The implementation of the National Health Insurance Pilot Program in the Tshwane District: Learning from Stakeholders in the Healthcare Sector

Abstract

The National Health Insurance is a health financing system that aims to redistribute South Africa’s financial resources by pooling funds from the public and purchasing healthcare services on behalf of the population from accredited private and public service providers. Part of transitioning from the current healthcare system to the NHI policy involved the implementation of the NHI pilot program in eleven districts across South Africa. The objective of this doctoral thesis was to evaluate the implementation of the NHI pilot in the Tshwane District. This was done by conducted 72 in-depth interviews and three focus group discussions with policymakers, government officials and healthcare workers. Findings from this study show that what was piloted during the NHI pilot program in South Africa is not what was supposed to be piloted. Disagreements between the National Department of Health and Treasury led to a compromised NHI pilot program which implemented the primary healthcare reengineering strategies instead of setting up the NHI Fund and testing how pilot districts would purchase healthcare services on behalf of the population. The results show that PHC strategies that were tested during the NHI pilot program in Tshwane District such as General Practitioner Contracting, District Clinical Specialist Teams, Centralised Chronic Medicines Dispensing and Distribution, Integrated School Health Service, and the Ward-based Outreach Teams improved the delivery of healthcare services in public health facilities and the communities. However, shortages in medical equipment and medication, deteriorating infrastructure, water and electricity cuts, lack of human resources, labour unrest and precarious work contracts made it difficult for these PHC interventions to achieve their intended goals. This thesis locates the NHI pilot program within the politics of evidence-based policy in health policymaking in which government officials, policymakers, and healthcare workers with different pockets of power shape the process of implementation of pilot programs.