

National Health Insurance in South Africa History of National Health Insurance in South Africa: Download full PDF Document A National Health Service attempted in the 1940s The WHO tells of the attempted introduction of a National Health Service in South Africa in the 1940s, saying “A scheme for a national health service broadly similar to the British model was proposed in South Africa in 1944, comprising free health care and a network of community centres and general practitioners as part of a referral system, but was not implemented.” (World Health Organization (2000). The World Health Report 2000: Health Systems: improving performance Geneva. p13 URL: http://www.who.int/whr/2000/en/index.html ) Prof Anne Digby has written a very interesting paper on the reforms in South Africa in the 1940s, contrasting them with the reforms that created the National Health Service in the UK at the same time. The role of vested interests in influencing the implementation of NHI is a cautionary tale. Digby, A. (2008). ‘Vision and Vested Interests’: National Health Service Reform in South Africa and Britain during the 1940s and Beyond. Social History of Medicine, 21(3), 485-502. URL: http://shm.oxfordjournals.org/cgi/content/abstract/21/3/485 “Both Britain and South Africa considered major health reforms during the 1940s and there was mutual interest in the ideas being generated. In South Africa, the Report of the National Health Services Commission of 1944 advocated a national health service based on health centres that would integrate curative, preventive and promotive work. Parallel with this were plans by the provinces for free hospital treatment. Scarce finance, together with political and medical vested interests, meant that the health centre ideal only survived in minor form. In Britain, a free national health service was created in 1948, in which a reformed structure of hospitals was central, and early plans for health centres were marginalised. In each country, limited financial resources and vested interests- in the form of powerful medical professional associations or (in the case of South Africa) of provincial administrations-delayed, scaled down or reshaped the original reforming vision.” Proposals from 1994 to 1999 The current National Health Insurance reform has its origins in the ANC Health Plan of 1994 which included the introduction of a mandatory insurance system. This key document is still used extensively to guide the direction of reforms throughout the health system. African National Congress (1994). A National Health Plan for South Africa Johannesburg: African National Congress. URL: http://www.anc.org.za/show.php?doc=ancdocs/policy/health.htm Subsequent committees of inquiry confirmed the need for the reform of healthcare financing: 1994: Health Care Finance Committee 1995: Committee of Inquiry into National Health Insurance 1997: Department of Health SHI Working Group 2002: Taylor Committee of Inquiry into Social Security 2004/5: Ministerial Task Team for Implementing SHI The 1995 Committee of Inquiry, led by Dr Jonny Broomberg and Dr Olive Shisana, confirmed the principles in the ANC Health Plan and provided more detail of the intended role of medical schemes in NHI. Broomberg, J., & Shisana, O. (1995). Restructuring the National Health System for Universal Primary Health Care. Report of the Committee of Inquiry into a National Health Insurance System. Executive Summary. June 1995. [download here] The Department of Health White Paper of 1997 provides material on the whole health system and a draft document in the same year provided detail on the role of the private sector in healthcare financing. Department of Health (1997). White Paper for the Transformation of the Health System in South Africa. April 1997. Pretoria. URL:http://www.doh.gov.za/docs/policy/white_paper/healthsys97_01.html Department of Health (1997). Reforming Financing of Private Health Care in South Africa: The Quest for Greater Access and Efficiency. A Draft Policy Document. August 1997. Pretoria. [download here] Social Security Reform and the Taylor Committee of 2002 The Taylor Committee Report of 2002 provides a vision for the transformation of all aspects of social security, including retirement reform and healthcare reform. This is an important document and the recommendations are still being implemented. The section on healthcare is only some 7 pages in a 190 page document. More detail on the healthcare section is provided in the Department of Health submission to the Taylor Committee, which is some 180 pages in its own right. That document has a useful history of the public and private sectors, an assessment of the challenges and recommendations for comprehensive reform. Department of Social Development (2002). Transforming the Present - Protecting the Future. 2002. Pretoria: Report of the Committee of Inquiry into a Comprehensive System of Social Security for South Africa. Previously available on DoSD web-site. [Download here] Department of Health (2002). Inquiry into the Various Social Security Aspects of the South African Health System: Policy Options for the Future. 14 May 2002. Previously available on DoSD web-site. [Download here] Towards Implementation: 2003 to 2007 The Department of Health established two Consultative Task Teams followed by the Ministerial Task Team to look at detailed aspects of the implementation of Social Health Insurance. The Consultative Task Team reports and the International Review Panel assessment are in the public domain. However none of the many Ministerial Task Team reports were placed in the public domain and only the last report is included in the list of documents below. Department of Health (2003). Opening Address to the Consultative Forum on Risk Equalisation by Dr Ayanda Ntsaluba, Director-General, Department of Health. 