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National Health Insurance: South Africa’s most progressive reform to date

Although the National Health Insurance (NHI) White Paper takes a socialist approach to universal health care, how will it be implemented in South Africa’s neo-liberal environment? Additionally, support from key stakeholders including citizens and doctors is necessary as is decentralisation and proper funding, write Shakira Choonara and John Eyles.

‘Implementation of NHI is a reflection of the kind of society we wish to live in: one based on the values of justice, fairness and social solidarity. Implementation of NHI is consistent with the global vision that health care should be seen as a social investment and therefore should not be subjected to market forces where it is treated as a normal commodity of trade ... The key focus of the NHI transformation is to create a single, publicly owned and administered NHI Fund that purchases health services on behalf of the entire population from suitably accredited providers. Transforming the health care financing system requires changing how revenue is collected to fund health services and, even more importantly, addressing how generated funds are pooled and how quality services are purchased. This is critical for improving the use of available financial resources and the health of the population’ – White Paper National Health Insurance 2015. Globally, under Sustainable Development Goal 3 (SDG) – target 3.8 calls for member countries of the United Nations (UN) to achieve Universal Health Coverage (UHC). Margaret Chan (director-general) of the World Health Organisation (WHO) describes UHC as the single most powerful concept in public health. It refers to ensuring that all citizens have access to affordable quality care without suffering any financial hardship to pay for it. Health reforms were put on the agenda in South Africa as early as 1928. In 1994 health reform was on the agenda of the African National Congress (ANC). However, it was only at the party’s elective conference in 2009 that a firm commitment to implementing UHC was made. Two years later, the SA government released the Green Paper on NHI which is a solidaristic transformation with serious financial challenges. NHI is crucial to addressing the inequities of the past, especially when it comes to the provision of health care. Presently the private health sector covers only 16.2% of the population and enjoys the majority of financial and human resources in the country, while the public health sector serves the remaining 84% of the population. The NHI Green Paper argues that over the past decade private hospital costs have increased by 121%, specialist costs have increased by 120% and member contributions to medical aid schemes have doubled over a seven-year period. Members of private medical schemes are also subject to high co-payments for services which are not covered by medical schemes and out-ofpocket payments when medical savings/benefits are exhausted. Providing health care through private mechanisms is proving to be unsustainable. On the other hand, public sector woes are constantly reported in the media and experienced by patients on a daily basis. The public sector in SA is poorly managed, characterised by poor quality, extremely long waiting times, unclean facilities and frequent drug stock-outs. NHI might not address all challenges in both the private and public sector but the SA government is certainly on the right path to doing so.

Taking stock of the NHI

Broadly, the NHI is described as a health financing system that is designed to pool funds to provide Broadly, the NHI is described as a health financing system that is designed to pool funds to provide access to quality, affordable health services for all SA citizens based on need, irrespective of their socioeconomic status. The Green Paper in 2011 set a 14-year timeline for the implementation of NHI which was broken down into three phases. Below are some of the […]


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