South Africa's health system carries the heavy imprint of history. The apartheid era bequeathed a fragmented, inequitable system in which race determined access to care, geographic distribution of resources favoured white minority areas, and public facilities serving the black majority were systematically under-resourced. Nearly three decades after the democratic transition, these inequities persist, writes Mark Burke in this latest opinion article.

The country spends roughly 8.5% of GDP on health (comparable to many OECD nations), yet achieves outcomes more typical of lower-income countries. Life expectancy, which rose from 52 years in 2005 to 61 years by 2021, largely driven by the scale-up of antiretroviral therapy, remains below the global average for upper-middle-income countries.

Two decades of investment in strengthening primary health care (PHC), district health services, and digital transformation have produced a landscape of parallel initiatives. Each well-intentioned, operating within its own logic, yet collectively failing to deliver the integrated, patient-centred care that patients experience as a continuous journey. The National Health Insurance (NHI) Act, signed into law in May 2024, together with the country's emerging Digital Public Infrastructure (DPI) and interoperable digital health systems, creates both the drive and the opportunity to fundamentally rethink how public health services are designed, governed, implemented, and continuously improved.

This essay argues that the next frontier of health reform in South Africa lies beyond the horizon of digitising existing processes or connecting systems through interoperability. Rather, it lies in shifting the unit of design from individual programmes and information systems to end-to-end service journeys that are patient-centred, data-enabled, and integrated across institutional boundaries. Using diabetes as a case study, it examines what this shift means for service design, delivery, governance, organisational arrangements, capabilities and continuous improvement.

When health reform, service improvement, and digital transformation meet

South Africa's health reform agenda has evolved through multiple, overlapping pathways. The National Health Insurance (NHI) represents the most ambitious restructuring of health financing and service provision since 1994. It seeks to provide universal coverage of quality health services through a centralised, national insurance fund from which the government will buy healthcare services from healthcare providers in both public and private sectors. For the NHI to succeed, it requires a health system capable of delivering integrated, continuous care along the reform pathways the country has been building, albeit in fragmented ways.

The Primary Health Care (PHC) re-engineering strategy and District Health Services (DHS) strengthening have sought to shift care closer to communities through Ward-based Primary Healthcare Outreach Teams (WBPHCOTs), integrated chronic disease management (ICDM), and the Ideal Clinic Realisation and Maintenance Programme. The Integrated Chronic Disease Management (ICDM) model represents an early attempt to integrate care for chronic conditions at the primary care level, combining clinical guidelines, supply chain management, and patient support.

Alongside these service improvement initiatives, South Africa has invested substantially in digital health infrastructure. The Health Patient Registration System (HPRS), Central Chronic Medicines Dispensing and Distribution (CCMDD) programme, Medicine Stock Management System (MSMS), MomConnect maternal health platform, District Health Information System (DHIS), and disease-specific information systems have each addressed specific functional requirements. The National Health Normative Standards Framework (HNSF) for Interoperability in Digital Health, now being extended into a Health Enterprise Architecture (HEA), provides the technical foundation for interoperability across these systems.

What makes this moment distinctive is the convergence of these reform pathways with South Africa's broader Digital Transformation Strategy. The government's Roadmap for the Digital Transformation of Government, launched in 2025, aims to establish functional digital identity, data exchange, digital payments, and trusted digital channels as the four key pillars, built on Digital Public Infrastructure (DPI). These are platforms intended to transform how all public services are accessed, delivered, and experienced. When applied to health, they create the possibility of a fundamentally different relationship between citizens, providers, and the state. One in which identity verification, data sharing, payment processing, and service access are seamless, secure, and potentially citizen-controlled.

This convergence reshapes expectations in three critical ways. First, it raises the stakes for service integration. Patients and health providers increasingly expect that care will flow continuously across facilities, provinces, and levels of the system, with information following the patient. Second, it demands new forms of accountability. Digital traceability makes it possible to track not just whether services were delivered, but whether they were delivered in the right sequence, at the right time, and with the right outcomes. This shifts accountability from inputs and processes to patient journeys and health outcomes. Third, it creates pressure for genuine patient-centredness. Digital channels can give citizens more control over how they access and manage their health information.

From programmes and systems to service journeys

Despite these convergent pressures, much of South Africa's health reform remains organised around individual programmes, facilities, projects, and information systems. The limitations of this approach become visible when examined through the lens of a specific condition such as diabetes mellitus. The prevalence of the disease has rapidly increased in South Africa, from 4.5% in 2010 to 12.7% in 2019. It is estimated that about 4.5-million people aged 20–79 years have diabetes in South Africa in 2019, of which 52.4% were undiagnosed.

Consider the journey of a patient newly diagnosed with type 2 diabetes (a type of diabetes mellitus) in the public health system. The patient may first encounter the system through community screening by a ward-based outreach team or by presenting to a clinic with symptoms. Screening may involve a finger-prick glucose test, but the result may or may not be captured in a system that communicates with the facility where the patient will receive care. Upon diagnosis, the patient must be registered, potentially in the HPRS, but also in the clinic's paper-based records, and possibly in a disease-specific register. Treatment initiation requires a consultation with a clinician who may or may not have access to the patient's full medical history, and who may be working from guidelines that differ from those used in the screening programme.

