1. Introduction
The boundaries between public and private provision in health systems are increasingly fluid. Across high-income countries, governments facing fiscal constraints, ageing populations, and rising demand have turned to private sector actors to supplement or substitute for public provision (Maarse, Reference Maarse2006; Toth, Reference Toth2016). This trend, described as privatisation, marketisation, or the development of ‘mixed’ health systems, takes multiple forms: contracting out public services to private providers, encouraging private health insurance (PHI) to reduce public sector demand, and creating competitive dynamics intended to improve efficiency (Thompson and Mossialos, Reference Thompson and Mossialos2009; Wendt, Reference Wendt2014).
Yet, the consequences of this shift remain contested. Proponents argue that private sector innovation, competition, and efficiency can strengthen overall system performance while offering choice to consumers (Porter and Kramer, Reference Porter and Kramer2011). Critics warn that privatisation fragments risk pools, exacerbates inequalities, and diverts resources and workforce away from public provision, ultimately undermining the principles upon which many health systems were founded (Ellis, Reference Ellis1998; Hunter, Reference Hunter2016; Pollock, Reference Pollock2004). Empirical evidence remains mixed and context-dependent, with outcomes shaped by pre-existing institutional arrangements, regulatory capacity, and the specific mechanisms through which private actors engage. Despite growing private sector involvement in health systems globally, systematic comparative analyses examining how the same private actor functions across different institutional contexts remain limited. This gap constrains our understanding of whether private sector impacts reflect inherent characteristics or are fundamentally shaped by institutional arrangements.
This paper addresses this gap through a comparative case study of the Discovery Group, a multinational private health insurer that administers insurance and wellness programmes in both South Africa and the United Kingdom (UK) under the brands Discovery Health/Vitality (South Africa) and Vitality (UK). We selected Discovery as our case study for three reasons. First, as a multinational insurer operating in divergent institutional contexts, it enables direct examination of how the same business model functions differently depending on health system architecture: a mature universal system (the National Health Service (NHS) in the UK) versus a transitional dual system moving toward universal coverage through National Health Insurance (the NHI in South Africa). Second, Discovery’s ‘shared value insurance’ model, linking behavioural incentives to member benefits, represents a distinctive form of private sector innovation that explicitly frames commercial activity as aligned with public health goals of prevention and chronic disease management. The framing warrants critical examination. Third, Discovery’s substantial market share presence (13% of UK PHI market,Footnote 1 59.15% of South African open medical schemesFootnote 2 ) means its practices have implications beyond individual member outcomes. Detailed background on the Discovery Group’s corporate structure, market positioning, and the ‘shared value’ (Vitality) model is provided in Appendix A1.
Our analysis demonstrates that the impact of PHI on universal health systems is neither uniformly beneficial nor inevitably harmful, but fundamentally context-dependent and mediated by institutional arrangements, regulatory frameworks, and the stage of universal coverage development. This paper investigates three interrelated questions:
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1. How does Discovery Group’s shared value insurance model operate across the UK and South African health systems, and what are the observable mechanisms through which it interacts with public sector functions?
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2. What associations exist between the PHI market and health system performance across the World Health Organization Building Blocks domains?
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3. What contextual factors explain differences in Discovery’s role and impact between the two countries, and what lessons can be drawn for governance of private sector engagement in universal health systems?
2. Background: health system contexts
2.1. Universal healthcare trajectories: UK and South Africa
Both the UK and South Africa represent different stages along the trajectory toward universal coverage through tax-funded NHSs (Dayan et al., Reference Dayan, Kumpunen, Reed and Richardson2025; WHO, 2025), though from fundamentally different starting points. The UK NHS, established in 1948, exemplifies a mature Beveridge-model system now navigating pressures of fiscal constraint, demographic change, and capacity limitations (Anderson et al., Reference Anderson, Pitchforth, Edwards, Alderwick, McGuire and Mossialos2022). South Africa’s NHI Act, signed into law in May 2024, sets out a phased move towards universal health coverage, aiming to redress entrenched inequities in a two-tier health system shaped by apartheid-era legacies and persistent implementation constraints in the post-apartheid period (Coovadia et al., Reference Coovadia, Jewkes, Barron, Sanders and McIntyre2009; Republic of South Africa, 2024). Despite this shared commitment to NHS-style systems, both face mounting pressures that have created space for private sector expansion.
2.2. The UK: supplementary private insurance in a mature universal system
The NHS provides care free at the point of use to the entire population and delivers around 600 million patient interactions annually (Buckingham, Reference Buckingham2025; Powell and Williams, Reference Powell and Williams2024). However, it faces interconnected pressures (Anderson et al., Reference Anderson, Friebel, Maynou, Kyriopoulos, McGuire and Mossialos2024; Friebel and Juarez, Reference Friebel and Juarez2020; Friebel et al., Reference Friebel, Fisher, Deeny, Gardner, Molloy and Steventon2019, Reference Friebel, Henschke and Maynou2021; Wallenburg et al., Reference Wallenburg, Friebel, Winblad, Pujolras and Bal2023), and waiting times for elective procedures have increased substantially, with over six million patients on waiting lists (The King’s Fund, 2025), while population ageing and multimorbidity have shifted the burden of disease toward chronic conditions (Watt et al., Reference Watt, Raymond, Rachet-Jacquet, Head, Kypridemos, Kelly and Charlesworth2023), creating both fiscal pressures and market opportunities for prevention-focused private insurers.
Against this backdrop, around three million people in the UK hold private medical insurance, primarily to access faster elective procedures and diagnostics (Anderson et al., Reference Anderson, Pitchforth, Edwards, Alderwick, McGuire and Mossialos2022; Keith et al., Reference Keith, Lawless, Ewbank, Boshari and Gardner2024). PHI has existed in the UK for decades, and barriers to entry for both consumers and private providers have been reduced over time resulting in a gradual growth in PHI use (Calnan, Reference Calnan2000; Doyle and Bull, Reference Doyle and Bull2000). Critically, PHI in the UK operates as a supplement rather than a substitute: it cannot be used to opt out of the NHS and is primarily used to access faster care or services not routinely funded by the NHS (Keith et al., Reference Keith, Lawless, Ewbank, Boshari and Gardner2024). This institutional arrangement (mandatory universal public entitlement with optional private supplementation) fundamentally shapes how private insurers operate and what role they play in the broader health system.
