How South Africa is legislating its way into a healthcare crisis:
Clumsy law-making on healthcare and the failure to correct it have resulted in medical schemes carrying an almost unlimited liability for prescribed minimum benefits (PMBs), while nearly 10??million people are being denied low-cost benefits for primary healthcare.
Unregulated consultant tariffs and the reluctance of the Council for Medical Schemes (CMS) — the government’s chief proxy — to approve low-cost benefits schemes are driving medical inflation and sending medical aid premiums soaring, according to Rajesh Patel, the head of health systems strengthening at the Board of Healthcare Funders (BFH), and Charlton Murove, the head of research.
They said the National Health Insurance (NHI), which looms on a 10- to 20-year time horizon, would effectively put paid to medical schemes. The government says the NHI aims to enable equitable access to quality healthcare.
The BHF is the representative organisation for the majority of medical schemes in South Africa, Namibia, Zimbabwe, Botswana and Lesotho.
Patel and Murove said healthcare in South Africa is unnecessarily complex, with dismal regulatory oversight in which patients suffer financial hardship while struggling to negotiate a healthcare funding jungle.
Against this backdrop, industry experts have welcomed a recent web-based innovation, MedicalAid.comm, which provides accurate medical aid comparisons through a sliding premium affordability button while listing benefits.
“One of the biggest oversight challenges is PMBs [prescribed minimum benefits] — a set of conditions which medical schemes are obliged to pay for in full — but have no idea what they’re in for,” Murove said.
“To make matters worse, healthcare practitioners (consultants mainly), determine the cost, often charging more than their usual tariffs when it’s a PMB-related condition. There’s also upcoding, which is when a healthcare provider makes a PMB-related diagnosis so they can get access to this unlimited bucket of funds.”
Prescribed minimum benefits are poorly defined in regulation, creating too many grey areas that can be taken advantage of, Patel weighed in.
“South Africa’s version, passed in 2003, was based on research done in Oregon in the United States, except that there, they have put in place defined procedures and coding, while here we’ve dropped the technical specifications, blurring interpretations,” Patel said. “So, service providers are incentivised to charge as much as possible.
“When you access a consultant, you don’t know the cost and you’re not able to negotiate. While there are Health Professions Council of South Africa ethical rules around informed consent, in practice this doesn’t occur enough. There’s often no discussion around price, irrespective of PMBs. Often a patient goes to a doctor and the receptionist asks: ‘Do you have gap cover?’
“If you say yes, they charge more. People don’t know about PMBs and non-PMBs. Also, when you are sick, you’re at your most vulnerable. If, for example, you have cancer — are you able to say let’s negotiate a price for my care?” Murove posited.
Even for those who work in this environment, it’s a minefield, Patel said, calling for better stewardship and oversight. “We’re currently sitting with a politicised healthcare system. There is more politics at play than efforts to solve the problem.”
Allowing more affordable low-cost benefit options (medical aid products, not insurance) would enable people who cannot afford higher end medical plans to at least access primary healthcare products, Patel said, taking a huge burden off the state.
He noted that the Competition Commission’s 2019 Health Market Inquiry chaired by former chief justice Sandile Ngcobo had said there should be some consultant tariff ceiling and made specific recommendations, but the health department had not moved on implementing any of them.
“We applied for exemption from the Competition Commission so we could do collective bargaining while the government gets its act together, but politics came into play, and we’ve now been sitting with the Competition Commission for over two years.”
Patel said a holistic review of PMBs and allowing low-cost benefit options (LCBOs), “would change the entire environment”, but bemoaned the shortage of skills and seeming lack of will in the health department and the CMS.
“The [department] has simply relegated it to the CMS who haven’t moved on this for nearly eight years. I mean a single medical aid can change its benefits within one year, but the CMS seems incapable. They say they’re busy reviewing PMBs, but it’s treacle-slow,” he added.
Murove went further, accusing the CMS of deliberately trying to frustrate the feasibility of medical schemes to further the NHI — while rendering patients vulnerable.
