The origins of National Health Insurance

The White Paper on National Health Insurance was published on 11 December.

This draft policy has its origins in debates that emerged in the late 1980s.

For those of you interested in the history of these debates, read the publication below that was published by Wits University’s Centre for Health Policy in 2000.

The document talks about the important design features of different policy proposals during the 1990s, as well as the lessons learned during this time with respect to managing the process of policy development.

The document is out of print, but I’ve managed to resurrect it using an old copy.

Doherty J, McIntyre D, Gilson L, Thomas S, Brijlal V, Bowa C, Mbatsha S. 2000. Social health insurance in South Africa: past, present and future. Johannesburg: Centre for Health Policy, for the Centre for Health Policy (University of the Witwatersrand) and the Health Economics Unit (University of Cape Town).

Achieving universal health coverage in South Africa requires higher public sector spending

This article was published in The Conversation on international Universal Health Coverage Day on 12 December:

Doherty J, McIntyre D. 2015. South Africa needs to spend more on health care to achieve universal cover. The Conversation – Africa. 12 December 2015.

Universal health coverage assessment: South Africa

If anyone missed this in an earlier blog, I’ve posted a preliminary assessment of South Africa’s progress towards universal health coverage here.

The purpose of the assessment is to use what data are available to analyse the extent to which South Africans are enjoying financial protection against the costs of using health care services, and accessing the services they need.

Getting South Africa ready for National Health Insurance: critical next steps

Here are the powerpoint slides for a recent presentation I gave about National Health Insurance to a Symposium by Economic Research Southern Africa (ERSA) on 6 February 2014:   ERSA NHI presentation_Jane Doherty 

The theme of the Symposium was “Critical choices regarding universal health coverage” and it was held at the Stellenbosch Institute for Advanced Study.

My presentation was titled “Getting South Africa ready for NHI: critical next steps.” 

If you look on ERSA’s website you will find more details on the Symposium.

NHI Snippets (6): NHI and staff shortages: how can clinical associates help?

South Africa has begun producing a new type of health professional – a clinical associate.

You can read a bit more about clinical associates here but, in brief, they are people ideally suited to working in hospitals, helping doctors carry out some of their tasks – like dealing with emergencies and doing procedures.

Clinical associates don’t replace doctors or nurses  – they work with them, sharing some of their workload, and allowing them to concentrate on the tasks for which only they are qualified.

There is no doubt that more doctors and nurses need to be trained and recruited into the South African health system. But will this alone solve the country’s staff shortages? Realistically, how many decades will it take to fill all the country’s vacant posts? Can the country afford a system exclusively based on doctors and nurses? Is this even necessary?

It takes less time to train a clinical associate. They can become very good at what they do because they focus on a special set of skills and are supervised by doctors. They are recruited from rural and disadvantaged communities. Health workers a bit like them have made an enormous difference to many health systems around the world, especially in Africa but even in the United States.

So clinical associates could do a lot to address staff shortages in the public sector, especially in district hospitals. They could help bring good quality care closer to communities in a way that is affordable for the country. Along with other initiatives – such as strengthening hospital management – they could help produce public services that live up to the aspirations of the NHI policy.

So why isn’t there more excitement about this new category of health professional? Why don’t we hear about them in the press or from government spokespeople?

Clinical associates are noted as a priority in the latest government human resource strategy but the future of clinical associates and the strategy of NHI need to become much more closely intertwined.

NHI Snippets (5): The government’s green paper on NHI

Some of you who have been following my ‘NHI Snippets’ blog may be feeling frustrated because I haven’t yet summarised the government’s NHI proposal or begun to analyse its strengths and weaknesses.

Please be patient! – I’m trying to set down some background information so that we can have an informed discussion. 

In the meantime, if you want to read the National Department of Health’s Green Paper on National Health Insurance in South Africa, you can find it here on the Department’s website.

The same website also has as useful summary of the main implications of the Green paper which can find here.

When discussing a reform as potentially wide-ranging as NHI I think it is important to have read the original documentation!

NHI Snippets (4): Too many women die in South Africa from causes related to childbirth

In NHI Snippets (2) I made the point that health in South Africa is poor, especially when viewed in light of the country’s relative wealth.

I gave some figures on how many women die from causes related to childbirth.  I know these figures can seem very abstract so, as promised, I’ve found a graph (by Jack Langenbrunner) that helps to show how well South Africa does in preventing these deaths compared to other countries. 

Click “MMR relative to other countries” to see the graph and here to see the full presentation which includes additional graphs on other health indicators (the link takes you to the Health Systems Trust page with all the conference presentaitons – you will find Jack Langenbrunner’s presenation on Day 2).

As you can see, South Africa does badly when one considers both its average per capita income and its average per capita spending on health (in the graph, countries in the top right block manage to ‘buy’ much less health for the money they have at their disposal).  In this sense, South Africa is much less ‘efficient’ than some poorer countries that do much better.

NHI Snippets (3): Will NHI lose jobs?

Today I read an article in The Star’s business report entitled Private hospitals highlight danger of job losses (page 15 with a follow-up on page 16).

One of the points made is that the private hospital industry makes a large contribution to the economy, both directly and indirectly, through job creation and tax contributions.  If patients who were formerly privately insured were no longer able to afford private cover (and use private hospitals) because they were obliged to pay mandatory NHI contributions, this could result in job losses, at least according to the article.

