oa South African Health Review - Social health insurance : chapter 7
It was in the 1980s that social health insurance was first proposed as a key mechanism for extending health care coverage and promoting equity in South Africa. More than a decade later, and despite intensive investigation by three government committees since 1994, social health insurance is no nearer implementation. Lack of policy action on this front means that the wide disparities between health care in the public and private sectors remain untouched. What lessons does this experience teach us? This chapter explains why consensus was never reached on the exact form social health insurance should take, and suggests strategies for building support - and offsetting opposition - amongst important stakeholders. The chapter also critiques features of the government's most recent proposal, published in 1997. It is argued that this proposal will have a limited impact on equity and is not sufficiently robust to generate the 'virtuous cycle' of improvements in resource availability and quality of care so badly needed by the public sector. Technical analyses are suggested that might resolve disputes about the fundamental principles underlying social health insurance in the South African context, thereby strengthening the design and acceptability of the policy. The chapter also highlights the importance of both hospital management transformation and fee policy reform as precursors to the successful implementation of social health insurance. It is crucial that these issues be understood by more than a small circle of senior policy makers and academics. Social health insurance is a wide-ranging reform that seeks to translate societal values into real changes in access to health care on the ground: this makes it a policy worthy of extensive public debate. The resurgence of public discussion is warranted now, in particular, as social health insurance has been tabled once again for consideration by government, this time as part of a Cabinet-sponsored process to develop a co-ordinated social security system for the entire country. Given past experience it is important to ensure that social health insurance emerges from this process as an equitable and sustainable policy and that, this time around, it stands a chance of implementation.
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