“We’ve taken them to court on judicial review and what we saw in their documentation was a very deliberate attempt to delay LCBOs as much as possible. We can clearly see that if they did approve LCBOs, the NHI would become less appealing to the public,” he said.
“Approving LCBOs would make a big difference to millions of lives, especially with the medical tax savings — and medical schemes would be far more sustainable. In the [department of health’s] estimation allowing LCBOs will create a bigger pool of people who won’t need an NHI because they’re being looked after by medical schemes.”
Both Patel and Murove said that young and healthier patients were moving to unregulated insurance products, leaving the sick and older people in medical schemes and creating “a vicious cycle” in which medical aid premiums were becoming increasingly expensive.
“The more this happens the more youngsters (often newly married with young children) move out into insurance, leaving older people paying increasingly. Medical aids will just get increasingly expensive — which suits the NHI proponents,” Patel said.
“If you want social solidarity you need to reduce the number of risk pools. If you don’t attract the young people, you can’t keep contributions down and you’ll always have contributions more than CPI [consumer inflation] plus five percent.”
Murove and Patel said both the BHF and the Orthopaedic Society of South Africa had applied for exemption from the Competition Commission.
“Between the funders and the service providers there’s an urgent need to sit around the table to discuss what’s reasonable and fair pricing. Hopefully, the regulators will come to the table, and we can do real structural reform. Let the players find their own solution instead of the [health department] ignoring our input. We’re not against universal healthcare. We just want to reduce pressure on the healthcare system and have input into NHI benefits. LCBOs would be a primary healthcare package, like an entry point to the NHI environment — a mutually beneficial one.”
They said the failure to implement the recommendations of the Health Market Inquiry “makes no sense in the bigger scheme of things” and that allowing low-cost benefit options under the CMS would provide “fertile ground” to trial healthcare provision in an NHI environment.
“It seems clear that the government has a perception that if you improve the medical scheme environment it will be a threat to NHI implementation. It seems clear that people on medical aid schemes will be the last to be brought into the NHI. However, if you trial a partnership with the private sector now, you’ll reduce the burden on the state and can then eventually wind down on the medical schemes when it becomes an easy migration,” Patel said.
The pair said offering low-cost benefit options packages at affordable premiums of about R200 to R300 a month for primary health cover would enable as many as 10??million people to benefit.
“Many are willing to pay from their own pockets to avoid taking time off work or losing income waiting in the public sector. It’s a significant number — and the medical tax credit they’d get just further increases the potential,” Patel added.
Media coverage of the government’s position revealed huge suspicion of the private sector as purely profit driven, Patel said.
“Instead, what’s true is that our sector has done much to add value. It’s sad that they see us in this way. It shows a lack of understanding. What they’re describing as bad in the insurance environment is something they’re perpetuating. They cite medical schemes’ administration costs. Well, LCBOs can be self-administered with nobody making any profit,” he argued.
“For those in the insurance market, moving to a medical scheme will be a great boon via the tax rebate. If an insurance product is not performing, they can increase premiums and cut benefits — and there’s no insurance ombudsman to run to. There’s been a deliberate misunderstanding of the facts and criticism of LCBOs.”
Asked about allegations of some doctors “gaming the system” by conducting unnecessary procedures, the chief executive of the South African Private Practitioners Forum (SAPPF), Simon Strachan, said although it did not have a monitoring mechanism, the profiling of doctors was done by almost every medical scheme administrator — or by the hospital itself for hospital-based consultants.
Many specialities and medical organisations partnered with funders to profile pre-identified “outlier” practices. Any suggestion that consultants were inflating their prices was “simply wrong”, he added.
“You have a duty to discuss payment options with your patient. I see nothing wrong in asking patients how they aim to pay for your services. One thing the SAPPF is very clear on is that healthcare professionals should have a one-off fee, not one for prescribed minimum benefits, and another for non-PMBs. You can decide whether to discount that fee or not. If you have gap cover, I should still charge you my regular fee.”
