A quantitative study to evaluate the controls and accountability measures in place to alleviate the leadership and governance challenges impacting the realization of the National Health Insurance (NHI) in South Africa

Abstract

Objectives

Governance and leadership are regarded as the most crucial aspects in delivering quality health care, and yet they are arguably the most complex functions of any health system. The objective of the study was to investigate the structural problems affecting the implementation of the National Health Insurance (NHI) and address the challenges affecting the NHI building blocks. Further objective of the study was to evaluate if there were appropriate controls and accountability measures in leadership and governance to inform the development of a workable model for the implementation of the NHI in South Africa.

Design

A quantitative study was undertaken to interrogate the structural problems affecting the implementation of the NHI by seeking to address the challenges affecting the NHI building blocks.

Setting and participants

The study was undertaken with participants who are decision-makers and/or contribute to the health sector reforms in South Africa in the realization of the NHI.

Main outcome

The main outcome of the study was to determine the requisite interventions to deal with challenges that affect governance and/or leadership functions in the implementation of the NHI.

Methods

The questionnaire was distributed via SurveyMonkey over a period of 2 months, and the data were analysed using R Statistical computing software of the R Core Team, 2020, version 3.6.3. The results were presented in the form of descriptive and inferential statistics.

Results

The study found that the success to implement NHI needs to be supported by clarity and commitment to specific policy fundamentals aimed at improving efficiency, stakeholder participation, and accountability. This imperative remains very much in doubt since the different occupations hold different views about the progress made in the implementation of the NHI across the governance and leadership functions.

Conclusions

The study confirmed the interrelatedness of the subthemes identified for the governance and leadership construct and pointed to the importance of sharpening policy development and implementation approaches in collaboration with all relevant stakeholders.

Protocol registration

The Ethics approval reference number is HSSREC 00002565/2021.

Background

Governance and leadership are regarded as the most crucial aspects in delivering quality health care, and yet they are arguably the most complex functions of any health system. Governance is said to be key to the likelihood of Universal Health Coverage (UHC) being adopted and implemented since it is a prerequisite for policies, shapes the likelihood of pro-UHC forces winning in politics and finally affects the likelihood that programs will be entrenched [1]. The World Health Organization (WHO) states that leadership and governance ensure strategic policy frameworks exist and that they are combined with effective oversight, coalition-building, regulation, attention to system design and accountability [2].

In its efforts to implement UHC, the South African government identified leadership and governance as one of the National Health Insurance (NHI) building blocks that lends itself to challenges affecting the health system in South Africa – the others being service delivery, health workforce, availability of medical products and technologies and health care financing challenges [3]. Accordingly, the government of South Africa introduced and processed a number of interventions pertinent to health care system reforms. Chief amongst which includes a policy outlook for the country with priority strategic issues for the betterment of the country, named “National Development Plan 2030” (2012) and a range of legislative changes aimed at reforming the healthcare system, which encompasses the NHI legislation.

The transformation of the health care system is among the 13 objectives or major thematic areas as set out in the National Development Plan, a plan that is said to provide a broad strategic framework to guide choices and actions (NDP 2030, page 26) [4]. The NDP acknowledges that the state of the public and private health sectors within the South African health system are not sustainable and do not support the objective of attaining quality health care for all. The NDP suggests that this unacceptable state of the healthcare system must be remedied and that SA’s broken public health system must be fixed and despite the greater use of private care where users pay via their health insurance and is part of the solution, it must be clear that this is by no means a substitute for improving public health care [4]. From a policy perspective, there is, therefore, a clearly stated objective about the end state of the healthcare system in SA by 2030, “a health system that provides quality care to all, free at the point of care to all, or paid for by publicly provided or privately funded insurance” [4].

Measures to introduce enabling legislation for the implementation of the National Health Insurance (NHI) are at an advanced state and the NHI bill that was passed by the National Assembly in June 2023 was signed into law by the President, Matamela Cyril Ramaphosa on 15 May 2024. The process started in 2011 when the NHI green paper was published for public consultation, followed by NHI pilot projects in 2012, which had a goal of strengthening health system initiatives. The year 2015 saw the publication of the NHI white paper, which paved the way for the introduction of the NHI bill for processing through the parliamentary processes.

These are just some of the governance and leadership efforts which, according to Fulop and Ramsay (2023), constitute the macro-, meso- and micro-level issues denoting different actions by the stakeholders (both the public and the state) in dealing with the envisaged reforms. Fulop and Ramsay (2023) define these levels as follows [5]:

• (a) Macro-level governance which sets overarching directions and priorities for quality and safety (e.g. national recommendations) and may feature a variety of bodies serving different functions, including regulatory roles.

• (b) At the meso-level, organizations develop and implement strategies aimed at delivering high-quality, safe care to the populations they serve.

