Universal health coverage financing in South Africa: wishes vs reality

Background In 2011, the South African health minister, proposed a national health insurance (NHI) for South Africa with the aim to deliver universal health access and care to all South African residential citizens, with a single fund to cover all people, no matter their income. The first five years were reached at the end of year 2017-2018. In order to achieve universal health coverage (UHC), primary health care (PHC) re-engineering and NHI have been chosen as key strategic interventions to be implemented. These reforms are currently being piloted in 11 selected districts in South Africa since 2011. Methods The purpose of this paper is to compare and contrast the proposed South African NHI financing reforms (wishes) versus what has been implemented to date (current financing and service delivery reality on the ground) highlighting potential stumbling blocks. A review of both published and grey literature mainly sourced from the departments of health South Africa, statistics South Africa, world health organisation and world bank reports was carried out. Key documents reviewed included the South African national health insurance whitepaper, South African governmental financial reports, health systems trust reviews, mid-term report on universal health coverage and World Bank report on appropriate universal health coverage financing, progress reports on UHC and published research from leading health economists. Results Independent medical schemes, people as taxpayers and as consumers, rampant unemployment, lack of trust in public institutions and regressive aspects of value added tax, budgets, fickle political will, corruption, drivers of private health costs, provincialization as opposed to district health authorities, incompetent leadership and a cocktail of epidemics were revealed as potential stumbling blocks. Conclusions As international support for UHC grows pace, the issue of how to finance improved financial protection and access to needed health services becomes ever more urgent. Exploring how the proposed South Africa national health insurance UHC financing reforms compare and contrast with the situation on the ground, helps highlight potential stumbling blocks that need addressing as SA moves towards UHC. The paper concludes by calling for innovative, inclusive and sustainable UHC financing and service delivery solutions and the upholding of political will and commitments made, if South Africa is to achieve UHC by 2026.