the botswana medical aid funds 2019report annual · the board of healthcare funders (bhf) is...

The Botswana Medical Aid Funds

ANNUAL REPORT2019

THE BOTSWANA MEDICAL AID FUNDS ANNUAL REPORT 2019B

The Board of Healthcare Funders (BHF) is pleased to present this report on medical aid funds in Botswana. This is the first report prepared by the BHF for medical aid schemes from the SADC region. It is a useful tool for measuring the performance of these funds and highlights their contribution to the health of the population.

2019ANNUAL REPORTBOTSWANA MEDICAL AID FUNDS

Prepared by the Board of Healthcare Funders

ANNUAL REPORT 2019 THE BOTSWANA MEDICAL AID FUNDS 1

PREPARED BY THE BOARD OF HEALTHCARE FUNDERS NPC

CONTENTS

EXECUTIVE REPORTS1Executive summary02

Message from the Managing Director of the BHF04

Message from Chairman of the Botswana Association of Medical Aid Funds06

Message from the BHF Botswana Country Representative08

MEDICAL AID FUNDS REPORTS2Medical aid funds’ membership10

Medical aid funds’ disease burden13

Medical aid funds’ quality of care16

Medical aid funds’ healthcare expenditure19

Out-of-pocket expenditure24

Medical aid funds’ financial performance26

ANNEXURES AND REFERENCES3Annexure A: Medical aid fund beneficiaries28

Annexure B: Consolidated financial statements 29

List of tables30

List of figures31

List of acronyms and abbreviations31

THE BOTSWANA MEDICAL AID FUNDS ANNUAL REPORT 20192


EXECUTIVE SUMMARY

In 2019, there were five medical aid funds in Botswana registered with the NBFIRA, the same as in 2018.

Of the five medical aid funds registered with the Non-Banking Financial Institutions Regulatory Au-thority (NBFIRA) in Botswana, four are members of the Board of Healthcare Funders (BHF) and submit-ted data for the preparation of this report. These four funds represent approximately 95% of the lives cov-ered by medical aid funds in Botswana.

There were 327 500 beneficiaries covered by these four funds in 2019, up from 309 500 in 2018 – rep-resenting an increase of 5.8%. The average family size in 2019 was 2.32. The average age of beneficiaries in-

creased slightly from 29.43 in 2018 to 29.52 in 2019, while the pensioner ratio increased marginally from 2.68% in 2018 to 2.89% in 2019.

Across the four funds, there were 30 benefit options in 2018 and 29 benefit options in 2019. The average number of options was therefore 7.25 in 2019. The av-erage option size (by number of beneficiaries) increased by 9.5% from 10 317 in 2018 to 11 293 in 2019.

The funds received gross contributions of P1.92 billion in 2019, up from P1.76 billion in 2018, an increase of

9.4%

GROSS EXPENDITURE

9.2%

GROSS CONTRIBUTIONS

5.8%

BENEFICIARIES(of the four funds)

327 500 (2019)309 500 (2018)

P1.92bn (2019)P1.76bn (2018)

P1.64bn (2019)P1.50bn (2018)



9.2% year on year. Gross healthcare expenditure in-creased by 9.4%, from P1.50 billion in 2018 to P1.64 billion in 2019. The reserves of these funds, calculat-ed as a proportion of gross annual contributions, grew from 50.6% in 2018 to 51.6%% in 2019.

The average contribution per beneficiary per month (pbpm) was P490 in 2019 while in 2018 it was P475, increasing by 3.2% from 2018 to 2019. Annual in-flation as measured by the consumer price index in-creased by 2.85%; contribution increases were there-fore 0.35% higher compared to inflation. Affordability of medical aid fund cover is important as it improves long-term sustainability.

Healthcare expenditure by medical aid funds in 2019 was P418 pbpm, representing 85% of the gross contri-butions received in 2019. Non-healthcare expenditure accounted for 11.0% of gross contributions in 2019.

AVERAGE OPTION SIZE2019: 11 293 2018: 10 317

AVERAGE MONTHLY CONTRIBUTION

2019: P4902018: P475

In 2018, non-healthcare expenditure represented 13.2% of gross contributions. Non-healthcare expend-iture declined in monetary terms from P63 pbpm to P54 pbpm from 2018 to 2019. This makes available more financial resources for healthcare expenditure and contributes towards affordability.

In 2019, claims submitted to medical aid funds amounted to P2.02 billion while P1.61 billion was paid in respect of these claims. Out-of-Pocket (OOP) ex-penditure by beneficiaries was at least P403 million. This OOP expenditure represented approximately 20% of total healthcare expenditure in 2019, higher than the WHO’s recommended limit of 15%.

CHARLTON MUROVEBHF Research: Head


MESSAGE FROMDR KATLEGO MOTHUDI

BHF MANAGING DIRECTOR

BHF provides the following services for its members in the region Access to discounted rates for the Wits Business School /

BHF Trustee Development Programme

Access to discounted rates to the BHF Annual Conference

Legal Services on issues of common interest

Country Annual Reports

Fraud waste and abuse frame work

Fraudwasteandabusecollaborativeportal

AccesstothePracticeCodeNumberingSystematdiscountedrates

Industry benchmarking research

REGIONAL MEMBER SERVICES



The Board of Healthcare Funders is pleased to present this report on medical aid funds in Botswana. This is also the first report

prepared by the BHF for medical aid schemes from the Southern African Development Community (SADC) region. It is a useful tool for measuring the performance of these funds and highlights their contribution to the health of the population.

The SADC countries have the attainment of Univer-sal Healthcare Coverage (UHC) as an objective. The BHF’s effective coverage tool for its membership in the region measures progress towards the attain-ment thereof. The BHF therefore recommends that member schemes adopt effective coverage.

The BHF’s strategic focus includes providing value to its members and this entails assisting members to pro-vide maximum value to their beneficiaries. To achieve this, the BHF advocates and advises its membership to implement progressive health policies.

Regional integration is important and harmonising local industry policies is vital to achieving the desired out-comes. These include improved health outcomes and reducing the impact of Fraud Waste and Abuse (FWA) in the region.

This report measures the growth of medical aid funds in respect of membership and financial per-formance. These metrics are a proxy indicator of the performance and sustainability of medical aid funds in Botswana. They provide a strong basis from which the funds may expand their membership and provide better value for beneficiaries. During this reporting period, the funds’ membership grew and their finan-cial performance was strong.