• (c) The micro-level encompasses activities where front-line staff deliver care due to inherent professional competencies and experience.

The purpose of the NHI bill (2019) is to establish and maintain a National Health Insurance Fund in the Republic funded through mandatory prepayment that aims to achieve sustainable and affordable universal access to quality healthcare services. It seeks to [6]:

• (a) serve as the single purchaser and single payer of health care services in order to ensure the equitable and fair distribution and use of health care services;

• (b) ensure the sustainability of funding for health care services within the Republic; and

• (c) provide for equity and efficiency in funding by pooling funds and strategic purchasing of health care services, medicines, health goods and health-related products from accredited and contracted health care service providers.

This noble purpose might, however, be plagued by the implementation challenges as identified in the NHI white paper (2017) [3]. Countries in the Asia–Pacific region, according to Yeoh et al. (2019), also conducted similar investigations of governance pathways for UHC implementation. In this review, Yeoh et al. (2019) relied on the WHO’s governance for UHC framework given in the Health Systems Governance for Universal Health Coverage: Action Plan to develop questions to assess health system performance [7]. The five key governance functions identified in the plan used in the article by EK Yeoh et al. (2019) were (1) formulating policy and strategic plans, (2) generating intelligence, (3) putting in place levers or tools for implementing policy, (4) collaboration and coalition building, and (5) ensuring accountability [7].

The rationale of the study, which is to conduct a review of leadership and governance challenges impacting health care and the intended health reforms in the form of the NHI, is informed by the need to achieve the NHI objectives. The aim of the study was to investigate the structural problems affecting the implementation of the NHI and address the challenges affecting the NHI building block of leadership and/or governance.

Methods

Design, procedures, population and participants

This is a descriptive, experimental quantitative study that used an anonymous questionnaire to collect the data.

The target population was drawn from people involved in leadership and governance in the areas of healthcare funding and management, medical products and technologies, and information and research in healthcare.

Individuals and stakeholders who interact with and/or are in the employment of the following formations, such as the Statutory health councils, regulatory bodies, medical aid administrators, medical schemes and voluntary bodies/organizations were included, as well as health care workers registered with the statutory councils being the South African Pharmacy Council (SAPC), South African Nursing Council (SANC) and Health Professions Council of South Africa (HPCSA).

The participants were selected on the basis that they are important and interested stakeholders with the potential to contribute meaningfully to the NHI discourse due to their wealth of experience in the various spheres as well as the oversight they are exercising in their current roles. In their current roles, the contribution of the participants is seen but not limited to the following areas.

• (a) Formulation and application of legislative framework and manage professional practice.

• (b) Provide health care services, including administrative and management services, both in the private and public sectors.

• (c) Contribute to Legislative framework, including inspection and compliance with practice requirements.

• (d) Determine and monitor practice requirements, lobby and advocate for policy acceptance and implementation.

In addition, the target population is at the forefront of the healthcare industry engagements aimed at improving healthcare, has a keen interest in the developments around NHI and has the capacity to influence sentiment around the attainment of the NHI objectives. They are involved in providing healthcare in both the private and public sectors.

Sample size

The calculated sample size was 660 participants. Given that α = 0.05, β = 0.2 and degrees of freedom (df) = 65 and using G Power 3.1.9.7 sample size calculation software, it was estimated that a minimum sample size of 660 was required to detect small to medium effect sizes of at least 0.25 about 80% of the time (have 80% power of test) with 95% confidence (Fig. 1).

Fig. 1

Determination of the sample size (n = 660)

Data collection tool and procedure

The data collection tool was a web-based five-point Likert scale anonymous survey questionnaire that consisted of 44 questions. The first part of the survey questionnaire dealt with the population demographics, consisting of two questions. The remaining 42 questions focused on aspects of the structural problems that are said to affect the implementation of the NHI as identified in the NHI white paper. The questions related to leadership and governance, healthcare financing, health workforce, medical products and technologies, information and research on service delivery coverage that has an impact on the implementation of the NHI.

Data analysis

The statistical data analysis was conducted using the R Statistical computing software of the R Core Team, 2020, version 3.6.3. The results were presented in the form of descriptive and inferential statistics. Where applicable, the descriptive statistics of numerical measurements were summarized as the minimum, maximum, quartiles, interquartile ranges, means, standard deviation and coefficient of variation. On the other hand, the categorical variables were described as counts and percentage frequencies. Some of the results were visualized in the form of bar charts, Likert and correlation plots. Cronbach alpha was used to measure the internal consistency of items that were grouped into a section (construct). Kruskal–Wallis was applicable in testing differences in the scores between at least three groups, followed by Wilcoxon pairwise tests. All the statistical tests were conducted at a 5% level of significance.

Results

A total of 678 responses were received, exceeding the calculated sample size of 660, giving a response rate of 102%.

