Affordable, Quality, Healthcare

Neil Nair shares his thoughts on healthcare in South Africa


SAMWUMED is an accredited, self-administered medical aid scheme for local government employees. Neil Nair, Principal Officer (PO), discusses the challenges within the country’s healthcare sector and the importance of Corporate Social Investment (CSI).

Could you please tell us a bit more about SAMWUMED and your role within the organisation?

SAMWUMED is a restricted medical aid operating within the local government sector. We were established as a self-administered medical scheme in 2001. Our Scheme has a long and rich history of working to improve people's health and quality of life. Operating under the philosophy that all South Africans are entitled to affordable quality healthcare, we have evolved from a bargaining council fund to one of the largest self-administered medical aid schemes for workers in the local government and government support industries nationally. My role as the PO is to provide the strategic direction of the Scheme to achieve its mandate, as prescribed by the Board of Trustees. I am largely responsible for the day-to-day running of the Scheme as well as strategic management, in consultation with the Board of Trustees. As a self-administered medical scheme, I also serve as the Chief Executive of the Scheme’s administration.

What are the greatest challenges that you find in the healthcare sector within South Africa?

Improvements to the cost benefit of our members remain our number one priority. We have thus embarked on a project to improve our risk management efforts for improved overall health outcomes and in this way, improve our risk profile and make the Scheme more affordable and sustainable for all our members. The issue of high-cost claiming remains a critical one, which contributes significantly to the sustainability of our medical scheme. We believe that by raising awareness, we could improve both the health and cost outcomes to the benefit of all. A further concern relates to the interpretation of the provisions relating to the Prescribed Minimum Benefits (PMBs) as contained in Regulation 8 of The Medical Schemes Act. Regulation 8 deals with the diagnosis, treatment and care costs related to Prescribed Minimum Benefits (PMBs). While the Regulation has the protection of medical scheme members as its aim, the inadvertent consequence has been its deliberate abuse by service providers (albeit a small percentage) charging exorbitant fees and in so doing, placing these members’ “access to quality care” at risk. The introduction of the Medical Schemes Act and the regulations thereto, clearly intended to limit the benefit barriers for the diagnosis and treatment of certain life-threatening illnesses (PMBs), ensuring the continuity of care for patients covered under medical schemes. Simply put—PMB legislation intended to ensure that medical schemes may not relinquish responsibility for care simply because the member had exhausted the benefit (no benefit limits for PMB conditions). It did not intend that a doctor or hospital could charge what they liked.

However, there is a discord between legislative intention, on the one hand, and industry practice on the other. In the absence of an agreed upon tariff (deemed uncompetitive) and a literal interpretation of the wording of Regulation 8 (as regards PMB conditions), certain health service providers and their industry bodies see this as an opportunity to unashamedly fleece medical aid schemes and, thereby, the scheme members. They see it fit to charge whatever they wish since the term “payment in full” implies that medical schemes must pay the full amount demanded, whatever this may be. In other words, service providers see themselves as having a blank cheque for their treatment of PMB conditions. Whilst these practices are indeed sporadic at present, if given continued legitimacy by CMS and the Department of Health, the practice will naturally spread—to the point of self-destruction, at the expense of the people.

What is SAMWUMED’s stance on preventative healthcare?

SAMWUMED has pioneered this form of healthcare management and prevention strategies for several years. Our Preventative Healthcare Programme is an extension of our fully comprehensive benefit offering, which allows our members to enjoy quality, private healthcare throughout the year, without inordinate out-of-pocket expenditure. For example, some of the benefits of our Preventative Healthcare Programme are that members receive free screening tests such as mammograms, prostate cancer, blood Cholesterol, diabetes type II and many more tests free of charge from any preferred provider. This programme is also extended to expecting moms who receive all the necessary screenings and supplements they and their babies require during and post-pregnancy.

Please tell us a bit more about the ethos of SAMWUMED?

Our Ethos is firmly entrenched in the struggle for social, economic and political equity. Alas the struggles continues post democracy, it is grounded in the principle that healthcare is a human right. Using this as a starting point any form of healthcare commercialisation, we are therefore opposed to.