2.3. South Africa: substitutive private insurance in a transitional dual system
South Africa’s healthcare system is defined by a two-tiered structure, with a tax-funded public sector serving approximately 84% of the population and a privately financed sector serving the remaining 16% (National Department of Health, 2018; Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020). This structure has deep roots in apartheid-era policies and is compounded by persistent governance failures in the post-apartheid period (Coovadia et al., Reference Coovadia, Jewkes, Barron, Sanders and McIntyre2009; Rispel et al., Reference Rispel, de Jager and Fonn2016). Despite relatively high total health spending (8.7% of GDP in 2023), the public sector receives less than half of total health expenditure while serving the vast majority of the population, with per-capita private sector spending nearly five times higher than the public sector (Ataguba and McIntyre, Reference Ataguba and McIntyre2012; World Bank, 2025). The majority of doctors work in the private sector, exacerbating barriers to access such as overcrowded hospitals, long waiting times, and inadequate specialist care in the public system (Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020). In a survey of South African households, 23% faced affordability constraints to healthcare, and 27% faced availability constraints, particularly in rural areas (Burger and Christian, Reference Burger and Christian2020).
In response to these systemic inequities, South Africa’s NHI Act was signed into law in May 2024, with implementation planned on a phased basis (Republic of South Africa, 2024). The NHI seeks to establish a single, publicly administered fund to purchase healthcare services for all South Africans, eventually constraining private medical schemes to providing complementary cover for services not included in the NHI benefit package (Ataguba and McIntyre, Reference Ataguba and McIntyre2012; Republic of South Africa, 2024; Solanki et al., Reference Solanki, Wilkinson, Myburgh, Cornell and Brijlal2024). However, fiscal sustainability, institutional capacity to manage a fund of this scale, political economy obstacles, and governance concerns mean full implementation is projected to take over a decade (Nordling, Reference Nordling2024; Solanki et al., Reference Solanki, Wilkinson, Myburgh, Cornell and Brijlal2024). This prolonged transition period means private insurers like Discovery Group will continue to play a substantial role in South African healthcare for the foreseeable future.
2.4. Divergent institutional contexts, different private sector roles
These structural differences produce fundamentally different roles for PHI. In the UK, PHI provides faster access to services guaranteed by the NHS, creating what Propper (Reference Propper2024) describes as a ‘pro-poor’ distribution of quantity of healthcare but a ‘pro-rich’ distribution of quality and experience. In South Africa, PHI functions as substantive coverage, effectively determining whether quality care is accessible at all for conditions requiring specialist interventions. See Table 1 for a summary of key dimensions of PHI in both countries.
Private health insurance in the UK and South Africa
Table 1. Long description
The table compares key dimensions of private health insurance (PHI) in the UK and South Africa across several categories. It has 8 rows and 3 columns. The columns are labeled Dimension, UK, and South Africa. The rows are labeled Role of PHI, Role of public coverage, Share of PHI coverage, Current health status, Health market, Regulatory, Interaction, and Equity. Row 1: Dimension, Did, 9; N 1, 28.221196; Bucket, bucket underscore 2. Row 2: Role of PHI, Supplementary to NHS services, pro richer faster access and choice, especially for elective procedures, Primarily substitutive, offers comprehensive care as an alternative to the public sector, which is under-resourced. Row 3: Role of public coverage, 100 percent, Langenbrunner, 2020, 100 percent, Statistics South Africa, 2013, National Department of Health, 2018. Row 4: Share of PHI coverage, 11 percent, 2020, Figures, 9, 13 percent, 2013, Figures, 9. Row 5: Current health status, 1 percent, 2020, Office for National Statistics, 2020, 6 percent, 2019, World Health Organization, 2020. Row 6: Health market, 95 percent market concentration in four major providers, Asia, Africa Health, and Vitality Health, 2020, administrators, 43 percent, Council for Medical Schemes, 2020, Discovery Health 40 percent, administrators 35, 20 percent, open scheme beneficiaries, followed by Medscheme Holdings 11 percent, 3 percent, and self-administered schemes, 11 percent, the remaining share is split across Momentum Health 10 percent, and other administrators. Row 7: Regulatory, Regulated by the Financial Conduct Authority, FCA, Prudential Regulation Authority, PRA, and the Care Quality Commission, CQC, England, Governed by the Medical Schemes Act 131, 1998, by the Council for Medical Schemes. Row 8: Interaction, United integration, PHI insurance covers services affecting access to public provider-based coverage, Minimal integration, PHI insurance enables access to private providers and shorter wait times. Row 9: Equity, Risk of two-tiered system, PHI ensures universal access to essential services, High inequity PHI enables high-quality care for a minority, public sector remains overburdened and under-resourced.
a Including GDP spent on voluntary health insurance schemes only. Excluding household out-of-pocket payments for other services (eg, dental care, prescription fees).
In both countries, private insurance growth reinforces a distinct private provider sector with separate capacity, pricing structures, and workforce allocation. In the UK, this is most salient in elective care, where dual practice by NHS consultants can amplify two-tier dynamics when demand shifts toward privately funded pathways (Dayan et al., Reference Dayan, Gainsbury and Bagri2024; Friebel et al., Reference Friebel, Fistein, Maynou and Anderson2022; Propper, Reference Propper2024). In South Africa, private medical schemes finance a parallel hospital and specialist sector, contributing to persistent resource and workforce concentration (Ataguba and McIntyre, Reference Ataguba and McIntyre2012; Competition Commission South Africa, 2019; Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020). These dynamics shape the governance challenge of aligning private activity with universal coverage objectives (Competition Commission South Africa, 2019; Propper, Reference Propper2024).
Consequently, the Discovery Group occupies a different position in each system. In the UK, Vitality offers speed and choice within a functioning safety net. In South Africa, Discovery Health provides access to quality care that may otherwise be unavailable. This fundamental difference shapes all subsequent analysis and aligns directly with the broader question of whether private sector impacts reflect inherent characteristics of commercial insurance provision or are shaped by institutional context.
3. Methods
3.1. Research design
This study employs a comparative qualitative policy analysis approach grounded in Marmor and colleagues’ framework for cross-national policy comparison (Marmor et al., Reference Marmor, Freeman and Okma2005). We selected the UK and South Africa as cases because both operate or aspire to NHS-style universal health systems, enabling comparison across similar policy goals; Discovery Group operates in both countries using a comparable business model, providing a natural comparison in how the same private actor functions across contexts; and the systems represent different stages of development, offering insights into private sector roles at different points in universal coverage trajectories.
Our analytical approach is descriptive and interpretive in nature, consistent with qualitative comparative case study methodology (Sibbald et al., Reference Sibbald, Paciocco, Fournie, Van Asseldonk and Scurr2021; Steiner-Khamsi and Morais de Sa e Silva, Reference Steiner-Khamsi and Morais de Sa e Silva2024). We do not seek to quantify outcomes across systems or establish causal relationships between Discovery’s presence and health system performance metrics. Rather, we explore institutional mechanisms through which a private insurer influences and interacts with the public sector functions and examine how contextual factors shape these interactions and their consequences.
