GEMS actively increasing healthcare access for women in the public sector”.
Government Employment Scheme

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
South Africa (SA) has historically been a male-dominated, traditional society. However, post democracy, the leaders of the country worked actively to promote women’s rights. In recent years there has been much success in gender equality in SA with EY’s 2013 Worldwide Index of Women as Public Sector Leaders ranking SA fourth among the G20 countries. With more than 62.5% of public servants being female, women play a pivotal role within government and the SA economy. They are the main healthcare decision makers and also have considerable medical needs of their own. In terms of their health and wellbeing and that of their families, most of these ordinary women, many of whom are breadwinners, remained disempowered in the past as medical schemes were the domain of higher-income earners. Stress is a tremendous factor with women trying to juggle work and family responsibility. Employees suffering from high stress levels can become susceptible to health problems, including headaches, muscle tension, chest pain, fatigue, a change in sex drive and gastrointestinal problems. If left untreated, chronic levels of stress can lead to or worsen heart disease, asthma, obesity, anorexia, diabetes, depression and anxiety, Alzheimer’s disease and can even cause premature death. Collectively stress, anxiety and depression are cited as the main reasons for work absence, thereby costing the economy dearly. A large percentage of individuals are furthermore at risk of obesity or developing lifestyle-related illnesses with SA reflecting the highest rate of obesity of any sub-Saharan African country. This problem is worse in women, with over 60% of SA’s women being considered obese and 45% leading an inactive lifestyle when compared to just 28% of men. Obesity is associated with non-communicable diseases, including Type 2 diabetes, hypertension and heart disease. With a 500% increase in sick leave since 2001, SA has steadily slipped down global competiveness rankings. In the process a mammoth R19 billion is lost every year due to absenteeism, thereby placing the economy at serious risk. The public sector is perfectly positioned to reverse this trend as it can reach large segments of the population. This will not only improve the health, wellbeing and productivity of government employees but can also have a knock-on effect at community level, thereby playing an integral role in improving the healthcare outcomes of individuals across the board. With women at the forefront of the public sector, but also at the greatest risk of obesity and its associated diseases, their health and the health of the economy are inextricably linked, and to protect the one is to protect the other. Investing in the health of the public sector workforce was a business imperative that could result in higher levels of productivity, decreased rates of absenteeism and improved efficiencies. A quality medical scheme providing for public sector families across the board, but specifically for lower-income families which previously did not have access to private healthcare services before, was sorely needed, particularly when it came to the more frequent and intense medical needs of women.

B. Strategic Approach

 2. What was the solution?
The Government Employees Medical Scheme (GEMS) was initially tabled by Cabinet when a closed medical scheme framework policy was adopted. The vision of Cabinet was centred on the principles of equity, efficiency and differentiation. GEMS aims to provide affordable healthcare cover for public service employees in South Africa. The positive impact GEMS is having on the medical schemes industry is setting an example to employers in all sectors of our economy where there is still a need to redress past imbalances while ensuring equity across conditions of service. The Scheme has changed an entire industry by proving that ideology can translate to reality through focused practice, dedication and innovation. GEMS was registered on 1 January 2005 and actively started to enrol members from January 2006. The Scheme reports to the Registrar of the Council for Medical Schemes, and is a body corporate that undertakes liability related to its members’ healthcare benefits in exchange for receiving contributions. GEMS is a separate legal entity that does not form part of any Government department or public entity. It is a restricted scheme for Government employees; only those persons employed within the public service or by employers approved as participating employers by the Board of Trustees can become members. The GEMS benefit plans, namely Onyx, Ruby, Emerald, Beryl and Sapphire, are 10% to 25% less expensive, with similar or increased benefits, when compared to other medical schemes on the market. Sapphire was specifically engineered to be an inexpensive option and achieves this by providing out-of-hospital care at private facilities and in-hospital cover at public facilities. 67.4% of GEMS members are women, and with a beneficiary base of more than 1.85 million public employees, it has resulted in a significant increase in healthcare access for women in the public sector workplace. When one considers that without GEMS, an estimated 219,438 principal members and 594,309 dependants would not have medical scheme cover at all, the impact that GEMS has had on the public sector becomes obvious. To have at least equivalent cover in the absence of GEMS, public sector employees would need to spend R306,667,485 more to buy the same level of healthcare cover. This means that a significant majority of women on GEMS would otherwise not have the healthcare they and their families require. With single-mother families on the rise, it means that many of these women are not only the main breadwinners, but often the only earners in their families. GEMS has empowered their female members by making healthy choices for them and their families more accessible and affordable. GEMS is also the only medical scheme in South Africa to communicate with its membership base in all 11 official languages, thereby reaching individuals at each and every level of the public service in their language of choice.

