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1. Considering this context, discuss the role of different participants involved in the
policy-making process. In your answer, explain how each participant influenced the formulation,
adoption, and implementation of the policy, using the NHI policy as a practical example.
Essay 1
The Role of Different Participants in South Africa's NHI Policy-Making Process
Introduction
The development of South Africa's National Health Insurance (NHI) policy represents one of the
most ambitious and contested policy reforms in the country's post-apartheid history. Signed into law
in May 2024 after nearly three decades of debate, the NHI Act aims to establish a unified,
state-managed fund to provide universal healthcare access, addressing the stark disparities inherited
from the apartheid-era two-tiered system (National Department of Health, 2024). Yet as of 2026,
implementation remains suspended pending multiple legal challenges before the Constitutional Court
(Business Day, 2026). The NHI's journey from concept to legislation—beginning with preliminary
discussions in the early 1940s, accelerating through the Green Paper (2011) and White Papers
(2015/2017), culminating in the 2019 Bill's introduction and eventual enactment in May
2024—illustrates the complex interplay of actors that shapes public policy in South Africa's
democratic dispensation (South African Government, 2019; Cullinan, 2021).
This essay examines the diverse participants involved in the NHI policy-making process, analysing
how each influenced the formulation, adoption, and implementation of this transformative legislation.
Drawing on political economy analysis frameworks, the discussion illuminates how stakeholder
preferences, power dynamics, and strategic behaviour have shaped both policy content and the
trajectory of health reform in South Africa (Fryatt, Mills & Nordstrom, 2017).
Government Institutions: Steering the Reform Agenda
The Department of Health as Policy Entrepreneur
The National Department of Health (NDoH), under successive ministers including Dr Aaron
Motsoaledi (2009–2019) and Dr Zweli Mkhize (2019–2021), served as the primary policy
entrepreneur driving the NHI agenda. During the formulation phase, the Department exercised
considerable influence by framing the policy problem: persistent two-tiered inequality, fragmented
financing, and exclusion of the poor from quality care (Motsoaledi, 2011). The release of the Green
Paper (2011) marked the Department's first comprehensive articulation of NHI's design, proposing a
single public fund that would pool resources from general taxes and mandatory contributions,
thereby cross-subsidising from the wealthy to the poor (National Department of Health, 2011).
The Department's influence extended into the adoption phase through strategic parliamentary
engagements. By piloting the 2019 NHI Bill through the National Assembly and the National
Council of Provinces, the Department successfully defended key features—including the
controversial Section 33(2)(a) prohibiting private insurers from covering services paid for by the
NHI Fund—against opposition amendments (Parliamentary Monitoring Group, 2020). Critically, the
Department shaped implementation planning through the creation of the NHI Fund's transitional
structures and the Office of Health Standards Compliance, mandated to certify public and private
facilities for NHI accreditation (National Department of Health, 2020). However, the Department's
influence has been constrained by technical capacity gaps, with audits revealing insufficient actuarial
modelling and financial sustainability analysis (Office of the Auditor-General, 2023).
, The National Treasury: Fiscal Guardian and Reluctant Participant
The National Treasury has played a dual role as both a necessary enabler and a sceptical gatekeeper
throughout the NHI process. During formulation, Treasury officials expressed consistent reservations
about fiscal affordability, arguing that the proposed funding model—increasing VAT and payroll
taxes—was inadequately modelled and would crowd out other developmental priorities (National
Treasury, 2017). Treasury's influence is evident in successive funding revisions: the 2011 Green
Paper's estimate of R125 billion gradually increased to R256 billion by the 2017 White Paper, and
independent assessments later suggested full implementation could exceed R500 billion annually
(McIntyre, 2019).
During the adoption phase, Treasury's influence waned as political leadership overrode fiscal
objections. The 2019 Bill proceeded without Treasury's formal endorsement of the funding
mechanism, reflecting a broader tension between the health ministry's transformative agenda and
Treasury's fiscal conservatism (Fryatt & Hunter, 2021). However, Treasury has regained influence
during the implementation phase by controlling the release of allocated funds. As of 2026, only 12%
of the projected first-phase budget has been disbursed, partly due to Treasury's insistence on strict
conditionality before releasing appropriations (National Treasury, 2025). This inter-ministerial
conflict has contributed to the stalled rollout, even as legal challenges proceed.
