Lessons to draw from South Africa’s national health policy

Since South Africa is Zimbabwe's neighbour and faces mostly similar challenges to Zimbabwe, it will be wise to review South Africa's approach towards NHI, so that Zimbabwe makes a better strategy on the same issue of NHI.

In March (2024), it was reported that Zimbabwe's Ministry of Health is planning on a strategy which will ensure that all public health facilities (clinics and hospitals) will offer, completely-free healthcare services for all citizens.

This would mean that, each visit to the clinic or hospital and any treatments (including specialised procedures) within those institutions, would be offered for free, without the payment of a single cent. Such a strategy for public healthcare is also called "National Health Insurance (NHI)". For citizens who may be willing to use medical aid schemes or cash, in order to access private healthcare (private doctors) instead, they will still be free to do so (in Zimbabwe).

A number of countries around the world offer National Health Insurance, which provides totally free public healthcare for citizens. These include; the UK, Italy, Austria, etc. South Africa's government, has also recently decided to implement NHI, as President Ramaphosa consented for it to be implemented on the 15th of May (2024). The country (South Africa) had released its National Health Insurance strategy (also known as the NHI Bill) far back, in 2017.

It is the same one which eventually received Presidential approval on the 15th of May.

Since South Africa is Zimbabwe's neighbour and faces mostly similar challenges to Zimbabwe, it will be wise to review South Africa's approach towards NHI, so that Zimbabwe makes a better strategy on the same issue of NHI.

How it will work in SA

In South Africa, any citizen (young or old) willing to benefit from the NHI, will have to register at a clinic (not hospital) which is nearest to their place of residence. Once registered, their registration details will be archived by South Africa's Ministry of Home Affairs and Ministry of Health.

When the citizen falls sick, they will have to visit the same clinic where they are registered, in order to get assistance. If their sickness demands specialized attention, the clinic will refer the patient (citizen) to the nearest hospital. The citizen will then be treated for free at the hospital. Almost all kinds of medical procedures will be available entirely for free, including organ transplants.

If the citizen is far away from the clinic where (s)he had registered, they can still use a clinic in another area, although that will not be particularly encouraged. Once the patient (citizen) is treated, the government will then make payments to the clinics and hospitals, in line with the volumes of patients that they would have treated.

In terms of doctors and clinics, all doctors (private and public) wishing to serve patients and benefit from government payments under NHI, will also need to be registered for the NHI programme. This means that private doctors will also offer free healthcare to citizens, whilst benefiting from government payments for their services.

South Africa's NHI will also be rare in that, all private doctors will have to participate in the NHI, since medical aid schemes which used to facilitate their activities will no longer be useful. That essentially means that, any South African private doctors who are unwilling to participate in the NHI will have to leave South Africa (emigrate to other countries) or stop practicing.

It is important to emphasize that, medical aid schemes in South Africa will not be permitted to provide cover for services which the government will provide under NHI.

This means that, there will be very limited room or no room at all for them (medical aid schemes) to continue operating, since the government intends to cover (pay for) almost all kinds of healthcare services (mental health, chronic diseases, dentistry, optometry, injuries, maternal health, organ transplants, etc). That also means that, if the NHI is implemented in its current form in South Africa, medical aid schemes are likely to close down, in the forthcoming years towards the full operationalisation (implementation) of the NHI.

The involvement of the private sector doctors (private healthcare) in NHI, should also result in the greatest geographical spread and availability of healthcare services to all citizens (in the rural, suburban or township areas).

This was necessitated by the fact that, currently, public healthcare in South Africa is overstretched. 84% of the citizens are serviced by public healthcare, for which the government funds it with 49% of the country’s annual total healthcare expenditure.

On the other hand, the other 16% of the population, is served by private healthcare, whilst it personally spends a huge 51% of total annual healthcare expenditure. It is essential to emphasize that, private healthcare is funded by the personal wealth and incomes of the citizens who use it, unlike public healthcare which is funded by the government.

Since the 84% of the population spends (through government) almost the same monetary amount on healthcare as the 16% which enjoys private healthcare, South Africa's overall healthcare system is characterized by serious disparities (differences).

Public healthcare has much fewer doctors and health workers, although it serves a much larger proportion (84%) of the population.