Could you please tell us a bit more about your CSI initiatives and what you are involved in?

Medical schemes, by statute, are social solidarity organisations. Our very existence is driven by social investment—this includes our not-for-profit administration model—making us one of the highest value medical schemes in SA. Notwithstanding this, we contribute more directly to social investment per the below mentioned.

Being an organisation that is very community-driven, we have embarked on several Social Responsibility Initiatives, including what has now become our Annual Nelson Mandela Day Soup Kitchen, which we’ve been running since 2013. The soup kitchen involves the preparation of hot meals (soup) for the underprivileged community of Athlone, which is where our Head Office is based. We are also a main sponsor of the Saartjie Baartman Centre for Women and Children in Cape Town, which provides shelter for destitute women and their children who come from unbearable and abusive backgrounds. We make a concerted effort to give back to our communities, especially where it involves vulnerable children and women. Over the past two years, we’ve also conducted a Beanie Collection Campaign where we encourage our members (young and old) to knit or donate a beanie in the winter months for primary school children to keep warm. This was also inspired by the late Nelson Mandela. We have donated beanies to a few schools, including the Athlone School for the Blind, the Siyaphambili Orphan Village in Langa and Bergsig Primary School in Bonteheuwel. More recently, we have also been supporting farm workers with resources.

Can anyone join SAMWUMED or must they be members of SAMWU?

SAMWUMED is open to all local government (municipal) employees, including the associated privatised services, such as Water Boards and electricity suppliers. The Scheme is not limited to SAMWU members.

How does SAMWUMED offer such affordable cover—what do you do differently to ensure this?

Our benefit design is anti-corporate. We offer what is needed and charge accordingly. We also do not subscribe to new age marketing gimmickry or to savings accounts—our benefits are fully insured. We contain expenditure by in-housing key operations and this affords us the opportunity not to extract any profit from the Scheme and pass these savings back to our members. Thus, our administration costs are almost half of what the industry charges—this is where profit is extracted from medical schemes.

SAMWUMED is able to achieve this by applying very prudent methods in curbing high expenditure on non-healthcare related costs. This, together with a healthy reserve ratio, allows for us to save our members the much-needed cash.

Please could you provide us with your career and educational background?

I have worked for SAMWU and, subsequently, SAMWUMED since its launch in 2001—thus, collectively, approximately 27 years. I was engaged in student activism from an early age and served as the SRC Chairperson and as an activist in the heady days of the student uprisings in the 1980s—within the student, civic and UDF movement. I joined the progressive trade union movement in 1993, where I was primarily focused on employee benefits. In this capacity, I championed the launch of many employee benefit options for workers previously denied access to social benefits. I also served as a founding delegate to the SALGBC's Employee Benefits Working Group. This working group was instrumental in drafting the framework for the rationalisation of medical schemes in the local government sector—including the equalisation of employee benefits.

I was a founding labour delegate to the National Information Technology Forum (NITF)—under the then Minister of Telecommunications, Jay Naidoo. He also served as a Director of the Board of Healthcare Funders of Southern Africa (BHF,) where I sat on the Constitutional Review Panel. I also served briefly as the Deputy Chair of the BHF. Prior to Joining SAMWUMED as the Principal Officer in 2001 (in which capacity I presently serve), I was a Technical Advisor to the Scheme's board from 1998. I played a leading role in the Scheme's transformation from a regional bargaining council benefit to a self-administered, national medical scheme. I became the Principal Officer in 2001, a position I hold to this present day.

I also served as a Technical Advisor to the Ministerial NHI Advisory Sub-Committee: Purchasing and Benefits, under the Chairpersonship of Professor Di McIntyre. This committee is responsible for devising strategies to allocate resources towards the introduction of the National Health Insurance benefit structure. In addition to this, I had been appointed as one of four medical scheme representatives to serve on a council for the medical scheme’s task team. This team has been set up to review sections of the Medical Schemes Act with specific reference to Prescribed Minimum Benefits.

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This edition

Issue 68