3.2. Analytical framework
To guide this comparative analysis, we adopt the WHO’s Health Systems Framework, which identifies six interdependent building blocks (ie, service delivery, health workforce, health information systems, medical technologies, health financing, and leadership and governance) essential for achieving improved health outcomes, responsiveness, financial protection, and efficiency (WHO, 2010). We selected this framework for three reasons: its broad policy relevance across diverse health system configurations; its focus on the foundational components of system performance rather than specific organisational models; and its established use in health system research and policy analysis internationally (Borghi and Brown, Reference Borghi and Brown2022; Kebede et al., Reference Kebede, Tor, Aklilu, Petros, Ifeanyichi, Aderaw, Bognini, Singh, Emodi, Hargest and Friebel2023).
We recognise important limitations of this framework. Its functionalist orientation may underemphasise political economy dynamics, power relations, and conflict of interest between actors (Mounier-Jack et al., Reference Mounier-Jack, Griffiths, Closser, Burchett and Marchal2014). The building blocks are presented as distinct domains, yet in practice they are interconnected, and interventions in one domain typically affect others. For our purpose, the framework serves to ensure systematic coverage of key health system functions rather than as a causal model of how systems operate.
3.3. Data sources
Our analysis synthesises three categories of evidence: i) policy and regulatory documents (eg, national health policy frameworks such as the NHS Long Term Plan, regulatory frameworks governing private insurance; government health system performance reports), ii) academic and grey literature (eg, peer-reviewed research on Discovery Group programmes and outcomes, independent policy analysis of PHI impact, comparative health systems literature on privatisation and mixed systems), and iii) Discovery Group corporate materials (eg, annual reports and investor presentations, media releases, public policy statements).
We acknowledge that substantial evidence regarding Discovery’s activities is sourced from company-published material or company-commissioned research. We address this limitation through triangulation with independent academic research where available, explicit attribution of claims to their sources throughout the analysis, critical examination of methodological limitations in company-commissioned studies, and maintaining analytical distance between Discovery’s self-reported activities and independently verified outcomes.
3.4. Analytical process
We conducted analysis in four stages. First, for each of the six WHO building blocks, we extracted relevant information from all materials. We created structured extraction tables organised by country, evidence type, and source. A summary of the evidence sources used is included in Appendix A2. Second, for each building block in each country, we synthesised evidence to characterise how the public health system approaches this function; how Discovery Group insurers operate within or alongside the public system; what evidence exists regarding the impact of Discovery’s activities; and what gaps or limitations exist in available evidence. Third, we systematically compared findings across UK and South Africa for each building block, including similarities in Discovery’s approach; differences in implementation or emphasis; contextual factors that might explain divergent patterns; and differential consequences across two settings. Fourth, we integrate findings across all building blocks to develop overarching insights about the mechanisms through which private insurers influence health system functions; the role of institutional context in shaping private sector impacts; tensions between commercial objectives and universal coverage principles; and policy implications for governance of mixed public–private systems.
4. Health system building blocks
4.1. Service delivery
4.1.1. Service delivery in public systems
The NHS delivers most of the healthcare in England through publicly financed, publicly provided services free at the point of use. The system facilitated over 600 million patient interactions annually as of 2024, delivered through approximately 1.5 million healthcare workers across government-owned facilities (The King’s Fund, 2024). However, service delivery faces significant challenges. Waiting times for elective procedures have increased substantially, with over six million people on the waiting list for elective non-urgent procedures (The King’s Fund, 2025). Public satisfaction with NHS access has declined, with surveys indicating that 64% of patients report administrative challenges in accessing timely care (Cream et al., Reference Cream, Wellings, Wenzel, Lant and Pett2025; Keith et al., Reference Keith, Lawless, Ewbank, Boshari and Gardner2024; UK Department of Health and Social Care, 2025).
In response to capacity constraints, individuals seeking healthcare are increasingly turning to the private sector. Difficulty accessing NHS services during the pandemic and long waiting times have pushed more people to purchase PHI (Dayan et al., Reference Dayan, Gainsbury and Bagri2024; Keith et al., Reference Keith, Lawless, Ewbank, Boshari and Gardner2024), and there were 16% more privately funded, privately provided hospital spells in 2022/23 compared to 2019/20 (Dayan et al., Reference Dayan, Gainsbury and Bagri2024).
South Africa’s healthcare system remains sharply divided along socioeconomic lines. A dual structure persists, with the tax-funded public sector serving approximately 84% of the population yet receiving less than half of total health expenditure (Ataguba and McIntyre, Reference Ataguba and McIntyre2012; National Department of Health, 2018; Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020). Public services are delivered through an extensive network of clinics and hospitals, but chronic underfunding, uneven infrastructure, staff shortages, and long waiting times have undermined their responsiveness and quality (Solanki et al., Reference Solanki, Wilkinson, Myburgh, Cornell and Brijlal2024).
In contrast, the private sector, financed through medical schemes and out-of-pocket payments, caters to a minority of the population, mostly higher-income, formally employed individuals (Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020). Against this backdrop, PHI is often viewed not merely as a financial product but as a practical necessity for those who can afford it. For many middle- and upper-income South Africans, enrolling in a private medical scheme is a way to ensure timely access to care, higher quality services, and continuity of preventive interventions, benefits that are inconsistently available in the public sector (Ataguba and McIntyre, Reference Ataguba and McIntyre2012; Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020).
4.1.2. Discovery’s service delivery activities
Vitality in the UK operates as supplementary insurance, providing faster access to diagnostics and elective procedures that are available through the NHS but subject to waiting lists. According to company materials, Vitality members can access services such as private general practitioners (GPs) and specialist consultations, mental health support, and physiotherapy (Vitality UK, 2026a). Importantly, Vitality functions alongside rather than replacing NHS provision. Members retain full NHS access and typically rely on the NHS for primary care, emergency services, and complex medical management (Emmerson et al., Reference Emmerson, Frayne and Goodman2001). The Vitality wellness programme adds a preventive layer, offering health screenings, fitness incentives, and healthy lifestyle rewards.
Discovery’s service delivery role in South Africa is more comprehensive, effectively serving as the primary healthcare access mechanism for its members rather than supplementary coverage. Discovery Health administers multiple medical schemes which provide a range of coverage based on plan type through networks of private GPs, specialist consultations and hospital care in private facilities, comprehensive pharmaceutical benefits, and allied health services (Discovery Health, 2026).
