Health insurance

Since the 2009 Lancet Health in South Africa Series, important changes have occurred in the country, resulting in an
increase in life expectancy to 60 years. Historical injustices together with the disastrous health policies of the previous
administration are being transformed. The change in leadership of the Ministry of Health has been key, but new
momentum is inhibited by stasis within the health management bureaucracy. Specific policy and programme changes
are evident for all four of the so-called colliding epidemics: HIV and tuberculosis; chronic illness and mental health;
injury and violence; and maternal, neonatal, and child health. South Africa now has the world’s largest programme of

South Africa’s health system is undergoing a muchneeded strategic review. Both the public and the private sectors are affected. And the role of regulators remains crucial in this changing environment. The Council for Medical Schemes continued to execute its mandate in the financial year under review. By guiding the medical schemes industry into unprecedented stability and performance, Council continued to support e¥orts aimed at strengthening the entire health system of the country.

There is widespread consensus that providing universal, sustainable, affordable and quality health services underpins efforts to achieve equitable health outcomes. UNICEF in 2010-2011 conducted a two-phase landscape analysis, funded by the Rockefeller Foundation, to investigate how health insurance and other social health protection mechanisms contribute to achieving universal health coverage (UHC). The work built on previous research examining the protection from impoverishment that health insurance provides to vulnerable groups, the potential for increasing and expanding insurance coverage, and the options for and constraints limiting the use of insurance to attain UHC. 

The use of ‘co-payments’ to deal with possible ‘over-utilisation’ of health care services is a key point of contention in policy debates related to South Africa’s National Health Insurance proposals.

Over-utilisation occurs when health care provision (in instances when it is free at the point of service), leads to inappropriate and excessive utilisation.  Co-payments mean users still receive health services that are heavily subsidised (from public funds in the case of the proposed NHI), but have to pay something towards the cost of services – this aims to curb the frivolous use of services and avoid over-utilisation.

The South African Health Review 1996 documents the degree to which structural reform and policy formulation within the health sector has translated into real improvements in service delivery and the quality of peoples lives. In sum, the Review reveals a mixed scorecard. Progress has been excellent in some areas, whereas others show little movement. This, the Review argues, is the nature of health reform.

Perhaps the overriding success of the Ministry of Health has been the process of restructuring towards primary health care, reflected both in the organisation of health care and expenditure patterns. Equally impressive has been the introduction of an essential drugs list within the public sector, which is likely to improve the availability of medicines over a relatively short period of time. At local level, the Department of Health can take credit for generating tremendous enthusiasm for change amongst service managers and health workers.

But in the critical areas of financing and health legislation, progress has been slow. Discussions about some form of social health insurance have borne little fruit. A new Health Act is in its seventh draft, but has not been available for public comment. In addition, controversy over Cuban doctors and vocational training for new graduates has often obscured the need for a comprehensive plan for addressing the maldistribution of health personnel in South African - from province to province, between public and private sector, and between hospital and primary care facilities. All of the above need to be addressed as a matter of urgency in the next year.

The South African Health Review 1996 tackles Sarafina 2 head-on, and considers its effect on HIV/AIDS prevention, the ability of the Department to make progress over the past year, and the relationship between the executive and legislative arms of health governance. But it places the biggest controversy faced by the Health Department during 1996 in the context of the full programme of health care reform initiated by the Ministry. Areas of energy and activity which serve as the vanguard of health reform have been identified, as have bottlenecks which impede progress.