Access to quality healthcare is a fundamental pillar of any thriving society, and the evaluation of healthcare systems plays a crucial role in shaping policies and improving outcomes. In this article, we explore various national health insurance systems in the world and assess South Africa’s readiness for its ambitious program. By examining key criteria such as accessibility, affordability, quality of care, health outcomes, and efficiency, we aim to shed light on the strengths and weaknesses of both global examples and the South African healthcare system.
Achieving Equitable Universal Health Care: Success Stories
Universal health insurance, also known as universal healthcare or national health insurance, has been implemented successfully in several countries around the world. These countries have recognised the importance of providing accessible and affordable healthcare to all citizens, and have designed comprehensive systems to achieve this goal. One notable example is Canada, which implemented a single-payer healthcare system known as Medicare in the 1960s.  Under this system, all Canadian residents are entitled to basic medical services, regardless of their income or employment status. Another successful example is Germany, where a social health insurance system has been in place for over a century. The German system is funded through mandatory contributions from employees and employers, ensuring that everyone has access to comprehensive healthcare services. France is also renowned for its universal health insurance system, which provides high-quality healthcare to all residents. The French system is primarily funded through a combination of payroll taxes and contributions from individuals. Other countries that have achieved successful transitions to universal health insurance include Australia, Japan, and the United Kingdom. 
Each of these countries has developed unique healthcare models that prioritise accessibility, equity, and quality of care. These successful implementations of universal health insurance demonstrate that it is possible to provide comprehensive healthcare coverage to all citizens, regardless of their socioeconomic status. By pooling resources and implementing efficient healthcare delivery systems, these countries have improved health outcomes, reduced healthcare disparities, and ensured that their populations have access to the care they need.
Many developing countries transitioning to middle-income status are aiming to expand government-run social safety nets, including the creation of universal health insurance programs. Some countries like Thailand have created a single-payer-like system funded by tax revenues and small copays, which has improved healthcare utilisation and outcomes. Other countries, including Ghana, Kenya, the Philippines, Vietnam, and Indonesia, are also pursuing similar efforts. 
Thailand’s Healthcare System: A Model for Universal Coverage
Thailand boasts a healthcare system that has made remarkable strides in providing accessible, high-quality care while ensuring financial sustainability. With its universal healthcare coverage and focus on primary care, Thailand has become a model for other countries seeking to achieve equitable healthcare outcomes.
The country operates three main healthcare schemes: the Universal Coverage Scheme (UCS), the Social Security Scheme (SSS), and the Civil Servant Medical Benefit Scheme (CSMBS). These schemes collectively cover the entire Thai population, ensuring that everyone has access to essential healthcare services. The system is financed through a combination of general tax revenue, contributions from formal sector employees, and premium subsidies for the informal sector. The UCS is primarily funded through general taxes, while the SSS and CSMBS rely on payroll contributions. The government’s commitment to healthcare investment has contributed to its sustainability. Moreover, Thailand has implemented cost-containment strategies, such as bulk purchasing of medicines and negotiations with healthcare providers, to control healthcare expenditures.
Significant investments have been made in Thailand in healthcare infrastructure, education, and technology to deliver high-quality care. It has a robust network of healthcare facilities, including public and private hospitals, clinics, and community health centers. Thailand’s healthcare professionals undergo rigorous training and are known for their expertise and dedication. They also implemented various quality improvement initiatives, such as accreditation programs and clinical practice guidelines, to ensure standardised care delivery.
Thailand’s universal health coverage in 2002 led to a significant increase in public health expenditure, from 63% in 2002 to 77% in 2011. Out-of-pocket expenses decreased from 27.2% to 10.5%. The General Government Health Expenditure also increased from 8% to 11% in 2002-2003, to 11% to 13% in 2006-2011. Around 70% of total health spending was dominated by curative expenditure. 
Indonesia’s National Health Insurance Scheme: Towards Universal Health Coverage
In 2014, Indonesia introduced a national health insurance scheme, Jaminan Kesehatan Nasional (JKN), with the aim of achieving UHC by 2019. Although the target was not met, the scheme has registered over 220 million participants, making up 82% of the national population, making it one of the world’s largest single-payer health insurance schemes.
Health service availability and use in Indonesia varies greatly, with 5% of districts having no easy access to a hospital and 17% having complete access. Around 4.7% of Indonesians reported using inpatient services in the past year. The use of such services ranges from 2.6% in Papua (in the far East) to 6.7% in Aceh (in the far West). The 2018 data showed a discrepancy between the number of people the insurer reported as members of Indonesia’s JKN health insurance (71%) and the number of citizens who reported being insured (61%). A significant percentage of the wealthiest respondents reported having state-subsidised insurance, suggesting potential misallocation of resources. Insurance coverage appeared to decrease with socio-economic status, with a significant portion of the poorest households reporting being uninsured, despite likely qualifying for subsidised insurance. Some poorer people may be unknowingly covered by government-paid premiums.
The quality of healthcare services in Indonesia varies across regions and facilities. While major cities generally offer higher-quality care, there are concerns about the consistency and standardisation of healthcare provision. Limited resources, overcrowded hospitals, and a shortage of well-trained healthcare professionals can impact the quality of care.
In Indonesia, healthcare financing relies on a combination of public and private sources. The Indonesian government mandates participation in a health insurance programme, with premiums largely covered by employers and the state. The state pays 69% of all premiums, covering its employees as well as the poor and near-poor. However, around 30 million unsalaried workers are expected to pay their own premiums, although many do not. The premiums start at IDR25 500 (US$1.80) and can go up to IDR80 000 (US$5.52) for first class service. Over 2300 hospitals, including 1700 private ones, accept patients under this scheme. The program covers primary care and many complex treatments at all premium levels.