The Vitality wellness programme is embedded within these schemes in both countries. Most Discovery-administered schemes include coverage for annual screenings for blood pressure, glucose, cholesterol, and BMI as part of core benefits (Discovery South Africa, 2025). The programme incentivizes health behaviours including preventive screenings and assessments, physical activity through gym partnerships and wearable device integration, healthy food purchasing through supermarket rewards programmes, medication adherence for chronic condition management, and disease management programme participation. According to Discovery, over 60% of medical scheme members enrol in the Vitality wellness programme (Hafner et al., Reference Hafner, Pollard and Van Stolk2018).
4.1.3. Evidence and assessment
Several studies, primarily commissioned or co-authored by Discovery researchers, report associations between Vitality membership and healthcare utilisation patterns in South Africa. Lambert and Kolbe-Alexander (Reference Lambert and Kolbe-Alexander2013) find that members with higher engagement were associated with lower hospital costs, shorter length of stay, and healthier dietary habits compared with less-engaged members. However, this study compared highly engaged to less-engaged members, both of whom self-selected into Vitality; no comparison to non-members was available.
Another study found that members achieving recommended physical activity thresholds experienced 27% fewer hospital admissions, 8.5% shorter hospital stays, and 14% lower hospital costs than inactive members, after controlling for baseline characteristics (Steenkamp et al., Reference Steenkamp, Saggers, Bandini, Stranges, Choi, Thornton, Hendrie, Patel, Rabinowitz and Patricios2022). However, unobservable characteristics such as health motivation that independently affect outcomes have not been accounted for.
This limitation affects interpretation. Vitality enrolment and active engagement are voluntary, thus individuals may differ systematically from non-enrollees in unmeasured ways. The populations studied represent middle to high-income, formally employed individuals. Whether findings extend to broader population groups with different profiles remains unknown. Finally, while Vitality may reduce per-member costs, per-capita private sector spending (∼4.4% of GDP for ∼16% of the population) far exceeds public sector spending (∼4.1% of GDP for ∼84% of the population) (Ataguba and McIntyre, Reference Ataguba and McIntyre2012; National Department of Health, 2018). Whether prevention investments in advantaged minorities represent efficient resource allocation from a societal perspective remains unclear.
Discovery’s service delivery role differs fundamentally across contexts. UK Vitality provides supplementary access within a strong universal system, potentially relieving some NHS elective demand. South African Discovery Health provides comprehensive alternative coverage. This creates different equity implications. In the UK, private ability to pay determines speed but not eventual access (Propper, Reference Propper2024). In South Africa, private insurance often determines whether quality care is accessible at all for specialist conditions (Ataguba and McIntyre, Reference Ataguba and McIntyre2012; Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020).
4.2. Health workforce
4.2.1. Workforce context in public systems
The NHS faces a severe and long-standing workforce crisis. As of 2025, there are approximately one hundred thousand unfilled positions across medical, nursing, and allied health professions (NHS England only) (NHS England Digital, 2025). Without intervention, workforce shortages will worsen as demand increases and the existing workforce ages (The King’s Fund, 2018).
A variety of factors contribute to this issue. There are pipeline issues in the development of the future workforce, with insufficient training places for doctors and nurses relative to projected need; and retention challenges for the existing workforce with high workload intensity, and early retirement and emigration (The Health Foundation, 2024; The King’s Fund, 2018). Compounding this, the reduced European Union workforce mobility after Brexit has exacerbated shortages while an ageing population and rising multimorbidity have increased demand for health workers (McCarey et al., Reference McCarey, Dayan, Jarman, Hervey, Fahy, Bristow and Greer2022). The private sector draws from the same workforce pool. Nearly 90% of private consultant physicians also work part-time for the NHS, splitting their time between public and private practice (Keith et al., Reference Keith, Lawless, Ewbank, Boshari and Gardner2024).
South Africa’s workforce challenges are more severe. Although the country has approximately 5.88 skilled health professionals per 1,000 population, higher than global averages, distribution is highly inequitable (Mofolo et al., Reference Mofolo, Heunis and Kigozi2019). The majority of doctors work in the private sector, while the public sector, which serves the vast majority of the population, suffers from persistent vacancies and geographic maldistribution (Competition Commission South Africa, 2019). The 2030 Human Resources for Health Strategy projects a shortfall of nearly 97,000 healthcare workers by 2030, with particularly acute deficits in rural areas and specialist positions (Republic of South Africa Department of Health, 2020). Public sector healthcare workers face challenging conditions: resource constraints, high patient volumes, administrative burden, and comparatively lower compensation than private sector alternatives.
4.2.2. Discovery’s workforce interactions
Vitality’s relationship with the NHS workforce is indirect but consequential. The company contracts with private hospitals and clinics that employ or host NHS consultants working in private practice. As many doctors split their time between the private and public sectors, the increasing demand of the private sector potentially makes it harder to expand care paid for by the NHS (Dayan et al., Reference Dayan, Gainsbury and Bagri2024). This has the potential to create a cyclical relationship where insufficient NHS staff leads to longer waiting times for public health services, causing more individuals to seek private care for quicker access to services, driving an increase in staff opportunities in the private sectors, and further drawing NHS staff into private work (Foubister and Richardson, Reference Foubister and Richardson2016; The King’s Fund, 2018).
While there has been limited quantitative analysis on the medical workforce impact of shared work across the public and private sector, qualitative analyses have begun to assess the implications of this split time. Initial studies have found evidence of cultural and structural tensions developing in settings where NHS staff split work with the private sector (Fletcher et al., Reference Fletcher, Eddama, Anderson, Meacock, Wattal, Allen and Peckham2024).
Discovery’s workforce relationship in South Africa is more direct and multifaceted. As the dominant administrator within open medical schemes, Discovery shapes financing and contracting arrangements that influence workforce deployment and incentives in private provision (Council for Medical Schemes, 2024). Discovery employs substantial administrative, analytical, and management workforce for scheme administration, and employs or contracts private GPs, specialists, allied health professionals such as dietitians, health coaches, and wellness specialists for programme delivery. Workforce shortages in the public sector are exacerbated by ‘internal brain drain’ to private provision, in part driven by poor working conditions and lower salaries in the public sector (Govender, Reference Govender2024).
4.2.3. Evidence and assessment
Direct quantitative evidence on Discovery’s specific workforce impacts is limited. There is some evidence that NHS consultants working across public and private sectors report conflicts of interest, perceptions of reduced NHS availability, and tensions between staff engaged and not engaged in private practice (Fletcher et al., Reference Fletcher, Eddama, Anderson, Meacock, Wattal, Allen and Peckham2024). However, causal attribution to the private health sector specifically is not possible. In the UK, approximately 90% of private consultants also work in the NHS, indicating workforce sharing rather than separation. This dual practice predates Discovery’s market entry and involves multiple insurers. Whether Vitality’s growth has increased NHS consultant time in private practice cannot be determined from available data.
