
Towards Addressing Policy Gaps in South Africa’s Healthcare System: A Sustainable Approach to PMBs and Medical Schemes Reform
The health policy framework for South Africa’s healthcare system after the establishment of democracy included the creation of medical schemes alongside a tax-funded public sector, focusing on the ideals of solidarity and equity. However, significant shortcomings and inconsistencies have developed over the years have hindered the effective implementation of these policies and their translation into practical benefit design. The authors argue that incomplete coverage under PMBs has created gaps in healthcare access.
This, combined with adverse selection by beneficiaries and schemes, has led to market failures and inefficiencies. CMS reports and analysis suggest that incomplete coverage and anti-selection have a compounding effect, weakening the risk pool and escalating costs.
The design of benefit options that include both Prescribed Minimum Benefits (PMBs) and supplementary benefits adds complexity to the system. This integration undermines the principles of equitable access to essential healthcare and increases cost pressures, as each option must be self-sustaining. As a result, the PMBs are not financed through the most significant risk pool.
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