Since the dawn of democracy, the health sector has undergone several reforms to establish a more equitable, accessible and affordable healthcare system, that can meet the health needs of all South African residents. However, these past reforms have been too little and too slow.

Everyone has the right of equal access to quality and affordable healthcare. Fundamental changes are required to create a strengthened healthcare system capable of providing this level of service.

The problem: South Africa’s health system is very complicated and fragmented, resulting in high levels of waste. Consequently, health outcomes do not match the resources invested into the system. Both public and private sector have challenges that make current healthcare delivery systems unsustainable.

The plan to strengthen the health system: South Africa is a member of the United Nations community and has committed to implement universal health coverage, as have all other 95 member states. The desired outcome is that “all people have access to the full range of quality health services they need, when and where they need them, without financial hardship”.

The National Health Insurance (NHI) is South Africa’s strategy to achieve universal health coverage. The NHI is a centralised, national insurance fund from which the government will buy healthcare services from healthcare providers in both public and private sectors. All eligible South African residents, as defined in the NHI Act, will be able to visit these providers whenever they need healthcare, without any payment. The NHI will make healthcare more affordable, by reducing the cost of healthcare due to the economies of scale that can be achieved by purchasing healthcare for the entire population. Like home or car insurance, everyone will contribute to this fund routinely, whether they need healthcare or not, and then make a withdrawal from these pooled funds when they need healthcare. Contributions will be made through taxes and special contributions, in line with what each person can afford. “Withdrawals” will be made every time they visit a healthcare provider. When visiting a healthcare provider, they will not have to make any payment, because the NHI Fund will pay for the costs of care.

NHI’s History: The NHI is a journey to transform South Africa’s health sector. It will take many years to be fully realised and requires input from all sectors to ensure no one is left behind. For the NHI Fund to be effective, the entire health system will undergo reform for many years to come. These reforms include integration of the private and public sectors and reforms to make both sectors more effective and more efficient, which will include implementation of robust governance structures.

The NHI is not a new concept, nor specific to South Africa. Many countries around the world implement a similar structure to provide affordable and accessible quality healthcare. The NHI journey started in 2011 when the NHI Green Paper was published for public consultation. This was followed by NHI pilot projects in 2012 with a focus on health system strengthening initiatives. The NHI White paper was published in 2015 laying the foundation for the NHI as the vehicle to achieve universal health coverage and a unified health system.

The signing of the NHI Bill into law on the 15^th May 2024 by the President was a key milestone in the journey towards universal and comprehensive quality health coverage for all.

Now that the Bill has been assented to by the President, the National Health Insurance (NHI) Act will be phased in gradually, using a progressive and programmatic approach based on financial resource availability from 2024 to 2028. The Act will be implemented in two phases:

• Phase 1 commenced in 2023 and will continue for a period of three years until 2026.
• Phase 2 will commence in 2026 and will run for a period of another three years until 2028.