Power, Politics, and Universal Health Coverage: Stakeholder Conflict in South Africa’s National Health Insurance Reform

South Africa’s National Health Insurance (NHI) reform was enacted in May 2024. It is the country’s most ambitious effort to achieve Universal Health Coverage (UHC). South Africa has one of the most unequal healthcare systems globally. NHI debates are often framed in technical terms, focusing on cost and feasibility. This analysis shows that power relations and stakeholder interests fundamentally shape the reform’s design. This study draws on policy documents, parliamentary records, and stakeholder submissions from 2011 to 2024, with the political background from 2007 and legal documents to 2026. It applies Walt and Gilson’s policy triangle framework to examine how context, actors, and policy content interact. Key design provisions were embedded in the policy from its inception. These include the continuing voluntary role of medical schemes and accreditation frameworks for private healthcare providers. They reflect the private sector’s structural influence and fiscal constraints rooted in South Africa’s political economy. These are not concessions made during legislative passage. Public-interest civil society organizations were substantively engaged in the NHI process. These include health rights groups, trade unions, and rural health networks. Their influence was limited by restricted access to decision-making forums. The analysis draws lessons for policymakers pursuing UHC reform in contexts where the private health sector is powerful and governance is fragmented. Effective implementation requires governance capacity before or alongside financing. Sustained civil society engagement is an essential mechanism of accountability.