South Africa's universal health coverage reforms in the post-apartheid period

- South Africa's universal health coverage options are currently in debate.
- Recent reform proposals favour the establishment of a single monopoly scheme.
- Prior reforms favoured a plural design, with more decentralisation and choice.
- The recent proposals may permit risk-based discrimination in private insurance.
- The chosen reform path should progressively improve coverage without risking existing coverage.

In 2011, the South African government published a Green Paper outlining proposals for a single-payer National Health Insurance arrangement as a means to achieve universal health coverage (UHC), followed by a White Paper in 2015. This follows over two decades of health reform proposals and reforms aimed at deepening UHC. The most recent reform departure aims to address pooling and purchasing weaknesses in the health system by internalising both functions within a single scheme. This contrasts with the post-apartheid period from 1994 to 2008 where pooling weaknesses were to be addressed using pooling schemes, in the form of government subsidies and risk-equalisation arrangements, external to the public and private purchasers. This article reviews both reform paths and attempts to reconcile what may appear to be very different approaches. The scale of the more recent set of proposals requires a very long reform path because in the mid-term (the next 25 years) no single scheme will be able to raise sufficient revenue to provide a universal package for the entire population. In the interim, reforms that maintain and improve existing forms of coverage are required. The earlier reform framework (1994−2008) largely addressed this concern while leaving open the final form of the system. Both reform approaches are therefore compatible: the earlier reforms addressed medium- to long-term coverage concerns, while the more recent define the long-term institutional goal.