Medication management introduces further complexity. The patient may collect medicines monthly from the clinic, or may be enrolled in CCMDD and collect from a community pick-up point or accredited pharmacy. The MSMS may track stock levels, but may not be linked to the patient's adherence data. Monitoring requires regular HbA1c testing, which may be captured in a laboratory information system that does not automatically update the patient's primary care record. If complications develop, such as diabetic retinopathy (an eye condition caused by damage to the blood vessels in the retina), nephropathy (progressive kidney disease caused by damage to the small blood vessels in the kidneys), or neuropathy (nerve damage throughout the body), the patient must be referred to specialist services. This triggers a separate administrative process that may or may not be digitally tracked. Rehabilitation and long-term self-management depend on community-based support that operates largely outside the formal health information infrastructure.

At each transition point, from screening to diagnosis, diagnosis to registration, registration to treatment, treatment to monitoring, monitoring to referral, referral to specialist care, care to community support, the patient risks falling through gaps created by system boundaries. Information may be lost. Appointments may be missed. Medication may be interrupted. The patient experiences these failures not as technical glitches in discrete systems, but as a fragmented, and often demoralising journey through an institutionally divided landscape.

The concept of the health service journey offers an alternative unit of design. Rather than enhancing individual programmes or systems, the journey approach designs for the complete path of the patient experience. This requires fundamentally different ways of organising work, allocating accountability, and measuring success. Shifting to service journeys implies several consequential changes.

First, it requires cross-functional teams that span organisational boundaries (clinicians, community health workers, pharmacists, laboratory technicians, specialists, and administrators) who are jointly accountable for patient outcomes rather than individually accountable for programme targets. Second, it requires information systems designed around patient needs rather than organisational functions, with interoperability devised as the seamless flow of clinically relevant information along the care pathway. Third, it means measuring the actual success and long-term results of a process, rather than checking steps along the way. Instead of counting what was done, it tracks how well it worked for the end-user over time.

A diabetes service journey would be measured by the proportion of diagnosed patients who achieve blood sugar control within six months, remain in care at twelve months, and experience no preventable complications within five years.

Digital Public Infrastructure and the future of health services

South Africa's emerging Digital Public Infrastructure provides critical enabling capabilities for this journey-based model, but its transformative potential depends on how these capabilities are designed into the service architecture rather than merely deployed as technical infrastructure.

At the governance layer, the functional digital identity system creates the foundation for patient identification across the health system. For diabetes care, this means a patient can authenticate their identity at any point of service, whether a clinic, pharmacy, community pick-up point, or specialist facility, without carrying physical documents. The verified credentials wallet to be developed will allow patients to share only necessary information without revealing irrelevant personal details. The governance layer must establish not only technical standards but also legal frameworks, oversight mechanisms, and redress processes that ensure digital identity serves inclusion rather than exclusion. This includes addressing: who controls the biometric data? What happens when identity verification fails? How are the rights of undocumented migrants, children, and other vulnerable groups protected?

The data exchange layer, envisioned as a cross-government platform offers the technical capability for seamless information sharing. For diabetes care, this could mean that a patient's screening result at a community venue automatically populates their primary care record; that Haemoglobin A1C (HbA1c – measure of your average blood sugar levels) results from the National Health Laboratory Service appear in the clinician's dashboard; that medication dispensing data from CCMDD community pick-up points feed into tracking if the patient is taking their medication; and that referral outcomes from specialist clinics update the primary care team's care plan. This requires trust among patients, providers, and institutions that data sharing serves patient interests rather than institutional surveillance.

The digital payments layer, including the proposed Public Payments Utility, creates possibilities for new financing models under NHI. Flat fee payments for chronic disease management, pay-for-performance based on journey completion and outcomes, and direct patient reimbursements for transport or digital health tools all become technically feasible. Of course, how you pay doctors changes how they treat patients. Paying per visit provides little incentive to help patients prevent illness. Paying for successful results encourages better care, but only if outcomes can be accurately measured.

The service delivery layer is where DPI capabilities translate, or fail to translate, into improved patient experiences and health outcomes. For diabetes care, this layer includes the digital platforms through which patients schedule appointments, receive reminders, access educational health content, report symptoms, and communicate with care teams. It includes clinical decision support tools that help providers adhere to evidence-based guidelines, dashboards that help managers monitor population health trends, and analytics that help policymakers allocate resources.

The critical insight is that interoperability alone is insufficient to improve health outcomes. Connecting systems technically does not ensure that care is coordinated clinically, that services are experienced as seamless by patients, or that information flows translate into better decisions. The HNSF provide the technical architecture for interoperability, but service design determines whether that architecture serves patient needs. The value of DPI depends on its integration into service journeys that are designed from the patient's perspective, governed by clear accountability for outcomes, and continuously improved based on evidence.