Only 30% of the country’s doctors serve in public healthcare, whilst the other 70% serves in private healthcare. Public healthcare is characterized by long queues, delays, lack of medication, and at times, patients are turned away, due to overcrowding and lack of capacity at the facilities.

As a result of the differences, the poor, who mostly use public healthcare, have a greater burden of disease within South Africa. This also means that, due to such challenges (of greater frequency of sickness), they cannot be as productive as the more affluent middle-class and the rich. Also, in cases of medical emergencies which need urgent attention, the poor are likely to spend their savings, if they visit private healthcare providers, and pay for services which are unavailable in public healthcare.

This greatly limits the chances of them (the poor) to escape poverty through wealth creation, since the little that they have saved up, can easily end up being used to attend to medical emergencies which cannot be accommodated by public healthcare (government clinics and hospitals). Due to such challenges, the poor are likely to remain poor and also pass on their poverty to their children. In effect, this leads to generational poverty.

It is such concerns which have led the South African government to decide that a National Health Insurance would be a better option, so that both private and public healthcare workers can serve all citizens, whilst the government pays health workers for services provided.

In effect, the elimination of medical aid companies implies that the (South African) government will be the largest and only “buyer” (on behalf of citizens) of medical services which are provided by both private and public healthcare facilities. The responsibility to pay for the healthcare needs of all citizens also implies that the government can benefit from lower costs through economies of scale (large scale transactions).

Under NHI, the fees charged by doctors and all healthcare workers will also be regulated by the government. Such a decision was made necessary by the fact that, private healthcare providers in particular, are known to be profiteers who engage in serious price gouging. That means that, South Africans who use private healthcare have also been subject to extortionate (extremely high) charges.

The country's (South Africa's) NHI Bill (NHI Strategy), which was released in 2017, clearly described those relative charges for medical aid schemes and healthcare services in the private sector, are the highest in the world, reaching up to 6 times higher than charges in OECD (the world's richest) countries. So, if the NHI were to function as planned, citizens who use private healthcare can eventually save more of their incomes which were meant for medical expenses in private healthcare.

In terms of cost, the NHI in South Africa is expected to cost at least 2 times more than the current government expenditure for public healthcare (which is mostly financed through the national budget). Currently, the South African government provides about R200 billion (or US$11 billion) for public healthcare, each year. On the other hand, experts predict that the NHI will need at least R450 billion (or US$25 billion) per year, upon its full implementation.

Other experts go on to argue that the program may even be much more expensive, costing up to R1 trillion (US$55 billion) each year, upon full implementation. These are clearly huge amounts of money and what is worrying is that, the South African government does not have much room for new financial demands of that size. Perhaps, what is even more concerning is that the actual amount needed for the full implementation of the NHI is not known. So, pursuing the NHI will be a true journey into the unknown.

This is not to say that the NHI cannot be successful. Rather, it is an accurate description of what awaits the South African government in their desire to provide NHI to its citizens.

It is also important to outline that, the NHI in South Africa will not be fully implemented immediately. Rather, there will be a number of years where incremental steps will be made towards its full implementation. After its approval by the President (Ramaphosa), the next stages of implementation will result in the setting up of government institutions which will be essential in managing the NHI.

At about the same time, the county's laws will be amended and updated, in order to enable the NHI to function without legal hindrances. Thereafter, the NHI will proceed to provide full benefits (totally free healthcare) for the vulnerable in the South African society. These include women, children, the disabled, etc. The final stage of implementation will result in the provision of full benefits of free healthcare to all citizens.

South Africa's Minister of Health predicts that the process may reach full implementation only from 2028, going forward. However, experts who are doubtful of the government's capacity to carry out such a huge project, indicate that it could take as much as 20 years before the programme reaches full scale implementation.


This article intends to describe the issue of National Health Insurance, which the Zimbabwean government has been contemplating to introduce, for more than a decade.

Since Zimbabwe's Ministry of Health has taken a while to implement its own NHI, the writer chose to describe the NHI as envisaged in South Africa, which is Zimbabwe's neighbouring country.

The aim of this article is to provide more details on how a National Health Insurance system can be structured and reasons for its establishment. The next article (to be published next week), will discuss the advantages and disadvantages associated with South Africa's NHI. Such an analysis should be able to provide Zimbabwe with information to make an informed decision, on whether to go on with the idea of implementing its own NHI or to abandon it.


Related Topics