The results were grouped into themes and subthemes representing the details of the NHI function leadership and/or governance.

The population demographics and only the results of the challenges relating to leadership and/or governance are presented in this paper.

Descriptive statistics were generated on each item comprising the structural challenges that might affect the implementation of the NHI in response to the research questions. These descriptive statistics included:

• (i) Population demographics.

• (ii) The Cronbach’s alpha coefficient (> 0.7) shows the degree to which all the items in the questionnaire measure the same attribute. The items measured on the leadership and governance theme were found to be consistent with a Cronbach Alpha of 0.921 (> 0.7).

• (iii) Sub-theme median scores spoke to the research objectives, indicating whether participants were in support or not in support of a research item.

• (iv) Correlation analysis of the themes, also known as bivariate, which is concerned with finding out whether a relationship exists between variables and then determining the magnitude and action of that relationship.

• (v) Theme analysis by occupation using the Kruskal–Wallis H test to determine if there are any significant differences in the response between the occupations.

Respondents’ demographics

The demographic data of the participants related to their area of work and/or employment or deployment in the health sector, both in the public and private healthcare sectors, is depicted in (Fig. 2).

Fig. 2

Demographic profile of the study population user sample (n = 678)

The highest responses were received from the health workforce (67%), followed by medical products and technologies (13.3%), with just 1.3% responses received from NHI implementers.

Participants’ responses per sub-theme

The leadership and governance efforts for the implementation of the NHI were reviewed using questions formulated around the five functions: formulating policy and strategy, generating intelligence, implementing policy: levers and tools, collaboration and coalition building and accountability and some general leadership and governance issues, which did not fall directly under the five functions. The results are presented under each of the functions of leadership described as subthemes. First, descriptive statistics representing the participants’ responses (Fig. 3) are presented. The participants’ responses by occupation to the NHI initiatives were then examined to determine if there are significant differences in the responses per occupation based on the Kruskal–Wallis H test (Table 1). Finally, using the correlation results, the relationship between the subthemes is examined.

Fig. 3

Participants responses to the leadership and governance theme (n = 678)

Table 1 Instances where there were differences in the ranking of the responses between specific occupations – Kruskal–Wallis H test

The items measured on the leadership and governance theme were found to be consistent, that is, they were appropriate measures to measure the theme with a Cronbach alpha of 0.921 (Online Appendix 1).

Leadership and governance

Focusing on the subtheme of leadership and governance, a majority of the respondents (94%, n = 678) maintain that committed political leadership on its own is not sufficient. They believe that managers, administrators, service users from the population, academia, and professional associations have a critical role in contributing to the political discourse with quality information for policy formulation and resource allocation and in driving the performance of healthcare systems.

The respondents (76%, n = 678) believe that there is a need to support and sustain political leadership and health system stewardship and governance to ensure a successful implementation of the much-needed healthcare reforms. We also examined whether South Africa compares favourably with other countries in Sub-Saharan Africa with strong governments and whether South Africa is making progress in the design and implementation of specific policies within a specific context. To this, 53% of the respondents disagreed, with only 27% agreeing (n = 678). Another area of concern examined was the ability of South Africa to marshal country and partner resources towards agreed NHI strategies, to which again 55% disagreed, with only 25% agreeing (n = 678).

Formulating policy and strategic plans

On the function of formulating policy and strategic plans, 46% of the respondents do not believe that the approach adopted and followed by the government in formulating policy and strategic plans to support the NHI (service coverage or financial coverage decisions) will ensure that these commitments are acted upon, only 35% are in the affirmative (n = 678).

When asked whether the governance reforms embarked upon as stipulated in the NHI bill adequately address the fundamentals for decentralization to improve efficiency, stakeholder participation, and accountability, 50% disagreed, whilst only 28% agreed (n = 678).

A sizeable majority of 55% of the respondents believe that there is no role clarity across the spheres of government for the implementation of the NHI, whilst 21% thought there was (n = 678).

Generating intelligence

On setting up systems to use intelligence to inform decisions 58% disagreed that SA has a secure health information system to ensure financial protection, and 19% thought the system was secure enough to ensure financial protection. Further to that, 56% of the respondents thought there was no consensus regarding Health Technology Assessment (HTA) policy, whilst a mere 18% thought there was consensus. Finally, 66%, as opposed to 11%, believe that there is insufficient mitigation to overcome the barriers to the HTAs initiatives in the various settings of the healthcare system (rural, urban and peri-urban areas).

Implementing policy: levers and tools

Regarding the levers and tools meant to assist policy implementation, a majority of the respondents (66%, compared with 15% n = 678) stated that there was no clarity regarding the institutional arrangements to enable the NHI. A total of 58% against 16% held the view that the NHI policy initiatives such as purchaser–provider split, greater provider autonomy, and greater engagement of private providers, as well as making explicit the roles and responsibilities of actors within the health system, using tools such as benefit packages to ensure success in the delivery of healthcare service in the NHI space have not been sufficiently socialized with all stakeholders.

