Towards systematic assessment of health governance: a framework-based assessment of the South African National Health Insurance (NHI) Governance Structure
1
School of Public Health, University of Cape Town, Cape Town, South Africa
2
SEAD Consulting, Cape Town, South Africa
3
Nelson Mandela UNiversity, Gqeberha, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1478
ABSTRACT
BACKGROUND:
Governance is an important but under-assessed determinant of health system performance, particularly in low- and middle-income countries (LMICs). While existing literature speaks to the impact of the ‘micro-practices’ of governance, there is limited literature examining governance implications of ‘macro-practices’. We aimed to develop and demonstrate the value of systematically evaluating governance implications of health sector legislation, using South Africa's National Health Insurance (NHI) Act as a case study.
METHODS:
A bespoke governance assessment framework was developed using a combination of South Africa’s King IV Report on Corporate Governance; and the Organisation for Economic Co-operation and Development Guidelines on the Governance of State-Owned Enterprises. Four pillars of governance were defined: (1) leadership and composition; (2) accountability and oversight; (3) transparency and public engagement; and (4) integrity and risk management. The governance design of the NHI Act (2023) structures was assessed using a qualitative framework analysis.
RESULTS:
Application of the framework to the NHI Act highlights an over-concentration of authority in the Minister of Health, who is able to determine, or overtly influence all key appointments to senior NHI positions, creating structural risks for political interference and a reduction in operational autonomy. The analysis also demonstrates the lack of parliamentary oversight and an absence of independent citizen redress mechanisms. These results indicate risks to health system performance.
CONCLUSIONS:
This study illustrates how governance assessment frameworks can be applied to understand the implications of the ‘macro-practices’ of governance. This case study demonstrates deviations in the NHI Act from governance norms, with resultant over-centralisation of authority in NHI governance structures creating risks for political interference, weakened operational autonomy and compromised independence of dispute resolution. The study highlights the importance of developing a consensus international framework for ex-ante analysis which provides a replicable methodology for governance assessment, offering a tool for LMICs legislating reforms.
Governance is an important but under-assessed determinant of health system performance, particularly in low- and middle-income countries (LMICs). While existing literature speaks to the impact of the ‘micro-practices’ of governance, there is limited literature examining governance implications of ‘macro-practices’. We aimed to develop and demonstrate the value of systematically evaluating governance implications of health sector legislation, using South Africa's National Health Insurance (NHI) Act as a case study.
METHODS:
A bespoke governance assessment framework was developed using a combination of South Africa’s King IV Report on Corporate Governance; and the Organisation for Economic Co-operation and Development Guidelines on the Governance of State-Owned Enterprises. Four pillars of governance were defined: (1) leadership and composition; (2) accountability and oversight; (3) transparency and public engagement; and (4) integrity and risk management. The governance design of the NHI Act (2023) structures was assessed using a qualitative framework analysis.
RESULTS:
Application of the framework to the NHI Act highlights an over-concentration of authority in the Minister of Health, who is able to determine, or overtly influence all key appointments to senior NHI positions, creating structural risks for political interference and a reduction in operational autonomy. The analysis also demonstrates the lack of parliamentary oversight and an absence of independent citizen redress mechanisms. These results indicate risks to health system performance.
CONCLUSIONS:
This study illustrates how governance assessment frameworks can be applied to understand the implications of the ‘macro-practices’ of governance. This case study demonstrates deviations in the NHI Act from governance norms, with resultant over-centralisation of authority in NHI governance structures creating risks for political interference, weakened operational autonomy and compromised independence of dispute resolution. The study highlights the importance of developing a consensus international framework for ex-ante analysis which provides a replicable methodology for governance assessment, offering a tool for LMICs legislating reforms.
| eISSN: | 2654-1459 |
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