10 July 2003. Midrand. Document can be downloaded here (135 Kb) [Download here] McLeod, H., Matisonn, S., Fourie, I., Grobler, P., Mynhardt, S., & Marx, G. (2004). The Determination of the Formula for the Risk Equalisation Fund in South Africa. January 2004. Pretoria: Prepared for the Risk Equalisation Fund Task Group on behalf of the Formula Consultative Task Team. URL: http://www.medicalschemes.com/publications/publications.aspx?catid=23 Roux, A. (2004). The Funding of the Risk Equalisation Fund in South Africa. Prepared for the Risk Equalisation Fund Task Group on behalf of the Subsidy Consultative Task Team January 2004. Previously available on http://www.medicalschemes.com Armstrong, J., Deeble, J., Dror, D. M., Rice, N., Thiede, M., & Van de Ven, W. P. M. M. (2004). The International Review Panel Report to the South African Risk Equalization Fund Task Group. 16 February 2004. Pretoria. URL: http://www.medicalschemes.com/publications/publications.aspx?catid=23 Ministerial Task Team on Social Health Insurance (2005). Social Health Insurance Options: Financial and Fiscal Impact Assessment. Unpublished technical report to the Department of Health. June 2005. Draft legislation to implement the Risk Equalisation Fund, as a first step in the development of Social Health Insurance, was gazetted for submission to parliament in 2008. There were substantial objections to the Medical Schemes Amendment Bill (2008) from organised labour and civil society organisations and the bill does not seem to have been tabled in parliament. The progress of bills through parliament can be followed at http://www.parliament.gov.za/live/content.php?Category_ID=72 ) Summaries and Commentaries on the Process Prof Di McIntyre and Alex van den Heever provide a summary of the history of NHI from the 1940s to 2005. The paper is particularly useful as a summary of developments and for providing an understanding of proposals in terms of the four functions in healthcare financing: revenue collection, pooling, purchasing and delivery. They describe the “considerable discussion and sometimes very heated debates” and outline the core features of each of the proposals. McIntyre, D., & Van den Heever, A. (2007). Social or National Health Insurance. In S. Harrison, R. Bhana & A. Ntuli (Eds.), South African Health Review 2007. Durban: Health Systems Trust. URL: http://www.hst.org.za/uploads/files/chap5_07.pdf URL for whole SAHR 2007: http://www.hst.org.za/publications/711 “While there are some differences of opinion in relation to certain design features for mandatory health insurance, there is considerable consistency in the fundamental objectives put forward for pursuing this form of health care financing.” “South Africa has missed previous windows of opportunity to initiate a mandatory health insurance scheme. ... This is the moment when we need to reach public consensus on mandatory insurance. It is our belief that this can best be achieved by avoiding the past definitional debates and by instead focusing on the primary objectives of a mandatory health insurance and identifying how the key functions of health care financing of revenue collection, pooling, purchasing and provision can be structured to achieve these objectives.” It is useful to stand back from the detail of the reforms and understand the factors that influence the implementation of reforms. Two papers are highly recommended: McIntyre, D., Doherty, J., & Gilson, L. (2003). A tale of two visions: the changing fortunes of Social Health Insurance in South Africa. Health Policy Plan, 18(1), 47-58. URL: http://heapol.oxfordjournals.org/cgi/reprint/18/1/47 Thomas, S., & Gilson, L. (2004). Actor management in the development of health financing reform: health insurance in South Africa, 1994-1999. Health Policy Plan, 19(5), 279-291. URL: http://heapol.oxfordjournals.org/cgi/reprint/19/5/279 “Health reform is inherently political. Sound technical analysis is never enough to guarantee the adoption of policy. Financing reforms aimed at promoting equity are especially likely to challenge vested interests and produce opposition. This article reviews the Health Insurance policy development in South Africa between 1994 and 1999. Despite more than 10 years of debate, analysis and design, no set of social health insurance (SHI) proposals had, by 1999, secured adequate support to become the basis for an implementation plan. In contrast, proposals to re-regulate the health insurance industry were speedily developed and implemented at the end of this period. The processes of actor engagement and management, set against policy goals and design details, were central to this experience.” << Back to NHI Background Briefs and History of NHI	Contact Details: Innovative Medicines SA Val Beaumont P.O. 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National Health Insurance in South Africa
History of National Health Insurance in South Africa:

The WHO tells of the attempted introduction of a National Health Service in South Africa in the 1940s, saying “A scheme for a national health service broadly similar to the British model was proposed in South Africa in 1944, comprising free health care and a network of community centres and general practitioners as part of a referral system, but was not implemented.”