On the question of whether the South African regulatory framework and systems ensure improved value for money, help ensure that primary health facilities (in both urban and rural areas) are only using essential drugs and encourage the rational use of drugs by local health authorities is adequate, the respondents were split almost equally with 42% disagreeing and 40% in agreement. A total of 42% of respondents agreed that regulatory framework and systems – registration and licensing as well as the ability to enforce these systems are adequate, while 42% thought these aspects are inadequate. Fifty two percent (52%), as opposed to 18%, believe that the NHI regulatory framework sufficiently provides incentives and approaches to healthcare professionals to influence their behaviour.

Collaboration and coalition building

On the function of collaboration and coalition building (n = 678), 54% of the respondents are not convinced that the collaborative efforts of government with regards to the NHI programs and projects that are intended to deal with specific systemic challenges to enable the success of the NHI are sufficient, with only 26% believing otherwise. On the question of whether South Africa should welcome the funding and capacity-building support offered by international organizations such as the World Bank, UNICEF, and WHO, 33% of the respondents were against it, with 46% for it. An overwhelming majority of the respondents (80%) believe that efforts to facilitate and nurture greater collaboration between the public and private sectors to foster good stakeholder relations and build mutual trust (e.g. Public-Private Partnerships (PPPs), etc.) should be undertaken for the successful NHI implementation.

Accountability

On accountability as one of the governance functions, 54%, as opposed to 18%, thought that the accountability focus for all stakeholders had not been clearly defined. A majority of the respondents, 96%, agreed with the need for financial accountability tools to be put in place. A majority of 85% agreed that greater performance accountability by doctors, nurses, pharmacists, and allied health professionals, as well as traditional medical practitioners, requires the formulation and promulgation of appropriate regulations, including practice standards and sanctions. The respondents unequivocally agreed (88%) that engaging civil society and feeding community concerns and suggestions back into the policy and decision-making processes is an essential imperative for the success of the NHI.

The results (Fig. 3) reveal a negative perception of the efforts by the political leadership for the implementation of the NHI, pointing to a potential crisis situation where the respondents either do not believe that policymakers are on the right track or that the measures taken to address the challenges are not adequate.

Participants’ reactions to NHI initiatives by occupation

We then went further to determine if there were statistically significant differences between two or more occupations of an independent variable for leadership and governance using the Kruskal–Wallis H test. The table below shows the instances where there were differences in the ranking of the responses between specific occupations. The results show that the differences were between those employed in leadership and/or governance occupations and the following two groups of occupations: those employed in/as the health workforce, information and research (service delivery). These differences occurred consistently across all the subthemes except the subtheme generating intelligence.

The table also shows instances where there were statistically significant differences in the ranking of the responses.

Correlation of subthemes identified in the leadership and governance

Correlation analyses were used to examine the relationship between the subthemes identified in leadership and governance.

The researchers aimed to study how the themes are related and how their relationship can help to shape leadership and governance construct and determine the controls that are supposed to be in place to realise the attainment of the NHI in South Africa. In this regard, we wanted to establish if there is some association in the observed themes.

The researchers also wanted to establish how weak or strong the correlation is between the themes in order to sketch a picture of how dire the situation is, ranging from crisis to moderate to no crisis. Thus, for the purpose of interpreting the relationships between the themes in this study, the researchers decided to look at the correlation from three cut-off points being 0–0.33 (weak correlation), 0.34–0.66 (moderate correlation) and 0.67–1.00 (strong correlation).

Table 2 shows a monotonic relationship between two variables in which (1) as the value of one variable increases, so does the value of the other variable, or (2) as the value of one variable increases, the other variable value decreases.

Table 2 Correlation of the leadership and governance themes (P value < 0.001)

The study shows that the themes are positively correlated implying that when sentiment on one variable goes up and the other will follow. Of the fifteen pairs of themes identified in leadership and governance, three (generating intelligence, formulating policy and strategic plans and implementing policy) show a strong correlation (0.67 to 1.00) and the balance (12) show a moderate correlation (0.34 to 0.66).

The results demonstrated a strong positive correlation between generating intelligence (n = 678, P < 0.001) and implementing policy viewed as a serious challenge in the realization of the NHI. There was also a moderate correlation between generating intelligence (n = 678, P < 0.001) and collaboration and coalition building and accountability.

Results further indicated a strong positive correlation between formulating policy and strategic plans (n = 678, P < 0.001) and implementing policy and generating intelligence viewed as a serious challenge in the realization of the NHI. Formulating policy and strategic plans (n = 678, P < 0.001) also showed a positive correlation, albeit moderate, with collaboration and coalition building and accountability.

