Table 1 Summary of the nine phases of health system reform in South Africa (Source: Author)

1. 1926 to 1939. The election of the Pact Government enabled the institution of a South African welfare state comprised of direct grants for the elderly and disabled (in addition to other forms of social spending). At the same time, support for HSR was growing among health professionals and government officials.

2. 1940s and 1950s. The election of the United Party, and the publication of the Beveridge report, combined with support of health professionals and the appointment of Gluckman as Minister of Health set the stage for HSR in the form of a centrally-funded NHS open to all South Africans. However, opposition from the Medical Association of South Africa, and the introduction of apartheid prevented its implementation.

3. 1960s and early 1970s. The apartheid government begins tightly regulating the private health sector. Steps included the establishment of the De Villiers Commission showing the pernicious impact of the private sector on public health services, and the introduction of the Medical Schemes Act to protect private sector users.

4. Late 1970s and 1980s. Increasingly organised and militant apartheid opposition, combined with pressures on the public budget forces a change in the government’s stance on private healthcare. Deregulation of the private sector allows racial discrimination to be replaced by socio-economic discrimination, while limiting political damage to the National Party. However, concern about increasing healthcare costs, fragmentation, and the abdication of the state’s responsibility to provide health services reignites calls for HSR in the late 1980s.

5. 1990 to 1993. As the ANC prepares to govern the ‘new’ South Africa, political and economic pressures, reflecting the hegemony of neoliberal economic ideas, push the party’s development policy toward more economically conservative proposals. In the HSR debate, these pressures, combined with the size and strength of the for-profit health sector, result in proposals that envision a continued role for private actors.

6. 1994 to 1998. After the first democratic election, the new government inherits significant governance and bureaucratic challenges. In the health sector these include service delivery challenges in the public sector, and cost-escalation in the private sector. The new Minister of Health initiates a series of deliberative fora for HSR, but their recommendations fail to align with the Minister’s personal values, preventing policy progress.

7. 1999 to 2006. The government’s refusal to roll-out an HIV treatment programme in the face of an escalating epidemic distracts policy-makers and civil society from HSR efforts, but also reaffirms the role of the state in providing health services and regulating the private sector. Recommendations for an SHI, laying the groundwork for more fundamental reforms are rejected as infeasible, and efforts to regulate the private sector to contain costs have limited success.

8. 2007 to 2015. Zuma is elected president of the ANC and then of the country. Zuma’s pro-poor populism is distinguished from Mbeki’s ‘cold’ neoliberalism, and Zuma reignites the HSR agenda by promising the implementation of the NHI. However, the policy development process is contentious, and Zuma’s presidency is defined by grand-scale corruption and governance failures that undermine public trust in the state.

9. 2016 to 2019. In the shadow of state capture, Motsoaledi continues to drive the NHI policy process forward, hampered by contention surrounding the role of the private sector. Ultimately, Motsoaledi’s stance on private sector involvement softens, but concern about the capacity of the state to regulate the private sector, deliver public health services, and manage NHI funds persists.