 3. How did the initiative solve the problem and improve people’s lives?
The focus of GEMS is squarely on providing members with access to excellent healthcare that is both affordable and administratively efficient. Unrivalled innovation and the ability to design and implement benefits and services that consistently meet and exceed the needs of members sets GEMS apart from other medical schemes. In terms of understanding and meeting the needs of women members, approximately 70% of the GEMS total staff complement and 62.5% of the Executive Committee members are female. Representation of women in leadership roles unleashes their talents, bringing powerful and positive change to bear while increasing the likelihood of better outcomes for all concerned. Female members have free access to the innovative GEMS Maternity Programme, specifically designed to provide women with support, education and advice throughout their pregnancy, confinement and postnatal period, including a private hospital maternity benefit. The programme is headed by registered nursing professionals with specialised midwifery qualifications, and is managed to ensure that expectant mothers receive only the finest care. A work-based exercise and lifestyle programme for members aims to tackle poor lifestyle decisions to improve the health of all members, lower their risk of medical incidence and curb the obesity crisis in SA.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The GEMS Business Plan, which consisted of five benefit options, was submitted to the Registrar of Medical Schemes in 2004. The overall objective was to develop and implement a restricted medical scheme for public service employees and meet the specific objectives of equity, efficiency, accessibility, affordability, quality and good governance. The overall goals of the Scheme were: • the extension of medical scheme coverage to public service employees currently without cover • equitable access for all public service employees to a competitive benefits package • member flexibility to purchase additional benefits to meet medical needs and affordability constraints • sustainability of benefits across all options through benefit and contribution differentiation • an innovative approach to provider contracting to maximise delivery savings and ensure quality outcomes through the leverage of economies of scale • encouragement of the use of primary care services to control unnecessary utilisation of secondary and tertiary care • facilitation of Broad-Based Black Economic Empowerment through procurement policy • alignment with government’s Social Health Insurance Policy objectives. After registration, a task team comprising representatives from National Treasury, the Department of Public Service and Administration and GEMS was established. This team was responsible for the development and finalisation of member enrolment strategies that balanced the need for equity and increased access against the cost implications to Government as an employer. This plan was presented to Cabinet for approval, followed by negotiations with labour in the Public Sector Co-ordinating Bargaining Council. Marketing was staggered over a five-year period in an effort to cause the least amount of disruption in the industry. It also allowed the scheme the time to reach its full operational capacity and to be mindful of the financial implications for members who were currently without medical cover but would ultimately participate in the scheme. The target market was divided into three broad categories: uncovered employees, new employees and covered employees. One of the realities of a Government scheme was that various consultative processes needed to be followed before an enrolment strategy could be finalised. Moreover, the particular fashion in which the various groups was targeted during the enrolment strategy was directly dependent on the financial implications. Offering a ‘best estimate’ of the member enrolment scenario, it was anticipated that the Scheme would sign on a compulsory group of approximately 70 000 members when operations commenced in 2006. Membership enrolment thereafter would be on a voluntary basis. It was furthermore anticipated that during the various consultative processes between the Department of Public Service and Administration and labour forums, the possibility of introducing a subsidy structure would be explored. This had been identified as an important risk mitigation factor. Prior to official launch a comprehensive communication strategy included: • a clear message of what needed to be understood by the membership • an evaluation of the best methods and mediums to facilitate member understanding • methods to facilitate member feedback and criteria to evaluate the efficacy of the campaign • time frames for the respective deliverables of road shows, establishment of call centres, etc. The aim of the campaign was to remove the 'public service' stigma that could be associated with the Scheme. It was also to inform members of benefits available and to emphasise the advantages of participating in GEMS. The plan acknowledged that a more forceful marketing strategy would be required during the phases where membership would be voluntary.