We have included measures of the medical fund in-dustry’s risk profiles. This is useful for future planning and the establishment of industry-wide responses to challenges. The average age of beneficiaries was relatively low – about 29 years; in South Africa the average age is approximately 32 years. Similarly, the pensioner ratio is also low, at about 3%. The dis-ease burden faced by the funds is high and on the

increase; the prevalence of HIV and cardiovascular conditions is very high. These funds need to put in place health interventions to manage these condi-tions to limit their effects on sustainability.

Included in this report are measures of quality of care, an important component of UHC and in most cases an aspirational goal. Achievement thereof requires contin-uous improvement. The components of quality of care included in the report are measures of the proportion of chronic beneficiaries receiving minimum standards of care. It is important that as an industry we continue measuring these, together with service providers. This not only leads to better health outcomes but also im-proves the long-term sustainability of funds. Healthy beneficiaries tend to claim less and contribute to med-ical aid funds for longer.

Another key measure included in this report is OOP expenditure by medical aid beneficiaries. Healthcare costs can be catastrophic and lead to financial ruin of households. Limiting OOP payments is crucial to the attainment of UHC. In this report, OOP expend-iture was estimated as the difference between the total claims submitted and the total paid by medical aid funds.

DR KATLEGO MOTHUDIBHF Managing Director

REPORT HIGHLIGHTS Metrics to measure the growth of

medical aid funds in Botswana

Assessment of the performance and sustainability of medical aid funds

Measures of the risk profiles of the medical fund industry

Measures of quality of care, an impor-tant component of UHC

Measure to track out-of-pocket ex-penditure by medical aid beneficiaries

MESSAGE FROMLESEGO PULE

CHAIRMAN OF THE BOTSWANA ASSOCIATION OF MEDICAL AID FUNDS

• Ensuring sustainability of the healthcare sector • Advocating policy positions • Creating economies of scale to enable members

to deliver value to their membership in return• Providing stewardship and thought leadership• Facilitating private sector participation in

achieving universal health coverage• Driving fraud waste and abuse framework

implementation

WE STRIVE

TO SERVE &

PROMOTE

THE COMMON

INTERESTS OF

OUR MEMBERS

KEY STRATEGIC GOALS



Botswana Medical Aid (Bomaid)

Botswana Public Officers’ Medical Aid Scheme (BPOMAS)

Doctors (Pty) Ltd t/a Doctors Aid Medical Aid Scheme

Pula Medical Aid Fund

Botsogo Health Plan

Registered Medical Aid Funds

Government

Regulator (NBFIRA)

Healthcare professionals

Medical aid fund members

Employer groups

Our Stakeholders

Botswana Medical Aid (Bomaid)

Botswana Public Officers’ Medical Aid Scheme (BPOMAS)

Pula Medical Aid Fund

Botsogo Health Plan

Our Members

As an industry we are very excited about the report and would like to take this opportunity to thank the Board of Healthcare Funders for championing this project in Botswana. This report will serve to assist us in achieving our strategic goals.

Medical aid funds (MAFs) in Botswana are licensed by the NBFIRA, which regulates and supervises MAFs. Five funds are registered with the NBFIRA. At present, there are no subordinate regulations for the licensing and monitoring of MAFs.

In 2018, the Health Funders Association Botswana (HFAB) was successfully revived. As an association our aim is to drive the improvement of the quality of healthcare in Botswana, and create access to affordable health services to the population.

LESEGO PULEChairman of the Botswana Association of Medical Aid Funds



In terms of health and development, Botswana has made progress in improving geographical access to health services, including almost universal access to

antiretroviral delivery and prevention of mother-to-child transmission.

The country has adopted the Universal Healthcare Coverage concept and, as an industry, our aim is to play a meaningful role towards achieving this global agenda.

During this period, we saw the implementation of the amended Botswana Financial Intelligence Act of 2018. With the introduction of this act, all institutions are expected to exercise due diligence with all their stake-holders to minimise the use of medical aid fund sys-tems for money laundering activities.

Industry growth remained fairly stagnant due to a number of factors, such as the slowdown in econom-ic growth and the closure of some of the country’s major mines. New mining ventures are expected to be revived on the horizon.

INDUSTRY HIGHLIGHTS

Increase in healthcare costs

Lack of growth

Fraud, waste and abuse

Student visa requirements in South Africa

Regulatory gaps

MORAKI MOKGOSANA BHF Botswana country representative

We are honoured as Botswana to be part of the BHF board. This has provided opportunities to promote regional collaboration, as well as access to a wealth of industry experts through learning from other well-es-tablished institutions.

MORAKI MOKGOSANABHF Botswana country representative

COUNTRY REPORT BACK



VALUE CHAIN

ALIGNMENT

UNIVERSAL HEALTH

COVERAGE

THOUGHT LEADERSHIP

& BRAND

FINANCIAL STABILITY

MEDIUM TERM GOAL

MEDIUM TERM GOAL

Fully aligned ecosystem where

member needs are driven by all

stakeholders

Be the trusted driver of health

system reform that incorporates all

stakeholders

STRATEGIC DRIVERS OF THE THE BHF

Collaborative innovation

Stakeholder participation

BHF internal processes and structures

Vulnerable members’ support

Inter-operable industry

Shaping NHI

Medical Scheme reform

Member expectations

Relevant research

BHF Conference relevance

Product improvement

BHF Academy

Industry information hub

BHF brand building

Revenue generating principles

Membership, fees and structure

Training offerings

Consulting and research offering

Conferencing offering

Joint industry issue resolution

Associate membership

MEDIUM TERM GOAL

MEDIUM TERM GOAL

Proactively drive content and

position BHF as the industry thought

leader

Generate more revenue whilst fundamentally

serving our members



MEDICAL AID FUNDS’ MEMBERSHIPOn 31 December 2019, 327 500 beneficiaries belonged to the four funds included in this report. The number increased from 309 500 in 2018 to 327 500 in 2019, equiv-alent to an annual growth rate of 5.8%. This increase in membership is largely attributable to growth in the number of child dependents by 8.8% from 2018 to 2019. Fig-ure 1 highlights the overall bene-ficiaries in 2018 and 2019.

There were more female than male beneficiaries in both 2018 and 2019. This applies to both principal members and their de-pendents. The number of adult

dependents is very low, repre-senting only 28% of all adult ben-eficiaries in 2019.

