Achieving universal healthcare access in South Africa: A policy analysis of consensus reform proposals

Abstract

Background. South Africa’s ongoing efforts to realise universal health coverage (UHC) have produced three discernible policy trajectories: UHC0, the de facto configuration of public and private health systems; UHC1, the incremental reform framework initiated post 1994 and recently revisited by the Universal Healthcare Access Coalition; and UHC2, the centralised National Health Insurance approach formalised in a 2017 White Paper. Objective. To offer a comparative analysis between the three alternative policy trajectories, to determine which offers the most productive pathway to deepen UHC. Methods. This analysis uses the organising principle of subsidiarity, which argues that decision-making authority should be handled at the most local level possible, with higher levels stepping in only when needed. A qualitative comparative policy analysis methodology is applied to assess the institutional design, financial sustainability, governance integrity, implementation feasibility and equity outcomes of these approaches. Results. Drawing from primary policy documents, the study finds that UHC1 provides the most feasible and constitutionally aligned pathway for realising UHC. UHC2, by way of contrast, is least likely to be implemented, with design features that deviate substantially from the principle of subsidiarity. UHC0, the status quo option, also incorporates severe deviations from the principle of subsidiarity and is likely to perpetuate systemic inequity and poor outcomes. Importantly, continued attempts to implement UHC2 effectively converge on UHC0, with the result that UHC0 is likely to continue indefinitely unless revised toward UHC1. Conclusion. Of the three options, UHC1, as envisaged in the 1990s, remains the most viable approach to deepen UHC, with UHC2 unlikely to achieve any key UHC goals owing to design weaknesses that deviate from the principle of subsidiarity and financial constraints. Attempts to implement UHC2, thereby obstructing the implementation of key aspects of UHC1, defaults the health system to the residual UHC0 approach – which lacks any strategic vision for deepening UHC.