Module 2

Module 2 Appendix NHI

National Health Insurance timeline: Key dates and events
August 2019 

The analyses and debates about the National Health Insurance (NHI) Bill rage on following its introduction to Parliament early this month. The tabling of the Bill was long in coming as the mooting of ideas to reform healthcare financing in South Africa are not new and date as far back as the late 1920s. [Below we trace] the historical timeline of the Bill (only looking at the democratic dispensation [period from 1994]) and highlight key dates and events, from when healthcare financing proposals were initially put forward, to date.

1994: Healthcare Finance Committee

In the early 1990s, the spotlight turned to the possibility of introducing some form of mandatory health insurance and after the 1994 elections; there were several policy initiatives that considered either social or national health insurance. The Healthcare Finance Committee of 1994 recommended that all formally employed individuals and their immediate dependents should initially form the core membership of social health insurance arrangements with a view to expanding coverage to other groups over time.

1995: Commission of Inquiry on National Health Insurance

The 1995 Commission of Inquiry on National Health Insurance fully supported the recommendations of the 1994 Committee. A strong case was made for primary healthcare services by its commissioners but is unclear whether their recommendations were taken forward fully at that time.

1997: The Social Health Insurance Working Group

In 1997, the Social Health Insurance Working Group developed the regulatory framework that resulted in the enactment of the Medical Schemes Act in 1998. This Act was meant to regulate private health insurance as well as entrench the principles of open enrolment, community rating, prescribed minimum benefits and better governance of medical schemes. However, despite the introduction of the Act and the supporting principles the level of coverage for the national population has remained below 16 percent.

2002: Committee of Inquiry into a Comprehensive Social Security for South Africa

In 2002, the Department of Social Development set up the Committee of Inquiry into a Comprehensive Social Security for South Africa. The Commission recommended that there be mandatory cover for all those in the formal sector earning above a given tax threshold and that contributions should be income-related and collected as a dedicated tax for health. The Committee also recommended that the State should create a national health fund through which resources should be channelled to public facilities through the government budget processes.

2002: Ministerial Task Team on Social Health Insurance

To implement the recommendations of the aforesaid Committee, the Department of Health established the Ministerial Task Team on Social Health Insurance. The Task Team’s primary mandate was to draft an implementation plan with concrete proposals on how to move towards social health insurance and to create supporting legislative and create supporting legislation and institutional mechanisms that will in the long term result in the realisation of National Health Insurance in South Africa. However, the path to achieving universal coverage through a social health insurance model was not widely supported and the implementation of the supporting proposals thus stalled.

2009: Advisory Committee on National Health Insurance

In August 2009, the Ministerial Advisory Committee was established and tasked with providing the Minister and Department of Health with recommendations regarding the relevant health system reforms and matters relating to the design and roll-out of National Health Insurance. This was to carry forward the Resolution passed at the ruling ANC’s Polokwane Conference in 2007.

2011: Department of Health Policy Paper

In mid-2011, the Department of Health released a policy paper titled “NHI in South Africa” for public consultation. The paper proclaimed that “South Africa is in the process of introducing an innovative system of healthcare financing with far-reaching consequences on the health of South Africans.” The National Health Insurance was to ensure that everyone has access to appropriate, efficient and quality health services.

2012-2017: NHI pilot projects rollout

Following release of the 2011 policy paper, implementation phase commenced in 2012, with its overarching focus being the piloting of health system strengthening (HSS) initiatives; the establishment of the NHI Fund and key institutions; and the moving of central hospitals to the national sphere. According to then Minister of Health, Dr Aaron Motsoaledi, the transition was expected to take about 15 years in three phases.

2015: Department of Health White Paper

In 2015, the Department of Health released a white paper titled ‘National Health Insurance for South Africa: Towards universal health coverage.’ It “laid the foundation for moving South Africa towards universal health coverage (UHC) through the implementation of National Health Insurance (NHI) and establishment of a unified health system.”[1] The Department pointed out that implementation of NHI will require amendments to related existing legislation and enactment of new laws to ensure that there is not only legislative alignment but also policy consistency across government departments and spheres of government. The paper would serve as the precursor to the drafting and subsequent introduction of NHI Bill.

2018: National Health Insurance Draft Bill

In June 2018, the Department of Health invited written comments from the public on the proposed draft NHI Bill. The draft Bill’s aim was “to provide mandatory prepayment health care services in the Republic in pursuance of section 27 of the Constitution; to establish a National Health Insurance Fund and to set out its powers, functions and governance structures; to provide a framework for the active purchasing of health care services by the Fund on behalf of users; to create mechanisms for the equitable, effective and efficient utilisation of the resources of the Fund to meet the health needs of users; to preclude or limit undesirable, unethical and unlawful practices in relation to the Fund and its users; and to provide for matters connected herewith.”

2019: Introduction of NHI Bill before Parliament

In August 2019, the NHI Bill was introduced to Parliament and is currently under consideration by the National Assembly’s Portfolio Committee on Health. The Bill will have to go through the stipulated parliamentary processes, which will include a public participation period, which might inform some amendments to the Bill, before it is put before the National Assembly for a vote. The Portfolio Committee has invited stakeholders and interested parties to submit written submissions on the Bill. You can find the full details and a guide on how to write a submission by following the links. This is an opportunity for all South Africans to have their voices heard and give meaningful input to legislative processes.

If the National Assembly passes it, it will be referred to the National Council of Provinces (NCOP), for a similar process and concurrence. If the NCOP passes it, it will then be referred to the President who must give assent and sign it into law.

The South African National Health Insurance: A Revolution in Heath Care Delivery?!