RISK POOLING

There were 30 and 29 benefit op-tions in 2018 and 2019, respec-tively, across the four funds. The smallest benefit option had ap-proximately under five beneficiaries while the largest had approximately 157 000 beneficiaries.

Benefit option size is important as larger options provide better risk pooling. Figure 2 shows the size of benefit options in 2018 and 2019.

Two very large options account for more than half of beneficiaries. The remaining options are much smaller and share the remaining beneficiaries. The risk pooling is rather fragmented.

Table 1 shows the summary of benefit options in the same peri-od. The average number of bene-fit options across all four funds in 2018 and 2019 was 7.5 and 7.25 per fund, respectively.

FAMILY SIZE

Of the 327 500 beneficiaries in 2019, 141 305 were principal

66 825 68 572 135 397

69 197 72 108 141 305 20 140 31 328

51 468

20 757 32 030

52 787

61 916 60 725

122 641

67 223 66 168

133 391

M F TOTAL M F TOTAL

2 0 1 8 2 0 1 9

Principal Adult Child

Figure 1: Medical aid fund beneficiaries



members, 52 787 were adult de-pendents and 133 391 were child dependents. Table 2 provides ad-ditional detail on the beneficiary profile from 2018 to 2019.

The dependent ratio measures the average number of depend-

ents per principal member. It in-creased from approximately 1.29 dependents per principal member in 2018 to 1.32 dependents per principal member in 2019. This indicates a slight increase in the number of dependents per princi-pal member.

RISK PROFILE OF BENEFICIARIES

The risk profile of beneficiaries is important to monitor. Older beneficiaries tend to claim more than younger ones. For medical aid funds to be sustainable, there

Figure 2: Benefit option sizes

Year Number of funds

Minimum number of options per fund

Maximum number of options per fund

Average number of options

2018 4 3 12 7.52019 4 3 12 7.25

Table 1: Summary of benefit options in 2018 and 2019

Dependent Type 2018 2019 % increasePrincipal 135 397 141 305 4.4%

Adult 51 468 52 787 2.6%Child 122 641 133 391 8.8%Total 309 506 327 483 5.8%

Table 2: Number of beneficiaries by dependent type



must be enough cross-subsidisa-tion between younger and older beneficiaries.

The average age of beneficiaries in 2019 was 29.52 years, while the pensioner ratio (proportion of beneficiaries aged 65 or more) was 2.89%. The average age in-creased slightly in 2019; it was 29.43 in 2018. The pensioner ra-tio also increased marginally from 2.68% in 2018. Table 3 shows

the average age of beneficiaries by gender and pensioner ratio. Figure 3 shows how the age pro-file of beneficiaries changed from 2018 to 2019.

Membership was low in the age band 20-29 in both 2018 and 2019. Beneficiaries in this age range tend to claim less, thus con-tributing positively to the risk pool.

There were more beneficiaries

aged 5-9 years in both 2018 and 2019, compared to other ages. The age range 35-49 also ac-counted for a significant propor-tion of beneficiaries.

Figure 3 further shows that there is consistent growth in beneficiar-ies aged 35 and above. This is a concern as beneficiaries in age bands over 50 years tend to have a higher average healthcare cost, relative to their contributions.

Risk profiles 2018 2019 % change

FemaleAverage age 29.70 29.79 0.30%

Pensioner ratio 2.54% 2.74% 7.67%

MaleAverage age 29.13 29.23 0.35%


TotalAverage age 29.43 29.52 0.33%


Table 3: Average age and pensioner ratios

-

5 000

10 000

15 000

20 000

25 000

30 000

35 000

40 000

NU

MBE

R O

F BE

NEF

ICIA

RIES

2018 2019

Figure 3: Number of beneficiaries by age band



MEDICAL AID FUNDS’ DISEASE BURDEN

The health of a medical aid fund’s membership is important as it im-pacts their healthcare needs and ultimately the fund’s claims expe-rience. The prevalence of chronic diseases is increasing in sub-Sa-haran countries. It is therefore important to monitor this. Funds that actively manage these spec-ified chronic conditions tend to register beneficiaries on their dis-ease management programmes.

This section therefore focuses on the proportion of beneficiaries reg-istered on these programmes. It also reports on the number of new beneficiaries registered during the

reporting period. These new reg-istrations are an indicator of either the incidence of the chronic condi-tions, better screening by medical aid funds or both. It does, however, show the increasing disease bur-den for funds over time.

For the purposes of this report, the chronic conditions reported on are:• Human Immunodeficiency Virus

(HIV).• Diabetes mellitus (DM), including

both type 1 and type 2. • Respiratory (RES) conditions, in-

cluding asthma and chronic ob-structive pulmonary disease; and

• Cardiovascular (CVS) diseases, which include hypertension, coronary artery disease, cardio-myopathy, cardiac failure and ischaemic heart disease.

CHRONIC DISEASE PREVALENCE

HIV remains the most prevalent chronic condition among medical fund beneficiaries. In 2019, the prevalence of HIV was 39.6 per 1 000 beneficiaries, compared to 39.9 per 1 000 beneficiaries in 2018. CVS-related diseases were the second most prevalent, with a prevalence of 27.9 per 1 000

5,93 6,34

27,0645,60

6,62 6,60

30,0145,17

4,33 7,54

24,21

33,65

4,49 7,90

25,54

33,57

RE S D M CV S HI V RE S D M CV S HI V

P RE V AL E N CE 2 0 1 8 P RE V AL E N CE 2 0 1 9

PREV

ALEN

CE P

ER 1

000

BEN

EFIC

IARI

ES

F M

Figure 4: Chronic disease prevalence



beneficiaries in 2019. This is high-er than the prevalence of 25.7 per 1 000 beneficiaries in 2018. Fig-ure 4 highlights the prevalence of chronic conditions during the re-porting period by gender.

The prevalence of respiratory dis-ease and DM are very low; both have a prevalence of less than 10 per 1 000 beneficiaries in 2018 and 2019. The prevalence is higher among female beneficiaries com-pared to males for all chronic con-ditions reported on except DM.

CHRONIC DISEASE INCIDENCE

Figure 5 shows the number of new chronic beneficiaries regis-tered in both 2018 and 2019. The

number declined between 2018 and 2019. It is important to un-derstand the reason for this.