(World Health Organization (2000). The World Health Report 2000: Health Systems: improving performance Geneva. p13 URL: http://www.who.int/whr/2000/en/index.html )

Prof Anne Digby has written a very interesting paper on the reforms in South Africa in the 1940s, contrasting them with the reforms that created the National Health Service in the UK at the same time. The role of vested interests in influencing the implementation of NHI is a cautionary tale.

Digby, A. (2008). ‘Vision and Vested Interests’: National Health Service Reform in South Africa and Britain during the 1940s and Beyond. Social History of Medicine, 21(3), 485-502.
URL: http://shm.oxfordjournals.org/cgi/content/abstract/21/3/485

“Both Britain and South Africa considered major health reforms during the 1940s and there was mutual interest in the ideas being generated. In South Africa, the Report of the National Health Services Commission of 1944 advocated a national health service based on health centres that would integrate curative, preventive and promotive work. Parallel with this were plans by the provinces for free hospital treatment. Scarce finance, together with political and medical vested interests, meant that the health centre ideal only survived in minor form. In Britain, a free national health service was created in 1948, in which a reformed structure of hospitals was central, and early plans for health centres were marginalised. In each country, limited financial resources and vested interests- in the form of powerful medical professional associations or (in the case of South Africa) of provincial administrations-delayed, scaled down or reshaped the original reforming vision.”

The current National Health Insurance reform has its origins in the ANC Health Plan of 1994 which included the introduction of a mandatory insurance system. This key document is still used extensively to guide the direction of reforms throughout the health system.

African National Congress (1994). A National Health Plan for South Africa Johannesburg: African National Congress. URL: http://www.anc.org.za/show.php?doc=ancdocs/policy/health.htm

Subsequent committees of inquiry confirmed the need for the reform of healthcare financing:

1994: Health Care Finance Committee
1995: Committee of Inquiry into National Health Insurance
1997: Department of Health SHI Working Group
2002: Taylor Committee of Inquiry into Social Security
2004/5: Ministerial Task Team for Implementing SHI

The 1995 Committee of Inquiry, led by Dr Jonny Broomberg and Dr Olive Shisana, confirmed the principles in the ANC Health Plan and provided more detail of the intended role of medical schemes in NHI.

Broomberg, J., & Shisana, O. (1995). Restructuring the National Health System for Universal Primary Health Care. Report of the Committee of Inquiry into a National Health Insurance System. Executive Summary. June 1995. [download here]

The Department of Health White Paper of 1997 provides material on the whole health system and a draft document in the same year provided detail on the role of the private sector in healthcare financing.

Department of Health (1997). White Paper for the Transformation of the Health System in South Africa. April 1997. Pretoria.
URL:http://www.doh.gov.za/docs/policy/white_paper/healthsys97_01.html

Department of Health (1997). Reforming Financing of Private Health Care in South Africa: The Quest for Greater Access and Efficiency. A Draft Policy Document. August 1997. Pretoria. [download here]

The Taylor Committee Report of 2002 provides a vision for the transformation of all aspects of social security, including retirement reform and healthcare reform. This is an important document and the recommendations are still being implemented. The section on healthcare is only some 7 pages in a 190 page document. More detail on the healthcare section is provided in the Department of Health submission to the Taylor Committee, which is some 180 pages in its own right. That document has a useful history of the public and private sectors, an assessment of the challenges and recommendations for comprehensive reform.

Department of Social Development (2002). Transforming the Present - Protecting the Future. 2002. Pretoria: Report of the Committee of Inquiry into a Comprehensive System of Social Security for South Africa. Previously available on DoSD web-site. [Download here]

Department of Health (2002). Inquiry into the Various Social Security Aspects of the South African Health System: Policy Options for the Future. 14 May 2002. Previously available on DoSD web-site. [Download here]

The Department of Health established two Consultative Task Teams followed by the Ministerial Task Team to look at detailed aspects of the implementation of Social Health Insurance. The Consultative Task Team reports and the International Review Panel assessment are in the public domain. However none of the many Ministerial Task Team reports were placed in the public domain and only the last report is included in the list of documents below.

