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The national health insurance scheme in South Africa: a pre-implementation evaluation of systemic threats, financial affordability and stakeholders’ sentiments.

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The impending national health insurance scheme is intended to provide all South Africans with access to high-quality, affordable services, regardless of socioeconomic status. However, there are concerns that the scheme may face various challenges, including gross systemic threats, cost-revenue imbalances and antagonistic stakeholder sentiments, thus undermining its benefits. In this study, a range of pre-implementation evaluation methods were used to assess the scheme. This includes systematic document reviews to identify systemic threats, analyses of projected costs and revenues using nonparametric and Monte Carlo techniques to assess the affordability of the scheme, and the use of the Stanford CoreNLP natural language processing to evaluate stakeholders' sentiments towards the scheme. The findings indicate that the scheme may fail if introduced on a derelict foundation due to administrative, resources and structural inadequacies. These challenges were further exposed during the current Covid-19 pandemic, emphasizing the threat they pose to the scheme. In terms of affordability, the analysis suggests that the scheme may be unaffordable due to the failure to raise sufficient revenues to fund the expected expenditure while keeping costs in line with the fiscal purse. From the examination of stakeholder sentiments towards the scheme, findings suggests that there is support for the scheme proposal but concerns regarding its operational and technical aspects are leading to negative sentiment against the scheme. The handling of the pandemic has also entrenched these negative sentiments against the scheme. These findings have several policy implications. First, there is a need to reform the healthcare system to avoid introducing the scheme on a weak foundation. Secondly, to ensure affordability of the scheme, the government may need to scale down the scheme and focus on primary care and less comprehensive benefit packages. Effort should be made to align expenditure with available resources. Finally, improved communication and stakeholder engagement may improve sentiments towards the scheme and identify problem areas within the implementation framework. The use of a natural language processing technique, which is a novel approach to studying stakeholder sentiments in healthcare, constitute this study’s contribution to the literature of policy development and implementation.


Doctoral Degree. University of KwaZulu-Natal, Pietermaritzburg.