CVS diseases had the highest number of new registrations com-pared to other chronic diseases. An additional 3.84 per 1 000 ben-eficiaries were registered in 2019. The number of new HIV registra-tions was also significantly high – 2.94 per 1 000 beneficiaries in 2019. DM recorded the lowest number of new registrations: 0.90 per 1 000 beneficiaries in 2019.

CHRONIC DISEASE BURDEN BY AGE

Figures 6 and 7 illustrate the age profile of chronic benefi-ciaries between 2018 and 2019,

respectively. The age profiles of beneficiaries are similar in both years. Most beneficiaries were in the age range 30-79 years, with the highest disease burden in the group aged 40-59.

HIV chronic beneficiaries are on average younger than CVS ben-eficiaries, which is to be expect-ed. Beneficiaries with respirato-ry conditions have two peaks: in children and much older individu-als. There are some children under five years of age with HIV, raising concerns about the success of mother-to-child transmission pre-ventative interventions.

Another concerning observation is the number of teenagers and young adults with HIV.

0,97

0,920,96

0,90

4,07

3,84

3,11

2,94

2 0 1 8 2 0 1 9

CHRO

NIC

PER

1 0

00 B

ENEF

ICIA

RIES

RES DM CVS HIV

Figure 5: New chronic beneficiaries registered



-

500

1 000

1 500

2 000

2 500

3 000

3 500

4 000

4 500

5 000

Num

berofchron

icben

eficiaries

Ageband

RES DM CVS HIV

Figure 6: Chronic disease prevalence by age band in 2018

-

1 000

2 000

3 000

4 000

5 000

6 000

Num

berofchron

icben

eficiaries

Ageband

RES DM CVS HIV

Figure 7: Chronic disease prevalence by age band in 2019



MEDICAL AID FUNDS’ QUALITY OF CARE

Ensuring quality care is important and entails providing timeous, ef-fective and affordable care to a patient when needed and within a safe environment. It directly im-pacts on the patient and their ex-periences. Ensuring quality of care essentially requires the patient to take responsibility and ownership for conditions that may need pre-ventative interventions.

Healthcare funders also have a significant role to play in influ-encing the quality of care their beneficiaries receive. This sec-tion focuses on quality of care for chronic beneficiaries. The process measure to assess quality of care is the coverage ratio, i.e. the pro-portion of chronic beneficiaries receiving appropriate care, as-sessment or intervention.

In the case of chronic beneficiar-ies, there are some minimum in-terventions that must be applied during episodes of care. These interventions should be available to both stable and unstable pa-tients, thus making them impor-tant markers of quality of care.

For instance, HIV beneficiaries must be monitored for viral load at least once a year. The coverage ratios of such interventions are monitored by the four chronic con-ditions discussed in this report.

DIABETES MELLITUS

DM is a condition in which either the pancreas does not produce enough insulin (a hormone that regulates blood sugar or glucose), or when the body cannot effec-

tively use the insulin it produc-es. In 2018, the number of DM patients was 2 141, compared to 2 365 in 2019. This equates to a 10.5% increase across the funds included in this report.

The coverage ratios of diabetes are shown in Table 4 below.

Process and outcome indicators

The minimum interventions in the care of diabetic patients are listed below:a) Creatinine/eGFR test: It is an

important marker of kidney function.

b) Haemoglobin A1c (HbA1c) Test: This test measures the amount of glucose in the blood over the past three months and

DIABETES 2018 2019 % changeNumber of chronic beneficiaries 2 141 2 365 10.5%Process indicator: Proportion of unique beneficiaries Receiving at least one creatinine/eGFR test 35.8% 36.5% 2.0% Receiving at least one HbA1c test 31.7% 30.4% -3.9% Receiving at least one cholesterol test 29.3% 30.1% 2.7%Outcome indicator: Proportion of unique beneficiaries Admitted in hospital at least once 17.7% 15.6% -11.9%

Table 4: Diabetes coverage ratios



is valuable because it is an indicator of disease control.

c) Cholesterol test: This test detects the cholesterol and triglyceride levels in a patient’s blood.

The coverage ratios for monitor-ing tests such as the creatinine test were 36.5%, while those for the HbA1c and Cholesterol tests were 30.4% and 30.1%, respec-tively, in 2019. The coverage ra-tios for DM are suboptimal.

RESPIRATORY CONDITIONS

Respiratory conditions are defined as any chronic lung disease that results from obstructions in the airways of the lungs, and which leads to breathing problems.

For the purposes of this report, respiratory conditions refer to asthma and chronic obstructive pulmonary disease. The num-ber of patients was 1 597 and 1 834 in 2018 and 2019, respec-tively. This translates to a 14.8% increase. The coverage ratios are shown in Table 5.


The minimum interventions in the care of beneficiaries registered for respiratory diseases are listed below:a) Lung function test: This test

measures respiratory function.b) Influenza vaccine: Respiratory

patients are susceptible to complications if they contract the influenza virus. Vaccination is a preventative measure for such complications.

The coverage ratio for the lung function test was 0.1% in both 2018 and 2019. Furthermore, very few beneficiaries with res-piratory conditions received the flu vaccine in both 2018 and 2019.

CARDIOVASCULAR DISEASES

CVS diseases are those affecting the heart or blood circulatory system. Those included in this report are hypertension, cardiac failure, cardi-omyopathy, ischaemic heart disease

and coronary artery disease.

In 2018, the number of CVS chron-ic beneficiaries was 7 952, while in 2019 there were 9 126. This trans-lates to a 14.8% increase. The cov-erage ratios for CVS conditions are shown in Table 6.


The minimum interventions in the care of CVS patients are listed be-low:a) Electrocardiogram (ECG): The

ECG is used to measure the electrical activity of the heart, which is important as it highlights irregularities and changes in function.

b) Creatinine/eGFR test: This test measures the level of creatinine in the blood. It is an important marker of kidney function.

c) Cholesterol test: This test is very important because it detects high cholesterol and triglyceride levels in a patient’s blood.

The coverage ratio for the creati-nine test was 32%, while those

Table 5: Respiratory diseases coverage ratios

RESPIRATORY DISEASES 2018 2019 % changeNumber of chronic beneficiaries 1 597 1 834 14.8%Process indicator: Proportion of unique beneficiaries Receiving a flu vaccine at least once 0.1% 0.1% 0.0% Receiving a lung function test at least once 0.6% 0.2% -61.3%Outcome indicator: Proportion of unique beneficiaries Admitted to hospital at least once 13.7% 13.1% -4.6%



for the ECG and Cholesterol tests were 10.5% and 25.8%, respec-tively, in 2019. The coverage ra-tios are again suboptimal, yet hos-pitalisation increased. It could be a function of member growth in 2019.