Professor Shan Naidoo, Occasional Piece: Journal of Public Health, 7th November 2011 

South Africa has embarked an on a bold new direction for its national health system with the publication of the government’s Green Paper on National Health Insurance (South Africa, 2011). It proposes four key interventions: i) a complete transformation of healthcare service provision and delivery; ii) a total overhaul of the health care system; iii) a radical change of administration and management; iv) the provision of a comprehensive package of care underpinned by a re-engineered system of primary healthcare. 

This is a momentous step forward for South Africa, in many ways reminiscent of the 1948 proposals for a National Health Service in the United Kingdom post World War II. 

The national policy document describes the history of the South African health system as one that was fragmented and racially biased in ways which largely benefitted the white minority population. Following democratic elections in 1994 the process of creating a single, non-discriminatory healthcare system was thwarted by the de facto development of a two-tiered approach, public and private, largely based on social class determinants, which perpetuated inequalities. 

Currently, the expenditures in both private and public sectors are roughly the same (about R100 billion each) and together make up about 8.5% of GDP. But the inequity is in the coverage – the private sector serves 16% of the population whilst the public sector serves the rest (84%), who are largely poor and black. The NHI policy green paper refers to the two-tiered system as unsustainable, destructive, very costly and highly curative or hospi-centric. 

Furthermore, South Africa also faces a huge quadruple burden of disease made up of HIV/AIDS and TB, maternal and childhood diseases, non-communicable diseases, and violence and injuries. This is further compounded by a shortage of key human resources in the health sector and in particular the public sector. 

To address these challenges the National Health Insurance Policy is guided by the following social justice principles: a) The Right To Access, a constitutional right of every South African guaranteed by our Bill of Rights; b) Social Solidarity, financial risk protection for the entire population; c) Effectiveness, through the adoption of evidence-based interventions; iii) Appropriateness, through the adoption of fit-for-purpose health service delivery models; e) Equity, ensuring universal coverage with care according to need; f) Affordability, services procured at reasonable cost recognising that health is a public good and not a tradeable commodity; and g) Efficiency, ensured by creating new administrative structures that avoid duplication across national, provincial and district spheres of governance. 

So, in essence the objective of the NHI scheme is to provide improved access to quality health services for all South Africans. It bases its approach largely on the Brazilian experience and focuses on a ‘re-engineered primary healthcare system’ that will focus mainly on community outreach services using a defined comprehensive primary care package of services. The primary health care services will be delivered through three streams according to the NHI policy document as follows:

  1. District-based clinical specialist support teams supporting delivery of priority healthcare programmes at district level. To address the high maternal and child health mortality and to improve general health outcomes each team will include a principal obstetrician and gynecologist; a principal pediatrician; a principal family physician; a principal anesthetist; a principal midwife and a principal primary health care professional nurse as a start. The ‘principal’ designation refers to very senior appointments.
  2. School health services to be delivered by a team headed by a professional nurse which will provide health promotion, prevention and curative services that address the health needs of school-going children.
  3. Municipal ward-based primary healthcare teams (a ward is a municipal-based demarcation) with a health professional heading each team and each member of the team allocated a certain number of families (much like the health activists in India). The main focus of these teams is to facilitate health promotion activities through community involvement.

There is also provision in the policy for the delivery of PHC through private providers accredited and contracted within districts. Hospital–based benefits are also described according to the designation of the hospital which range from district, to regional, to tertiary as well as central hospitals and specialised hospitals. 

An Office of Health Standards and Compliance (OHSC) will be established to inspect and accredit facilities and services, set norms and standards for these facilities and services and offer an independent office for ombudsman services. The NHI policy document also covers the principles for payment of providers and pushes a risk-adjusted capitation system as its favoured method of payment. It also does preliminary costing estimates using the approach recommended by the International Labour Office (ILO). 

The plan for the NHI is to phase it in over a 14-year period with the initial phase being the piloting of the re-engineered PHC system in 10 districts (of a total of just over 50 in the country), the establishment of the OHSC and the investment in infrastructure which includes the building of a new medical school (the capital expenditure of these capital projects is estimated to exceed the costs of that of all the stadia built for the 2010 Soccer World Cup). These are indeed ambitious proposals, and the real challenge will be in implementation. In the meantime, we can only compliment the Minister and the National Department of Health for this visionary policy that places a much-needed emphasis on equity and social justice in health care.


  1. South Africa. (2011). National Health Act, 2003: Policy on National Health Insurance. Government Notice No. 657. Government Printers: Pretoria.

Professor Shan Naidoo, President of the College of Public Health Medicine, Head of Department of Community Health, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand. 

Readings, legislation and videos

NHI South Africa as a Universal Health Coverage model 
  1. NHI Bill including the Memorandum of Objects* 2019 – Department of Health (DoH) NHI Portal with NHI Bill in multiple languages and more . The memorandum of a bill is critical to read as it sets out the rationale and allows for a grappling with underlying political economy questions and choices being made
  2. Understanding National Health Insurance – healthcare for all South Africans (DOH publication undated) 
  3. Nkosi MS (2020) ‘National Health Insurance (NHI) – towards Universal Health Coverage (UHC) for all in South Africa: a philosophical analysis’  
  4. Dr Greg Martin (2017) on Universal Health Coverage:
  5. Blecher M, Daven J, Harrison S, Fanoe W, Ngwaru T, Matsebula T, Khanna N ‘NHI: vision challenges and potential solutions’ in South African Health Review (2019): 
  6. Reynolds L ‘Opinion: Reframing the right to healthcare in terms of insurance cover is a bad idea’ (April 2022) 
  7. NHI – Is the problem that we’re trying to do it on the cheap? – The Big Debate (April 2019) 
  8. Health-e News Services: Everything you need to know about the NHI (Nov 2019) 
  9. National Insurance Bill – Summary 
  10. For a repository of documents on the NHI, see the Peoples Health Movement website: