Integrating HIV Financing and Services into South Africa’s Emerging National Health Insurance System

The Challenge

South Africa’s government has committed to achieving universal health coverage. A proposed national health insurance (NHI) system would consolidate resources in a centrally managed Fund that purchases services on behalf of the entire population. In preparation, the government is already reengineering primary health care to ensure all public clinics are adequately staffed, equipped, and managed.

At the same time, South Africa has embraced UNAIDS’ ambitious 90-90-90 targets for HIV services. Today more than 3 million South Africans living with HIV receive life-sustaining therapy, reflecting the country’s rapid scale-up of treatment and prevention. Until a cure emerges, they and 4 million additional people living with HIV will need treatment for the rest of their lives. Meeting their health needs will require even greater investment in HIV services, which already consume more than a tenth of the government’s health budget.

Integration of financing for HIV and other health services may be a means of promoting health system efficiency, especially if systems of service delivery, procurement, and oversight can be aligned and strengthened across program areas. If carefully implemented, integration may also enable a smooth phase-out of external funding for South Africa’s HIV response, including from PEPFAR and the Global Fund to Fight AIDS, TB, and Malaria.

The Opportunity

South Africa needs an HIV financing strategy that supports and expands high-quality HIV care and treatment, ensures widespread and equitable access to services, and promotes efficiency in service delivery. NHI will introduce a purchaser-provider split into the government-financed health system, signaling a shift to contractual, output-based payments to public- and private-sector service providers. Many HIV prevention, care, and treatment services are likely to be included in the benefits package to be paid for by the NHI Fund.

Integrative financing reforms require careful examination of the three health financing functions—revenue collection, pooling of funds and risk, and purchasing of services—as well as of service delivery. Reconfiguring one or more of these can imply significant changes throughout the health system, from the systems required centrally to monitor performance, to the district-specific resource requirements for delivering essential services, to the day-to-day incentives influencing clinical practices.

Our Work

R4D supports the Government of South Africa to design and implement an NHI system that will sustain and expand the country’s formidable HIV response. Building on its groundbreaking work on HIV financing integration, R4D collaborated with the National Treasury and the National Department of Health to evaluate multiple scenarios for financing integration. We developed the scenarios in close consultation with senior government officials and other stakeholders. We then evaluated them using a novel framework focused on health system impact and legal, political, and technical feasibility.

R4D is also partnering with the National Department of Health and USAID’s Financing Capacity Building and Technical Support Project (FIN-CAP) to conduct consolidated expenditure tracking and mapping for South Africa’s HIV and TB programs, analyzing spending by the government, PEFPAR, and the Global Fund.

Previously, R4D advised the government of South Africa on resource allocations for HIV and TB for financial years 2017/18 to 2019/20 and supported the government’s Primary Health Care Costing Task Team, including facilitating regular meetings, providing methodological and analytical guidance, and compiling a synthesis of participants’ studies on public- and private-sector costs.

R4D’s work on HIV financing integration in South Africa was supported by UNAIDS in 2015-16 and has continued under the USAID-funded Health Finance and Governance Project (HFG), in collaboration with Abt Associates.



South Africa




Abt. Associates



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