HUMAN IMMUNO- DEFICIENCY VIRUS

HIV is spread through direct expo-sure to bodily fluids; it attacks the body’s immune system, specifical-ly the CD4 cells. HIV was the most prevalent condition in both 2018

and 2019. In 2018 and 2019, the number of HIV patients was 12 335 and 12 969, respectively. This equates to a 5.1% increase. The coverage ratios for HIV condi-tions are shown in Table 7.


The minimum interventions in the care of HIV patients are listed be-low: a) Viral load: This test is used to

monitor the patient’s response to antiretroviral therapy.

b) CD4 count: This test is a good indicator of the state of a patient’s immune system.

These coverage values are low, while hospital admissions re-mained relatively unchanged in 2019 compared to 2018.

The coverage of HIV monitor-ing tests decreased slightly from 2018 to 2019. These ratios were 29.4% for the viral load test and 14.7% for the CD4 test in 2019. In 2018, the coverage ratios were 30.2% and 15.5%, respectively.

CARDIOVASCULAR DISEASE 2018 2019 % changeNumber of chronic beneficiaries 7 952 9 126 14.8%Process indicator: Proportion of unique beneficiaries Receiving at least one creatinine/eGFR test 31.8% 32.0% 0.6% Receiving at least one electrocardiogram 10.6% 10.5% -1.2% Receiving at least one cholesterol test 25.8% 25.8% -0.1%Outcome indicator: Proportion of unique beneficiaries Admitted to hospital at least once 13.4% 13.4% 0.2%

Table 6: Cardiovascular disease coverage ratios

Table 7: HIV coverage ratios

HIV 2018 2019 % changeNumber of chronic beneficiaries 12 335 12 969 5.1%Process indicator: Proportion of unique beneficiaries Receiving a viral load test at least once 30.2% 29.4% -2.4% Receiving a CD4 count test at least once 15.5% 14.7% -4.9%Outcome indicator: Proportion of unique beneficiaries Admitted to hospital at least once 10.7% 10.7% 0.4%



MEDICAL AID FUNDS’ HEALTHCARE EXPENDITURE

Healthcare expenditure is the larg-est expense for medical aid funds. It is important to monitor this ex-penditure to ensure efficiency and sustainability. This section’s ex-penditure figures are slightly dif-ferent from those in the financial statement, mainly due to the fact that it takes into account treatment items; such as ‘claims incurred but not reported’ used in the financials.

Figure 8 depicts the propor-tions of expenditure paid to var-ious healthcare providers for the period 2018-2019. In 2019, the bulk of expenditure went to Health-care Service Providers (HSPs); they

received 43% of total expenditure, while hospitals received 27%. In comparison, expenditure on med-icines and devices outside hospital accounted for 29% of total expend-iture in 2019.

Expenditure at HSPs was P627 million in 2018, increasing to P691 million in 2019, a 10% increase year on year. Expenditure on medicines and devices dispensed outside hospitals increased by 8% from P430 million in 2018 to P466 million in 2019. Healthcare expenditure at hospitals increased by 0.2% to P435.5 million in 2019 from P434.7 million in 2018.

Figure 9 shows the total health-care expenditure across bene-ficiaries by age band. The line graphs in the same figure repre-sent the number of beneficiaries over age. Healthcare expenditure is lower in younger beneficiaries aged up to 29, though the num-ber of beneficiaries is higher. Among the older age bands, from 35 years onwards, expenditure is high while the number of bene-ficiaries increases. This form of cross-subsidisation is supported.

A positive observation one can make from Figure 9 is that the number of beneficiaries is increas-

29%

42%

28%

1%

2018

Hospitals

HSP

Medicines / Devices

Other

27%

43%

29%

1%

2019

Figure 8: Healthcare expenditure in 2018 and 2019



ing across all age bands. Figure 10 depicts the principle of cross-sub-sidisation better. It shows medi-cal aid funds’ expenditure by age band on a pbpm basis.

In 2019, medical aid funds spent on average P411 pbpm, an in-crease of 1.2% from P406 pbpm

in 2018. Figure 10 shows that for age bands below the two hori-zontal lines (average expenditure in 2018 and 2019), beneficiar-ies are contributing positively to cross-subsidisation. In age bands above the average expendi-ture, beneficiaries benefit from cross-subsidisation.

HOSPITAL EXPENDITURE AND UTILISATION

Hospital expenditure accounted for 27% of total healthcare ex-penditure in 2019, down from 29% in 2018. The number of ad-missions fell from 244 per 1 000 beneficiaries in 2018 to 192 per

Figure 10: Average healthcare expenditure by age band

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5

10

15

20

25

30

35

40

0,00

50,00

100,00

150,00

200,00

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of b

enef

icia

ries

(thou

sand

s)

Expe

nditu

re (

P m

illio

ns)

HE_2018 HE_2019 Ben_2018 Ben_2019

Figure 9: Healthcare expenditure by age band

0

500

1000

1500

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3000

Expe

nditu

re p

bpm

(P)

HE_pbpm_2018 HE_pbpm_2019 Ave_HE_pbpm_2018 Ave_HE_pbpm_2019



1 000 beneficiaries in 2019. Sim-ilarly, the average length of stay decreased from 3.12 days per ad-mission in 2018 to 3.04 in 2019. The average cost per admission was P4 633 in 2019, up from P4 006 in 2018. Figure 11 illustrates the average cost of admission and number of admissions over age.

The rates of admission are highest in older beneficiaries, who tend to be admitted more frequently and whose cost per admission is high-er too. It is important for medical aid fund benefits to target inter-ventions that reduce hospital ad-missions in the elderly, e.g. flu vac-cines, disease management and

outpatient quality improvement.

Figure 12 illustrates admission rates and the average length of stay per day for hospital ad-missions. The graph indicates a strong correlation between the admission rate and average length of stay in hospital. In age bands

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Figure 12: Hospital admissions – average length of stay and number of admissions

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Cost per Admission - 2018 Cost per Admission - 2019

Figure 11: Hospital admissions – average expenditure and number of admissions



where admissions are high, the average length of stay is higher.

