Supporting South Africa’s National Treasury in the Development of National Health Insurance

The challenge

South Africa faces considerable challenges in ensuring quality, affordable, and universal health care for its population of 53 million. It is home to the world’s largest HIV epidemic affecting almost one-fifth of the general population, suffers from high health insurance and service delivery costs, and faces high income inequality. As a result, only about 16 percent of South Africans are enrolled in health insurance.

In 2011, South Africa’s government launched an ambitious plan to cover all citizens under a single-payer National Health Insurance (NHI) system by 2025. But important policy questions—such as sourcing funds for the NHI, deciding on what services to cover and how to pay for them, and establishing a national insurance fund—remained outstanding. Government officials in key departments such as the National Treasury (NT) expressed a need for critical support and advice on best practices and emerging wisdom in system-wide health financing reforms, service delivery, and governance. Overall, these government departments also needed actively facilitated background engagements and discussions to support the formal process of negotiations on policymaking.

The opportunity

From 2012 to 2015, with support from the Atlantic Philanthropies, R4D provided intensive analytical and capacity building assistance to South Africa’s National Treasury as it engaged in a process of dialogue with other government agencies to design key components of the NHI reform. As South Africa prepared to join other lower- and middle-income nations in pursuing universal health coverage (UHC), R4D’s assistance to the NT enabled the country to benefit from cutting edge policy advice, and avoid investing time and resources in false starts. This work also furthered R4D’s commitment to the global UHC agenda and provided a chance to impact health outcomes in South Africa in the long run, particularly for the large number of South Africans outside the net of affordable and quality health care coverage.

Our solution

R4D adopted a three-prong approach to supporting policymakers in the National Treasury:

  • We worked with the NT Public Finance Division to identify and prioritize system design questions, and produced analytic reports on international experiences and expert advice tailored to South Africa’s context.
  • R4D provided ongoing, rapid assistance to the NT in the form of feedback on proposals and summary memos as the NT prepared key policy documents.
  • Finally, R4D conducted and facilitated workshops in South Africa where government officials, representatives from the private health care sector, and South African experts considered and debated R4D’s analysis of salient reform questions.

R4D assembled a team of staff, South African consultants, and leading international experts in health care financing and reform policy to carry out these activities. Overall, during the three-year project, R4D successfully enhanced knowledge and understanding among key government officials within the NT to engage with their counterparts on designing the proposed NHI, produced analytic outputs and conducted workshops to structure engagements among important stakeholders and move policy forward, and provided ongoing support to ensure that discussions on policy options were backed by evidence and international experience. Specific activities included the following:

  • The R4D team started with a country mission to engage policymakers, learn about key priorities, and convey international experience and practices. The trip successfully enhanced the NT’s understanding of key NHI concepts and facilitated progress on several design elements of NHI. Most importantly, it contributed to the development of the White Paper on NHI, including elaboration of service delivery, financing, and governance options such as mechanisms for purchasing services, developing an NHI fund, and creating a benefits policy.
  •  R4D furthered this work in year 2 of the project by producing a comprehensive report (attached below) detailing how Chile’s AUGE health reform could inform important NHI concepts related to benefits policy and purchasing. These focus areas were the highest priorities for the NT as interagency debate on and drafting of the NHI White Paper continued. In April 2014, R4D led a full-day learning session with participants from the National Treasury, public and private health sector representatives, and other interested stakeholders on benefits and purchasing reform in South Africa in light of international experience.
  • In year 3 of the project, to inform the development of an NHI Fund in South Africa, R4D produced a detailed report (attached below) containing case studies on the governance of public health insurance in Brazil, Canada, Chile, Colombia, and Thailand. The report responded to the NT’s interest in models for governing large public sector entities for purchasing healthcare by detailing relationships in the wider government context within which public sector healthcare purchasers operate, the arrangement of oversight and financing relationships for numerous functions performed by these purchasers, their size and scope, and the evolution of such entities over time. In June 2015, R4D led a workshop in Pretoria to discuss the findings of the report and engage in dialogue with the NT and other stakeholders on important questions for South Africa to consider. Participants discussed how a centralized NHIF may be designed within South Africa’s federated context and what the role of provinces and district health authorities will be in managing and purchasing health care.



South Africa


Atlantic Philanthropies


South Africa National Treasury



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