Evaluating NHI Phase 1 pilot implementation for Department of Health

South Africa has struggled with delivering high-quality health services to the majority of its population. This is a central challenge the country’s National Development Plan (NDP) 2030 aims to address. Universal Health Care (UHC) is being pursued in South Africa through the government’s policy of National Health Insurance (NHI).

The first phase of the NHI policy focused on preparing primary health care (PHC) for implementation by introducing health system strengthening (HSS) interventions in 10 designated pilot districts between 2012 and 2017.

We undertook an evaluation of this NHI Phase 1 implementation in South Africa. The core objective was to assess if the interventions successfully achieved the goal of strengthening PHC facilities. Additionally, the evaluation sought to identify vital lessons to inform the sustainability and scaling up of these interventions in the future.

Our approach involved both secondary and primary data collection. We began with two literature reviews: one to examine NHI implementation in other low-to-middle income countries for transferable lessons, and a second to summarise previous NHI annual assessments. This latter review helped identify implementation gaps and guided the development of primary data collection tools.

For primary data collection, we visited all 10 NHI pilot districts and interviewed key stakeholders at national, provincial, district, and facility levels. These interviews provided qualitative insights into the successes, challenges, and lessons learned from the first phase. In parallel, we completed a quantitative ecological analysis of the District Health Information System (DHIS) data over five years to assess the performance of key NHI indicators in PHC facilities.

The resulting in-depth evaluation report outlined both the successes and challenges of the NHI Phase 1 implementation. The report contained clear recommendations for future planning and implementation, directly supporting the National Department of Health (NDOH) as it transitioned into Phase 2. The findings and recommendations were presented in Cape Town to the then Minister of Health, Dr Aaron Motsoaledi, in November 2018.