Parliament and the Portfolio Committee on Health
Parliament, particularly the Portfolio Committee on Health, served as a critical arena for interest
mediation during the adoption phase. The Committee's influence lay in its ability to conduct public
hearings, summon stakeholders, and amend the Bill before referral to the National Assembly.
Between 2019 and 2023, the Committee received over 120,000 written submissions and held 18
weeks of public hearings across all nine provinces (Parliamentary Monitoring Group, 2022). This
process allowed civil society and professional bodies to shape provisions concerning benefit design,
accreditation standards, and appeals mechanisms.
Notably, the Committee introduced four significant amendments: expanding the definition of "user
fees" prohibited under private cover, extending the transitional period for medical schemes from five
to seven years, establishing a statutory NHI Ombud, and mandating parliamentary oversight of the
Fund's annual performance (Portfolio Committee on Health, 2023). However, the Committee
declined to amend the most contested clause—Section 33—despite opposition testimony,
demonstrating the limits of parliamentary influence when faced with executive determination
(Cullinan, 2021). The National Council of Provinces subsequently passed the Bill without further
substantive changes, and President Ramaphosa assented on 15 May 2024 (South African
Government, 2024).
The Presidency: Political Authorisation and Strategic Leadership
The Presidency, under President Jacob Zuma (2009–2018) and Cyril Ramaphosa (2018–present),
exercised agenda-setting power and strategic direction-setting. While Zuma's administration
prioritised NHI as part of the National Development Plan 2030, implementation advanced slowly,
with the 2015 White Paper languishing for two years before parliamentary processing (National
Planning Commission, 2012). Under Ramaphosa, the NHI gained renewed momentum, partly due to
political calculations around the 2019 and 2024 general elections, where health reform featured
prominently in the African National Congress (ANC) manifesto (ANC, 2019).
1. Considering this context, discuss the role of different participants involved in the
policy-making process. In your answer, explain how each participant influenced the formulation,
adoption, and implementation of the policy, using the NHI policy as a practical example.
Essay 1
The Role of Different Participants in South Africa's NHI Policy-Making Process
Introduction
The development of South Africa's National Health Insurance (NHI) policy represents one of the
most ambitious and contested policy reforms in the country's post-apartheid history. Signed into law
in May 2024 after nearly three decades of debate, the NHI Act aims to establish a unified,
state-managed fund to provide universal healthcare access, addressing the stark disparities inherited
from the apartheid-era two-tiered system (National Department of Health, 2024). Yet as of 2026,
implementation remains suspended pending multiple legal challenges before the Constitutional Court
(Business Day, 2026). The NHI's journey from concept to legislation—beginning with preliminary
discussions in the early 1940s, accelerating through the Green Paper (2011) and White Papers
(2015/2017), culminating in the 2019 Bill's introduction and eventual enactment in May
2024—illustrates the complex interplay of actors that shapes public policy in South Africa's
democratic dispensation (South African Government, 2019; Cullinan, 2021).
This essay examines the diverse participants involved in the NHI policy-making process, analysing
how each influenced the formulation, adoption, and implementation of this transformative legislation.
Drawing on political economy analysis frameworks, the discussion illuminates how stakeholder
preferences, power dynamics, and strategic behaviour have shaped both policy content and the
trajectory of health reform in South Africa (Fryatt, Mills & Nordstrom, 2017).
Government Institutions: Steering the Reform Agenda
The Department of Health as Policy Entrepreneur
The National Department of Health (NDoH), under successive ministers including Dr Aaron
Motsoaledi (2009–2019) and Dr Zweli Mkhize (2019–2021), served as the primary policy
entrepreneur driving the NHI agenda. During the formulation phase, the Department exercised
considerable influence by framing the policy problem: persistent two-tiered inequality, fragmented
financing, and exclusion of the poor from quality care (Motsoaledi, 2011). The release of the Green
Paper (2011) marked the Department's first comprehensive articulation of NHI's design, proposing a
single public fund that would pool resources from general taxes and mandatory contributions,
thereby cross-subsidising from the wealthy to the poor (National Department of Health, 2011).
