The ‘Friends of NHI’ are those who support the principles of NHI, but certainly have concerns on certain aspect of the bill.

History shows that in Germany and the UK the universal health coverage was implemented over a period of time with various iterations, and with benefit packages linked to the economy and what the government could afford.


Some who take to this route of debate bother me, as this is confusing not only for health professionals but also the public at large. I really do not think we should pretend to support NHI in South Africa. The majority support NHI but have concerns that need clarity. I read and hear that implementation of NHI is disingenuous in the present economic climate and given the poor fiscal control in many parts of our economy.

This is true, but the Bill explains the funding sources, and the minister of health has explained that the process will be incremental and within the fiscal constraints. History points to the fact no country waited for economic prosperity, nor was there evidence of economic stability at the time universal health programmes were implemented.

Historical evidence is that we need visionary leadership and political will to start the process even in adversity but appropriately. The oldest national health programmes were implemented when the economy was at a pretty low level. They had to start at some stage.


The programmes were in iterations and within the fiscal constraints. The health benefits offered were based on what could be afforded in terms of available resources. The benefits were not open-ended, ie not limitless. The health benefits were guided by the economy of the time. They are extended over a period of time, after economic and actuarial evaluations.


The question is when and under what political and economic conditions have countries made or considered making progress towards the goals of UHC in the past. Two common mechanisms for providing financial risk protection were:

1. National Social Health Insurance as developed in Germany
2. General Tax revenue as used by the UK to launch the National Health Service.

Let’s revisit Germany and let’s take a lesson from their National Health Insurance. In 1883, Bismarck’s intention was to establish several so-called ‘sickness funds’ that had a mandatory enrolment and defined benefits. Under Bismarck’s leadership Germany took a fundamental step towards greater social protection. It specified government’s involvement in health, specifying mechanisms to guarantee financing with defined benefits delivered through existing public and private facilities. The main point to understand is that the system evolved over roughly a century and it extended piecemeal to eventually include all German citizens.

We can take lessons from this and other international initiatives to implement in a shorter period. Nowhere in our South African National Health Insurance (NHI) Bill in the says it will be implemented in totality immediately. This is impossible. South Africa’s NHI Bill lays down the National Health Programme and the intention to ensure coverage of all its citizens. However, history shows that in Germany and the UK the universal health coverage was implemented over a period of time with various iterations, and with benefit packages linked to the economy and what the government could afford.

Likewise, the Beveridge Report and the British National Health Service, which was implemented in 1948, was designed from the beginning to offer all medically indicated services to any resident without payment at the point of services. This resonates with our NHI and Universal Health Coverage (UHC) programmes. The UK started with health delivered by private physicians in public hospitals. This predated the full NHS programme.

Initially in the UK, it was during the unstable 1920s, and the Great Depression, and after two decades of trials with these haphazard social and health security benefit systems that paved the way for NHS. History allows us to interrogate the evolution of UHC as a programme that needed leadership and the need to construct the health system based on political will and to fashion the programme within the resources available. It is not possible to arrive at a situation that the economy will fully support the programme completely.

But it is important to start at some stage. Whatever this stage, there will be individuals and groups that will be unsupportive and create confusion in the minds of most people. UHC (NHI) encompasses every aspect of the health sector, which means the effective leadership is essential. There will always be a number of challenges being faced at the level of leadership and governance when it comes to accomplishing UHC. Let us view the implementation of NHI and view it through the lens of what history has taught us, and how we can mitigate these challenges.

UHC is complex and has a number of technological challenges. It underpins the notion that health is a right for all and not a privilege for a few. The first challenge for universal healthcare is that by 2030 everyone has access to essential, quality healthcare, regardless of their ability to pay. Despite progress being made, the recent World Health Organization and World Bank Group estimates show us that 400 million people lack access to essential health services and 6% of people in developing countries are tipped into or pushed further into extreme poverty because of healthcare spending.

A challenge UHC has is to drive it to a triple win – improve ‘people’s health, reduce poverty and fuel economic growth’. To achieve this governments, the private sector and civil society, as well as other development partners need to work together to establish systems for fair, efficient and sustainable financing of health. UHC goes hand in hand with health system strengthening and resilience. There are a number of other challenges such as ending poverty, increasing equity and shared prosperity. It also is an instrument that can stop the cycle of poverty and ill-health.

To this end UHC and Healthcare Delivery is a fundamental investment in human capital and in economic capital. Many countries are finding that the universality of access and financial protection can be a tough challenge. There are choices and trade-off policy that must be made between dimensions of population coverage, service coverage and financial protection. This is linked to another complex challenge, raising necessary resources and then allocating and managing these resources efficiently and equitably. What is needed to achieve the goals and realisation of UHC is political and technical leadership.

We can argue that the cause of inadequate implementation of Universal Coverage is multi-factorial; with not enough visionary, innovative, decisive, responsible and responsive, transparent, exemplary and inspirational leadership that will influence all stakeholders to work together to achieve the constructive purpose of Universal Coverage in low-income countries. Regardless of the existing states of health systems and resources in these countries, effective leadership would form a clear national vision towards Universal Coverage.

Political leadership towards Universal Health Coverage is a pre-requisite. To achieve UHC there must be political stewardship. In low-Income countries that achieved Universal Coverage political leadership emanated from the highest political office i.e. the Presidency. It is noted that presidential leadership facilitates collaboration across an entire government and pressures all stakeholders to deliver successful outcomes. It is also believed that genuine and sustainable political leadership should seek to legally institutionalise universal health coverage, as health is a basic human right.

This is indeed what has happened in South Africa: The UHC (NHI) is now, within the presidency. To mobilise the political stakeholders and the stakeholders at large, the office of the presidency is coordinating the UHC (NHI) programme with the Ministry of Health. President Cyril Ramaphosa has established a Social Health Compact with a number of stakeholders to work with the presidency towards implementation of UHC (NHI). This has been a positive initiative as it has created an urgency and commitment for all stakeholders to work through a process of rational consultative dialogue to seek solutions to implement UHC.

The leadership is further supported with a minister of health who has embraced the need for partnerships and an invitation for all stakeholders to be part of the journey towards implementing UHC (NHI) in South Africa. Political leadership must be supported by technical leadership at all levels of national health system. To achieve the holistic strategic vision towards UHC in low-Income countries health systems require technical leaders who understand health as a human right and are technically competent.

These technical leaders will seek to understand the existing status of the health systems and constraints that are preventing them from moving towards universal coverage and will conduct a participatory and comprehensive situation analysis. The technical leadership is also instrumental to conceive and develop an essential health benefit package, based on interventions targeting the preventive and curative aspects of the burden of disease that the country faces.

These technical experts with the assistance of the relevant consultants will develop the essential health package based on local epidemiology, resource availability, cost effectiveness, feasibility and equity. However, an important challenge will always be as documented by all countries seeking UHC is that you will always start with resource deficiencies, and with visionary leadership you can steer towards a UHC in iterations. This is exactly the strategy that the Ministry of Health in SA will employ. The NHI in South Africa is a broad vision and will need to be implemented in ‘chunk bites’.

AUTHOR: Prof Morgan Chetty, visiting Prof: Health Sciences, DUT chairman, IPAF, CEO: KZNDHC