I think it is valid to explore the impact of any proposed reform on the economy (as long as one balances this against other benefits) and I would be very interested in seeing modelling exercises that attempt to estimate this impact comprehensively.

Off the top of my head, though, I question the logic of the article on the following grounds:

1. The public health sector is already a massive employer, far larger than the private sector, and is set to grow under NHI.  This is because NHI is intended to expand health care coverage dramatically.  This will require an expanded workforce, especially in the public sector but quite possibly also in the private sector, especially at the primary care level.

2. As the article states, only a quarter of those who gain employment because of the existence of private hospitals are directly employed by those hospitals.  The other three-quarters are employed by companies that service private hospitals in some way.  If patients were to shift to public hospitals under NHI, presumably there would be a similar positive knock-on effect for entities (both public and private) that service public hospitals. 

3. NHI is intended to make financial protection for health care more affordable for everyone, including employers who currently pay large subsidies towards workers’ medical scheme cover.  This should make it cheaper for employers more generally to take on additional staff and boost employment.   

3. In the long term, improving the health of a country’s population leads to economic growth (at some stage I’ll haul out some evidence for this).  

So I can’t see NHI damaging employment, at least if it is designed and implemented well.  In any case, I think the heart of the affordability problem is really the high cost of private care, especially in hospitals.  We can talk later about the reasons for this but, in the meantime, you might like to read some facts about the efficiency of the private sector in a related post (click here).

NHI Snippets (2): Poor health in South Africa

Oops, an earlier version of this post had incorrect information! – I copied it from what I thought was a reliable source but didn’t check it.  This is what happens when writing late at night!  In future, if any readers notice mistakes, please let me know.  Here is the corrected version …

“In my previous post I made two points – one, that South Africa spends a large amount on private health care and, two, that the health of South Africans is poor in comparison to other countries of equivalent wealth.

I’m going to elaborate the second point here.

Set aside for a moment the question of why health is poor, and concentrate on grasping some simple health indicators.

One of the most shocking statistics is that, every year, 147 women die from causes linked to child birth for every 100,000 births.  This is known as ‘the maternal mortality rate’ and is around 4 times higher than the target of 38 set for the Millennium Development Goals (high-income countries usually have rates that are in the single digits as shown here). 

Of course, one could argue that South Africa’s high maternal mortality rate reflects the HIV/AIDS epidemic.  This is true to some extent:  it is estimated that just under half (around 44%) of maternal deaths can be attributed to HIV/AIDS.1  Yet this still leaves South Africa with a high non-HIV/AIDs-related maternal mortality rate and, in any case, a good health system should be able to reduce the impact of HIV/AIDS on maternal mortality.

Here are some indicators that reflect the poor health of children in South Africa:



(around 2008)

2015 Millennium Development Goal target

Number of children who die before they reach the age of 5 for every 1,000 who are born



Number of children who die before they reach the age of 1 for every 1,000 who are born



For a later post I’ll find you some graphs that show how this performance compares to other upper middle-income countries.

I’ll also see whether I can source some more up-to-date statistics for South Africa from the Medical Research Council’s Burden of Disease Unit.”


1.  Burden of Disease Unit.  2008.  Every death counts:  saving the lives of mothers, babies and children in South Africa – data supplement.  Cape Town:  Medical Research Council.  (Click on the link to read this easy-to-understand policy brief or click here to read the academic article that was published in The Lancet.)

2.  National Department of Health.  2011.  Human Resources For Health South Africa.  HRH Strategy for the Health Sector 2012/13-2016/17.  Pretoria:  National Department of Health.

NHI Snippets (1): Where do I start?

National Health Insurance in South Africa:  Where do I start? 

“Start with something sensational,” said a friend, “otherwise no-one will read your blog.” 

The trouble is, though, that National Health Insurance is a complex concept.  It’s hard to explain and it’s hard to tease out all the arguments underlying the way it has been conceptualised. 

So I think this blog needs an audience that is willing to put an effort into understanding NHI, whether or not I write sensationally.  Let me put my faith in you …


To start, then, I think there are two basic facts about the South African health system that we need to know to gain some perspective on the NHI debate:

Fact 1: 

South Africa channels as much money through medical schemes as it gives in taxes to health care services.1  There is no other country in the world that relies to such an extent on private health insurance.2 

Fact 2:

The health of the average South African is poor relative to the wealth of the country.  South Africa is an outlier on graphs that compare the health indicators of countries against their GDP per capita.3

The poor performance of both the public and private health care sectors lies behind these two facts.  It is this that has driven the development of the NHI proposal.


P.S.  Don’t worry if you don’t understand the term ‘National Health Insurance’ or what the South African government is currently proposing.  I will deal with this in later posts.




1.  McIntyre DE, Doherty JE, Ataguba JE. (forthcoming). Health care financing and expenditure – progress since 1994 and remaining challenges. Health and health care in South Africa (2nd edition). Van Rensburg H. Pretoria: van Schaik Publishers.

2.  Drechsler D, Jutting J. (2005). Is there a role for private health insurance in developing countries?  Berlin:  German Institute for Economic Research.

3.  Langenbrunner J. (2011).  Presentation to National Health Insurance Conference:  Lessons for South Africa, 7-8 December 2011,  Gallagher Estate, Midrand, South Africa