In South Africa, approximately 70% of doctors work in the private sector serving only 16% of the population (National Department of Health, 2018; Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020). Discovery, as the dominant administrator within open medical schemes, is a major workforce employer and contractor in the private sector (Council for Medical Schemes, 2024). However, public–private workforce imbalances predate Discovery’s founding and reflect broader structural inequities including working conditions, resources, and compensation differentials. Private providers, including Discovery-affiliated facilities, typically contribute less to medical education, research, and workforce training than public systems (National Department of Health, 2011; Sims et al., Reference Sims, Zingela, Mokhachane, Botha, Mawela, Singaram, Baatjes, Green-Thompson and Begg2025). Discovery’s specific investment relative to other insurers is undocumented.
Strengthening public sector working conditions and expanding the training pipeline are essential in both contexts but alone do not address maldistribution. Regulatory approaches (eg, mandatory public service periods, progressive taxation on private practice) face implementation challenges. Task-shifting to allied health professionals may partially mitigate constraints but requires clear regulation, workforce integration and credible evidence on quality and safety (Bognini et al., Reference Bognini, Oko, Kebede, Ifeanyichi, Singh, Hargest and Friebel2023; Kebede et al., Reference Kebede, Beyene, Ifeanyichi, Bognini, Takele, Hargest and Friebel2025; Leeftink et al., Reference Leeftink, Bikker, Vliegen and Boucherie2018; Pradelli et al., Reference Pradelli, Risoli, Summer, Bellini, Mozzarelli, Anderson, Guasconi, Artioli, Bonacaro and Sarli2025; Taberna et al., Reference Taberna, Gil Moncayo, Jané-Salas, Antonio, Arribas, Vilajosana, Peralvez Torres and Mesía2020).
4.3. Health information
4.3.1. Health information in public systems
The NHS has invested significantly in digital health infrastructure; however data collection and management remain fragmented across providers, regions, and care settings. The UK Department of Health and Social Care’s Medical Technology Strategy identifies enabling infrastructure and systematic data integration as key priorities. Currently, data management and collection in the NHS is piecemeal and purpose-driven, meaning that there is no singular data standard (The King’s Fund, 2018; UK Department of Health and Social Care, 2024a). A more systemic adoption of data-led practices is needed to support a meaningful impact across the health sector (UK Department of Health and Social Care, 2024b).
Frameworks such as the data strategy for health and social care (UK Department of Health and Social Care, 2022) seek to provide the platform for a more systemic approach to data integration. However, as it currently stands, NHS data collection from patient interactions is highly fragmented across providers and categories of care. This may not be a matter of insufficient staffing, as the NHS employs approximately 10,000 individuals in analytical roles (Bardsley, Reference Bardsley2016); but rather a case of underutilisation, with much of this capacity directed toward reactive, routine tasks instead of being leveraged for data-driven innovation and strategic service design (Keith et al., Reference Keith, Grimm and Steventon2022).
South Africa’s public sector health information systems face more fundamental challenges. Many public facilities still rely on paper-based records, and electronic health records (EHRs) are not universally implemented (National Department of Health (NDoH), 2019). Where digital systems exist, they are often siloed. The National Digital Health Strategy for South Africa outlines ambitions for nationwide EHR implementation, health information exchange platforms, mobile health solutions for reaching rural populations and integration with NHI data systems. Several barriers stand in the way of developing a national-level EHR system, including lack of national leadership, insufficient technical staff, and limited investment in infrastructural needs (Katurura and Cilliers, Reference Katurura and Cilliers2018; Zharima et al., Reference Zharima, Griffiths and Goudge2023).
4.3.2. Discovery’s data infrastructure and capabilities
Discovery Group insurers operate sophisticated, integrated data systems that are central to their business model. The Vitality programme is data-driven, collecting granular information on members to enable personalised risk assessment, targeted interventions, and actuarial modelling.
This data covers a broad range of information, such as biometric data on blood pressure, glucose, cholesterol, and BMI; activity data including daily step counts, exercise sessions, and gym attendance; sleep quality information; claims utilisation data; consumer behaviour such as food purchases, app engagement, and reward redemptions (Discovery Health, 2024a). While the data collected varies across the UK and South Africa, it remains a fundamental building block of Discovery’s approach to insurance underwriting. Vitality has recently partnered with Google to expand their health analytic capabilities and provide personalised health recommendations to help reduce illness and extend healthy years (Vitality UK, 2025b).
4.3.3. Evidence and assessment
Discovery’s data infrastructure demonstrates capabilities potentially applicable in public systems, subject to important caveats. Real-time monitoring and longitudinal tracking paired with behavioural insights provide individualised and population-level health analysis. However, several differences between Discovery’s data and population health management requirements warrant consideration. First, members’ data is collected for commercial purposes, representing a different use case from public health data registers. The use of AI models for health prediction warrants additional oversight and accountability controls. Second, Discovery’s data come from privately insured, predominantly higher-income, healthier populations and cover a narrower range of conditions than the NHSs in the UK and South Africa. Algorithms and risk models developed from this data may not generalise to broader populations with different risk profiles and disease burden. Moreover, individuals enrolling in and actively engaging with wellness programmes and tracking technologies differ systematically from non-enrollees. Intervention effectiveness measured in this population may misestimate effects achievable in broader rollout.
4.4. Medical technology
4.4.1. Medical technology in public systems
The NHS spends an estimated £10 billion on medical devices per year, with the goal of using this technology to reduce the backlog of elective care (UK Department of Health and Social Care, 2024a). Policy frameworks have called for greater implementation of technology-driven approaches to promote patient health (UK Department of Health and Social Care, 2014). However, digital health engagement is highly varied across NHS clinical commissioning groups (Allcock et al., Reference Allcock, Zhuang, Li and Zhao2024), and an increase in the digital technology and health informatics workforce in the NHS is needed to accomplish the digital transformations set out in the Topol Review and NHS Long Term Plan (Liu et al., Reference Liu, Calder, Milsom and Gill2021).
South Africa’s policy vision for medical technology centres on expanding access to diagnostics and digital tools, particularly in underserved areas. The National Digital Health Strategy 2019–2024 outlines goals for telemedicine platforms, mobile health solutions, and EHRs (National Department of Health (NDoH), 2019). The NHI Bill mandates development of a National Health Information Repository supporting technology-enabled care (National Health Insurance Bill, 2019). The public health system in South Africa faces constraints to this adoption, including limited budgets for technology procurement, infrastructure challenges in rural areas, workforce training and technical capacity gaps, and regulatory capacity limitations. Despite budgetary constraints, South Africa has committed to scaling access to cost-effective and quality-assured medical devices through the Essential Equipment List and has established a regulatory framework under the South African Health Products Regulatory Authority (SAHPRA) to improve safety and efficiency in the adoption of technologies (South African Health Products Regulatory Authority, 2026). The SAHPRA Essential Equipment List identifies priority technologies, but actual availability in public facilities often falls short (South African Health Products Regulatory Authority, 2026).
