within the regulatory parameters, thereby further easing the burden on the public health system.

HFA members, including leading lights in the industry such as Bankmed, CAMAF Medical Scheme, Discovery Health Medical Scheme, Fedhealth, Glencore Medical Scheme, Momentum Medical Scheme, Profmed and PPS Healthcare Administrators, are ready to work with government to develop evidence-based solutions that will help secure access to quality healthcare for all South Africans. 

Until the NHI is fully implemented there is a joint responsibility to do everything possible to preserve the pockets of excellence in the public sector and find workable solutions to raise the level of healthcare generally to the standards of care that private healthcare funding has made possible.

This fundamentally includes protecting and nurturing our precious and increasingly scarce healthcare skills and resources. Implementing NHI will be a Herculean and potentially multigenerational task. Healthcare will be stronger if the internationally competitive healthcare financing systems we have in SA have the opportunity to contribute constructive strategic input now. 

• Makatini is CEO of the Health Funders Association.