Department of Health (2003). Opening Address to the Consultative Forum on Risk Equalisation by Dr Ayanda Ntsaluba, Director-General, Department of Health. 10 July 2003. Midrand. Document can be downloaded here (135 Kb) [Download here]

McLeod, H., Matisonn, S., Fourie, I., Grobler, P., Mynhardt, S., & Marx, G. (2004). The Determination of the Formula for the Risk Equalisation Fund in South Africa. January 2004. Pretoria: Prepared for the Risk Equalisation Fund Task Group on behalf of the Formula Consultative Task Team.
URL: http://www.medicalschemes.com/publications/publications.aspx?catid=23

Roux, A. (2004). The Funding of the Risk Equalisation Fund in South Africa. Prepared for the Risk Equalisation Fund Task Group on behalf of the Subsidy Consultative Task Team January 2004. Previously available on http://www.medicalschemes.com

Armstrong, J., Deeble, J., Dror, D. M., Rice, N., Thiede, M., & Van de Ven, W. P. M. M. (2004). The International Review Panel Report to the South African Risk Equalization Fund Task Group. 16 February 2004. Pretoria.
URL: http://www.medicalschemes.com/publications/publications.aspx?catid=23

Ministerial Task Team on Social Health Insurance (2005). Social Health Insurance Options: Financial and Fiscal Impact Assessment. Unpublished technical report to the Department of Health. June 2005.

Draft legislation to implement the Risk Equalisation Fund, as a first step in the development of Social Health Insurance, was gazetted for submission to parliament in 2008. There were substantial objections to the Medical Schemes Amendment Bill (2008) from organised labour and civil society organisations and the bill does not seem to have been tabled in parliament. The progress of bills through parliament can be followed at
http://www.parliament.gov.za/live/content.php?Category_ID=72 )

Prof Di McIntyre and Alex van den Heever provide a summary of the history of NHI from the 1940s to 2005. The paper is particularly useful as a summary of developments and for providing an understanding of proposals in terms of the four functions in healthcare financing: revenue collection, pooling, purchasing and delivery. They describe the “considerable discussion and sometimes very heated debates” and outline the core features of each of the proposals.

McIntyre, D., & Van den Heever, A. (2007). Social or National Health Insurance. In S. Harrison, R. Bhana & A. Ntuli (Eds.), South African Health Review 2007. Durban: Health Systems Trust. URL: http://www.hst.org.za/uploads/files/chap5_07.pdf
URL for whole SAHR 2007: http://www.hst.org.za/publications/711

“While there are some differences of opinion in relation to certain design features for mandatory health insurance, there is considerable consistency in the fundamental objectives put forward for pursuing this form of health care financing.” “South Africa has missed previous windows of opportunity to initiate a mandatory health insurance scheme. ... This is the moment when we need to reach public consensus on mandatory insurance. It is our belief that this can best be achieved by avoiding the past definitional debates and by instead focusing on the primary objectives of a mandatory health insurance and identifying how the key functions of health care financing of revenue collection, pooling, purchasing and provision can be structured to achieve these objectives.”

It is useful to stand back from the detail of the reforms and understand the factors that influence the implementation of reforms. Two papers are highly recommended:

McIntyre, D., Doherty, J., & Gilson, L. (2003). A tale of two visions: the changing fortunes of Social Health Insurance in South Africa. Health Policy Plan, 18(1), 47-58.
URL: http://heapol.oxfordjournals.org/cgi/reprint/18/1/47

Thomas, S., & Gilson, L. (2004). Actor management in the development of health financing reform: health insurance in South Africa, 1994-1999. Health Policy Plan, 19(5), 279-291.
URL: http://heapol.oxfordjournals.org/cgi/reprint/19/5/279

“Health reform is inherently political. Sound technical analysis is never enough to guarantee the adoption of policy. Financing reforms aimed at promoting equity are especially likely to challenge vested interests and produce opposition. This article reviews the Health Insurance policy development in South Africa between 1994 and 1999. Despite more than 10 years of debate, analysis and design, no set of social health insurance (SHI) proposals had, by 1999, secured adequate support to become the basis for an implementation plan. In contrast, proposals to re-regulate the health insurance industry were speedily developed and implemented at the end of this period. The processes of actor engagement and management, set against policy goals and design details, were central to this experience.”