The Department's influence extended into the adoption phase through strategic parliamentary
engagements. By piloting the 2019 NHI Bill through the National Assembly and the National
Council of Provinces, the Department successfully defended key features—including the
controversial Section 33(2)(a) prohibiting private insurers from covering services paid for by the
NHI Fund—against opposition amendments (Parliamentary Monitoring Group, 2020). Critically, the
Department shaped implementation planning through the creation of the NHI Fund's transitional
structures and the Office of Health Standards Compliance, mandated to certify public and private
facilities for NHI accreditation (National Department of Health, 2020). However, the Department's
influence has been constrained by technical capacity gaps, with audits revealing insufficient actuarial
modelling and financial sustainability analysis (Office of the Auditor-General, 2023).
, The National Treasury: Fiscal Guardian and Reluctant Participant
The National Treasury has played a dual role as both a necessary enabler and a sceptical gatekeeper
throughout the NHI process. During formulation, Treasury officials expressed consistent reservations
about fiscal affordability, arguing that the proposed funding model—increasing VAT and payroll
taxes—was inadequately modelled and would crowd out other developmental priorities (National
Treasury, 2017). Treasury's influence is evident in successive funding revisions: the 2011 Green
Paper's estimate of R125 billion gradually increased to R256 billion by the 2017 White Paper, and
independent assessments later suggested full implementation could exceed R500 billion annually
(McIntyre, 2019).
During the adoption phase, Treasury's influence waned as political leadership overrode fiscal
objections. The 2019 Bill proceeded without Treasury's formal endorsement of the funding
mechanism, reflecting a broader tension between the health ministry's transformative agenda and
Treasury's fiscal conservatism (Fryatt & Hunter, 2021). However, Treasury has regained influence
during the implementation phase by controlling the release of allocated funds. As of 2026, only 12%
of the projected first-phase budget has been disbursed, partly due to Treasury's insistence on strict
conditionality before releasing appropriations (National Treasury, 2025). This inter-ministerial
conflict has contributed to the stalled rollout, even as legal challenges proceed.
Parliament and the Portfolio Committee on Health
Parliament, particularly the Portfolio Committee on Health, served as a critical arena for interest
mediation during the adoption phase. The Committee's influence lay in its ability to conduct public
hearings, summon stakeholders, and amend the Bill before referral to the National Assembly.
Between 2019 and 2023, the Committee received over 120,000 written submissions and held 18
weeks of public hearings across all nine provinces (Parliamentary Monitoring Group, 2022). This
process allowed civil society and professional bodies to shape provisions concerning benefit design,
accreditation standards, and appeals mechanisms.
Notably, the Committee introduced four significant amendments: expanding the definition of "user
fees" prohibited under private cover, extending the transitional period for medical schemes from five
to seven years, establishing a statutory NHI Ombud, and mandating parliamentary oversight of the
Fund's annual performance (Portfolio Committee on Health, 2023). However, the Committee
declined to amend the most contested clause—Section 33—despite opposition testimony,
demonstrating the limits of parliamentary influence when faced with executive determination
(Cullinan, 2021). The National Council of Provinces subsequently passed the Bill without further
substantive changes, and President Ramaphosa assented on 15 May 2024 (South African
Government, 2024).
The Presidency: Political Authorisation and Strategic Leadership
The Presidency, under President Jacob Zuma (2009–2018) and Cyril Ramaphosa (2018–present),
exercised agenda-setting power and strategic direction-setting. While Zuma's administration
prioritised NHI as part of the National Development Plan 2030, implementation advanced slowly,
with the 2015 White Paper languishing for two years before parliamentary processing (National
Planning Commission, 2012). Under Ramaphosa, the NHI gained renewed momentum, partly due to
political calculations around the 2019 and 2024 general elections, where health reform featured
prominently in the African National Congress (ANC) manifesto (ANC, 2019).
