Medical Scheme / Healthcare Finance Numbers
MEDICAL SCHEME NUMBERS
Statistics from last year’s annual report from the Council for Medical Schemes provide valuable context to the NHI debate.
- Out of a population of about 58 million, about 9 million South Africans, or fewer than one in six, are covered by a medical scheme.
- Gross medical scheme contributions for the 2017/18 year were about R180 billion, which equates roughly to R20 000 per beneficiary for the year.
- Gross expenditure by medical schemes for the 2017/18 year was about R175bn, or about R5bn less than contributions received. (Schemes have other sources of income, including investment income.)
- Of the gross expenditure, about R160bn (91%) was on health-care costs and R15bn (9%) was on non-healthcare expenditure.
- Of the non-healthcare expenditure, about R12.5bn (83.7%) was for administration costs and about R2.2bn (14.5%) was on broker fees and distribution costs.
WHAT THE NHI BILL SAYS
Here are the salient points of the bill as tabled, as it applies to you, the user:
- Its purpose is to establish an NHI Fund, funded through “mandatory prepayment”, that aims to provide sustainable, equitable and affordable universal access to “quality healthcare services” by acting as the single payer and single buyer of such services.
- Services and products will be sourced from accredited and contracted providers.
- It will apply to all health establishments, excluding military ones.
- It will cater for the healthcare needs of South African citizens, permanent residents, refugees, prison inmates, and certain categories of foreign visitors.
- Asylum seekers and illegal immigrants will be entitled only to emergency services and services for “notifiable conditions of public health concern”.
- It will cover all children, including those of illegal immigrants.
- You will have to be registered and you will be issued with an NHI card, which you will have to present on receiving healthcare services.
- To register, you will have to provide an identity card or birth certificate, photograph, proof of residence and biometrics, such as fingerprints.
- You will have the following rights:
– To receive the service free at the point of care from an accredited provider.
– To be treated within a reasonable time period.
– To not be refused access or unfairly discriminated against.
– To have access to information relating to your health as kept by the fund.
– To be treated with a professional standard of care.
– To make reasonable decisions about your health care.
– To complain about a service provider or service by the NHI Fund, or appeal a decision made by the fund. - You will have to go first to a primary healthcare service (such as a clinic or general practitioner) in order to be referred, if necessary, to a specialist or hospital. If you do not follow the prescribed referral pathway, you will not have access to the healthcare system.
- The bill provides for complementary voluntary services not covered by the NHI Fund. For these services, you will have to pay directly or use a medical scheme or other private health insurance.
