Premiums Paid, Claims Unpaid: Africa’s Medical Aid Crisis
SADC’s insurers and state health schemes collect billions in premiums and contributions, yet patients and healthcare providers are increasingly being left waiting for claims to be paid. From Mbabane to Nairobi, the problem is raising questions about whether Africa’s health-financing systems can deliver when people need them most.
MBABANE/PRETORIA — Millions of Africans pay monthly premiums and contributions to medical aid schemes, private health insurers and government-backed healthcare programmes. The expectation is that those funds will cover medical treatment when it is needed.
Across Eswatini, South Africa, Zimbabwe, Kenya, Nigeria and Ghana, however, patients and healthcare providers are reporting rejected claims, delayed reimbursements and growing payment backlogs.
The disputes are putting pressure on patients, doctors, hospitals, pharmacies and laboratories and raising questions about the ability of health-financing systems to meet their obligations.
For patients, delayed or rejected claims can result in unexpected medical bills, postponed treatment or disputes with healthcare providers. For hospitals and other providers, unpaid claims can create cash-flow problems and affect their ability to pay staff, purchase medicines and maintain services.
Eswatini
The issue has reached Parliament in Eswatini.
Senator Lindiwe Ngwenya told the Senate that her office had received complaints from policyholders who alleged that a local insurance company had collected premiums from them for years but repeatedly gave reasons for not settling their claims.
Ngwenya did not name the insurer. She said she would engage the Financial Services Regulatory Authority (FSRA) privately and provide information that could assist an investigation.
“It is frustrating for the clients,” Ngwenya said, referring to what she described as changing explanations given to claimants seeking payment.
Tony Sibandze, chairman of the Ministry of Finance Portfolio Committee, warned that allegations against an unnamed insurer could affect the reputation of the wider insurance industry, including companies that were meeting their obligations.
Finance Minister Neal Rijkenberg called on anyone with information about wrongdoing to report it to the FSRA.
The African Chronicle has established that the medical aid provider referred to by Ngwenya was Oracle Medical Aid.
People familiar with the matter told the publication that some members were considering leaving the scheme because of concerns over claims and seeking alternative medical aid providers.
Oracle is not the only medical aid scheme facing scrutiny in Eswatini.
SwaziMed, the country’s oldest and largest medical aid fund, now trading as Eswatini Med, has also faced complaints over unpaid providers.
The Eswatini Sunday reported that SwaziMed marketing manager Sicelo Mkhonta had said invoices were being settled within 30 days. The statement came amid concerns from parliamentarians and healthcare providers over outstanding payments.
Mbabane East MP Welcome Dlamini later questioned Finance Minister Rijkenberg in Parliament about whether SwaziMed remained fit to operate given its reported difficulties in meeting its obligations.
Separate reporting on the scheme’s finances described its reserves falling from more than E350 million to below E100 million around the period when it financed construction of Ezulwini Private Hospital.
A patient on a hospital bed. Picture: Pexels
Doctors, private clinics, laboratories and dentists treating SwaziMed members have also raised concerns.
Local reporting quoted a scheme insider as saying payments and practice numbers had been withheld from several hospitals, laboratories, dentists and doctors as management sought to reduce costs.
Three local laboratories were reportedly unable to operate after their practice numbers were withdrawn. Healthcare providers also threatened to stop treating SwaziMed patients.
One insider described the situation as “compromising patient care and lives”.
SwaziMed chief executive Peter Simelane said the situation was under control and that providers were being paid according to schedule. Clinics and doctors disputed this, reporting payment delays lasting months.
The dispute later reached the Industrial Court of Eswatini in a matter involving Simelane in 2025.
South Africa
South Africa’s medical schemes industry handles hundreds of billions of rand in member contributions and benefit payments.
The country’s 71 registered medical schemes collected R232 billion in member contributions during the 2023/2024 financial year and paid R218 billion in benefits, according to the Council for Medical Schemes’ most recent annual report.
