CORRESPONDENCE

Concerns regarding bias in article on achieving universal health coverage in South Africa

To the Editor: I refer to your journal's recent online publication authored by Alex van den Heever, titled 'Achieving universal healthcare access in South Africa: A policy analysis of consensus reform proposals'.^[1] While I acknowledge the value of rigorous academic debate and appreciate the journal's role in facilitating open discourse, I would like to respectfully raise several concerns regarding the article's framing, tone and analytical balance. I raise these in the following paragraphs:

The lack of objective assessment and apparent bias against UHC2

Although the article is presented as a comparative policy analysis, from the start it displays a clear preference for UHC1 and portrays UHC2 (as articulated in the National Health Insurance (NHI) reform documents) in an overtly negative light. The analysis and approach applied commonly presumes failure in the implementation of UHC2 without fully exploring risk mitigation strategies or alternative interpretations. This raises questions about the neutrality of the piece, particularly given the author's previously documented involvement in shaping some of the policy foundations of UHC1 - a potential conflict of interest that is not transparently disclosed. The article also disproportionately cites the author's own previous work, which further calls into question the objectivity of the analysis, and the subsequent selection of the preferred option.

Limited assessment of the potential strengths of UHC2

While the article critiques UHC2's centralised funding approach and alleged complexity, it largely overlooks key features of the proposed NHI institutional and organisational reforms. For instance, while funding for healthcare services will be centralised through the NHI Fund, service provision and managerial autonomy are explicitly decentralised to the provider establishment level, with planning and monitoring delegated to district health structures, which include the newly legislated 'contracting units for primary health care'. The policy also proposes a single benefit package - a simplification rather than a complication - and outlines efficiency-enhancing mechanisms such as strategic purchasing, uniform accreditation and provider contracting, and performance-based reimbursement systems - all important aspects for ensuring accountability of providers for health outcomes.

The potential for greater equity, improved procurement efficiency and a streamlined financing system under UHC2 deserves more robust and nuanced engagement than what is currently the simplistic and wafer-thin assessment offered in the article.

Under-emphasis on the political economy context

The article expresses concern over the political motivations behind UHC2, implying an undue desire for central control. However, it largely sidesteps the political and social realities that render UHCl's revival highly improbable - including entrenched inequities and systemic fragmentation that continue to favour wealthier populations at the expense of those who really need healthcare. There is no reference to other key publications that have indicated the inverted nature of who benefits the most from the health system. A more comprehensive analysis would consider the constitutional imperative to redress historical injustices, and the practical limitations of consensus-based reform processes in a deeply unequal society.

Deliberate omission for consideration of the transitional mechanisms

Perhaps most troubling for me is the article's lack of attention to the phased implementation framework outlined in the NHI Act 20 of 2023,^[2] specifically section 57. Rather than engage with the transitional steps already legislated, the article implies that UHC2 is 'fatally constrained' - a claim made without acknowledging possibilities for policy adaptation as the implementation process unfolds and matures. This all-or-nothing framing oversimplifies the policy and legislative landscape, and undermines constructive dialogue on pragmatic reform pathways.

Conclusion

To conclude, the article disappointingly lacks the analytical depth, objectivity and policy rigour required of an academic journal contribution. Its strong normative positioning, limited engagement with countervailing evidence and insufficient attention to transitional dynamics make it more akin to an opinion editorial than a scholarly analysis.

These comments are provided in the interest of contributing to a balanced, constructive discourse on how best as a country we can achieve universal health coverage.

M Nkosi

Chief Directorate: Healthcare Benefits and Provider Payment Design, National Department of Health, Pretoria, South Africa Moremi.Nkosi@health.gov.za

References

1. Van den Heever A. Achieving universal healthcare access in South Africa: A policy analysis of consensus reform proposals. S Afr Med J 2025;115(7):e3673. https://doi.org/10.7196/SAMJ.2025.v115i7.3673        [ Links ]

2. South Africa. National Health Insurance Act No. 20 of 2023.         [ Links ]