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The necessity for GEMS stemmed from the imperative of Government as employer to protect, improve and support the health and wellbeing of its workforce in a manner, and at a cost, that is affordable. In 2002 Cabinet approved a framework policy for a medical scheme restricted to civil servants. An interdepartmental working group was appointed to research and develop the concept further. It comprised representatives from the Department of Public Service and Administration, National Treasury, the Departments of Health and Education, as well as Correctional Services and the South African Police Service. The policy developed by this interdepartmental working group centred on the principles of equity, efficiency and differentiation. Employees should have equal access to the most extensive set of equal basic benefits under equitable remuneration structures, subject to affordability. Efficiency in respect of costs and delivery of benefits was essential and employees who opted for more extensive cover should enjoy equal access to this. The feasibility of creating a scheme, its operational design and its governance structure, was thoroughly tested by Government. This included public consultation and significant pieces of research. GEMS’ role as an agent for change and transformation, as a force and leading player in the development of our nation, is enshrined in the Constitution. Central to our transformation of the public service is the concept of a caring organisation that is the employer of choice which our leading minds aspire to be a part of.
 6. How was the strategy implemented and what resources were mobilized?
Prior to its implementation, the Scheme requested only R70 million in seed money from Government. GEMS is immensely proud of the fact that the Scheme did not have to ask for further cash injections from National Treasury. When Cabinet approved the implementation of GEMS and its operational structure in November 2004, much work had been undertaken to arrive at an ideal structure by which to govern and manage GEMS. GEMS’ operational structure consists of a Board of Trustees that directs the Scheme’s activities, a Principal Officer (CEO) who implements the directives of the Board and a Scheme executive which supports the Principal Officer in monitoring and managing the service levels and contractual obligations of outsourced services. The structure chosen lends strategic autonomy to the Scheme’s management so that it is not hindered by operational activities, while performance can be monitored constantly. The Scheme’s first operational service providers were appointed in October 2005. The Scheme selected ‘best of breed’ healthcare partners, procured through a thoroughly transparent tender process, through whom the Scheme delivers professional healthcare-related services to its members. Together, these healthcare service providers provide a unique and powerful service offering to all GEMS members.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
GEMS has changed an entire industry and is an example from which all of us can draw inspiration. The Scheme proved that ideology can translate to reality through focused practice, passion, dedication and innovation. The Scheme’s non-negotiable commitment to the King III good governance principles has become a powerful brand characteristic. GEMS has clearly demonstrated ongoing commitment to the mandate that had been set for the Scheme and shown a determination to strive to achieve greater heights. Notably, the Board and the executive of GEMS have always been responsive to change, with GEMS being the only scheme in the country to communicate with its membership base in all 11 languages. From an operational perspective, GEMS emerged as the largest closed scheme in the country, and the second largest medical scheme in South Africa overall. It reported a R1.2 billion surplus for the 2013 financial year and its administrative costs were well below the industry norm. Moreover, it was rated the country’s best in its category by the prestigious Orange Index for two years. By far the majority of the 1.85 million beneficiaries of GEMS have never before enjoyed medical scheme cover. More importantly, thanks to a 100% government subsidy, many employees, particularly those in need, are getting their medical cover for free. The socio-economic impact of GEMS is viewed as immeasurable by several industry commentators. Women have responded well to the Maternity Programme, and it seems to be a standout service for women that consistently receives positive feedback. It is believed that this is a result of the clear insight into the healthcare needs of women because the female influence at the Scheme enables GEMS to put women first. A healthier public service overall is a real result of GEMS. The continued support of healthcare screenings aimed at early detection for women of breast cancer, cervical cancer, cholesterol and diabetes has meant that what would otherwise go undetected and untreated because members could not otherwise afford medical aid, has been swiftly treated and managed, meaning that fewer days are missed and fewer days are spent in hospital. Healthcare issues are dealt with thoroughly and timeously. GEMS is an excellent example of how Government delivers on its promises to its own employees, as well as to the citizens of SA.

