PULA MEDICAL AID FUND

The Pula Medical Aid Fund is Botswana’s premium health partner

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Established in 1991, Pula Medical Aid Fund has become one of the most trusted Medical Aid funds in Botswana, and is administered by the Associated Fund Administrators of Botswana (AFA).

Pula Medical Aid Fund is open to all institutions in the private sector, such as parastatal organisations, NGOs, et cetera, and members have the certainty that they belong to a Fund that offers the most comprehensive benefits in the industry and continues to deliver value for money.

“Pula was formed by a group of employers who essentially came from the private sector and decided that they wanted to provide medical aid cover for their employees,” explains Principal Officer, Dr Thato Moumakwa. “Over the past 25 years, the Pula Medical Aid has fulfilled its core mandate of being a leader in the provision of cost-effective health care solutions. At present Pula’s membership is about 18 000 principal members, and in terms of total lives covered, we have in excess of 41 000 lives covered under our book.”

The affairs of the Fund are managed under the direction and supervision of a 10-member Board of Trustees, which convenes in accordance with the Rules of the Scheme. Members of the board are nominated by the various employer groups and appointed by the relevant appointing authorities as prescribed in terms of the Rules.

”So in terms of its constitution, it draws its mandate from the notarial Deed of Trust. In addition to that we’ve got the rule book which also draws from the notarial deed of trust in terms of giving guidance on how the medical aid eventually operates,” he adds.

Pula offers a wide range of services and products and three main products, in terms of medical aid cover. The Executive Benefit option offers the most extensive care and broader access to healthcare professionals, the deluxe Benefit option, which offers a comprehensive and convenient cover and the Standard benefit option, which offers the most efficient basic healthcare.

Dr Moumakwa explains that in terms of offerings, they remain pretty traditional, however, he believes that all three products are very, very competitive, Pula’s main focus being to ensure that all offerings are very strong in addressing their mandate of ensuring access to healthcare and ensuring adequate cover. “Naturally, over the years in addition to the three products mentioned, we have gone on and introduced other complementary benefits or products, including funeral cover, the premium waiver cover, the preventative benefits cover and travel insurance cover, which is valid everywhere in the world and which is one of our most-valued services. As we are a medical aid for employer groups, we find that many of our members are people who work for big organisations where some of the executives have to do a certain amount of travel in their day-to-day business, and that is why at some point we felt it was necessary for us to actually introduce the travel insurance cover which has been extremely welcomed by members,” says Dr Moumakwa.

“In addition to that we’ve also got the HIV/Aids benefit cover that has been around for many, many years, Emergency Medical Evacuation cover, Pula Baby and more. Our Managed Care Programme offers access to quality care without compromising member welfare. It endeavours to manage the costs related to chronic illnesses through specialised expertise and knowledge in evidence based medicine. Pula helps you manage chronic illnesses and ailments through the service provider of your own choice. Pula also offers free counseling services for members with chronic illnesses. With our Value Add Partnership Programme, Pula offers you a great deal of savings through our carefully selected merchant partner programme VAPP CLUB. Members and their dependents are entitled to discounts when shopping at these select stores and hotels. So there are number of other things that we have added over the years that are very relevant in terms of the needs of our members,” he explains.

A unique aspect of Pula is that members are able to remain with the Fund even if relocating to another country. Pula offers medical aid cover throughout Botswana. However, those covered are also able to get access to healthcare services in any country outside the borders of Botswana. Most of their members regularly access healthcare services in South Africa and Namibia. In the event that members pay for themselves when accessing healthcare outside Botswana, Pula will reimburse them fully according to the agreed tariffs.

“Pula’s membership primarily comprises of employer groups that are all domiciled in the Republic of Botswana. The other membership category that we have is that of people who were part of an employer group but who, for one reason or the other, left that employer group but elected to remain a member with Pula. After all, if you’ve been an employee of an employer group for more than a year then you have the option of continuing as an individual member. “What has happened over the years is that, as much as our employer groups are domiciled in Botswana, people who have left the employer groups—some of them leave employer groups to go back to Namibia, South Africa, et cetera, and it being up to the main members of Pula, it means that we continue to cover them wherever they are. So that’s the membership side,” explains Dr Moumakwa.