Emerging approaches to next-generation public health service design and implementation

International practice offers a growing catalogue of approaches that could strengthen South Africa's capacity for journey-based service design. Human-centred design, with its emphasis on deep empathy for users, iterative prototyping, and testing with real patients and providers, offers methods for understanding the lived experience of diabetes care and co-designing solutions that address actual rather than assumed needs. Participatory and co-design approaches, which bring patients, communities, and frontline workers into the design process as partners rather than subjects, are particularly relevant in the South African context where historical inequities have created deep distrust between communities and the state.

Service blueprinting and journey mapping, increasingly used in digital health innovation, provide visual tools for mapping the complete service experience, from patient actions and touchpoints to frontstage provider interactions, backstage processes, and supporting infrastructure. For diabetes care, a service blueprint would reveal not only the patient's visible journey but also the invisible work of information flow, supply chain management, referral coordination, and payment processing that must align for the journey to succeed. Systems thinking, with its focus on feedback loops and emergent behaviour, helps designers understand how interventions in one part of a complex system produce effects in other parts. Public value design provides a normative framework for assessing whether services create genuine public value in terms of equity, inclusion, and democratic legitimacy.

Ecosystem orchestration recognises that contemporary health services are delivered by networks of public providers, private practitioners, community organisations, technology vendors, and patients themselves. Making this ecosystem work requires clear rules, standards, and rewards that enable different healthcare groups to collaborate on a patient's care. Inclusive and equity-centred design ensures that service redesign does not leave behind those in rural areas, those with limited literacy, or those without reliable connectivity.

Agile delivery, with its emphasis on iterative development, continuous user feedback, and adaptive planning, offers a methodological alternative to the waterfall approaches that have characterised many government IT projects. Rather than specifying all requirements upfront and delivering a complete system after years of development, agile approaches build minimum viable products, test them with real users, and refine based on evidence. For diabetes service redesign, this might mean piloting a digital care coordination platform in one district, measuring its impact on journey completion and patient satisfaction, and scaling only after demonstrated success.

Product management introduces the concept of service ownership, in which dedicated teams are responsible for continuously improving a service over its entire lifecycle. A diabetes service product manager would be accountable for the end-to-end patient journey, with authority to coordinate across organisational silos and a budget tied to journey outcomes rather than project deliverables.

South Africa's Roadmap for the Digital Transformation of Government explicitly embraces these approaches, establishing a Digital Service Unit under The Presidency to drive innovation, a sandbox environment for testing new technologies, and an agile methodology for piloting and scaling. The roadmap's emphasis on "experimentation and 'fail-fast'" signals a cultural shift away from risk-averse, compliance-oriented implementation toward evidence-based, learning-oriented delivery. Whether this cultural shift can be achieved in the health sector, where political accountability, media scrutiny, and patient safety concerns create strong pressures toward conservative implementation, remains an open question.

Towards a new approach to health service design

South Africa's next major challenge is no longer primarily the digitalisation of health systems. The HNSF, HEA, HPRS, DHIS, and emerging DPI provide a technical foundation that, even if imperfect and unevenly implemented.

This suggests a fundamental reorientation. The future of public health reform lies in moving from systems to services. This means shifting from optimising information systems as organisational infrastructure to designing service journeys as the primary unit of patient experience. It lies in moving from facilities to journeys, shifting from measuring clinic performance in isolation to tracking patient outcomes across the entire care pathway. It lies in moving from programmes to ecosystems in which services by a network of actors are orchestrated around shared patient journeys. And it lies in moving from implementation to continuous adaptation and learning.

Under NHI, this reorientation has particular urgency. The NHI Fund will contract providers based on accreditation against quality standards, payment based on flat fees or outcomes, and performance monitoring against agreed indicators. If these mechanisms are designed around traditional programme and facility metrics, they will perpetuate the fragmentation that currently undermines care continuity. If they are designed around journey completion, patient experience, and longitudinal outcomes, they could catalyse the shift from systems to services.

The diabetes case illustrates both the possibility and the difficulty. The technical infrastructure for a journey-based diabetes service, including digital identity, data exchange, digital payments, shared platforms, interoperability standards, is largely available or emerging. The policy framework, comprising the NHI Act, the National Strategic Plan for Non-Communicable Diseases, the Digital Health Strategy, and the Digital Transformation Roadmap, provides sufficient mandate. What is required is the institutional capability for next-generation service design and stewardship. This includes the governance structures, professional skills, organisational cultures, and continuous improvement mechanisms that can translate infrastructure and policy into lived experience and health outcomes.

The argument here is not that digital platforms are unimportant. They are essential foundations. But they are means, not ends. Their value depends on the ability of governments to design, orchestrate, implement, and continuously improve patient-centred health service journeys that create public value, improve health outcomes, support equity and inclusion, and adapt to changing needs over time.

For South Africa, the journey from systems to services is the defining challenge of the NHI era. Whether the country meets this challenge will determine not only the success of its health reform but the credibility of its broader digital transformation ambitions. Diabetes care, for example, experienced daily by millions of South Africans, is where the success of this journey will be judged.

Written by Mark Burke, a researcher and advisor with expertise in digital governance, and a focus on public-sector digital transformation. His research interests are digital identity, privacy, and citizenship in the digitalisation of public services.