Shake-up on the cards

Major changes to the South African healthcare landscape—and to the medical aid schemes industry—are in prospect following policy declarations at the ANC’s Polokwane conference late last year which have paved the way for the eventual introduction of a national health insurance system in this country.

The Board of Healthcare Funders’ (BHF) head of corporate communications, Heidi Kruger, says there is an essential difference between the two concepts: a social health insurance system, she notes, is designed only for people who are employed and who will contribute financially to the system, typically through regular premiums or a tax. It provides for such people to receive equitable healthcare benefits accordingly.

On the other hand, in a national health insurance (NHI) system—run along the lines of the National Health Service in the United Kingdom for example—healthcare will be made available to everybody on an equitable basis, regardless of whether they have jobs or not.
Working people will contribute financially through tax or whatever mechanism is legislated for, thus effectively cross-subsidising the poor and indigent.

“This will bring substantial and fundamental changes to healthcare delivery in South Africa,” Kruger said. The NHI would require the implementation of a basic benefits package of healthcare services to underpin the system. In the UK, with its significantly larger numbers of employed people, there is obviously considerably more money available to fund such a system and, as a result, the benefit package under Britain’s National Health Service is comprehensive.

In the current South African healthcare environment, a basic basket of benefits called the prescribed minimum benefits (PMBs) is in place, which by law all medical aid schemes have to offer their members and are obliged to pay for in full, regardless of which healthcare service provider supplies the service.

“This is an expensive basket of benefits,” Kruger points out, “comprising mostly hospital and referred-based care. It should have a primary and preventative care component built in, but doesn’t.”

Managing director of the BHF, Humphrey Zokufa, says that although legislation provides for these prescribed minimum benefits to be reviewed every two years, in practice the review has not been happening at this frequency. But, the Council for Medical Schemes and the national health department are now undertaking to review this basket of benefits.

“We have submitted a comprehensive proposal,” says Zokufa, “making the case for this package of prescribed minimum benefits to be scaled down somewhat and to include primary and preventative care benefits. Under the current medical scheme legislation, this benefit package must be paid for in full by medical schemes.”

An aggravating factor, Zokufa contends, is that no legislation is in place governing the pricing of these prescribed minimum benefits and, in theory, healthcare service providers can charge whatever they wish to. This presents medical schemes with an open-ended liability. “Healthcare costs have been escalating consistently and young and healthier people have opted out of the system because they cannot afford the medical aid premiums. The elderly and sick people remain on the system, which in turn makes medical aid more expensive for scheme members. 

“Our proposal is that this basic package of benefits needs to be reviewed in such a way that it takes a much broader view of healthcare policy—taking into consideration the National Health Act, the Constitution and the objectives of the millennium development goals.

“This is especially desirable and essential, given that we are going to have a national health insurance system in place, of which one of the building blocks is a basic benefits package to which everybody is entitled—and we submit that this needs to be a primary care-based package, one in which visits to doctors—among a number of basic healthcare services—would be covered,” Zokufa says.

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