Leadership and governance (n = 678, p < 0.001) also showed a positive correlation, albeit moderate, with Formulating Policy and Strategic Plans, Implementing Policy, Generating Intelligence, Collaboration and Coalition Building and Accountability.

Implementing policy (n = 678, P < 0.001) also showed a positive correlation, albeit moderate, with collaboration and coalition building and accountability.

Collaboration and coalition building (n = 678, P < 0.001) also showed a positive correlation, albeit moderate, with accountability.

Discussion and recommendations

We evaluated the participant’s views on whether there are appropriate controls and accountability measures to deal with the leadership and governance challenges impacting the attainment of the NHI in South Africa. The results will be discussed under each of the subthemes identified through the data analysis approach under the theme leadership and governance. The sub-themes are leadership and governance, formulating policy and strategic plans, implementing policy: levers and tools, collaboration and coalition building, accountability and generating intelligence.

The practical steps to address leadership and governance challenges identified are discussed in detail under each of the subthemes below and summarized in Table 3.

Table 3 A summary of practical steps to address leadership and governance challenges identified

Leadership and governance

The study found that committed political leadership on its own is not sufficient, and there is a critical role for managers, administrators, service users from the population, academia and professional associations in contributing to the political discourse with quality information for policy formulation and resource allocation and in driving the performance of systems in healthcare. Leadership and governance continuity are required to ensure a successful implementation of the envisaged healthcare reforms, and this aspect was found to be in doubt. Contrary to the findings, the South African Healthcare leadership believes that it has the savvy political leadership, long-term commitment and proactive, adaptable strategies to engage with stakeholders at all levels and sectors in order to re-orient towards public healthcare (PHC), which is a more equitable route to achieving UHC [4]. This signifies the tension between those employed in leadership and governance and the rest of the respondents employed in other occupations owing to the level of engagement or lack thereof. It is, therefore, necessary for those employed in leadership and governance, especially policymakers at the level of the government, to take note of this tension and not ignore it. This will require recognizing the importance of political economy as an enabler or constraint of social and economic reforms by forging closer collaborations over and above the current efforts to bring all parties together [2, 6].

The study found that South Africa does not compare favourably with other countries in Sub-Saharan Africa with strong governments and is not making progress as she is not able to design and implement policies within a South African-specific context. It was also found that South Africa is not able to marshal country and partner resources towards agreed strategies.

It must, however, be pointed out that some of the global health initiatives (GHI), including financial aid effectiveness, have come into question, as these were found to be fragmented and often contributed to the fragmentation of health aid [7]. Therefore, there is a need to ensure that partners and countries co-create conditions and standards for grants and not have them imposed upon countries [8].

Formulating policy and strategic plans

A greater number of governments (89%) have made UHC a central goal in their national health policy plans and strategies. However, only a few (41%) have enacted UHC laws to ensure equitable, affordable access to health services [9]. A 2023 UHC global monitoring report also states that important gains in service coverage (measured as service coverage index – SCI points) since 2000 have stalled in recent years, whereas since 2015, there was only a three-index-point increase [10]. This is despite a unanimously endorsed regional strategy by the South-East Asia region countries (SEAR), which details policy and strategic direction on issues affecting UHC [11]. The finding of this study aligns with the latter statements, where current policy and strategic formulation approaches support the NHI initiatives undertaken to support the aspirational goals of the UHC. However, when it comes to specific policy imperatives, such as decentralization of fundamentals to improve efficiency, stakeholder participation and accountability, the study found that the stakeholders were not convinced that the decentralization fundamentals would be addressed by the stated undertakings. This has become a contentious subject. Literature shows that the success of decentralization efforts for health services is very much country context specific. For instance, community-based models such as the deployment of health extension workers (HEWs) have become a success in Thailand, Pakistan and Ethiopia; however, shortage of human resources and medical supplies and poor physical health access, to name but a few, have become challenges towards UHC [12].

We also found that the stakeholders believe that there was no clarity of role across the spheres of government for the implementation of the NHI. Political interference and unclear roles and responsibilities of different governmental regulatory bodies are documented as the challenges that contribute to failures in service delivery and, by extension, to UHC efforts [12].

The study also found it doubtful that the approach adopted and followed by the government in formulating policy and strategic plans to support the NHI (service coverage or financial coverage decisions) will ensure that these commitments are acted upon. The results of a study by Yeoh et al. (2019) point to the fact that though there were good intentions about the implementation of the UHC driven by “Healthy Island Vision and the 2015 Yanuca Island Declaration,” there might still be challenges in enacting those policies and hence these countries embarked on different journeys to achieve the strategic imperatives of their UHC: [7]

• (i) Fiji has endorsed increased government spending to expand access to health services for the poor.

