South Africa

Total Population: 55,908,865 Membership: Associate Member Language: English, Afrikaans, Zulu, Xhosa, Southern Sotho, Tswana, Northern Sotho, Venda, Tsonga, Swati, and Ndebele

Achieving equity in access.

Through consistent political will, South Africa has made steady progress toward health for all

The Context

South Africa has sought to advance equity of health care for its citizens since 1994. Today, South Africa has a mixed health care system of private and public providers, with most of its health care services coming from public providers. These reforms had a transformative effect on health care utilization and although reforms have increased parity of health expenditure across the country, the country continues to face challenges from the burden of diseases like HIV, inadequate distribution of care and management mechanisms.

The introduction of National Health Insurance (NHI) could further transform the health landscape. Under the current system, South Africa struggles with an overburdened public sector. The NHI is intended to reform the existing health sector by revamping financing mechanisms through contracting public and private providers and balancing quality between private and public health care services. To achieve full health coverage through the National Health Insurance, the government will need to grapple with the interests of public and private stakeholders while developing sustainable financing frameworks.


South Africa’s most significant reforms centered on increased access to essential health care services. In 1994, the South African government ushered in a new policy for public health facilities by providing free health services to pregnant women and children under six and established free primary health care. These changes were buoyed by a sustained political focus on equitable distribution of resources across the country. Nevertheless, the removal of fees contributed to a significant increase in the utilization of health services, but only solved part of the challenge.

Users of health care services in South Africa were also hindered by a shortage of quality health care facilities. In response, the government commenced the Clinic Upgrading and Building and Hospital Revitalization programs. These programs focused particularly on upgrading health infrastructure through rebuilding current facilities, replacing equipment and constructing new facilities.

Reforms in all of these areas have continued with the expansion of free primary health care and the introduction of additional initiatives to strengthen the primary health care system. The National Health Act of 2003 created a framework listing administrative responsibilities of the health care system across all national, provincial and district levels. Additionally, the Re-Engineering Primary Health Care initiative sought to strengthen district health systems.

In 2010, the Department of Health proposed a ten-point plan to address the most persistent problems affecting health outcomes. One of these points lead to a green paper on National Health insurance that outlined a 14-year plan which became a white paper in 2017 that is the basis of the National Health Insurance scheme. The first phase of this launched a pilot of NHI and established crucial registration and payment systems and launched programs in various districts across the nation. A NHI bill is currently being considered by parliament. If passed, South Africa would enter phase two of the plan. This would focus in large part on state purchasing of services, implementation of provisional pooling and enforcement of NHI standards across public and private sectors.

South Africa in the JLN

As South Africa transitions to a new health system under the NHI, there is an interest in how countries in the JLN have handled major reforms and shifts in their health care system. South Africa plans to focus on payment mechanisms and health financing while the country is in the preliminary stages of expanding the network.