Insurance policy: the concept of social health insurance in South Africa

Social health insurance (SHI) takes many different forms around the world. Health insurance policy in South Africa has evolved over the years since the first democratic elections in 1994, but has yet to be implemented. Why has this proposal stagnated? How can the policy development process be improved?

Research at the University of Witwatersrand, South Africa, addresses these questions and asks whether the SHI proposal should be pursued. Obstacles to successful policy development include a failure to engage all actors fully in the debate. Decision-makers must strengthen policy formulation and implementation processes and address issues of equity.

Social health insurance has several key features that distinguish it from policies such as taxation, user fees and private insurance, including:

• government mandate
• regular, compulsory contributions
• no opt-out provision for eligible members
• premiums calculated according to income
• standardised benefit packages.

The concept of mandatory health insurance in South Africa grew out of opposition to the apartheid healthcare system in the late 1980s. 'National Health Insurance' displaced the notion of an entirely tax-funded National Health Service and acknowledged the strengths of the private health sector. This policy was itself replaced in the mid-1990s by the concept of Social Health Insurance and a tiered system of health services. Tax-funded public services would serve the poorest people; SHI-funded services would cater for low and middle-income families; the rich would continue to purchase additional services in the private sector. However, by 1999 there was no sign that the new SHI policy would be implemented.

The study suggests several causes for the stagnation of the policy process:

• The most important players have yet to agree on a set of objectives for SHI.
• Some decision-makers have blocked policy development because their concerns are not being addressed.
• There is no clear strategy for engaging actors with different interests and organisational positions in relation to the Department of Health.
• Health policy-makers have not taken ownership of SHI proposals.
• Technically-focused policy debates have inhibited broader public discussion of the issues.

The report suggests that future SHI policy must be underpinned by clearly acceptable principles and address equity issues such as the degree of cross-subsidisation between different healthcare sectors. This must be followed by technical work to prepare the policy for implementation, including the design of collection, reimbursement and administrative systems. The experiences of the provinces in these functions will provide an important input.

The report makes recommendations for improving SHI policy development and implementation, including:

• strengthening technical analysis
• improving the strategic skills and awareness of technicians
• building implementation concerns into design development
• allowing for the changing policy environment
• enabling implementation through leadership
• updating and improving policies through monitoring and evaluation.

Source(s):
‘Social health insurance in South Africa: past, present and future’, by J. Doherty et al., University of Witwatersrand Centre for Health Policy, Monograph 67 (2000)

Funded by: USAID; The European Union; South African Medical Research Council

id21 Research Highlight: 14 February 2002

Further Information:
Jane Doherty or Lucy Gilson
Centre for Health Policy
University of Witwatersrand
P.O. Box 1038
Johannesburg 2000
South Africa

Tel: +27 11 489 9941
Fax: +27 11 489 9900
Contact the contributor: lucyg@mail.saimr.wits.ac.za

University of the Witwatersrand, South Africa

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