CMS registrar Sipho Kabane said a full report with multiple stakeholder input on low-cost benefit options, dating to before the Covid-19 pandemic, was given to Health Minister Joe Phaahla last November and included the CMS advice on the main recommendations made by the Health Market Inquiry.
“We’ve added our regulatory perspective — I don’t want to muddy the waters now by commenting,” he said.
A CMS review on what should be included in PMB conditions, in line with scientific evidence, cost effectiveness and the protection of members and medical schemes was underway. One thrust would be including elements that reduced the need for curative and hospital services, thus improving health outcomes.
“We believe the only protection you enjoy as a medical scheme member are PMBs, which are a compulsory payment by schemes. We don’t think it makes sense to interfere and tamper with them,” Kabane added.
The CMS application to the appellate division of the supreme court in its legal wrangle with the BHF, due to be heard in April or May this year, could be rendered moot by the health minister’s decision.
“I’m sure we can find an amicable way to resolve the dispute,” he said.
Seven comedians, a musician, two actors and a social media creator walk into a house … the joke is for them not to laugh —the polar opposite of their day jobs. The punchline is that the ultimate victor earns a cash prize to donate to a charity of their choice.
That’s the broad premise of brand-new reality series Last One Laughing, which will debut on Prime Video on Friday, 16 February. Cleverly, the series’ acronym is LOL — ha, ha!
It sounds easy but, apparently, trying not to laugh is harder than winning a staring contest with a mirror, especially when among the 11 contestants are some of South Africa’s lollest people.
Internationally revered comedian and broadcaster Trevor Noah is the host and the show features comedians Celeste Ntuli, Jason Goliath, Tumi Morake, Robby Collins, Glen Biderman-Pam and Mojak Lehoko; singer Moonchild Sanelly; actors Nomzamo Mbatha and Thando Thabethe plus social media creator Lasizwe Dambuza.
So, this is roughly how it works — one comedian makes a pun, another pulls out a clever one-liner and the social media star drops a meme-worthy line. The atmosphere is tense as they all try to keep straight faces. But the jokes are so hilarious and unexpected that even the most stoic among them can’t help but crack a smile and burst into laughter.
And that’s when they realise the real challenge isn’t in making each other laugh, without smiling themselves, but in trying not to laugh at all. Because if you do, you’d literally be killing yourself laughing.
But when it comes to laughter, resistance is futile — especially when you’ve got a house full of comedic geniuses.
In a challenge lasting six hours, they’re pitted against each other in a house, reminiscent of Big Brother, except that it is funny ha-ha, not funny peculiar, in the jokers’ den.
Laughter and smiles are strictly forbidden, yet they must use every comedic trick in the book to crack each other up and secure eliminations.
The media had the opportunity to meet some of the cast members and watch the first two episodes of the unscripted series at The Galleria in Sandton, Johannesburg, this week.
It was a blue-carpet event, with blue mimosas and blue snacks making the rounds, while comedians, actors and social media personalities came dressed up to support their peers.
Participant Goliath says this is the first time he has not been absolutely in charge of a show.
“In every show I have done, I have been able to control the performance and the audience’s reactions, and you kind of know what people are going to expect,” he tells me.
“This is one of those shows where, even if I explained it to you for hours and hours, you would still not be ready for the twists and turns.
“As a comedian, it is like waking up in your worst nightmare and then you realise that the cameras are rolling and you have to stay in the game and commit.”
Goliath says the worst thing for any comedian is people not finding them funny and the show hits that nerve directly (or is it indirectly?).
“It does not matter how big the comedian you love is, they are so insecure about being funny. The show forced us to dig to a place where none of us have ever been before.”
Morake describes being a part of the show as “holding on to a secret and the secret is killing you — now imagine this secret is a laugh, that’s what this was like”.
She says she learnt a lot about herself as a comedian and the places she reaches from. She also mentions that the pandemic took her away from her industry friends so it was refreshing to share a space with them again.