 8. What were the most successful outputs and why was the initiative effective?
GEMS’ operational structure consists of a Board of Trustees that directs the Scheme’s activities, a Principal Officer, who implements the directives of the Board, and a Scheme executive that supports the Principal Officer in monitoring and managing the service levels and contractual obligations of outsourced services. This structure supports efficiency and effectiveness, so that appropriate resources can be dedicated to the sole purpose of providing state employees with affordable, quality healthcare. Key result areas contained in the Scheme’s strategic plan, namely the management of operations, the financial oversight and control, communication activities, governance and stakeholder relations are all directed by the office of the Principal Officer. The success of GEMS is largely attributable to three primary focus areas, namely: • operational and contractual efficiencies; • good corporate governance; • exemplary stakeholder relations. The advantages of competitive GEMS-specific tariffs secured directly with healthcare providers, and our low non-healthcare expenditure, have kept our costs well below the industry range. Savings and cost containment benefits are always passed back to members and evidence of this is seen in the pricing structure of the Scheme. The benefit of our efficient contracting and the rigorous preferred provider arrangements are both of considerable importance in ensuring added value for our members and the long-term sustainability of the Scheme. Customised reimbursement models are well used by GEMS with benefits being applied across the board to members and their families. These business strategies complement the firmly established operational infrastructure and culture of excellence that is positioning GEMS in a league of its own. Corporate governance has been a hot button at GEMS since inception, but with an objective board-effectiveness assessment being performed by an independent facilitator, the Scheme took its corporate governance to new heights. Key to membership growth and satisfaction is the final focus area that pertains to exemplary stakeholder relationships. With a stakeholder base in excess of 110 government departments and a total staff complement of over one million employees, transparency, active engagement and regular interaction cannot be over-emphasised by an organisation such as GEMS.

 9. What were the main obstacles encountered and how were they overcome?
From the outset the fledgling Scheme faced strong criticism and resistance from the private healthcare industry, particularly from other medical schemes. There was the risk of industry disruption, as well as a reputational and a credibility risk to Government. Among other threats, GEMS could also be faced by delays, uncompetitive product offerings and poor implementation processes. These could also lead to labour-relations issues. The possibility existed that GEMS could also find its executive unable to manage a scheme of its magnitude. In addition, the structure of the Scheme’s operations demanded various linkages between organisations. While this unique structure provided optimal control of the Scheme, it was untried and untested in the market. Administration risks lay largely with the size of the Scheme and the required administration capacity. There were also potential risks relating to the separation of membership management, call centre functions, claims processing, managed care services and electronic claims switching. New processes would be required for interfacing with PERSAL (the payroll system for employees in most national and provincial departments) for contribution and member management purposes. Furthermore, there was potential for dominant parties, such as the employer or labour organisations, to attempt to exert undue and illegal pressure in terms of decision-making processes regarding the management of GEMS. The Scheme overcame the challenges referred to through proactive and interactive stakeholder relations with groups representing Labour, the Regulator, Government as well as Industry Bodies. Contentious issues requiring consensus were addressed by the stringent recruitment of executives with the appropriate skills, motivation and a strong affinity for the mandate of the scheme. The phased approach adopted with the enrolment of members allowed for the gradual build-up of capacity by service providers who were contracted to deliver services to scheme members. This was key in ensuring the successes enjoyed by the scheme.