• (ii) Papua New Guinea’s Department of Health has worked with provinces to develop annual health service plans, informed by facility audits, covering services in health facilities, including aid posts, rural health centres and hospitals.

• (iii) The Solomon Islands have developed their pre-existing Role Delineation Policy (2011) in response to the national commitment to UHC made in 2013. As a result, the health system was reclassified from five to four levels, and the Ministry of Health and Medical Services undertook development of integrated service delivery packages, specifying essential services, staffing, equipment and infrastructure at each level of the health system, in collaboration with development partners.

South Africa, like some of the Asia–Pacific countries, will have to use its own approaches derived through collaborative means and informed by good intelligence gathered through health information systems to achieve the UHC commitments.

Implementing policy: levers and tools

Implementing policy is closely related to policy formulation and strategic plans. We found that there was negative sentiment around the indicators of policy implementation measured:

• (i) There was no clarity regarding the institutional arrangements when it comes to how existing institutions (Council for Medical Schemes, Medical schemes, etc.) and/or created new institutions (NHI fund) will operate and interact within the health system to support pro-NHI aims and policies.

• (ii) the NHI policy initiatives for example purchaser–provider split, greater provider autonomy, and greater engagement of private providers have not been sufficiently socialized with all stakeholders. The roles and responsibilities of actors within the health system have not been made explicit.

• (iii) The policy does not provide incentives to improve provider behaviour.

With regards to regulations and regulatory framework, we found that there is confidence that the regulatory framework and systems are adequate. However, some still believe it's inadequate.

These indicators have proven to be essential in efforts to progress towards UHC, as demonstrated by countries across the Asia–Pacific region; notably, those arrangements were not without glitches [7]. However, when it comes to South Africa, the stakeholders clearly lament the fact that there is no clarity when it comes to such legitimate expectations as institutional arrangements, socialization of the NHI policies, etc. Ironically, South Africa is credited with institutional reforms in the face of increased public expenditure on medicine when the Pricing Committee was set up [9]. There is, therefore, no reason why this cannot be emulated.

Generating intelligence

Generating intelligence is intended to ensure buy-in when setting up health technology assessments, which are intended to ensure agility in policy decisions pertaining to health requirements, be it monitoring global health requirements and assessing health system gaps [11]. However sufficient relevant stakeholder engagement is needed. Contrary to the intention, the study found that stakeholders thought there was no consensus regarding HTA policy and disagreed that South Africa has a secure health information system to ensure financial protection. Respondents still hold that there are still barriers to HTA acceptance.

A couple of countries, according to the study (Yeoh et al., 2019), have attained success in implementing health information systems that provide information that guides decision-making in both clinical and management settings – a case in point of Fiji [7]. The same also points to the fact that Important policy aspects of UHC, like the universal health benefits package and the National List of Essential Medicines, have been developed using the HTA, which was derived in a deliberative process to foster legitimacy and transparency [7].

We found that contrary to other countries where health information systems are extensively used to inform policy, the respondents believe that policy on NHI is not driven by intelligence derived from health information systems.

Collaboration and coalition building

Studies show countries have engaged in collaboration and coalition building with actors both inside and outside of government – including all three types of private sector players (for-profit formal service delivery, not-for-profit service delivery, and for-profit informal service delivery) to facilitate UHC implementation [7, 12,13,14]. Stakeholder collaboration was also seen to be a key facet of health system governance in the management of the coronavirus disease 2019 (COVID-19) pandemic, where stakeholder-specific relationships between various key stakeholders ensured health system resilience, and this can be exploited for UHC [12, 15]. The study found that respondents are not convinced that the collaborative efforts of government with regard to the NHI are programs and projects and are intended to deal with specific systemic challenges to enable the success of the NHI. To the contrary, we found that efforts to facilitate and nurture greater collaboration between the private and public sectors to foster good stakeholder relations and build the mutual trust required for a successful implementation of the NHI are lacking. This scenario clearly points to a breakdown of trust as a result of the “divide” between the public and private sectors.

A study showed that in Thailand, South Korea and China, inter-ministerial collaboration has taken place; in South Africa, this does not seem to be quite a problem. However, collaboration with stakeholders outside of government seems to be a problem [7]. Other studies have shown that though collaborative approaches might facilitate community-level change at a programme, organizational or neighbourhood level, such changes did not result in envisioned community health improvements – implying the complex nature of such transformations [16]. In this study the Kruskal–Wallis H test (Table 1) has shown that the stakeholders – those employed in leadership and governance and the health workforce have a different comprehension of the collaboration and coalition-building efforts.

Accountability

A clearly defined accountability focus for all stakeholders made up of responsiveness, meeting quality standards, meeting set targets, meeting public expectations and answerability of government is key to the attainment of the NHI objectives [7]. It is also a key enabler for efficient relationships among health sector actors [17]. This study found that the accountability focus (for responsiveness, meeting quality standards, meeting set targets and meeting public expectations, answerability of government) for all relevant stakeholders in the NHI has not been clearly defined.