The difference between contributions and benefits does not establish that the balance represents unpaid or rejected claims.
The regulator, however, recorded more than 2,000 member complaints during the period. More than half were upheld in favour of members, requiring schemes to pay claims they had initially declined.
More than 500 complaints involved Prescribed Minimum Benefits, which medical schemes are legally required to cover.
The Council also reported that some schemes continued applying monetary limits to certain PMB-related claims despite previous adverse rulings.
The financial pressures facing the industry became more visible in late 2025 when Sizwe Hosmed was placed under curatorship because of solvency concerns.
Zimbabwe
In Zimbabwe, concerns over medical aid payments have developed into a broader dispute over the structure of the industry.
Doctors, specialists, pharmacists and independent hospital operators told Parliament in May that vertically integrated medical aid societies, which own hospitals, clinics and pharmacies while collecting members’ contributions, were creating excessive concentration in the healthcare market.
Some providers described the system as resembling a “Ponzi scheme” and alleged that civil servants covered by the schemes were being turned away while some healthcare facilities faced drug shortages.
Healthcare providers have called for proposed Section 14A to prohibit the practice, arguing that scheme-owned facilities disadvantage independent providers.
Doctors attending to a patient. Picture: Pexels
Medical aid societies oppose the proposal.
Doug Bramson, chief executive of MASCA Medical Aid Society, told Parliament that removing clinics and hospitals from medical aid societies could affect pensioners who rely on scheme-owned facilities to avoid large co-payments.
More than 90% of Zimbabwe’s population remains uninsured and relies largely on out-of-pocket payments.
The government has placed medical aid societies under the supervision of the Insurance and Pensions Commission.
Namibia
Namibia has established separate mechanisms for dealing with clinical and financial risks in the medical aid sector.
The Namibian Association of Medical Aid Funds (NAMAF) oversees clinical matters, while the Namibia Financial Institutions Supervisory Authority (NAMFISA) is responsible for financial risks.
Members with unresolved claims disputes can refer complaints to NAMAF for mediation.
The Financial Institutions and Markets Act has also strengthened NAMFISA’s regulatory powers.
NAMFISA chief executive Kenneth Matomola said the regulator would be better placed to intervene where pricing or reimbursement practices cause harm to consumers.
The system provides members with a formal avenue to challenge disputed claims before they develop into prolonged disputes.
Kenya
Kenya’s Social Health Authority (SHA) was established in October 2024 to replace the National Hospital Insurance Fund.
The new system was intended to provide a more reliable mechanism for financing healthcare.
Instead, hospitals have reported billions of shillings in unpaid claims.
The Rural and Urban Private Hospitals Association of Kenya says SHA owes healthcare facilities approximately Sh35 billion. Some hospitals have reportedly waited five months or longer for reimbursement despite meeting the required conditions.
A Controller of Budget report found that SHA owed county health facilities at least Sh26.87 billion by March this year. That was more than three times the amount recorded three months earlier.
“It is frustrating for the clients”
Senator Lindiwe Ngwenya
The financial exposure is particularly significant for some faith-based hospitals.
Facilities represented by the Christian Health Association of Kenya say some depend on SHA for as much as 90% of their revenue.
Delayed reimbursements can affect hospitals’ ability to pay employees and purchase medicines.
Government officials have disputed how the arrears should be interpreted.
Deputy Speaker Gladys Boss Shollei recently argued that the debt showed that the scheme was functioning because healthcare providers could not be owed money for patients who had not received treatment.
Hospitals awaiting reimbursement remain exposed to the financial consequences of delayed payments.
Nigeria
In Nigeria, disputes have focused partly on treatment authorisation and unpaid claims involving private Health Maintenance Organisations (HMOs).
Nigerian media investigations have documented cases in which patients became caught between hospitals demanding upfront payment and HMOs taking time to authorise treatment.
Some hospitals have reported millions of naira in outstanding claims. In some cases, providers have reportedly placed HMO-insured patients in separate queues while waiting for authorisation or payment.