4.4.2. Discovery’s use of medical technology
The Discovery Group’s behavioural insurance programme actively promotes the use of digital tools, screening technologies, and preventive interventions (Discovery Health, 2024a). A key area of innovation has been the integration of wearable health technologies. Vitality’s Apple Watch Active Rewards programme, for example, demonstrated a 34% increase in physical activity among users, illustrating how pairing digital tools with behavioural incentives can contribute to health improvements (Hafner et al., Reference Hafner, Pollard and Van Stolk2018).
The Discovery insurers also invest in digital health platforms. Recently, the Personal Health Pathways programme launched in South Africa, an AI-enabled tool embedded in the Discovery Health app that generates personalised health actions and rewards members for completion. The platform is built on datasets including more than 50 million life years of health claims and clinical data and nearly 30 million life years of exercise and lifestyle data gathered through Vitality in South Africa (Discovery, 2025). These pilots function both as feasibility studies and market tests, which may inform wider adoption in the future.
4.4.3. Evidence and assessment
Discovery’s medical technology investments demonstrate several potential benefits. By subsidising wearable devices and embedding them in incentive structures, Discovery has helped normalise health technology use within its member population. Members become familiar with self-monitoring, data tracking, and technology-mediated health management. These digital health tools also provide data for evaluating emerging technologies. The Apple Watch study (Hafner et al., Reference Hafner, Pollard and Van Stolk2018) generated real-world evidence on whether financial incentives sustain physical activity increases, valuable information for technology assessment more broadly. Subsidised continuous screening technologies may enable earlier diagnosis of hypertension, diabetes, and cardiovascular risk factors, particularly for members who might not otherwise seek preventive care.
However, several equity and effectiveness concerns require consideration. First, early technology access remains confined to privately insured populations, which may deepen private–public healthcare disparities, as many Discovery-incentivized technologies are unavailable or unaffordable in public settings. Second, no peer-reviewed cost-effectiveness evaluation of wearable and digital health technologies has been published. Third, increasing digital health and wearable technology use may widen divides, disadvantaging older members less comfortable with technology and rural members with limited connectivity (Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020; Solanki et al., Reference Solanki, Wilkinson, Myburgh, Cornell and Brijlal2024).
4.5. Health financing
4.5.1. Financing structures in public systems
The NHS is primarily financed through general taxation, and current health expenditure represents 11% of GDP, with voluntary health insurance and out-of-pocket payments accounting for approximately 18% of total expenditure (OECD, 2025). PHI spending specifically comprises 2.0–2.5% of total health expenditure, representing a small but growing share (OECD, 2025).
There has been a recent rise in the proportion of acute elective inpatient activity that was privately funded to 8.3% in 2022/23 (up from 7.4% in 2019/20, England figures) (Keith et al., Reference Keith, Lawless, Ewbank, Boshari and Gardner2024). The increasing trend in privately funding health expenditure observed in England has been mirrored in Northern Ireland, Wales, and Scotland. From September 2019 to September 2023, admissions that were paid for out of pocket were up 218% in Northern Ireland, 124% in Wales, and 80% in Scotland (Dayan et al., Reference Dayan, Gainsbury and Bagri2024), reflecting the significant growth in privately funded healthcare in regions that have primarily more heavily relied on publicly funded healthcare.
Importantly, enrolment in PHI does not preclude use of publicly funded health services. For many of those who have PHI, combined use of private and public services is the norm, with privately insured individuals typically still reliant on NHS services for primary and emergency care (Emmerson et al., Reference Emmerson, Frayne and Goodman2001). Richer households are more likely to have PHI than poorer ones (41.2% of households in the richest decile versus 3.7% in the poorest four deciles) and those in higher-income deciles are more likely to have the insurance purchased for them by their employers (Emmerson et al., Reference Emmerson, Frayne and Goodman2001).
Health financing in South Africa reflects the country’s segmented healthcare system. Although total health expenditure is relatively high at around 8.5% of GDP, which is comparable to some high-income countries, the system is divided starkly between public and private sectors (Ataguba and McIntyre, Reference Ataguba and McIntyre2012; Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020). Government spending accounts for approximately 50% of this total, despite covering around 84% of the population, while the remaining half is channelled into the private sector, serving just 16% of the population (Competition Commission South Africa, 2019; National Department of Health, 2018). The result is a per-capita health expenditure in the private sector that is nearly five times greater than in the public sector (Nordling, Reference Nordling2024).
Voluntary medical insurance, purchased individually or provided through employers, constitutes the main source of funding for private healthcare. In 2024, only 15.5% of South Africans were members of a medical scheme (Statistics South Africa, 2025), with coverage skewed towards higher-income, urban populations. The private sector thus plays an outsized role in health financing relative to its reach, creating a dual system in which better-resourced care is largely reserved for those with the ability to pay (Competition Commission South Africa, 2019).
This financing structure creates what Propper describes as a system with ‘pro-poor’ distribution of quantity but ‘pro-rich’ distribution of quality, with the majority receiving publicly financed care of lower quality, while a minority access substantially better-resourced private care (Propper, Reference Propper2024). Although this statement was made in the context of the UK health system, similar patterns are observed in South Africa.
The current NHI Bill proposes fundamental financing restructuring: establishing a single, publicly administered fund to purchase services for all South Africans from both public and accredited private providers (National Department of Health, 2024; Solanki et al., Reference Solanki, Wilkinson, Myburgh, Cornell and Brijlal2024). Under this model private medical schemes would be restricted to providing only complementary coverage for services not included in the NHI benefit package.
4.5.2. Discovery’s financing model and evidence
Discovery’s UK financing role is straightforward: members or employers purchase coverage. The distinctive element is the shared value model, where engagement with the Vitality programme is linked to rewards and, in some product lines, premium adjustments. Active wellness participation can reduce premiums or provide rewards (Harvey, Reference Harvey2020; Vitality UK, 2025a). The underpinning logic is that healthier members make fewer and lower claims, generating savings that can be shared back with members through incentives and benefits.
