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Over the last two decades there has been growing interest in the potential of Social Health Insurance (SHI) as a health care financing mechanism in low- and middle-income countries. SHI schemes exist in many countries of Latin America and have also been introduced across Asia in recent years. However, few countries in Africa have implemented SHI. Despite the sustained interest in SHI, there are growing concerns about whether it will achieve equity and financial sustainability objectives. It is clear that the design of SHI is of critical importance in this regard. South Africa has debated whether or not to implement SHI for nearly a decade and a half, and the design of SHI proposals has changed dramatically over that period. This paper considers lessons that can be drawn from the South African experience of developing and adapting SHI design, in conjunction with recent evidence from other low- and middle-income countries. The paper illustrates how SHI design may be affected by the trade-offs that are made to accommodate key actors' views, an accommodation that may even undermine the achievement of key objectives. A critical design requirement to promote equity and sustainability is a common contribution and risk pool across the SHI and any existing private insurers. In addition, given the complexity of SHI reforms, and the fact that SHI is usually only one component of a broader package of health sector reforms, the appropriate sequencing of implementation of the SHI and associated, supporting organizational and financing reforms is essential. As SHI evolves within a country, it is important to benchmark the changing nature of its design against pre-determined objectives in order to protect the final integrity of the policy.

A tale of two visions: the changing fortunes of Social Health Insurance in South Africa