van den Heever BMC Public Health 2012, 12(Suppl 1):S5 http://www.biomedcentral.com/1471-2458/12/S1/S5 Page 4 of 13 Figure 1 Medical scheme beneficiaries from 1990 to 2010 Data from Council for Medical Schemes’ Annual Reports [29]. The deregulation of 1994 resulted in the movement of beneficiaries from closed schemes to open schemes. The drop in beneficiary growth from 2000 to 2006 resulted from a stagnation of economic growth. From 2006 most beneficiary growth results from the introduction of the Government Employee’s Medical Scheme (GEMS), with some growth also resulting from increased economic growth. The introduction of GEMS, which is a closed scheme, also resulted in a switch away from open commercial schemes. Within fifteen years seven more funds of this nature were established as the mining economy grew. Health insurance arrangements preceded the establishment of any government structure to supervise health care which occurred for the first time only in 1919 following the establishment of the Union of South Africa in 1911, which consolidated four separate countries following the Anglo Boer war, and the influenza epidemic of 1919. By 1940 around forty eight occupational schemes existed. Only from 1956 were medical schemes regulated for the first time. Due to the rapid growth of South Africa’s economy the number of schemes increased to 169 by 1960 with beneficiaries almost exclusively white. By 1990 the number of schemes peaked at around 230 with some schemes serving more than one employer [15]. The first coherent regulatory framework was imple- mented in 1967 which consolidated the legal definitions, historically spread through various pieces of legislation, and established registration and compliance structures. During this period and up until around 1984 medical schemes were non-competing occupational funds spon- sored by employers or industries. They were supervised as trust arrangements with boards representing the interests of beneficiaries and employers. No profits were permitted or surpluses distributed. Benefits and provider tariffs were also regulated by way of a highly contested scale of benefits prepared by the Representative Associa- tion of Medical Schemes (RAMS) a private association representing all medical schemes. Tension between RAMS and healthcare providers resulted in ongoing government vacillation between various models of col- lectivised tariff setting [15] . As medical schemes were predominantly non-competing at this time, with risk pools framed around medium-to- large employers and industries, benefit designs and the set- ting of contributions complied largely with the principals