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Achieving universal health coverage in South Africa

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Di Mcintyre, Jane Doherty and John Ataguba, from the Health Economics Unit at the University of Cape Town in South Africa, wrote an assessment of their country’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

In South Africa, everyone without voluntary health insurance is able to use public sector services that provide a relatively comprehensive range of care.

Although most public sector users must pay fees for hospital care, these are income-related and, more importantly, the poorest, young children and pregnant women are eligible for fee waivers.

However, the South African health system falls short of the goal of universal coverage, both in relation to some aspects of financial protection and equity in financing but particularly in terms of equitable access to needed, effective and good quality health care.

There is a six-fold difference in health care spending between voluntary health insurance members and those entirely dependent on public sector services.

There are a number of causes of these problems:

  • An onerous burden of out-of-pocket payments on some individuals due to the uneven implementation of user fee exemptions at public hospitals and for those not eligible for exemption from user fees, yet with limited ability to cover these fees on an out-of-pocket basis
  • A range of barriers to health service access other than user fees, including an under-supply and a maldistribution of health workers relative to the distribution of the population with the greatest need for health care
  • A relatively low share of mandatory pre-payment funding
  • Fragmented funding and risk pools, which limit the potential for income and risk cross-subsidies
  • Weak purchasing including a poor incentive environment

Within the context of considerable income inequalities (where the richest 10% of the population account for 51% of income and the poorest 10% for only 0.2% of income) and a far greater burden of ill-health and hence risk of needing health care on lower socio-economic groups, the importance of creating an integrated pool of mandatory pre-payment funds in order to pursue universal coverage is indisputable.

While the South African government has published a draft policy on National Health Insurance, many of the details are yet to be finalised.

Read more in: McIntyre D, Doherty J, Ataguba J. 2014. Universal health coverage assessment: South Africa. Global Network for Health Equity (GNHE). Available at: