Health Policy in South Africa - From 1994 to now: Towards convergence between public and private health financing

Optimism about the prospects of better healthcare for all ran high after SA’s peaceful transition to democracy in 1994. This policy paper reviews a series of health reforms instituted after the end of apartheid up to the president’s assent to the National Health Insurance (NHI) Act 30 years later. It considers which policy interventions have been most significant, the missed opportunities, and the role of various forms of collaboration between the public and private sectors. Given that the ANC’s NHI Act faces intense opposition from other political parties within the government of national unity and from other stakeholders intent on litigation, implementation is likely to be delayed. We therefore pose the question: if not NHI, then what? Informed by a series of discussions with experts, we argue that for a return to key steps in the reform path envisaged in the 1990s, seemingly abandoned after 2007. We suggest several ways in which greater collaboration between the public and private sectors should be sought, and in which regulated competition offers scope to improve healthcare in the medium term while contributing to more equal access to health services. This analysis is based on a review of national legislation, policy documents, peer-reviewed publications, commissioned reports, presentations to parliament and conferences, media articles, and the views of experts in the field. In-depth interviews of up to two hours were conducted with 13 key informants chosen for their experience and insight into health policy development and implementation. They include academic researchers, independent health analysts, and senior figures from the public and private sector.