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The most notable benefit of GEMS is that approximately 147,931 of the 219,483 female principal members (67.4%) would not have any medical scheme cover at all without GEMS. In addition, around 82,449 female members would have had to settle for lower cover without the competitive options that GEMS offers to the public sector. This means that over 230,000 South African women working in the public sector are better protected, better taken care of and more empowered in terms of healthcare than they otherwise would have been. Not only are these women able to provide the best for themselves and their families in terms of healthcare, but their overall lifestyle and health are constantly being nudged in the right direction. Many women are now benefiting from reduced risk of obesity and the associated non-communicable diseases that are plaguing the South African nation. Considering the demographic transformation of public service since 1994, GEMS is the first medical scheme of its kind. It is a restricted membership medical scheme established to provide all public service employees with medical cover, regardless of race, income, gender or creed. Whereas the obligations of human resource managers in the pre-GEMS dispensation only extended to informing public service employees of their medical assistance subsidy entitlement, human resource managers now have a vested interest in the efficient functioning of the Scheme. Managing a myriad of healthcare challenges effectively and ensuring a healthy workforce that can participate productively in the economy forms the cornerstone of sustainable economic growth. In so doing the many successes and considerable growth of GEMS has had a powerful knock-on effect on the South African Public Service and the overall economy of our country. GEMS has set an example to other employers who care for their employees’ health; it is promoting employment in the sector and it is generating a significant revenue stream for public sector facilities and independent practitioners. Extract from newspaper article – Personal Finance: The Saturday Star – 10 September 2011 More members but fewer schemes “Medical scheme membership grew by just over three percent in 2010 but the consolidation of schemes continued last year, with another 10 schemes disappearing, the Council for Medical Schemes’ annual report for 2010/11 shows. The number of registered medical schemes decreased from 144 in 2000 to 100 last year, and is down to 99 schemes this year. Membership Trends “The number of beneficiaries (members and dependants) increased by 3.1 percent to 8.3 million by the end of last year, the annual report shows. Much of the membership growth is a result of people joining the Government Employees Medical Scheme (Gems). Since 2006, people who become public servants may only join Gems, and there is a full subsidy for employees who belong to the scheme’s lowest-cost option. The scheme has taken on more than 520 000 members in its first five years, and Gems reports that about half of these members were not scheme members previously. The number of principal members of all schemes increased by 3.6 percent to 3.6 million members last year, the annual report shows. The number of dependants increased by 2.7 percent to 4.7 million. Since 2000, the number of beneficiaries in open schemes has increased only by about 100 000, whereas restricted schemes have taken on 1.4 million beneficiaries – many of them into Gems. The average age of scheme beneficiaries has fallen slightly, from 31.6 years in 2009 to 31.5 years in 2010 – largely as a result of government employees joining Gems. The average age of open scheme beneficiaries is, however, up from 31.9 years to 32.9 years. The ratio of pensioner members to members under 65 was 6.5 percent last year – unchanged from that in 2009, the annual report shows. The pensioner ratio of open schemes has, since the launch of Gems, been increasing, reaching 7.5 percent last year, against 5.1 percent in restricted schemes, affecting schemes’ claims.”