We also found that there is a need to have financial accountability tools put in place across all the health system stakeholders if the NHI objectives are to be attained. A global health action study asserts that anti-corruption, transparency and accountability measures are often missing from efforts to promote UHC, yet corruption represents a significant drain on domestic health resources and a barrier to achieving UHC [18]. In this regard, lessons can be taken from the healthcare system reforms in Ivory Coast, where they ratified the United Nations (UN) conventions against corruption in 2011 as a way of demonstrating their commitment to strengthening health sector governance [19].

Engaging civil society, feeding community concerns, and feeding suggestions back into the policy and decision-making processes is an essential imperative for the success of the NHI, which was found to be lacking. Success in UHC has been achieved by countries that have developed ways to engage with society [7]. Similarly, other studies point to lessons for applying a behaviour change lens to social accountability activities in order to strengthen health systems [20].

We also found that the stakeholders are of the view that greater performance accountability by doctors, nurses, pharmacists, and allied health professionals, as well as traditional medical practitioners, requires the formulation and promulgation of appropriate regulations, including practice standards and sanctions. Strong accountability is required to ensure that health system objectives and population needs are met, and resources are used effectively [7].

Crucial to this finding is the fact that there is a level of pessimism expressed by two occupation groups, which together form the majority of respondents: the health workforce and those employed in medical and product technologies. These two groups of occupations hold a different view from those employed in leadership and governance. Those employed in leadership and governance occupations are convinced that accountability has been strengthened to enable the achievement of health system objectives, ensure population needs are met, and ensure the effective utilization of resources.

We found that a majority of the subthemes are correlated, and these findings can be used to inform the practical steps to be taken in addressing the leadership and governance challenges:

• (i) More focus should be directed to generating intelligence in order to drive effective policy implementation.

• (ii) Good intelligence gathering can only happen in an environment where collaboration and coalition building are present, and all stakeholders are accountable.

• (iii) Policies and strategic plans that will ensure the attainment of the NHI objectives will be driven by a positive interaction in the areas of generating intelligence, collaboration and coalition building, and accountability.

• (iv) Positive sentiment and trust in the leadership and government’s ability to deliver on the NHI are dependent on appropriate policies and strategic plans, appropriate implementation of policy, generating intelligence, collaboration and coalition building, and taking accountability.

• (v) All stakeholders need to take accountability in order to foster an environment of collaboration and coalition building.

An important consideration in implementation of the recommendations is to note that based on the Kruskal–Wallis H test which ranks the responses according to their statistical significance shows that the different occupations hold different perceptions about the extent of the challenges facing the implantation objectives of the NHI.

The review of the responses per occupation using the Kruskal–Wallis H Test shows the leadership and governance occupations are more optimistic about the leadership and governance initiatives embarked upon for the implementation of the NHI as compared with those employed as the health workforce and information and research (service delivery).

Notably, this points to sharp differences in perception between those employed in leadership and governance roles and those employed in the health workforce and information and research (service delivery) on the efforts that have been taken to achieve the objectives of the NHI. These three occupations are key to ensuring that each one of the challenges affecting the NHI functions is addressed adequately; however, this difference in their outlook on the issues might derail the implementation efforts of the NHI. The above examples demonstrate that respondents, being composed of a variety of stakeholders, hold a wide range of perceptions of what makes policy decisions legitimate. Based on these perceptions, it is clear that they value specific policy choices more than others.

A study by Baltussen et al. (2018) shows that the more pluralist a society is, the greater the likelihood of disagreement among stakeholders about which policy options should be pursued. If ignored, such discordance risks compromising the legitimacy of decisions [21].

The study goes further to suggest a more systematic involvement of stakeholders in policy choices to achieve UHC and proposes the use of evidence-informed deliberative processes (EDPs) as an overarching framework [21]. This further supports finding where the respondents believe policy decisions are not informed by intelligence. The study suggests that EDPs provide a procedural approach for building consensus towards feasible, and ultimately, the most legitimate strategies for achieving UHC.

Therefore, as the study suggests, this discordance between those employed in leadership and/or governance and health workforce and information and research (service delivery) should not be ignored and all parties, should work on achieving consensus on policy decisions or risk the compromise of the legitimacy of those decisions.