HEALTH SERVICE PROFESSIONALS’ EXPENDITURE AND UTILISATION

The proportion of healthcare ex-penditure by medical aid funds to HSPs in 2018 and 2019 was 42% and 43%, respectively. In mone-tary terms this translates to a 10% increase in expenditure at HSPs. Figure 13 illustrates the health-care expenditure by disciplines of practice in 2018 and 2019.

General practitioners received the largest portion of expenditure in 2019: 25%, which is equivalent to P169 million. This was followed by dentists and pathologists, with each receiving 16% of healthcare expenditure at HSPs. Medical and surgical specialists received 14%

and 8% of healthcare expenditure, respectively. Similar trends in ex-penditure were observed in 2018.

Figure 14 shows the average ex-penditure per visit at HSPs in 2018 and 2019 by discipline. The average expenditure per visit at all HSPs increased by 6.4% to P365 in 2019, from P343 in 2018. The average expenditure per visit was highest for anaesthetists at P1 163 per visit in 2019. In 2018, average expenditure per visit was highest for dental specialists at P1 175.

General practitioners received the largest portion of HSP expend-iture: 25%, while their average expenditure per visit was P197 in 2019. In 2018, the average ex-penditure at general practitioners was P188.

Figure 15 depicts utilisation per

1 000 beneficiaries in 2018 and 2019. Across all disciplines, uti-lisation decreased by 0.1% year on year. Utilisation was 5 847 per 1000 beneficiaries in 2019, down from 5 853 per 1 000 beneficiaries in 2018.

Utilisation at general practition-ers was highest compared to other disciplines; 2 668 per 1 000 beneficiaries in 2019, up from 2 611 per 1 000 beneficiaries in 2018, an increase of 2.2%. Visits to dental specialist were very low, accounting for only 44 per 1 000 beneficiaries in 2019. This is both a utilisation and quality measure.

Allied professionals were the group with the second highest rate of utilisation at 1 060 visits per 1 000 beneficiaries in 2019. Utilisation was lowest for anaes-thetists, with 23 visits per 1 000 beneficiaries in 2019.

24%

14%

17%

15%

12%

8%

6%

3% 1%

2018 General Practitioners

Dentists

Pathology

Medical Specialists

Supplementary and AlliedHealth ProfessionalsSurgical Specialists

Radiology

Dental Specialists

Anaesthetists

25%

16%

16%

14%

12%

8%

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2% 1%

2019

Figure 13: Healthcare expenditure at HSPs by discipline



188

1036

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Dentists

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Expenditure per visit (P)

2019 Average exp 2018 Average exp

Figure 14: Healthcare expenditure per HSP visit

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Visits per 1 000 beneficiaries

2019 Visits per 1000 Ben 2018 Visits per 1000 Ben

Figure 15: Utilisation at health service professionals



OUT-OF-POCKET EXPENDITUREOut-of-pocket (OOP) expendi-ture is the money individuals use to pay directly for health services when they access care. For medical aid beneficiaries, the level of OOP expenditure represents a gap be-tween their healthcare expenditure and what medical aid funds pay on their behalf. It is probably an un-derestimate as it is based only on received claims – if a beneficiary pays OOP and does not submit a claim, that expenditure is not in-cluded in this calculation.

The total amount claimed for health services in 2019 was P2.02 billion, while the total benefit paid was P1.61 billion. OOP expend-iture was at least P403 million, representing at least 20% of total healthcare expenditure. In 2018, OOP expenditure was P355 mil-lion, representing 19% of total healthcare expenditure.

The World Health Organisation rec-ommends that OOP expenditure

not exceed 15% of total healthcare expenditure by individuals.

Table 8 shows the level of OOP in 2018 and 2019. Most OOP expenditure was at Healthcare Ser-vice Providers (HSPs) and amount-ed to P167 million in 2019. This was followed by medicines and devices outside hospital, amount-ing to P116 million. OOP was lower at hospitals – P111 million in 2019, translating to 20% of all healthcare expenditure at hospitals.

OUT-OF-POCKET EXPENDITURE BY AGE

Figure 16 shows OOP expenditure by age on a per beneficiary and per annum basis in 2018 and 2019. It increases with increasing age. For child dependents the levels of OOP are very low in nominal terms, how-ever as a proportion of total health-care expenditure it is consistent with other ages. The low OOP ex-penditure is therefore largely driven

by the claiming behaviour for child dependents, rather than the bene-fits on offer.

OOP expenditure among older ages was as high as P7 000 per beneficiary per annum in 2019. This amount translates to about 100% of the average annual contri-bution for medical aid fund mem-bership (adult contributions). Older beneficiaries need more protection from OOP expenditure.

OUT-OF-POCKET EXPENDITURE AT HSPs

OOP expenditure was highest at HSPs in 2019, compared to hospi-tals and OOP expenditure for med-icines and devices. The bulk of this went to pathologists, medical spe-cialists and general practitioners. Of the P167 million spent at HSPs, 30% was spent at both medical and surgical specialists. Figure 17 shows more detail on the level of OOP expenditure by discipline.

OOP Expenditure OOP %

Financial Year 2018 2019 2018 2019Hospitals 77.60 110.72 15% 20%Healthcare service professionals 157.02 166.78 20% 19%Medicines / devices 114.32 115.90 21% 20%Other benefits 5.75 9.13 26% 30%Total 354.68 402.53 19% 20%

Table 8: Out-of-pocket payments



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Figure 16: Out-of-pocket expenditure by age

14%

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2018 General Practitioners

Dentists

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Supplementary and AlliedHealth ProfessionalsSurgical Specialists

Radiology

Dental Specialists

Anaesthetists

14%

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24%19%

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4%4% 2%

2019

Figure 17: Out-of-pocket expenditure at HSPs



MEDICAL AID FUNDS’ FINANCIAL PERFORMANCEThe funds showed a healthy fi-nancial performance in both 2018 and 2019. Gross contribution in-come grew by 9.2% from P1.76 billion in 2018 to P1.92 billion in 2019. During the same period, healthcare expenditure increased from P1.50 billion to P1.64 billion, an increase of 9.4%. The increase in contributions and healthcare expenditure was attributable to both annual increase adjustments due to inflationary factors, as well as growth in membership.

COMPREHENSIVE INCOME

On a pbpm basis, gross contribu-tions grew by 3.2% from P475 to P490 from 2018 to 2019. Bene-ficiaries faced increases of 0.35% in excess of inflation. Annual infla-tion as measured by the consumer price index was 2.85% from 2018 to 2019. Healthcare expenditure grew at a slightly higher rate than gross contributions, 3.4% from

2018 to 2019 on a pbpm basis. Healthcare expenditure was P404 pbpm in 2018 and increased to P418 pbpm in 2019.