Maintaining access for those international individuals as well as all members and clients of Pula has been made easy with the Fund’s innovative digital platform. Since its inception, Pula has strived to be an innovative and technology-driven Fund and, as part of its aim to provide technology-driven health solutions, the Fund invested heavily in various systems over the years, and these investments have contributed greatly to its effectiveness to date. In 2012, Pula revamped its website and invested in a web portal that allows service providers and members to view transactions on their Pula account online.

Members of Pula Medical Aid Fund now have access to their Pula account information 24/7 around the globe. They can view recent transactions such as doctor visits and payments, outstanding balances for various benefit categories and other transactions that have occurred on their account.

“All businesses in this day and age need to have a good digital platform and it was definitely part of our efforts to ensure that we provide a good customer experience for our members. The work portal allows members to actually view their member information as well as their benefit information. Now, naturally, this is extremely important for the member because it allows them to understand what it is that is available to them, prior to accessing care, and I suppose in that sense it allows them to be able to plan accordingly, knowing exactly what is available to them in terms of their benefits, or the balances of benefits,” he says.

Regarding heath trends in Botswana, Dr Moumakwa says that, increasingly, some of the existing medical aids—and also many of the emerging medical aids—are coming into the market and introducing what he would call new generation products.

“These new-generation products include such benefits that are called savings within medical aids, cash-back claims, and some of them are introducing hospital cash plans—it is certainly the emerging trend that we seem to be seeing in the industry. Pula has been around for 25 years and, as I’ve said, in many ways, Pula still remains a fairly traditional medical aid. However, there have been discussions between myself and the Board that begin with us asking if we as Pula should start considering cash-back claims and payments within our products. So that is a conversation that has started, but we are not there yet.

“Our main offerings, to date, have been fairly traditional, I think there’s a certain level of happiness on our side in terms of us being able to address the mandate that we have.

”These new generation products do not immediately talk to our primary members but right now we are not completely closed to the idea of incorporating them into our services.

“At the right time we will look at when it makes more sense for Pula to perhaps consider introducing some of these new generation products, because it seems to be an issue that is quite alive out there, and if Pula is to stay on track with what is happening within the sector these are some of the things that you need to think about very carefully. But in introducing them, we need to ensure that we do not in away way erode under the parameters that we have always had in a sense of being a sustainable Fund, in terms of operating responsibly and profitably, and being able to guarantee access and the immediate ground to cover for our members,” says Dr Moumakwa.

On highlighting the successes of the Pula Medical Aid fund, Dr Moumakwa says that their greatest achievements lie in being transparent and honest with members and clients, and in the area of product leadership.

“We’ve put a lot of emphasis on and we pride ourselves in terms of having products that we believe hold the position of leadership in the market. They are well thought out, very competitive and showcase our mandate. The benefits that we provide are very comprehensive and they cover the needs and requirements of our members—and there is also no small print in terms of imposing limitations.

“A statement to that fact is that in the time that I have been the Principal Officer of the Fund, there has not been a single time that the Board has met to consider an ex gratia request from a member, which is when a member in the process of accessing care ran out of benefits, and that is something that I know is a standing agenda item for the Board in other medical aids. In Pula, it is something that has not happened in the last two years and it’s because the benefits that we provide are very, very comprehensive, they cover the needs and requirements of our members fully and there are no hidden agendas. When we say the overall hospitalisation benefit is this amount of money, that is exactly what you need. When you are in hospital we do not break it down into further sections that increase the figure. There is complete transparency,” explains Dr Moumakwa.

“I think that has been a major success because, for me, quite frankly it’s about providing access and, once you’ve provided sufficient access, to ensure that there is adequate cover to address what the intention is.

“Honesty and loyalty to all members and clients are our biggest aims and we believe that it is our transparency that will continue to strengthen our Pula’s reputation as one of the leading Medical Aid Funds in the country,” he concludes.

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