Two key research studies published in the Council for Medical Schemes’ 2024/25 annual report have underscored the urgent need for reforms in how chronic diseases are managed and how out-of-pocket (OOP) healthcare costs are addressed within South Africa’s medical schemes environment.
The studies form part of the CMS’s policy research outputs aimed at informing evidence-based health financing reforms and strengthening regulatory oversight. Both investigations highlight systemic gaps in disease management and financial protection for medical scheme beneficiaries, particularly vulnerable and high-risk groups.
Growing burden of chronic disease among medical scheme members
The first study, Prevalence of chronic diseases in the population covered by medical schemes in South Africa: 2014-2023, analysed nearly a decade of data to track trends in chronic disease prevalence and associated healthcare outcomes.
It found a steady and concerning rise in key chronic conditions such as hypertension, hyperlipidaemia, and Type 2 diabetes mellitus (DM2) – the most common conditions across open and restricted schemes. The burden was particularly heavy among members aged 60 years and older, who now represent almost 14% of the insured population and show significantly higher rates of multiple chronic conditions and hospitalisation.
While Scheme Risk Measurement (SRM) prevalence rates for conditions such as Type 1 diabetes and HIV/AIDS declined, overall prevalence rates remained higher, indicating that many patients are not being captured by risk-adjusted reporting mechanisms – often because they are not enrolled in disease management programmes (DMPs).
Gender disparities were also evident: women were more likely to be hospitalised for chronic conditions, even when prevalence was higher among men. The report also noted increases in respiratory and gastrointestinal illnesses such as bronchiectasis, chronic renal disease, and ulcerative colitis.
Given these trends, the CMS said reforms in chronic disease management are urgently needed. Recommended actions include broader enrolment in DMPs, targeted interventions for high-risk age groups, and gender-responsive care strategies. The study also called for a more integrated approach to data reporting, preventive care, and lifestyle modification programmes to help curb the rise in metabolic and cardiovascular diseases.
Out-of-pocket healthcare costs remain a growing concern
The second study, Analysis and intervention on high levels of out-of-pocket payments: a 2023 overview of chronic disease and diagnostic treatment pairs, examined the financial burden faced by members managing chronic conditions.
It found that open schemes recorded higher OOP costs overall, largely because of out-of-hospital care. Chronic renal disease emerged as the most expensive condition per patient, followed by haemophilia and cardiomyopathy. Provincial disparities were also apparent, with KwaZulu-Natal recording the highest OOP expenditure.
The research showed that children under five and adults over 75 years old are particularly exposed to high costs – younger patients mainly for cardiac conditions, and older adults for respiratory and cardiac diseases. Importantly, high OOP costs were often linked to common chronic conditions, not only rare diseases.
While gap cover policies provided some relief, the CMS cautioned that these products may mask the extent of catastrophic health expenditure faced by many households.
The study concluded that reforms are needed to strengthen financial protection for scheme members. Recommendations include expanding coverage for high-cost chronic conditions, improving benefit design, and addressing geographic disparities by improving access to specialist care.
The CMS said these research outputs align with its strategic objective of conducting policy-relevant studies that guide healthcare reform and promote equitable access to care. The findings, it said, will be used to support ongoing work to improve sustainability, affordability, and fairness in South Africa’s private health financing system.