The National Health Insurance Authority recorded 3,507 formal complaints in 2024.
Most were resolved, with refunds and sanctions ordered in cases where operators were found to have acted improperly.
The complaints data shows that members can obtain redress through the regulatory system, but also points to the number of disputes between consumers, providers and health-financing organisations.
Health policy analyst Chika Nzeribe told Nigerian media that regulation alone would not address the industry’s trust deficit.
One proposed solution is greater transparency, including a public dashboard showing how individual HMOs perform on claims. Such information would allow consumers to compare providers based on claims performance rather than reputation or marketing.
Ghana
Ghana’s National Health Insurance Scheme has also faced recurring reimbursement backlogs.
In April last year, private health facilities suspended services to NHIS cardholders after the National Health Insurance Authority fell months behind on payments.
The Private Health Facilities Association of Ghana said its members were still waiting for reimbursements despite repeated assurances that outstanding claims would be settled.
A drip running empty in a hospital. Picture: Pexels
The NHIA later released substantial payments, including more than GH¢157 million for claims dating back to 2019 and another GH¢219.8 million in July this year.
The payment problems have continued.
Nurses’ unions warned in May that new arrears were accumulating even as the authority reported improvements in reimbursement timelines.
The pattern has been repeated: arrears accumulate, payments are released, outstanding claims fall and new backlogs develop.
A growing problem for patients and providers
The cases across Eswatini, South Africa, Zimbabwe, Namibia, Kenya, Nigeria and Ghana involve different healthcare financing models.
Some involve private insurers and medical aid schemes. Others involve government-funded healthcare systems.
Some disputes concern rejected claims, while others involve providers waiting months for reimbursement.
The common issue is the delay between healthcare being provided and the money being paid.
Premiums and contributions are generally collected regularly, while claims and reimbursements can be delayed, disputed or rejected.
In Kenya and Ghana, government-backed systems have accumulated arrears owed to healthcare providers.
In South Africa, Eswatini and Zimbabwe, private medical schemes and insurers have faced complaints over rejected or delayed claims.
The result is financial pressure on both sides of the healthcare system.
Patients can face additional costs when claims are rejected or delayed. Providers can face cash-flow problems when reimbursements do not arrive on time.
Regulators under pressure
Regulators across the continent have mechanisms for complaints, investigations, mediation and intervention.
These include the Council for Medical Schemes in South Africa, FSRA in Eswatini, the Insurance and Pensions Commission in Zimbabwe, NAMAF and NAMFISA in Namibia and the National Health Insurance Authority in Nigeria.
However, the repeated emergence of claims disputes and reimbursement backlogs raises questions about whether existing regulatory systems are intervening early enough to prevent problems from becoming larger financial and healthcare crises.
Key questions facing regulators and policymakers include how quickly legitimate claims should be settled, what constitutes a reasonable basis for rejecting a claim and how much information insurers and medical schemes should disclose about claims rejection rates.
There are also questions about the reserves schemes should maintain to protect members and healthcare providers against liquidity pressures.
Another issue is whether consumers should be able to compare insurers and medical schemes based on their claims-payment records before choosing where to place their money.
Doctors operating on a patient in a hospital. Picture: Pexels
For patients, the consequences are immediate.
A delayed reimbursement can affect whether a hospital can purchase medicines, whether a doctor is paid, whether an elderly patient receives treatment or whether a family can afford additional medical costs.
Medical aid and health insurance are designed to provide financial protection when people need healthcare.
When contributions are collected on time but claims remain unpaid, delayed or disputed, that protection becomes less certain.
Across Africa, the cases documented in this investigation point to a fundamental question for the continent’s health-financing systems:
If patients pay for healthcare cover every month, why do so many still have to fight to receive the benefits they have already paid for?
The answer will have direct consequences for patients, healthcare providers, insurers, medical schemes and governments responsible for financing healthcare.
Bheki Dlamini
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