Discovery’s South African financing role is more nuanced. As the dominant administrator within the open medical scheme segment (administering 59.15% of beneficiaries), Discovery shapes financing patterns for substantial private healthcare provision (Council for Medical Schemes, 2024). The shared value model operates similarly in its behavioural logic; however, within medical schemes, community rating and social solidarity principles limit risk-rated premium differentiation at the individual level, and the Vitality behavioural programme is offered as a separately priced programme in line with the regulatory environment (Discovery, 2026; Medical Schemes Act [No. 131 of 1998], 1998).
Research reports associations between active programme participation and lower behavioural risk profiles, improved physical activity and diet, fewer hospitalisations, and lower per-member costs (Lambert and Kolbe-Alexander, Reference Lambert and Kolbe-Alexander2013). This cost reduction theoretically moderates premium inflation. However, we found no publicly available comparative data on premium inflation rates for Discovery-administered schemes versus competitors or market average, as well as limited information on claim ratios and margins compared to other insurers.
4.5.3. Evidence and assessment
In the UK, private insurance holders are generally higher-income and healthier than average (Emmerson et al., Reference Emmerson, Frayne and Goodman2001), creating risk pool differences between public and private providers. Some have proposed government subsidies for private insurance to reduce NHS waiting times (Propper, Reference Propper2018), raising questions about whether public funds should subsidise care for higher-income populations.
In South Africa, medical schemes must be community-rated with no risk-based premium differentiation (Medical Schemes Act [No. 131 of 1998], 1998). However, membership itself represents selection, as members are predominantly formally employed, higher-income, and healthier. Discovery’s Vitality programme may reinforce favourable selection by attracting more engaged, health-conscious members.
Private insurance growth has ambiguous public system financing effects. It may reduce demand on public services and preventative care may reduce the likelihood of more severe health conditions. However, it may draw healthier and wealthier individuals from public risk pools and divert healthcare spending toward serving a minority at higher per-capita cost.
4.6. Leadership and governance
4.6.1. Leadership and governance in public systems
In the UK, health governance is devolved across the four constituent countries. In England, healthcare planning and commissioning is overseen by NHS England, with healthcare responsibilities further devolved to NHS Trusts, which are responsible for delivery of care within a smaller geographical region. While everyone covered under the NHS is entitled to equal care, in practice this equality is difficult to maintain given differences in resources and community needs across the country (Anderson et al., Reference Anderson, Pitchforth, Edwards, Alderwick, McGuire and Mossialos2022; Dayan et al., Reference Dayan, Kumpunen, Reed and Richardson2025).
In South Africa, governance is divided between national and provincial levels, with the Department of Health setting national policy while provinces manage implementation. However, long-standing issues such as weak accountability, fragmented management, and inconsistent service quality have impeded the system’s capacity to deliver equitable care (Solanki et al., Reference Solanki, Wilkinson, Myburgh, Cornell and Brijlal2024). Health system oversight has historically been hampered by limited enforcement of standards, under-resourced regulatory institutions, and corruption, as exemplified through the misappropriation of public health funds during the COVID-19 pandemic (Magome, Reference Magome2024). Strengthening leadership capacity is therefore a central objective of the NHI reform, which seeks to unify governance and enhance transparency and stewardship across the health system (South African National Department of Health, 2020). Across South Africa, medical schemes are governed by the Medical Schemes Act, which enforces community rating and prohibits risk-based premium differentiation (Medical Schemes Act [No. 131 of 1998], 1998).
4.6.2. Discovery’s governance role and positioning
Discovery occupies a complex position in health system governance in both countries, simultaneously a regulated entity, policy influencer, and a thought leader.
In the UK, Vitality operates within regulatory frameworks for financial services, and quality of care is monitored by the Care Quality Commission in England. However, PHI in the UK has not been regulated with respect to its role as a provider of access to health care, and there is potential for gaps in regulatory oversight when care is delivered outside core NHS provision (Anderson et al., Reference Anderson, Friebel, Maynou, Kyriopoulos, McGuire and Mossialos2024; Foubister and Richardson, Reference Foubister and Richardson2016). NHS England’s elective care priorities explicitly include choice and focus on the incorporation of the independent treatment sector to accelerate treatment (NHS England, 2023), suggesting openness to an expanded private sector role that aligns with Vitality’s commercial interests.
Discovery’s governance role in South Africa is far more prominent. Discovery has been vocal in debates about NHI implementation, arguing that medical schemes should retain a significant role rather than being restricted to complementary coverage, and that NHI implementation without adequate preparation risks system collapse (Discovery Health, 2024b). Discovery’s policy positions align with its interests in preserving a robust private medical scheme market. While the company frames arguments in terms of system stability and patient welfare, these positions also serve to protect Discovery’s business model. This does not invalidate the substance of concerns raised, as questions about NHI implementation capacity and fiscal sustainability have been raised by health policy experts (Solanki et al., Reference Solanki, Wilkinson, Myburgh, Cornell and Brijlal2024), but it does require recognising the political economy context.
4.6.3. Evidence and assessment
Private actors in public health systems raise fundamental accountability questions. Public health systems are, in principle, accountable to populations through democratic governance. Private health insurers are primarily accountable to shareholders through corporate governance and to regulators through financial services law compliance. This creates several potential accountability gaps.
First, when private insurers determine coverage, or design benefit packages, these decisions affect health outcomes but typically lack the public deliberation and appeal processes characterising public sector resource allocation (Voorhoeve et al., Reference Voorhoeve, Dale and Gopinathan2025b, Reference Voorhoeve, Dale and Gopinathan2025a). Second, Discovery collects extensive personal health and behavioural data but is not subject to the same transparency requirements as public bodies. How data are used for risk selection, pricing, product development, or research is largely opaque to members and regulators. Third, Discovery has resources to shape policy debates through commissioned research, policy papers, media engagement, and advocacy. While policy debate engagement is legitimate, resource concentration in corporate actors creates asymmetric influence compared to civil society or public interest groups.
Discovery has positioned itself as a thought leader, particularly in the behavioural and preventative health space, commissioning research through its Vitality Research Institute to evaluate behavioural change impacts (Vitality UK, 2026b). Discovery’s adoption of Porter and Kramer’s ‘shared value’ language represents a framing that aligns commercial activity with social good.
5. Discussion
This comparative analysis of the Discovery Group’s operations in South Africa and the UK demonstrates that the impact of PHI on universal health systems is fundamentally context-dependent, mediated by institutional context, regulatory frameworks, and the stage of universal coverage development. We find that the same company using comparable business models plays different roles (supplementary in the UK versus substantive in South Africa) with different implications for equity, workforce distribution, and compatibility with universal coverage goals.
