CORRESPONDENCE

 

Response to the letter by the National Department of Health regarding 'Achieving universal healthcare access in South Africa'

 

 

To the Editor: I appreciate the opportunity to respond to the letter submitted by the National Department of Health (NDoH) concerning my article, 'Achieving universal healthcare access in South Africa: A policy analysis of consensus reform proposals'. The department raises important concerns, and I welcome the engagement in the spirit of constructive debate. However, it is necessary to correct several mischaracterisations and clarify the basis and intent of the analysis.

 

On bias and lack of objectivity

The article is explicitly framed as a comparative policy analysis grounded in the organising principle of subsidiarity - a new conceptual entry into the health reform debate in South Africa (SA). Each universal health coverage (UHC) model - UHC0 (status quo), UHC1 (incremental reform) and UHC2 (National Health Insurance) -is assessed against a set of clearly defined criteria: governance alignment, access equity, financial stewardship, and implementation feasibility. The application of these criteria is transparent and evidence-based, drawing on both public policy documentation and peer-reviewed literature. The concern about 'bias' appears to stem from the conclusion that UHC1 offers a more feasible and constitutionally aligned pathway than UHC2, a position that is at odds with the official position of the current NDoH. This outcome does not reflect bias, but rather the weight of available evidence on institutional capacity, fiscal constraints and governance risks associated with centralisation. That UHC2 remains largely unimplemented despite political support and legislation further supports this assessment.

Regarding conflict of interest: my past involvement in shaping UHC1-related reforms was public, principled and rooted in efforts to support constitutional health mandates. This contribution is no less legitimate than the department's own institutional commitment to UHC2. Transparency in public policy participation is important, but it should not be misconstrued as undue influence or invalidate evidence-based critique.

 

On 'excessive' self-reference

The NDoH's charge of 'excessive' self-citation is misplaced. The article's references to the author's own prior work are in fact essential, high-quality sources directly relevant to the analysis. Importantly, in many instances, no other authors have covered the same issues.

These cited works include the author's peer-reviewed studies in reputable journals (for example, a 2016 Health Policy analysis of post-apartheid UHC reforms,^[1] and a 2024 Health Economics, Policy and Law study of health financing outcomes^[2]), technical reports and expert reviews (such as the 'NHI Bill expert review' submitted to Parliament), and chapters in authoritative policy compilations on healthcare financing, social security and epidemic preparedness.

Referencing these works is both appropriate and necessary given the subject's complexity and considerable limitations on relevant published works. Many facets of SA's health system performance and reform history have been rigorously documented only through such in-depth research. Far from introducing bias, these self-references strengthen the article's framework by providing original research findings, formal policy documentation and expert interpretation that ground the discussion in evidence.

In academic practice, citing one's earlier relevant work is a legitimate means to build on established findings in a field where knowledge is cumulative - and builds on prior works. Accordingly, the article draws on the author's prior contributions not to promote a personal agenda but to supply a well-founded historical and analytical basis central to understanding SA's health policy evolution, and to credibly compare UHC models. This is precisely the kind of foundation required for an unbiased, informed policy analysis.

 

On 'underdeveloped' considerations of UHC2's strengths

The article did consider UHC2's potential benefits. These included the aims of greater equity and pooled financing. It, however, contextualised them within the constraints of implementation capacity and institutional coherence.

The claim that UHC2 ensures decentralised service provision is at odds with the model's design: financial control, provider payment decisions and benefit determinations are centrally located within the National Health Insurance (NHI) Fund and the Minister of Health. While 'contracting units for primary health care' are referenced in the NHI Act, they do not function as autonomous district health authorities, and lack constitutional standing or legislative independence. As such, they fall within a rigidly hierarchical structure subject to direct interference by political office-bearers, a clear flaw as evidenced in UHC0. These are relevant design weaknesses that warrant critical examination.

Efficiency mechanisms such as strategic purchasing, provider accreditation and uniform reimbursement systems are not unique to UHC2, and feature prominently in UHC1 proposals and international multi-payer systems. Their effectiveness depends not on centralisation per se, but on institutional integrity, regulatory capacity and adaptive governance. These are all areas where SA faces documented challenges.

 

On political economy considerations and equity

The article does not dispute the existence of deep inequities in SA's health system. Rather, it critiques the assumption that centralisation necessarily addresses them.

Historical evidence shows that institutional weakness and politicised governance, not structural decentralisation, have been key impediments to equity. The comparative success of certain provinces under the existing framework (e.g. Western Cape) highlights the importance of subsidiarity and locally responsive governance.

Furthermore, while UHC1 originated in a different political period, it has not been rendered obsolete. Its recent revival by the Universal Healthcare Access Coalition (UHAC), comprising a substantial portion of the health system, reflects a renewed consensus on incremental and constitutionally grounded reform. Reform feasibility must be evaluated not only by intention in the form of assertions, but by evidence of what has and can be implemented.

 

On transition planning and the NHI Act

The article does not ignore the transitional provisions in the NHI Act 20 of 2023. Rather, it argues that the implementation assumptions, including rapid fund establishment, tax restructuring and medical scheme dissolution, remain unsubstantiated and legally contested.

Importantly, the UHC2 design is expressly premised on the introduction of a substitutive tax to draw the medical scheme contributions into the system of general taxes, which is technically unachievable when government is at tax capacity, an official position of National Treasury and peer-reviewed research. Phasing cannot correct this important flaw, as it derives from the behavioural dynamics of tax systems - which operate differently to medical scheme contributions. Had the NDOH performed a financial feasibility study (distinct from a mere costing analysis), this would have become evident. The absence of any evidence to contradict this important public finance constraint is noteworthy.

Section 57's transitional provisions, while outlined in legislation (in the form of high-level reform intentions rather than concrete legislative provisions), fail to resolve the core feasibility concerns around institutional readiness, financing gaps and concurrent constitutional competencies.

Raising these limitations is not equivalent to dismissing reform, but is essential to ensuring that it is realistic and sustainable.

 

Conclusion

Policy debate on UHC in SA must rise above institutional defensive-ness and focus on evidence, feasibility and constitutional alignment. The article aims to foster exactly that through informed, comparative analysis grounded in both international principles and local realities. In this regard, all health reform proposals, including UHC2, must be subject to the same level of critical scrutiny.

I look forward to continued engagement on this important national project.

A van den Heever

Chair: Social Security Systems Administration and Management Studies, Wits School of Governance, Johannesburg, South Africa Alex.VanDenHeever@wits.ac.za

 

References

1. Van den Heever AM. South Africa's universal health coverage reforms in the post-apartheid period. Health Policy 2016;120(12):1420-1428. https://doi.org/j.healthpol.2016.05.012        [ Links ]

2. Van den Heever AM. Roadmaps to managed competition: To what extent does South Africa meet the preconditions for equity and efficiency? Health Econ Pol Law 2024:1-18. https://doi.org/10.1017/S1744133123000324        [ Links ]