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The Public Service is the largest employer in the country, with approximately 1.4 million employees spread over different geographical locations, departments and institutions, languages, skills levels, races, cultures and income levels. Each of our employees, the teachers, nurses, administrative personnel, ordinary workers and managers are all pivotal to the plans Government has in place to deliver on its promises and, as such, are highly valued. This is one of the reasons for us bringing a medical scheme to life that would look after the exclusive medical needs of our own employees, improving their health and wellness, accelerating productivity and strengthening the capacity of the public service to deliver on government’s mandate to the citizens of our country. Data released from Statistics SA in March this year reveals that lifestyle-related or non-communicable diseases are reaching close to epidemic proportions, with 70% of deaths in emerging markets being caused by chronic diseases such as hypertension, diabetes and HIV. This is obviously a matter of grave concern to Government. With a 500% increase in sick leave since 2001, SA is in danger of slipping down global competitive rankings with a considerable R19 billion being lost every year due to absenteeism in the workplace. The sick leave and incapacity leave experience of the public service leaves no doubt that there are, now more than ever, health risks that require our immediate attention, firm decision making and the introduction of effective and efficient controls. Ways have got to be found to empower individuals to take control of their health and wellbeing. GEMS is well positioned to provide employers with valuable information on the drivers of ill health, and the lack of productivity that often accompanies this. In so doing, effective and efficient interventions that can enhance productivity and the functional capacity of each individual Government employee can be implemented. The value being added by the Scheme is not limited to informing the development and implementation of interventions targeting the key drivers of ill health within the public service. The Scheme has, since its inception, rendered valuable support to departments in respect of measuring the effectiveness of interventions and has driven much needed changes where indicated. GEMS data furthermore provides an invaluable monitoring and evaluation tool for the public sector. The improved performance of the state, particularly the public service, will be at the core of how Government conducts business over the next five years. This once again highlights the importance of a healthy, productive public service and GEMS is pivotal in making this a reality. Managing a myriad of healthcare challenges effectively and ensuring a healthcare workforce that can participate productively in the economy forms the cornerstone of sustainable growth for the South African Public Service and for the economy of SA.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
A recent case study conducted by GEMS flagged membership eligibility, fraud and member communications as areas which needed further attention. With regards to eligibility, GEMS’ membership is defined by the Public Services Act. The issue arose that, as GEMS’ success became increasingly apparent, employees of state-owned enterprises (SOEs) and the Justice Department began applying to be members, although they were not eligible to be members within the Act’s definition. The grounds for the exemption application can be summarised as follows: • Governmental policy processes beyond the scope of the Medical Schemes Act are under way which may have a profound impact on the Scheme’s eligibility rules. Specific reference is made to the Public Administration Management Bill. • An uncontrolled membership expansion will have a profound impact on the Scheme’s operational capacity and procedures. • Increasing the scope of the Scheme’s eligibility rules in an uncontrolled manner and without engagement with the employer in respect of mitigating the financial impact on the Scheme will affect the Scheme’s financial stability. • The short-term impact on the healthcare sector in general. Fraud is another challenge faced by the Scheme, as GEMS handles 280 000 claim lines worth R80 million daily. The Board of Healthcare Funders estimates the cost of medical scheme fraud to be R22 billion annually. In 2008 the GEMS Board announced a zero tolerance approach to fraud and joined forces with the Special Investigating Unit in the police services. Its systems allowed for more refined statistical detection methodologies and an in-depth overview of billing behaviour of individual practices. This involved a multi-disciplinary skill set – statistical, clinical and actuarial. However, forensic investigations were often required to provide conclusive proof. Members are educated and encouraged to report fraud. Various fraud awareness campaigns were initiated throughout 2013, targeting GEMS members and healthcare providers. These, coupled with email alerts and the Scheme’s whistleblowing facility, resulted in the highest number of alleged fraud and abuse cases being identified and reported for investigation since inception. There has always been a dedicated focus on communication at GEMS. However, it was felt there was a need to go more public, particularly against the backdrop of modern social media. A stronger approach to general branding in the public arena has been proposed for the future, whereby the Scheme will share its story with the world at large. Government communication, along with marketing campaigns, road shows and wellness days, have driven membership growth. Radio and print have proved strong marketing tools in the past in promoting the value that GEMS offers to prospective members. These can be continued in the near future. There is, however, still a great deal of education required around what a medical scheme is. Generally Government employees have been very receptive, but some skeptics have expressed concern that their money would be ‘stolen’. Continuous education campaigns aimed at Government employees are vital to address this misconception about medical schemes in general.

Contact Information

Institution Name:   Government Employment Scheme
Institution Type:   Government Agency  
Contact Person:   Liziwe Nkonyana
Title:   Executive: Communication and Member Affairs  
Telephone/ Fax:   012 366 4500
Institution's / Project's Website:  
Address:   Private Bag x1,Hatfield
Postal Code:   0028
City:   Pretoria
State/Province:   Gauteng

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