“As the industry is waking up again, we have all been chasing our own tails, so it was really nice to be in a space where you know you are going to be with them for a long period of time and that was enough for me.”
Just after 7pm, we were escorted to our seats to watch the show. The ambiance was full of love, reminding me of Morake’s earlier comment that a lot of the participants had not seen each other post-Covid, making it even more special.
The place was roaring as the audience members failed to contain their laughter throughout the two episodes. I won’t spoil it for you by trying to retell any of the jokes. Just take my word for it that it was truly hilarious.
Afterwards, one of the audience members summed it up perfectly: “This is South African comedy at its best. This is South African entertainment at its best. We have the ability to laugh through anything and it is people like these guys who get us through. Top-notch entertainment.”
Last One Laughing will air on Prime Video on 16 February.
The prof keeps his politest Zoom face on as I read to him this excerpt from an article on the BBC’s website about South Africa’s Grammy-winning superstar, Tyla: “Before her rise to fame, the 21-year-old made a video proudly talking about her mixed-raced heritage on TikTok.
“In it she slicks her coily hair into Bantu knots, while donning a traditional beaded necklace, with the words, ‘I am a coloured South African’ splashed across the clip like a badge of honour.
“The star says this means that she ‘comes from a lot of different cultures’.”
He grimaces at the following from the article, which was published in December when the Tyla video threatened to spark a culture war: “It is a simple video intended to share a part of herself with her audience. But instead, her racial identity has stoked flames across the internet, most notably, in the US.
“Americans see the word as a slur, unlike Tyla’s South African community, who see it as a part of their culture. In South Africa, it is a distinct identity that is officially recognised.
“One US user on X, formerly known as Twitter, said: ‘We are not gonna call her coloured here and if she personally demands it, her career will end before it begins.
“She’s trying to cross over into an American market, she won’t be able to use that word here; she can use it somewhere else though.’”
I’m done and Adam Haupt, globally respected hip-hop scholar and director of the Centre for Film and Media Studies at the University of Cape Town, lets out a deep sigh.
We are discussing the race politics around Tyla who had a few days earlier become the youngest South African — she turned 22 on 30 January — to win a Grammy award in the new Best African Music Performance category for her amapiano/RnB floor-filler, Water.
Thankfully the American internet “backlash” did not spill over to the Grammy Awards, spoiling Tyla’s big night.
“I think it’s interesting how they read her racially, because there is a lack of nuance,” Haupt says.
He spends a lot of time engaging racial identity politics, which includes explaining the difference between the South African “coloured” and American “colored”.
The former laid a foundation for apartheid when the Population Registration Act of 1950 required South Africans to be registered into one of four racial categories: white, black, Indian or coloured.
As the BBC explains: “In the US, the word harks back to the Jim Crow era, when segregationist laws were instituted in the southern states to oppress black Americans after slavery was banned. Water fountains, toilets and bus seats were marked ‘whites only’ or ‘colored only’.”
The misunderstanding over Tyla’s Tik-Tok video was in the spelling.
“I mean, it’s the same problem that I have when I work with editors and publishers in the States,” Haupt says.
He noticed too late that all the “U”s in coloured were edited out in a recent article of his in a respected American anthropology journal.
“In South Africa, we spend a lot of time talking about or framing what the term ‘coloured’ means. I always have to explain how that spelling matters.”
Now, whenever possible, Haupt inserts a footnote early on in his text, so to say, “This is what this term means.”
“It’s not the pedantic point about British spelling versus American spelling. This is the historical and political significance of the term.
“It has a very different meaning here to what it would mean in, say, in the States, particularly the South.”
He apologises with a smile: “Sorry, that’s just my annoyance.”
The debate needs nuance, because “race lands differently in different places. Black isn’t just one thing. Blackness is broad and I’m always reminding people to see varieties of black experiences, as not essentially [just] one thing …”
Similarly, being coloured also means “different things in different spaces because not everyone’s lived experience is the same”, says Haupt, who grew up under apartheid in the poor working-class suburb of Bonteheuwel north of Cape Town.
