Lessons learnt can bolster SA’s public healthcare system

With Rwanda’s Universal Health Coverage (UHC) initiative ensuring adequate healthcare for almost 90% of its population, there are several learnings that South Africa can implement to ensure the long-term success of its planned National Health Insurance (NHI) initiative, writes Bada Pharasi, CEO of the Innovative Pharmaceutical Association South Africa (IPASA).

While South Africa enjoys excellent private healthcare1, its public healthcare system is under constant scrutiny. This as the World Population Review’s Best Healthcare in the World 2023 study ranks South Africa’s healthcare system 87th in the world, behind the likes of Vietnam, Botswana, Philippines, Sri Lanka and Mongolia2.

Although South Africa’s public hospitals are often underfunded and understaffed, much of the system’s scrutiny comes as a result of the country not having a universal healthcare system in place, and instead1, two parallel systems that drive an ongoing divide between the country’s low-, middle- and high-income socioeconomic groups.

The public healthcare system of South Africa is the backbone of its medical interventions and serves as many as 80%1 of its almost 60 million citizens3. Alarmingly, 80% of doctors operate in the private system, leaving the public system critically short of professional resources and invariably constrained1.

Universal healthcare initiatives have proven effective in other countries in an attempt to bridge this divide and is something that the Department of Health aims to emulate in South Africa with its proposed National Health Insurance (NHI) initiative.

One such example is Rwanda’s Universal Health Coverage (UHC) initiative, which has seen almost 90% of Rwanda’s population adequately covered for healthcare-related issues4. The successful implementation of the initiative has even received praise from the World Health Organization4, which has noted that the country is performing exceptionally well in ensuring its population meets Goal 3 of the United Nations sustainable development goals that calls for good health and wellbeing5. This includes ensuring that the population has access to the medical services they require, irrespective of their circumstances and without the threat of impending financial ruin4.

The country’s commitment to achieving this is evidenced by its 15.6% increase in health expenditure during the 2019/2020 financial year, which surpassed the 15% required by the former Organisation of African Unity’s Abuja Declaration4 – the entity now more commonly referred to as the African Union (AU).

To achieve this, the Rwandan government has, over the past few decades, built its strategy through several evidence-based and population-centric approaches. This includes increasing its health budget and the number of healthcare facilities, as well as bolstering service delivery and broadening community-based health insurance schemes4.

To this end, Rwanda increased its number of healthcare facilities from 1,036 in 2013 to 1,457 in 2020, which has greatly increased geographical accessibility and contributed to a reduction in the time spent to reach such a facility. Furthermore, broadening community-based insurance schemes has provided access to healthcare services to much of the population, and has reduced out-of-pocket costs – an expenditure which the majority of the poor and vulnerable simply cannot afford to incur4.

At the same time, while Rwanda’s UHC initiative may appear on track and that the country has achieved close to universal healthcare coverage is regarded as a notable achievement, conversations suggest that there are glaring gaps that require immediate attention should the country want to meet its goal of 100% universal healthcare coverage by 20304.

This includes implementing additional healthcare financing reforms, identifying policy options to expand coverage in remote and rural regions, and evidence-based policy reforms to ensure a clear course for service delivery4.

As the backbone of Rwanda’s UHC target, its community-based health insurance programme comes with additional challenges. This includes a disproportionate risk equalisation in the social healthcare insurance contributory system, unit costs exceeding some individuals’ income, cost escalations, and flaws in funding mobilisation and recovery6.  Still, there is sufficient evidence to suggest that South Africa should not to miss the opportunity to learn from Rwanda’s unique community-based health insurance programme and geographical expansion of accessibility.

To achieve South Africa’s National Health Insurance goal, the Department of Health will need to address the challenges presented by Rwanda’s UHC initiative, while also acknowledging and taking action on several problem areas in its own public healthcare system.

Research suggests that to prepare South African hospitals for the NHI initiative, finances, professional resources and staff numbers must be increased, infrastructure upgraded, access to medicines and equipment enhanced, and healthcare workers  given adequate training not only in their specific fields, but also on the intentions of the NHI7.

Given that reports indicate that the additional R23.7bn set aside by finance minister Enoch Godongwana for health expenditure over the medium term is insufficient for future healthcare sector upgrades8, there is crucial work to be done if South Africa wants its NHI initiative to be successful in the long term.



  1. Understanding South Africa’s Healthcare System and Policies [Internet]. International Citizens Insurance. 2021 [cited 2023 Mar 20]. Available from: https://www.internationalinsurance.com/health/systems/south-africa.php
  2. Best Healthcare in the World 2023 [Internet]. [cited 2023 Mar 20]. Available from: https://worldpopulationreview.com/country-rankings/best-healthcare-in-the-world
  3. Population of Southern Africa (2023) – Worldometer [Internet]. [cited 2023 Mar 20]. Available from: https://www.worldometers.info/world-population/southern-africa-population/#:~:text=Countries%20in%20Southern%20Africa&text=The%20current%20population%20of%20Southern,of%20the%20total%20world%20population.
  4. Yoganathan V. Lessons for SA from Rwanda’s universal health insurance scheme [Internet]. Juta MedicalBrief. Medical Brief; 2023 [cited 2023 Mar 22]. Available from: https://www.medicalbrief.co.za/lessons-for-sa-from-rwandas-universal-health-insurance-scheme/
  5. THE 17 GOALS [Internet]. [cited 2023 Mar 22]. Available from: https://sdgs.un.org/goals
  6. Nyandekwe M, Nzayirambaho M, Kakoma JB. Universal health insurance in Rwanda: major challenges and solutions for financial sustainability case study of Rwanda community-based health insurance part I. Pan Afr Med J [Internet]. 2020 [cited 2023 Mar 22];37. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648486/
  7. Mukwena NV, Manyisa ZM. Factors influencing the preparedness for the implementation of the national health insurance scheme at a selected hospital in Gauteng Province, South Africa. BMC Health Serv Res. 2022 Aug 6;22(1):1–13.
  8. Kahn T. Health sector offered little relief as budget shrinks in real terms [Internet]. Business Day. 2023 [cited 2023 Mar 22]. Available from: https://www.businesslive.co.za/bd/national/health/2023-02-22-health-sector-offered-little-relief-as-budget-shrinks-in-real-terms/