1. Expanding Health Insurance Coverage
National Health Insurance Policy Brief 2
Expanding Health Insurance Coverage
5 May 2009

2. Public-Private Coverage
Source: McIntyre D., van den Heever A. Social or National Health Insurance. In: Harrison S., Bhana R., Ntuli A., editors. South African Health Review Durban: Health Systems Trust; URL:

3. Medical Scheme Coverage
StatsSA figures from household surveys have underestimated medical scheme coverage since 2005, compared to using CMS data with ASSA2003 population.
Source: IMSA NHI Policy Brief 2: Health Insurance Coverage

4. Provincial Medical Scheme Coverage
StatsSA data for South Africa and Western Cape almost identical to CMS data with ASSA2003 population. Gauteng ? Quality of CMS provincial data untested. Perhaps beneficiaries living in other provinces allocated to workers in Gauteng.
Source: IMSA NHI Policy Brief 2: Health Insurance Coverage

5. Medical Scheme Coverage by Income Levels
There is a very strong pattern of coverage by income. Lower income groups unable to afford medical scheme contributions without substantial employer subsidy.
Source: IMSA NHI Policy Brief 2: Health Insurance Coverage

6. Phased Introduction of NHI
Estimate for 2009 using latest available medical scheme information from CMS and population from ASSA2003. Even if all earning any income and their insurable families are covered, only 51.1% of population would be covered.
Source: IMSA NHI Policy Brief 2: Health Insurance Coverage

7. Phased Introduction of NHI
Impact by province very different: Western Cape and Gauteng have most people covered for mandatory health insurance as more people are working in these provinces.
Source: IMSA NHI Policy Brief 2: Health Insurance Coverage

8. Anti-Selection in Medical Schemes
People stay out of voluntary medical schemes until they need care. Medical schemes have fewer early working age adults and more elderly than the population. Note many young adult men not on medical schemes and have low levels of income.
Source: IMSA NHI Policy Brief 2: Health Insurance Coverage

9. Anti-Selection in Medical Schemes
Maternity cover is part of minimum benefits. There are proportionality more women in medical schemes in the maternity years than there are in the general population.
Source: IMSA NHI Policy Brief 2: Health Insurance Coverage

10. Price of PMBs under Phased NHI
Illustrates effect of age and gender differences on price of minimum benefits at various phases of NHI. As more people added, price per person for minimum benefits decreases to 82.2% by Phase 4.
Source: IMSA NHI Policy Brief 2: Health Insurance Coverage

11. Conclusions
Proportion of people already covered by health insurance is at least 15.9% in 2008 and possibly 16.4% if bargaining council scheme beneficiaries included. This is higher than StatsSA survey estimates.
The extension of health insurance coverage to more people under a National Health Insurance system will probably be in phases.
Even if all workers (earning any amount) become contributors and their insurable families thus receive cover, only 51.1% of the population would be covered for health insurance.
54.0% of the population are in households receiving one or more social security grants.
Gauteng and the Western Cape will have the greatest proportion of people eligible for health insurance due to the greater numbers of people earning incomes in those provinces.

12. Conclusions on Price of NHI
The more lives added under mandatory coverage, the lower the average price of healthcare for all. The age and gender effects alone mean that the price of minimum benefits in medical schemes is some 18% higher than it would be under mandatory insurance covering all income earners.
There may well be additional price reductions under mandatory insurance due to the effect of anti-selection in the voluntary environment but the impacts are more difficult to estimate.
Critical to perform calculations for National Health Insurance by at least age and gender and preferably also by the burden of disease.

13. Innovative Medicines South Africa (IMSA) is a pharmaceutical industry association promoting the value of medicine innovation in healthcare. IMSA and its member companies are working towards the development of a National Health Insurance system with universal coverage and sustainable access to innovative research-based healthcare.
Contact details: Val Beaumont (Executive Director) Tel: Fax:
Innovative Medicines SA (IMSA) Cell:
PO Box 2008, Houghton, South Africa

14. Professor Heather McLeod
Material produced for IMSA by
Professor Heather McLeod