The JKN program, which covers a significant portion of the population, is financed through contributions from individuals, employers, and the government. However, sustaining adequate funding for the JKN program remains a challenge due to issues such as financial deficits, inefficient resource allocation, and the need for continued investment in healthcare infrastructure. 
Ghana’s Healthcare System: Advancing Towards Universal Coverage
Ghana’s healthcare system has made significant strides in recent years, focusing on improving accessibility, quality of care, and financial sustainability. With a commitment to UHC and innovative reforms, Ghana has aimed to provide equitable healthcare services to its population.
The National Health Insurance Scheme, established in 2003, plays a crucial role in promoting accessibility. It provides coverage for essential healthcare services to both formal and informal sector workers, as well as vulnerable groups. The National Health Insurance Scheme has increased the proportion of the population with health insurance coverage, reducing financial barriers to care. Ghana has also invested in strengthening primary healthcare infrastructure, including community health centers and clinics, to bring services closer to communities.
Focus has been placed on improving the quality of care provided across its healthcare system. Efforts have been made to enhance healthcare workforce capacity through training programs and deployment strategies, with an emphasis on rural areas. The country has also implemented quality assurance mechanisms, such as accreditation programs for healthcare facilities and professional regulatory bodies to uphold standards of practice. Furthermore, Ghana has prioritised the adoption of technology, including electronic health records and telemedicine, to improve healthcare delivery and access to specialised care.
Significant steps have been taken to ensure the financial sustainability of Ghana’s healthcare system. The National Health Insurance Scheme, funded through contributions from schemes members, seeks to pool resources and reduce out-of-pocket payments for healthcare services. Ghana has also implemented strategic purchasing mechanisms, including provider payment reforms, to improve cost-effectiveness and efficiency. The government has also increased budgetary allocations to the health sector and actively sought external funding partnerships to support healthcare infrastructure development and key health programs.
Ghana’s economy has experienced rapid growth since the early 2000s, with a significant acceleration in GDP growth during the 2000s, averaging 8.7% per year between 2008 and 2012. This outpaced population growth and led to a peak per capita GDP growth rate of 14.5% in 2011, the second highest globally. As a result, Ghana was upgraded from a low-income to lower-middle-income country in 2011. 
Table 1: Outline of Epidemiological, Health Care Input and Performance Indicators Across Selected LMICs Based on Most Recent Data. (Source: World Bank)
|Epidemiological indicators||Cause of death, by communicable diseases and maternal, prenatal and nutrition conditions (% of total deaths)||14||19||45||26|
|Life expectancy at birth, total (years)||79||68||64||62|
|Health care input indicators||UHC Service Coverage Index||82||55||48||71|
|Current health expenditure (% of GDP)||4.4||3.4||4||8.6|
|Physicians (per 1,000 people)||0.9||0.6||0.2||0.8|
|Nurses and midwives (per 1000 people)||3.2||4.0||3.6||5.0|
|Hospital Beds (per 1000 people)||2.1||1.0||0.9||2.3|
|Domestic general government health expenditure (% of GDP)||3.1||1.9||2.0||5.3|
|Domestic general government health expenditure per capita (current US$)||214.7||73.2||42.3||304.1|
|Health care performance indicators||Mortality rate, infant (per 1,000 live births)||7||19||33||26|
|Maternal mortality ratio (modeled estimate, per 100,000 live births)||29||173||263||127|
|Immunisation, measles (% of children ages 12–23 months)||96||72||94||87|
|People using safely managed sanitation services (% of population||26||–||13||–|
|Out-of-pocket expenditure (% of current health expenditure)||10.5||31.8||30.8||5.4|
South Africa’s Road to National Health Insurance: Challenges and Progress
A recently published study explored the readiness of a public hospital in South Africa for the implementation of the National Health Insurance scheme. Although some progress has been made, the findings reveal numerous challenges, including a lack of resources, outdated facilities, poor management, increased workloads, and a lack of training. The hospital’s current conditions, as indicated by the most recent ideal hospital framework review, suggest that it is not yet ready to implement the National Health Insurance scheme.
The lack of resources, including hospital equipment, human resources, and finances from the Department of Health (DoH), is a significant impediment to the hospital’s readiness for the National Health Insurance scheme. The hospital’s inability to offer excellent service, characterised by long waiting hours, suggests that it may struggle to cope with the demands of the National Health Insurance scheme. The continuous use of paper-based systems at the hospital indicates that it is not yet ready to implement a high-level medical system like the National Health Insurance fund, which would be better served by a fully computerised and automated information system. Despite the progress made, the findings suggest that the hospital still has a long way to go before it is ready for the implementation of National Health Insurance.
The study also highlights the issue of outdated facilities at the hospital. Despite changes in patient demographics and economic position, there has been little visible expansion of the hospital to accommodate patient needs. This lack of expansion is attributed to factors such as budget cuts and corruption. Moreover, the procurement processes for services and goods at the hospital are overly time-consuming and hindered by red tape, which participants attribute to management failures.
Furthermore, increased workloads have led to job dissatisfaction among hospital staff, affecting their views towards the National Health Insurance. Many feel that their minds are not yet conditioned to manage the National Health Insurance scheme and believe that increased remuneration for their work would motivate them. This lack of motivation and the current systemic challenges could potentially hinder the hospital’s preparation for the NHI’s implementation.
National health insurance has proven to be an effective mechanism for achieving positive outcomes in various countries such as Thailand, Ghana, and Indonesia. These nations have successfully implemented comprehensive healthcare systems that provide coverage to their populations, resulting in improved access to essential medical services, reduced financial burden on individuals, and better health outcomes overall. While South Africa still faces challenges in preparing for its National Health Insurance system, the ideology of healthcare for all should always be the aim.
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