The findings of the study pertaining to some of the policy aspects aligns with the very early stakeholder coalition discussion document in response to the publication of the NHI green paper in 2011 and the subsequent NHI pilots undertaken in 2012. This stakeholder coalition was made up of the People’s Health Movement South Africa (PHM-SA), SECTION 27, Treatment Action Campaign (TAC), Black Sash Rural Health Advocacy Project (RHAP), Rural Rehab Rural Doctor's Association of South Africa (RuDASA), Passop EarthLife Africa and Africa Health Placements (AHP) [22]. This coalition represented organizations and people involved in health care sector policy and implementation at that early stage. It is interesting that the sentiments expressed then continue to resonate with current stage of the NHI project [22]. The coalition then noted the positive aspects of the NHI that sought to address the fragmented or two-tiered health system, a sentiment embodied in the findings of the study where all agree the fragmented health system is not sustainable. Secondly, both the coalition discussion and the study recognizes the fact that a re-engineered PHC should be vehicle to implement the NHI [22].

Both the coalition discussion and the study findings also expresses similar concerns relating to cost of the NHI, role of medicals aids and the proposed new health tax aspects to fund the NHI [22].

Strengths, limitations and delimitations of the study

The study is the first of its kind and has participants comprising “industry captains” who have been at the forefront of the delivery of health care in South Africa. This cohort of participants has clearly been looking for an opportunity to show that they can contribute to the attainment of the NHI project. This is seen in the sentiment produced where they candidly point out that there are gaps that will negatively affect the implementation of the NHI while indicating that they believe in the NHI project. This stance shows that these study participants see themselves as co-contributors in realizing the implementation of the NHI.

The study was conducted amongst mainly role players concerned with the health care industry and the delivery of healthcare. This might have excluded other role players who might have provided a different context to the views provided.

It would be essential to have a much broader study that encompasses more than healthcare industry participants.

This study is significant because the data and findings will add to the limited quantitative data existing on the impact of the structural challenges, specifically how leadership and governance challenges will impact the implementation of the NHI. The interaction and relatedness of the themes will assist policymakers in focussing on those issues that are deal breakers and improving on those where the sentiment is positive. Specifically, the data and findings of the study will inform policymakers of the difference in their perceptions of themselves and ordinary health workers regarding their ability to deal decisively with these changes and achieve positive outcomes in the implementation of the NHI. Information could be drawn from this study to assist policymakers in ensuring that there is an increased rapport between them and those at the coal face of delivering healthcare services. In addition, these findings may be significant for the development of a workable model that creates synergy between the public and private health sectors to exploit the skills, resources, and capabilities of the broader public.

Limitations

The primary goal of this quantitative study was to investigate the challenges that impact the implementation of the NHI in South Africa, thus gaining more knowledge about the participant's attitudes and perceptions of the transition towards the NHI. However, caution must be exercised when making generalizations based on the findings of this study, as delimitations and limitations apply. The researcher noted the following limitations of the study: (a) Participants’ responses were self-reported, and it is assumed that participants gave honest responses. (b) The data were gathered using a web-based survey questionnaire that was designed based on the context of the challenges that might affect the implementation of the NHI, as defined in the NHI white paper. In addition, the survey did not provide a means for participants to write short responses to quantify the answers given. (c) Years of service, levels of experience and levels of exposure to healthcare challenges may lead to different responses from varied participants.

Delimitations of the study

The researcher imposed the following delimitations: The bias of the respondents, as well as the interpretation of the data, may produce potential limitations. The uncertainty and varied sentiments that exist in the public domain pertaining to the government's approach to the implementation of the NHI may affect outcomes. The researcher made the following assumptions: (a) The administered questionnaire is an accurate tool to measure perceptions regarding the implementation of the NHI in South Africa. (b) Subjects responded accurately and honestly to the survey. (c) Data received from the survey are an accurate representation of participants' perceptions about the challenges facing the implementation of the NHI in South Africa and how those challenges can be dealt with. (d) This research was a quantitative study of only participants who are involved in healthcare policymaking, regulation and service delivery.

Conclusion

The study has several implications for the successful implementation of the NHI since governance and leadership underscore a majority of the levers necessary to set appropriate policy and implementation mechanisms.

Though there is consensus on the need to implement NHI from a policy perspective, the ability to implement it needs to be supported by clarity and commitment to specific policy fundamentals aimed at improving efficiency, stakeholder participation and accountability. Secondly, there is no clarity on important policy directives on operational, legislative, and some of the political aspects that are regarded as essential policy levers that enable the necessary shift to the aspirations of the NHI. Thirdly, the success of UHC initiatives has been shown to be bolstered by clear collaboration and coalition-building strategies from actors in both government and non-state entities and in the case of South Africa, this has become a huge challenge. Both parties are acting with scepticism when it comes to either’s actions. Fourthly, South Africa falls amongst those countries where the ability to “move together”, as coined in the state of commitment to UHC Report 2030 (UHC 2030), is in doubt.

In evaluating the controls and accountability measures in place to alleviate the leadership and governance challenges impacting the realization of the National Health Insurance (NHI) in South Africa, we found that though there are formal commitments to NHI, the accountability mechanisms are deemed ineffective.