Medical schemes serve as a crucial buffer against the shortcomings of the public healthcare system. According to Stats SA, private medical schemes provide members (around 17% of the population in 2023), with access to better medical facilities, shorter waiting times, and advanced treatments that are often unavailable or delayed in the public sector. This access is indispensable in a country where the public system struggles to deliver timely care for critical treatments such as cancer care and surgeries. However, private facilities, which handle a large portion of hospital procedures, remain out of reach for the majority without medical scheme coverage.
Addressing key health risks through medical scheme coverage
Claims data from one of South Africa’s largest medical schemes, covering the period from January to December 2023, highlights the vital importance of comprehensive healthcare coverage across all age groups. See details below:
| Age 49 | Long-term use of ventilator (Infections) | R 9.5 million |
| Age 39 | Lung transplant | R 6.9 million |
| Age 59 | Long-term use of ventilator (Infections) | R 5.9 million |
| Age 37 | Diseases and disorders of the respiratory system | R 5.6 million |
| Age 61 | Liver transplant | R 5.3 million |
| Age 61 | Surgical procedures on the heart and/or chest (thorax) | R 4.2 million |
| Age 45 | Infections of the nervous system | R 4.2 million |
| Age 36 | Simple pneumonia and whooping cough | R 3.9 million |
| Age 1 | Surgical procedures for infections and/or parasitic diseases | R 3.9 million |
| Age 63 | Surgical procedures on the liver and/or pancreas | R 3.7 million |
Notes: Assumes an average risk contribution of R1 886 per member per month / Source: DHMS data – does not include any maternity claims
Additionally, data from the 2023 Council for Medical Schemes Industry Report highlights the major health risks driving medical scheme claims and expenditures in South Africa. These include chronic non-communicable diseases such as hypertension, diabetes, and hyperlipidaemia, respiratory diseases like chronic obstructive pulmonary disease and asthma, mental health disorders, as well as communicable diseases such as cancer and HIV/AIDS. Medical schemes enable proactive management of these conditions, which is essential for reducing complications, absenteeism, and disability.
- Chronic conditions: Hypertension, hyperlipidaemia, and type 2 diabetes mellitus are prevalent among adults over 45 and account for a significant portion of medical claims. Medical scheme coverage ensures continuous access to treatment, medication, and monitoring, which helps control these diseases and prevent costly complications that disrupt workforce productivity.
- HIV/AIDS: Despite advances in treatment, HIV/AIDS remains a significant health risk with a 20.6% increase in related expenditure reported in 2023. Medical schemes facilitate access to antiretroviral therapy and related healthcare services, helping employees manage their condition and maintain their work capacity.
- Respiratory diseases: COPD and asthma contribute notably to medical claims, with COPD expenditure increasing by 17% in 2023. Timely treatment through medical scheme reduces acute episodes that could lead to extended sick leave or decreased performance.
- Mental health: South Africa’s medical schemes face major challenges related to mental health care, this underscores the necessity for comprehensive strategies that encompass prevention, treatment, and rehabilitation.
Benefits of a medical scheme for employers and the economy
Medical scheme coverage is not only beneficial for individuals but also critical for employers and the broader economy. Employers who provide a medical scheme offering as an employee benefit experience several advantages:
- Reduced absenteeism and presenteeism: Faster access to private healthcare enables early diagnosis and treatment, leading to fewer sick days and improved on-the-job productivity. Wellness programs linked to medical scheme help reduce productivity losses caused by employees working while unwell.
- Enhanced employee retention and engagement: Offering medical scheme signals that employers value employee well-being, which improves morale, loyalty, and helps attract and retain skilled talent in a competitive labour market.
- Improved workplace safety and morale: Effective management of respiratory diseases and mental health challenges reduces workplace incidents and fosters a healthier, more positive work environment.
- Strategic workforce planning: Understanding employee health profiles enables employers to plan for potential disability, long-term absenteeism, or early retirement, ensuring operational continuity.
Challenges and solutions
Despite their importance, medical scheme coverage remains limited due to affordability and access issues. Employers can help bridge this gap by providing targeted subsidies for low-income workers or exploring alternatives to medical scheme cover such as medical insurance products to enable access to quality care. Collaboration with policymakers is also essential to maintain the viability of medical schemes alongside public healthcare reforms.
Closing remark
Medical schemes are more than just employee benefits in South Africa; they are strategic tools that contribute to the country’s economic resilience by fostering healthier, more productive workforces. They help ease the burden on the public healthcare system by promoting preventive care and managing chronic diseases effectively. As South Africa transitions toward a more integrated healthcare system under the NHI framework, collaboration among employers, insurers, and policymakers will be crucial to ensuring accessible, quality healthcare for all citizens.
Health Insights – July 2025