Since emerging from apartheid three decades ago, South Africa has worked to ensure access to healthcare, food, and social assistance, as promised in the 1996 Constitution’s Bill of Rights. Yet, despite investments, the public healthcare system remains hampered by resource inequity, unmet needs, and insufficient primary care access.
The proposed National Health Insurance (NHI) seeks to reshape healthcare delivery, prioritising quality and accessibility, particularly in underserved areas.
The National Health Act of 2003 established a framework for a uniform health system. However, limitations remain, including an absence of definitive guidelines for essential health services.
Investments often prioritise existing infrastructure rather than expanding essential healthcare access in under-resourced areas. NHI’s intent to prioritise primary care by district level could address this historical imbalance, but it will require focused planning and resource reallocation.
Key challenges facing the public healthcare system
South Africa’s public healthcare system faces declining per capita spending and an overwhelming focus on hospital-based care – 42% of the budget is allocated to central and provincial hospitals. Additionally, the system does not sufficiently consider the country’s changing demographics, including increased life expectancy and a rising young population.
A strategic shift toward primary healthcare and preventive services is needed to meet current and future demands.
NHI is a transformative step, moving away from provincial budget allocations based on historical use and toward a national system prioritising equitable healthcare distribution based on need. Under NHI, the public sector will focus on level-of-care budgeting, with district health management offices leading primary care initiatives.
This reallocation aims to make the healthcare system responsive to local needs, potentially reducing maternal mortality in rural areas, enhancing reproductive health access in urban centres, and expanding HIV and TB prevention programmes.
While NHI’s full implementation may take time, several initiatives could improve primary healthcare access today:
Expanding the district health programme grant: By broadening this grant, provinces can allocate resources to primary care initiatives, focusing on routine healthcare services, reproductive health, and preventive care. This approach also enables the inclusion of private providers, such as NGOs, pharmacists, and GPs, to bridge accessibility gaps in the public system.
Enhancing services for working-class citizens: An estimated 75% of working South Africans earn less than R6,000 per month and struggle to access essential primary healthcare services. Expanding service points, especially in urban areas, could support routine needs like family planning, GP consultations, and oral healthcare.
Repurposing the National Tertiary Services Grant: With an annual budget of R15 billion, this grant could support an in-depth review of public hospitals’ services, resource allocation, and alignment with district-level health needs, ensuring that tertiary services offer value in underserved areas.
Re-envisioning public healthcare beyond NHI: The NHI is often discussed as a state-operated insurance scheme. However, its broader potential lies in restructuring public healthcare to enhance efficiency and equity. Through NHI, South Africa could pivot toward a system focused on preventive, primary healthcare, responsive to local needs, and dedicated to eliminating resource disparities.
As South Africa builds its future healthcare system, NHI presents a unique opportunity to ensure accessible, quality care for all. The shift to a district-based, primary care-focused model promises a more equitable, sustainable healthcare landscape. With immediate actions to support primary care, South Africa can lay the groundwork for a more robust, more resilient healthcare system, fulfilling the Constitution’s promise of health and dignity for all.
- Rensburg is the director of the Rural Health Advocacy Project.