South Africa’s “Missing Middle” Strains Health System

Why this is here: When members of the “missing middle” exit private cover, they do not disappear from the health-care system—they shift into the public sector, adding pressure to a system serving over 84% of the population.

Kevin Aron, principal officer at Medshield Medical Scheme, describes a growing challenge for South Africa’s healthcare system. Roughly 14 to 16 percent of South Africans currently have private medical scheme cover, leaving most reliant on the public system. A segment of working people—the “missing middle”—earn too much for public support but struggle to afford private insurance, and are increasingly shifting to the public sector.

This influx strains an already burdened public system, delaying care and potentially worsening health outcomes. Simply reducing benefits in private schemes offers short-term relief but risks deferring costs. Aron suggests more flexible contribution models and network-based care, where schemes partner with select providers, could improve affordability.

Preventive care and aligning incentives for providers and patients are also key. Though medical schemes can drive change, the issue reflects broader economic inequalities requiring coordinated action from regulators, employers, and policymakers. The work to build a more inclusive system continues.