Non-healthcare expenditure rep-resents operational expenditure required to provide services. Low-er non-healthcare expenditure while meeting deliverables is an indicator of operational efficien-cies. Non-healthcare expenditure was 11.0% of gross contributions in 2019, i.e. P54 pbpm. In 2018, non-healthcare expenditure was P63 pbpm, representing 13.2% of gross contributions. Non-health-care expenditure declined both in monetary terms and as a propor-tion of gross contribution income from 2018 to 2019. This is a pos-itive as funds consequently have more financial resources available for healthcare expenditure.

The net healthcare result, calcu-lated as the difference between

gross contributions and expendi-ture, was positive for both 2018 and 2019. It was P31.1 million in 2018 and P71.6 million in 2019. During the same period, the funds’ investments were also pos-itive, contributing to a surplus in both years. This financial perfor-mance is summarised in Table 9.

FINANCIAL POSITION

In 2019, medical aid funds’ reserves increased by 11.4%, from P892 million in 2018 to P991 million. On a pbpm basis, this translates to a growth of 5.2%, increasing from P240 pbpm in 2018 to P253 pbpm in 2019. This level of growth in re-serves is very positive as growth in membership is often associated with a decline in reserves.

The funds are in a very strong finan-cial position; the reserves translat-ed to a solvency level of 51.6% of gross contribution income in 2019.

Million Pula Pula pbpm

2018 2019 % Change 2018 2019 % ChangeGross contributions 1 763.0 1 924.5 9.2% 474.7 489.7 3.2%Healthcare expenditure 1 499.9 1 641.3 9.4% 403.8 417.6 3.4%Non-healthcare expenditure 232.0 211.6 -8.8% 62.5 53.8 -13.8%Net healthcare result 31.1 71.6 130.4% 8.4 18.2 117.8%Other income 33.7 46.2 37.1% 9.1 11.8 29.6%Comprehensive income 64.8 117.8 81.9% 17.4 30.0 71.9%

Table 9: Statement of comprehensive income



There was a strengthening in the solvency level; it increased by 100 basis points from 50.6% in 2018. The financial position of the funds is summarised in Table 10.

ALLOCATION OF RESERVES

In 2019, a significant portion of the reserves was invested in mon-ey market instruments – 33%: these are secure investments that tend to provide returns below inflation. Bonds provide great-er returns but are generally less secure as they are long-term in-vestments. The funds had 10% of their reserves invested in bonds

at the end of 2019. Equity in-vestments generally provide long-term returns in excess of inflation, but these are risky investments. The funds’ exposure to equity in-vestments was 17% as at 31 De-cember 2019. Figure 18 provides more descriptive asset allocation as at the end of 2018 and 2019.

Medical aid funds generally have short-term liabilities and require exposure to investment that can be liquidated easily – suggesting that money market investments are suitable. However, contri-butions often increase at rates above inflation; likewise invest-

ment returns should increase above inflation so that beneficiar-ies are protected from the higher contribution increases necessary to maintain reserves.

Medical aid funds are therefore faced with a delicate balance: the need to ensure reserves are se-cure and yet provide long-term investment returns often greater than inflation. In line with inter-national standards, medical aid funds are encouraged to manage their reserves on a risk-based capital basis, which allows funds to use reserves in a more efficient way.

Million Pula Pula pbpm

2018 2019 % Change 2018 2019 % ChangeTotal investments 836.2 867.8 3.8% 225.1 220.8 -1.9%Current assets 241.3 344.1 42.6% 65.0 87.6 34.8%Current liabilities -185.7 -218.8 17.8% -50.0 -55.7 11.3%Reserves available for funds 891.8 993.0 11.4% 240.1 252.7 5.2%

Table 10: Statement of financial position

203,87 214,01

332,35 329,36

109,77101,16

146,40173,64

99,37 174,88

2018 2019

ASSETALLOCATION

Fixed Assets Money Market Bonds Equity Other Investments

Figure 18: Allocation of medical aid fund investments



ANNEXURE AMedical aid fund beneficiaries

ANNEXURES AND REFERENCES

FINANCIAL YEAR 2018 2019

Age Band Male Female Total Male Female TotalLess than one year 2 188 2 193 4 381 2 157 2 017 4 174

1-4 years 12 867 12 529 25 396 13 300 12 990 26 290

5-9 years 18 144 17 853 35 997 18 865 18 890 37 755

10-14 years 15 743 15 345 31 088 16 844 16 343 33 187

15-19 years 13 094 12 882 25 976 13 778 13 683 27 461

20-24 years 3 747 4 194 7 941 5 642 6 118 11 760

25-29 years 5 140 7 657 12 797 5 185 7 986 13 171

30-34 years 10 814 14 873 25 687 10 567 14 679 25 246

35-39 years 15 137 18 959 34 096 15 510 19 857 35 367

40-44 years 15 191 16 415 31 606 15 596 17 215 32 811

45-49 years 12 711 12 933 25 644 13 505 13 675 27 180

50-54 years 9 480 9 860 19 340 10 216 10 478 20 694

55-59 years 6 367 6 781 13 148 6 878 7 281 14 159

60-64 years 4 041 4 068 8 109 4 335 4 433 8 768

65-69 years 2 113 2 099 4 212 2 404 2 433 4 837

70-74 years 1 185 1 090 2 275 1 359 1 244 2 603

75-79 years 578 510 1 088 635 562 1 197

80-84 years 237 253 490 282 278 560

85 years+ 104 131 235 119 144 263

Total 148 881 160 625 309 506 157 177 170 306 327 483



ANNEXURE BConsolidated financial statements

Pula millions Pula pbpm

Calendar Year 2018 2019 % Change 2018 2019 %

Change

Gross contribution income 1 762.99 1 924.47 9% 474.68 489.71 3.2%

Savings contribution income - - - - - -

Net contribution income 1 762.99 1 924.47 9% 474.68 489.71 3%

Relevant healthcare expenditure 1 499.88 1 641.26 9% 403.84 417.64 3%

Net claims incurred 1 495.82 1 636.09 9% 402.74 416.33 3%

Accredited managed healthcare services (no transfer of risk) 4.07 5.17 27% 1.09 1.31 20%

