Medical Schemes and the Road Ahead

Healthcare as we know it – the poor and vulnerable are excluded

South Africa's health system consists of a very large public health sector and a much smaller private health sector. The public sector is grossly under-resourced and over-utilised, while the private sector, runs largely along commercial lines, and caters to middle- and high-income earners who tend to be members of medical schemes (and which represent just 18% of the population).

“Medical cover is thus only extended to the fortunate few,” says Joe Seoloane, Curator for Pro Sano Medical Scheme. “The majority of the population has little or no access to quality healthcare. The current situation is therefore one in which critical health care is provided not to those who need it most, but rather to those who are able to afford it.”

Some 7,8 million people in South Africa currently belong to a medical scheme. The remaining population, which amounts to an estimated R41 million South Africans, must make do with limited access to limited resources in the public health care sector.

Another serious challenge is that, due to difficult economic circumstances in recent times, many people have less disposable income to cover increasing expenses. “Being a grudge purchase, healthcare is often one of the first expenses to be cut in tough times,” says Seoloane. “The result is that the sector is experiencing only marginal growth of the number of beneficiaries covered by medical aid schemes, with younger, healthier members often dropping out to save money, leaving an aging and sickly membership base. This puts even further pressure on the limited resources in the pool, with the marginal increase in membership failing to meet the total costs of cover.”

While health remains a priority area for government spending, it remains unclear how this gap will be bridged. One option is the establishment of an alternative funding mechanism for health care in South Africa, such as the much-talked-about National Health Insurance (NHI) system, which would address the economic imbalances and ensure that all South Africans enjoyed access to decent health care.

“Working towards a NHI is a complex task,” says Seoloane. In order for the NHI to be set in motion certain building blocks need to be firmly in place. These include securing budgetary allocations from the fiscus, the revitalisation of the public hospital infrastructure and significant upgrading of public healthcare resources, as per government’s 10-point plan. It’s not going to happen overnight, says Seoloane, but it will ultimately ensure:

• that everybody pays an equitable amount for the same / equivalent benefits
• that there is a widening access to medical scheme cover – especially to lower-income households
• an increase in the number of people contributing to the pool
• that those who need care the most will be adequately covered

Expanding health cover could also be achieved through the improvement of existing public health care facilities, and through the establishment of mutually beneficial public-private partnerships. “It is patently clear that, no matter what form it takes, extending medical cover to the rest of the population and to those who need it most, is one of our country’s utmost priorities right now,” concludes Seoloane, “no matter what form it takes”.