Three overarching findings emerge from our systematic comparison across the WHO building blocks. First, private sector innovations in health information systems and data-driven care demonstrate promise where technical capabilities rather than distributional choices predominate. Discovery’s integrated data infrastructure links real-time health monitoring, personalised risk stratification, and member engagement with personal health data. The platform connects biometric, behavioural, claims, and lifestyle data enabling targeted interventions and continuous feedback loops. Public systems could replicate this infrastructure with adequate investment, though return on investment relative to priorities remains unclear. Discovery’s rapid development of wearable devices, telemedicine platforms, and digital health tools demonstrates how commercial incentives can accelerate technology diffusion.
However, equity concerns persist. Early technology access advantages remain confined to privately insured populations, potentially deepening disparities. Digital tools may widen divides, disadvantaging older members and those with limited connectivity (Ngobeni et al., Reference Ngobeni, Breitenbach and Aye2020). Comprehensive cost-effectiveness evaluations of wearable and digital technologies remain limited, as does evidence for long-term behaviour change (Charness and Gneezy, Reference Charness and Gneezy2009; Gneezy et al., Reference Gneezy, Meier and Rey-Biel2011; Mitchell et al., Reference Mitchell, Goodman, Alter, John, Oh, Pakosh and Faulkner2013; West et al., Reference West, Krukowski, Monroe, Stansbury, Carpenter, Finkelstein, Naud, Ogden and Harvey2022). Behavioural interventions, paired with more extensive policy interventions targeting the social and structural determinants of health, may prove an effective combination. By changing both behaviours and the systemic enablers of those behaviours, policymakers may begin to tackle prevention on both an individual and societal level.
Second, private insurance operations are associated with tensions with universal health system principles in resource allocation and workforce distribution, though magnitude and mechanisms differ by context. In both countries, but particularly South Africa, substantial workforce concentration in the private sectors is associated with public sector shortages. While multiple factors contribute, including higher compensation, better working conditions, and resource availability, private insurance growth creates private sector workforce demand that may exacerbate imbalances. Discovery, as a major market participant, is implicated in these dynamics, although disentangling Discovery’s specific contribution from broader private sector effects is not possible with available data.
The workforce dynamic illustrates a broader challenge. Private insurers, as entities accountable primarily to shareholders, face structural incentives potentially conflicting with universal coverage objectives. Workforce investments make sense when serving paying members, but not when requiring proportional contributions to training infrastructure or accepting private sector salary limitations to preserve public sector competitiveness.
Third, Discovery’s role and impacts differ fundamentally between the UK and South Africa, despite comparable business models, revealing how institutional context shapes private sector engagement. In the UK’s mature universal system with an effective safety net, private insurers offer supplementary access that accelerates elective care for those able to pay within a context ensuring eventual access for all. Equity concerns relate to timeliness and quality, rather than absolute access. In South Africa’s transitional dual system with weak public provision, private insurers effectively determine whether quality care is accessible at all for many conditions, particularly those requiring specialist interventions.
These differences matter for policy. In the UK, the challenge is managing mixed public–private dynamics while preserving the NHS’s core mission, which presents a governance challenge within a functioning universal system (Friebel et al., Reference Friebel, Molloy, Leatherman, Dixon, Bauhoff and Chalkidou2018; Propper, Reference Propper2024). In South Africa, the challenge is more fundamental, including whether building universal coverage is compatible with maintaining a large, high-spending private sector, or whether these objectives inevitably conflict (Competition Commission South Africa, 2019; Ataguba and McIntyre, Reference Ataguba and McIntyre2012). Discovery’s advocacy in South African NHI debates illustrates political economy complexity: the company raises legitimate concerns about implementation capacity and governance while simultaneously defending commercial interests in preserving private business space (Discovery Health, 2024b; Solanki et al., Reference Solanki, Wilkinson, Myburgh, Cornell and Brijlal2024).
5.1. Limitations
This analysis has several limitations. First, we rely exclusively on publicly available secondary sources, with no primary data collection through interviews, surveys, or organisational access. This constrains our ability to examine internal decision-making processes, informal practices, or stakeholder perspectives not captured in published material. Second, substantial evidence regarding Discovery’s activities comes from company-published material or company-commissioned research. While we triangulate with independent sources where possible, publication bias and commercial interests may influence the available evidence base. Third, we analyse Discovery Group as a single case of private insurance, without systematic comparison to other insurers operating in the same market. This limits insights into whether observed patterns are unique to Discovery’s shared value model or characteristic of private insurance generally. Fourth, evidence availability differs substantially between countries. South African contexts offer more published research on Discovery Health’s programmes and outcomes, while UK-specific evidence on Vitality is sparser. This limits the depth of cross-national comparison in some domains. Fifth, our analysis is largely cross-sectional, examining the current state of Discovery’s operations rather than longitudinal trajectories. We cannot examine temporal dynamics, such as whether Discovery’s prevention focus has strengthened or weakened over time, or how impacts evolve across policy cycles. The cross-sectional analysis also limits our ability to assess how behavioural changes trend over the life course and how these may impact health system burden as members age. Finally, the WHO Building Blocks framework, while useful for structure, may underemphasise political economy considerations including power dynamics, regulatory capture risks, and conflicts between commercial and public interest objectives. We attempt to address this issue through explicit attention to governance issues but recognise that a political economy framework might yield different insights.
5.2. Conclusion
Private insurers optimise for commercial success, which may align with public health goals such as prevention and efficiency but often diverges from universal coverage principles. The policy challenge is creating governance frameworks that enable beneficial contributions while protecting against harms. Our comparative analysis reveals that institutional context profoundly shapes private sector impacts. The same company, using a similar business model, plays very different roles in mature versus transitional universal coverage systems, with different equity implications and different degrees of systemic influence. This underscores that private sector engagement must be tailored to specific institutional contexts rather than adopted through generic models.
The question facing universal health systems is not whether to engage with the private sector, but how to structure that engagement to advance equity, quality, financial protection, and health for all populations. Discovery’s experience across two very different contexts offers valuable lessons, both cautionary and constructive, for this ongoing policy challenge.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1744133126100590.
Acknowledgements
We gratefully acknowledge comments provided by Christos Grigoroglou and participants at the European Health Policy Group Spring 2025 European-Americas Workshop meeting. We thank the anonymous reviewers and Dr. Iris Wallenburg for constructive feedback that substantially improved this manuscript.
Financial support
This work was funded by PP and KS’s LSE PhD Scholarship.
Competing interests
PP and KS are recipients of a no-obligation scholarship funded by Vitality through the Vitality–LSE research collaborative. The views and opinions represented in this manuscript are solely the authors and do not necessarily represent the views of Discovery Limited or Vitality Corporate Services Limited. Representatives of the Discovery Group insurers had no input into the research questions, methods, or interpretation presented in this manuscript.
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