This document aims to open debate and discussion about alternative pathways to universal health coverage (UHC) beyond the proposals contained in the Draft NHI Bill (2019). The proposed reforms, as they stand, represent a combination of policy building blocks sequenced in a particular way. This design is by no means the only path to UHC.

There are several reasons to revisit our chosen reform pathway. We find ourselves in changed circumstances, entering a period of austerity, accentuated by Covid-19. The reform pathway, as currently conceptualised, requires substantial reorganisation of a fragile system in a relatively short time frame. This big bang approach poses several risks; the biggest risk being that our system is never reformed because of resistance from across the political spectrum.

In Part A of this document we synthesise the various arguments around limited or reduced support for many of the critical positions taken in the Draft NHI Bill.

Incremental reform processes, with realistic milestones, are better suited to building trust and stakeholder buy-in. Our starting point is one of an ailing public sector, a resource-intensive private sector, fragmented financing, inequities within and between the public and private sectors, weak accountability, and a significant trust deficit. It is a far cry from the widely-supported principles of equity, efficiency, quality, sustainability and good governance which guide the reform process. One way to ensure that UHC continues to move forward is to remove the specifics of the modes of implementation in the policy documentation and to incrementally build stakeholder consensus as we move through the reform process. This will allow for a more agile and responsive process which is cognisant of shifts in context.

Building trust in the State’s ability to steer the system through the reform process is not just a ‘nice-to-have’ but has been shown to dramatically improve and strengthen UHC implementation in other countries. There is a large trust deficit in South Africa, in part due to the many false starts for UHC over the years, but also due to missed opportunities to showcase the public sector’s strengths. The wounds from State Capture and the failure of numerous large state institutions mean that reform processes that rest on the creation of new centralised institutions reliant on top-down accountability mechanisms are unlikely to be favoured over those that are more participatory in nature.

Report by Inclusive Society Institute