Gross healthcare result 263.10 283.21 8% 70.84 72.07 2%

Net non-healthcare expenditure 232.01 211.57 -9% 62.47 53.84 -14%

Net income/(expenses) on commercial reinsurance 12.86 12.81 0% 3.46 3.26 -6%

Broker costs 1.23 1.35 - 0.33 0.34 4%

Administrator expenditure 211.11 191.29 10% 56.84 48.68 -14%

Net impairment losses: trade and other receivables 6.81 6.11 -10% 1.83 1.55 -15%

Net healthcare result 31.09 71.64 130% 8.37 18.23 118%

Net impairment losses: other -3.84 -1.73 -55% -1.03 -0.44 -57%

Other investment income 29.47 42.45 44% 7.94 10.80 36%

Realised and unrealised gains/losses 16.28 6.43 -61% 4.38 1.64 -63%

Other income 1.39 0.67 -52% 0.37 0.17 -54%

Other expenditure -2.01 -2.83 41% -0.54 -0.72 33%

Finance costs -3.38 -3.38 0% -0.91 -0.86 -6%

Net surplus for the year 69.01 113.25 64% 18.58 28.82 55%

Other comprehensive income -4.24 4.58 -208% -1.14 1.16 -202%

Fair value adjustment on available-for-sale investments -4.34 4.49 -203% -1.17 1.14 -198%

Reclassification adjustment 0.10 - -100% 0.03 - -100%

Other - 0.09 0% - 0.02 0%

Total comprehensive income for the year 64.77 117.82 82% 17.44 29.98 72%



LIST AList of Figures

ANNEXURES AND REFERENCES

Figure 1: Medical aid fund beneficiaries ............................................................................................. 10

Figure 2: Benefit option sizes ............................................................................................................... 11

Figure 3: Number of beneficiaries by age band ................................................................................. 12

Figure 4: Chronic disease prevalence .................................................................................................. 13

Figure 5: New chronic beneficiaries registered .................................................................................. 14

Figure 6: Chronic disease prevalence by age band in 2018 ............................................................. 15

Figure 7: Chronic disease prevalence by age band in 2019 ............................................................. 15

Figure 8: Healthcare expenditure in 2018 and 2019 ........................................................................ 19

Figure 9: Healthcare expenditure by age band................................................................................... 20

Figure 10: Average healthcare expenditure by age band .................................................................. 20

Figure 11: Hospital admissions – average expenditure and number of admissions ...................... 21

Figure 12: Hospital admissions – average length of stay and number of admissions ................... 21

Figure 13: Healthcare expenditure at HSPs by discipline ................................................................. 22

Figure 14: Healthcare expenditure per HSP visit ............................................................................... 23

Figure 15: Utilisation at health service professionals ........................................................................ 23

Figure 16: Out-of-pocket expenditure by age .................................................................................... 25

Figure 17: Out-of-pocket expenditure at HSPs .................................................................................. 25

Figure 18: Allocation of medical aid fund investments ..................................................................... 27



Table 1: Summary of benefit options in 2018 and 2019 .................................................................. 11

Table 2: Number of beneficiaries by dependent type ....................................................................... 11

Table 3: Average age and pensioner ratios .......................................................................................... 12

Table 4: Diabetes coverage ratios ........................................................................................................ 16

Table 5: Respiratory diseases coverage ratios .................................................................................... 17

Table 6: Cardiovascular disease coverage ratios ................................................................................ 18

Table 7: HIV coverage ratios ................................................................................................................. 18

Table 8: Out-of-pocket payments ......................................................................................................... 24

Table 9: Statement of comprehensive income .................................................................................... 26

Table 10: Statement of financial position ............................................................................................ 28

LIST BList of Tables

BHF ..............Board of Healthcare Funders

CVS ..............Cardiovascular

DM ...............Diabetes mellitus

FWA .............Fraud, waste and abuse

HIV ...............Human immunodeficiency virus

HSP ..............Healthcare service provider

NBFIRA ........Non-Banking Financial Institutions Regulatory Authority

OOP .............Out-of-pocket

Pbpm ............Per beneficiary per month

PCNS ...........Practice Code Numbering System

SADC ...........Southern African Development Community

UHC .............Universal healthcare coverage

WHO ...........World Health Organisation

LIST CList of Acronyms and Abbreviations



CONTACT INFORMATION

Board of Healthcare FundersServing Medical Scheme Members

REGISTERED OFFICE

Lower Ground Floor,

South Tower, 1Sixty Jan Smuts

Jan Smuts Avenue Cnr Tyrwhitt Avenue

Rosebank, 2196

CONTACT DETAILS

Tel: +27 11 537 0200

Fax: +27 11 880 8798

Client Services: 0861 30 20 10

E-mail: [email protected]

Web: www.bhfglobal.com

COMPANY REGISTRATION NUMBER

2001/003387/08

1

2

6

3

5

4

1. REPRESENT MEMBER INTERESTS

Lobby and advocate policy position on behalf of our members

Assist members with regulatory compliance

Provide legal advice to membership on industry issues

Assist in containing healthcare costs

Protect the image of the industry

Identify and monitor trends impacting our members

Valu

e P

ropos i t ion

2. CREATE PLATFORMS FOR MEMBER ENGAGEMENT

Promote unity and collabo-ration by creating platforms that enable our members to engage with the BHF and participate in industry issues

Create networking opportu-nities

Engage and develop rela-tionships with key stake-holders

3. DEVELOP INDUSTRY STANDARDS

Promote best practice in the healthcare funding industry

Promote healthcare quality

Identify and recognise key role players in the industry

4. FACILITATE EDUCATION AND TRAINING

Provide guidance

Provide stewardship and facilitate thought leadership exchange on industry issues

Enhance skills and knowledge with-in our membership

Progress tracking reports on indus-try issues

Promote stakeholder, consumer awareness and medical scheme member education

5. TRANSFORMATION THROUGH DEVELOPMENT

Identify opportunities to drive transformation in the industry

Graduate programme develop-ment

PROVIDE AND IDENTIFY OPPORTUNITIES

Profile our members and our industry

The Botswana Medical Aid Funds2019ANNUAL

REPORT

Board of Healthcare FundersServing Medical Scheme MembersTel: +27 11 537 0200Fax: +27 11 880 8798Client Services: 0861 30 20 10E-mail: [email protected]: www.bhfglobal.com

the botswana medical aid funds 2019report annual · the board of healthcare funders (bhf) is...

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