Young Tyla, who grew up in post-apartheid Johannesburg, has a completely different experience of “colouredness” to someone from the Cape Flats, Eldorado Park, Langa or Gqeberha, for example.
He adds: “I mean, if you go to the Northern Cape, that’s a very different take on what coloured is.”
We are talking about a YouTube video where Tyla goes to a typical African hair salon. “The ritual of having your hair done is exactly like any other person on this continent. You go to a salon, and you have your hair braided.
“So, whether you want to claim her as exclusively coloured, I’m like, yeah, okay …”
It is about how she styles and represents herself.
“That is not just about claiming colour, but also that this is broader black and African-centric allegiance in a styling,” says Haupt.
Her form of blackness travels well, which is why Tyla is massively popular on the rest of the African continent and the diaspora.
“The way in which she aligns herself culturally … is why her music has taken off here,” Haupt explains.
American cultural imperialism and its accompanying myopia is, as Tyla’s generation would say, “a thing”.
Journalist Lynsey Chutel is one of the co-authors of Coloured: How Classification Became Culture.
She grew up in Eldorado Park in Johannesburg. She tells the story of how when she went to Columbia University in New York she had her own “Tyla experience” after she introduced herself as a coloured woman from South Africa on the first day.
“It did not go down well with her classmates; her roommate pulled her aside and said she had made the American students feel uncomfortable,” from the aforementioned BBC article. “She was forced to defend her own identity, background and culture while trying to assuage the discomfort of others.”
Chutel agrees with Haupt that Tyla has brought a different expression of blackness, by embracing being a coloured person. She has forced the diaspora, especially Americans, “to recognise a different history of blackness and a different history of oppression, because that’s where the word [coloured] comes from”.
“The reason we still use this word is because it represents a very particular South African and Southern African history of enslavement, colonialism and apartheid,” Chutel tells me. “But I think what’s also been really cool about her is the way in which she uses it, as someone who’s born free.”
Hers is a generation for whom being coloured is a term that has been passed on to them by their families and their communities, says Chutel. For them this as a culture rather than an apartheid classification.
“I have not spoken to her, but I’ve watched her interviews, and she seems to be an energetic, carefree 22-year-old, who uses the word without the baggage. And she uses it with a real sense of pride.”
But that does not translate into a narrow nativism, like one saw under apartheid, where collaborators bought into a “coloured nationalism” — some of which still lingers on today in right-wing offshoots.
Also for Chutel, Tyla’s hair, styling and music are important cultural signifiers. “I find that her willingness to wear her hair in cornrows clearly says something about identity as an African and as a South African.
“It is about being able to be coloured and still be South African and still be African.”
And, of course, there is the genre Tyla is part of — amapiano, with its truly African sound. It is unencumbered by borders — and you can turn it into what you need it to be.
“It’s also a style that is particularly inclusive. You don’t have to be from a particular neighbourhood, you don’t even have to be from a particular country to love it,” says Chutel.
“What that says reflects the creators who live in an online world … a far more fluid, globalised world, who may be sitting somewhere in Mamelodi, or somewhere, like in Tyla’s case in Joburg, but that producer also lives in the global world, that producer lives online.”
After Nigeria eliminated South Africa in the Afcon semi-finals earlier this month, a video clip went viral. It was of students at Ahmadu Bello University in the Nigerian city of Zaria, ribbing Saffas by pouring water over themselves while singing Tyla’s hit Water.
It was good-natured and most South Africans took it that way.
As William Shoki, the editor of Africa is a Country, wrote: “To my surprise, we were gracious in defeat. In victory, Nigerians were boastful and playfully smug. The memes were prolific and immaculate. Tyla’s Grammy win was immaterial, and Nigerians confidently declared that it was ‘Ourpiano’.
“South Africans wryly took it on the chin and mourned all our losses to the Nigerians, including but not limited to women and cities.”
Let’s hope we don’t have to explain this banter to Americans too. It was tough enough helping them make sense of the missing “U”.
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