Over 50% of South African adult women and 30% of adult men are either overweight or obese, and nearly half of all adults are insufficiently active, with major increases in obesity-associated healthcare expenditures since 1980, a high proportion of which are paid by private health insurance. In this paper, we describe the Vitality programme, an incentivized health promotion programme from South Africa's largest private health insurer, Discovery Health, with over 2.5 million beneficiaries. Wellness activities of the programme include health risk assessments, subsidized gym memberships and smoking cessation or weight loss programmes with many incentives, including cash back on purchases of healthy foods. This incentive-based programme has shown a significant relationship between levels of engagement in wellness activities, in particular increasing participation in fitness-related activities, with lower healthcare expenditure and an increase in the overall ratio of healthy foods to total food purchases. This programme demonstrates that incentives may reduce the barriers for entry into care, increase preventive screening and increase engagement in healthy behaviours for prevention and management of obesity. This 'carrots versus sticks' approach may have implications for public health policy even in lower- and middle-income settings and underserved communities.

Discovery Health’s ‘Vitality’ programme of incentives has been running for 12 years in South Africa, and is now being introduced to other parts of the world:

• it has been in place in the UK for about five years, with PruHealth;

• a new joint venture with Humana (Humana Vitality) was launched two weeks ago in the United States;

• a partnership with Ping An in China has being established.

While Vitality is a key part of the Discovery business, there are many ideas and initiatives in the programme that can be adapted and used in broader health promotion and healthcare policy.

Discovery was started in 1993 in South Africa, where it pioneered a consumer-focused health insurance product. Since its inception, the business has grown exponentially and broadened into other areas of financial services, as well as into other geographical regions.

Vitality, the scientific-based wellness company, was introduced to the South African market in 1998. At the time it really seemed like a novel idea to pay for health as opposed to sickness – over the last few years, we have, however, seen much greater awareness of preventative care and a much greater focus on wellness by industry and consumers.

Insurance is the product; Vitality is the incentive scheme.