Developing a framework for the long term monitoring and evaluation of national health insurance in South Africa

The South African health care system has gone through several reforms since 1994, beginning with the reorganization of primary health care and health infrastructure improvements to support the Primary Health Care approach. The current health system is characterized by a large public health sector that serves the majority of the people and a relatively large private sector, both in terms of funding levels and infrastructure that serves those with medical aid or private insurance and generally those who can afford to pay out-of pocket. Despite significant economic growth in the early 1990s, the levels of inequality have not changed partly because of the apartheid history and partly because of the non-inclusive economic growth. The Gini coefficient for South Africa is one of the highest in the world estimated at nearly 0.7. This is manifesting itself in various forms of inequalities in access to essential services including health services against the backdrop of a quadruple burden of diseases. Those who need health services the most are less likely to access quality health services than those who are able to pay for services. Consequently, the poor and vulnerable have disproportionately poor outcomes which threatens the achievement of MDGs by 2015. The challenges facing the health system are largely structural, that is: low levels of funding coupled by ineffective resource allocation and use; relatively more funding per capita in the private sector; more health workers in the private sector; inadequate infrastructure in the public sector to support provision of quality services; fragmented pooling and allocation of overall health system's financial resources resulting in unfair financing and poor financial risk protection. The release of the Green Paper on National Health Insurance (NHI) in August 2011 marked the beginning of major structural reforms in the health sector that seek to achieve universal health coverage (UHC) in South Africa by changing both the way the health systems is funded and how services are delivered.