All Botswana civil servants can enrol on BPOMAS for quality individual and family healthcare service

AFA's maiden flight was 18 years ago. The pilot, Kabelo Ebineng, recalls how he and his crew had to convince people to partake in a novel aviation experience. When the plane had enough passengers on board, it rolled down the runway, shot up into the sky and when it reached its destination, made a smooth landing. Ever since it has dominated the skies while it expands its fleet.

Translated that means that when Associated Fund Administrators was formed in 1990, Ebineng, the managing director and his staff, were seized with the daunting task of educating people on and asking them to invest in what then was a largely novel concept - medical aid. Presently this company is the largest medical aid administrator in Botswana, is still expanding and aiming for higher heights.

AFA's core competency is the administration of medical aid schemes, namely the Botswana Public Officers'Medical Aid Scheme (BPOMAS), and Pula Medical Aid Fund (PULA) which it has been administering since their inception in 1990 and 1991, respectively. In addition, the company has since 2005, been awarded a 12 months contract by the ministry of health to manage and coordinate antiretroviral therapy (ART) services for government-funded patients accessing this service in the private sector.

Explaining the rationale for the latter, Ebineng says that the overflow of patients from the public sector health system necessitated this outsourcing. The government needed somebody to handle the process. The service was put to tender and AFA won.

What can perhaps be counted as the company?s greatest achievement is that brainwaves that have radiated from it have helped reverse the HIV/AIDS scourge in Botswana. Presently, its model serves as an example not just to the continent but the entire world. It is little wonder then that the company's head, Ebineng, deputises for the Minister of Health in the health sector forum of the High Level Consultative Council which discusses national policy issues between the private and public sectors under the chairmanship of the President of Botswana.

AFA was born at a time when public heath care facilities were congested and there was clear need to develop private delivery capacity.

Quite apart from providing health care, it was an issue of development,? Ebineng says of the initiative to establish private health care financing.
There was also the problem of infrastructure and for that reason the distribution was not as wide and not as strong as it is presently.

AFA came into being at a time that the government was in the process of establishing a medical aid scheme.
Says Ebineng: There was agreement that the scheme should not be run within government but that it should be run by an outside entity which would operate it along business lines. A tender was put out and AFA made a good enough impression to get the job.

All that happened at a time when there was no systematic focus on a scourge that was encroaching upon the nation ? HIV/AIDS. What passed for intervention then was limited to providing information provided by the government and the World Health Organisation.

Ebineng says that around this time some sections of the treating population, notably private doctors, were disinclined to see HIV patients because the counselling and clinical attention took too long and was not cost-effective. We took the view that if the figures and information from the government and WHO were correct, in 20 to 25 years we would be looking at a situation where the country's population would be decimated if nothing were done.

We then recommended to BPOMAS that HIV/AIDS must be provided for in the benefit structure. There were heated debates with some people looking at the issue from a moral point of view and suggesting that only those who were irresponsible were at risk. "There were also others who felt that only the young would be affected",he recalls.

AFA's case was that if in the past Batswana had got by on meager resources, then the country's improved economy could be immensely helpful in turning around the HIV/AIDS situation.
By using mathematical and economic modeling, the company demonstrated that if Botswana could use revenues from its natural resources to fight HIV/AIDS, it could succeed in creating a population that would take the country farther. "Fortunately, our advice was taken by our clients",Ebineng says.

The breakthrough came in March 1993 at a crucial Pula special general meeting in a Gaborone Sun conference room.
Ebineng remembers of this meeting: ?This is where Debswana Diamond Company played a major part because, at the time, the company was just over 50 percent of Pula membership. They could make or break this thing.?

Fortunately, representatives of Debswana employees made that thing by endorsing the reforms that were being proposed. That cleared the way for a scheme that now offers comprehensive HIV coverage. The reforms were later adopted by BPOMAS.

Virtually all doctors practicing at the time had not had the advantage of classroom learning on HIV/AIDS because at the time they trained, the disease was either non-existent or not an issue. On that basis, it became necessary to plug this knowledge gap and through its professional linkage with the University of Cape Town, AFA began training private doctors during weekends. This professional development later evolved into formal lecture programme that benefitted doctors from different sectors.

BPOMAS and Pula have outsourced the function of member relations to AFA which assists scheme members understand their medical scheme benefits and rules, while facilitating the processing and payment of healthcare claims at the same time. The prime objectives of AFA's Member Relations programme are: collection of medical scheme contributions; adjudication of healthcare claims, including claim assessment; payments to healthcare providers and/or reimbursements to medical scheme members; management of the beneficiary database; and, resolution of queries from beneficiaries and healthcare providers.

AFA also plays a central role in ensuring the efficient spending of each healthcare pula received. Over and over again during the interview, Ebineng stresses the importance of providing cost-effective products and services that can be sustained over the long term. To AFA 'demand is not just a word that can be tossed about casually. The model it applies to determine whether there is demand for something positively answers the following test questions: what does society need? What can be provided? And what can the society be able to pay for?

"If something is needed, can be paid for on a sustainable basis, then there is demand," Ebineng says.

In addition to playing the role of context-setter in the Botswana private healthcare industry, AFA also participates in several complementary initiatives which include:
serving on most clinical forums in the health industry; participating in all government-initiated forums to which AFA or its personnel is invited, acting as HIV/AIDS benefit management adviser to a number of local companies, participating in healthcare administrators forums, serving on a number of international private healthcare and health-related development partner forums, accessing and utilising clinical teams in Southern Africa experienced in private healthcare financing, participating in and chairing the ongoing effort to establish a truly national private sector response to HIV/AIDS, working with the Botswana Confederation of Commerce, Industry and Manpower, the National AIDS Co-coordinating Agency, and other development aid partners, such as the BOTUSA project and the local UNAIDS office; and, representing the Botswana private healthcare funding sector at international trade association forum.

From the knowledge base that it has developed over the years, AFA has established a department that deals with not just AIDS but other chronic conditions which over time have become more and more expensive to treat.
"One of the things that we do is make information available to service providers through seminars," Ebineng says.

When it came into being, AFA?s equity split was as follows: 50 percent for Associated Insurance Brokers (which has now evolved into AON Botswana); 25 percent each for the other partners - Medscheme and Medtrac. Although the shareholding structure has not changed, the idea of giving citizens a stake in the company has been mooted.