The South Africa health reforms: 2015 – 2020. The Road Ahead

Background brief: 8th September 2022 

Edited by Malebona Precious Matsoso, Lindi Makubalo, Usuf Chikte, Yogan Pillay, and Robert (Bob) Fryatt


What is the book about?

This book provides a first-hand account of the progress and many challenges that South Africa has made over a five-year period (2015-2020). It follows the success of the first book covering South Africa’s health reforms between 2009 and 2014, which documented success and challenges and called for increased efforts to document, monitor and evaluate interventions to improve future planning and implementation. 

Why is this book significant?

The book will be a first-hand account of the ongoing story on the transformation and challenges of health and health policy in South Africa. As before we have brought together for each chapter a mix of policy makers and implementers to work with academics and researchers. This approach seeks to strengthen the links between research, evidence, and policy and improve the role of science in implementation. This is a case study covering the next 5 years and documents an emerging power’s efforts to deliver on the expectations brought by the onset of democracy, the HIV epidemic as well as respond to the ongoing Covid-19 crisis.

What is covered in the book?

The aims to document key events and initiatives between 2015 and 2020 impacting on health in South Africa and consider the future challenges and implications for the different institutions, practitioners and agencies involved in improving the health of South Africans. The editors and authors agreed to have five main themes running through-out the book:

  • Health Reform: The book is about South Africa ‘reforms 2015 - 2020’ – we are not looking just for a description of the important issues in each chapter, but whether reforms took place or not. Our definition of reform is a traditional one from WHO: “Health sector reform deals with fundamental change of processes in policies and institutional arrangements of the health sector, usually guided by the government.”
  • Gender: We see this as important for all chapters as gender inequality and discrimination faced by women and girls puts their health and well-being at risk. The UN refers to gender as “the social attributes and opportunities associated with being male and female and the relationships between women and men and girls and boys.”
  • Equity: What have been the trends on health equity in this period. Again, taken from WHO “Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Health inequities entail a failure to avoid or overcome inequalities that infringe on fairness and human rights norms.”
  • Community engagement: We see this as an important ingredient of success for health reforms. WHO has defined community engagement as “a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes”.
  • Inter-sectoral collaboration: We see intersectoral collaboration as a key action government should adopt both to address broader determinants of health and to improve the effectiveness of health programs. This was at the core of the declaration on Primary Health Care in the Alma Ata declaration.

Who are the lead authors?

Chapters: Chapter Lead Institution
Foreword Dr Joe Phaahla Minister of Health
Introduction Precious Matsoso Wits
Demographic and health trends: 2015-2020 Rene English SUN
Social, economic and environmental determinants Lungiswa Nkonki SUN
Primary Health Care Helen Schneider UWC
National Health Programmes Peter Barron Independent
Accelerating Access to Medicines and Health Technologies Shabir Banoo Right to Care
Hospital Services Terence Carter CHAI
Covid-19 and Emergencies Kerrigan Mcarthy NICD
Non-communicable Diseases Yogan Pillay CHAI
Mental Health Ashraf Kagee SUN
Occupational Health Barry Kistnasamy NDOH
Infrastructure Boitumelo Mashilo GTAC/Treasury
Quality Lilian Dudley SUN
Legislative Framework and Right to Health Sasha Stevenson Section27
Governance, Management and Leadership Beth Englebrecht UCT
Information, Indicators and Accountability Ronelle Burger SUN
Human Resources Ritika Tiwari SUN
Health financing Mark Blecher Treasury
Global and Regional Health Usuf Chikte SUN
Looking to the future Editorial Team

Synopsis of chapters

Chapter 1: The chapter provides a brief summary of the previous publication, covering the period 20091014, and then summarizes the main objectives of the book, its key themes, followed by a brief overview of the structure and content of the book.

Chapter 2: Demographic and health trends: 2015-2020. The chapter provides a summary on the recent demographic trends in South Africa, including latest data on the various aspects of equity, determinants of health, health status and access to services that are critical to improving health and well-being.

Chapter 3: Social, economic and environmental determinants. The chapter focuses on the main challenges facing South Africa in this period, in particular the macroeconomic situation, poverty, income inequality and unemployment, education and social security, nutrition and hunger, built environment, and safety and security. There is then a commentary on the lessons learned from the coordinated and intersectoral actions developed in response to COVID-19, including what the intersectoral structures achieved at National, Provincial, and Local level), using examples that applied a social determinants of health lens. Finally, the chapter considers the role of technology and regulation, ending with some recommendations for the future.

Chapter 4: Primary Health Care. The chapter describes the key contextual factors Impacting PHC, and then describes the national programmes and interventions on PHC active in the five-year period. These include Ward Based Primary Health Care Outreach Teams (WBPHCOTs), District Clinical Specialist Teams (DCSTs), Ideal Clinic Realisation and Maintenance, Centralised Chronic Medicines Dispensing and Distribution Programme (CCMDDP), PHC e-health programme, and private Sector contracting. The authors then summarize the main PHC performance indicators, covering financing, health workforce and PHC utilisation, and provide case studies of promising bottom-up health system strengthening, including Community Oriented Primary Care (COPC) in Tshwane, sub-district models (Kwazulu-Natal sub-district management model, and the 3-feet model in Limpopo and Mpumalanga) and the social accountability model of Ritshidze Community-Led Monitoring of PHC. The chapter ends with a summary of remaining challenges, and conclusions on the way forward.

Chapter 5: National Health Programmes. In this chapter there is a focus on three health issues which are used to illustrate the successes and failures of the health system’s response between 2015 and 2020. These are HIV/AIDS, tuberculosis, and maternal and child health. The review is complemented by two case studies. The first is the Western Cape Department of Health’s response to Tuberculosis using lessons learnt from the Covid-19 response and incorporating a whole of society approach. The second illustrates gender issues in relation to access to health services and human rights.

Chapter 6: Accelerating Access to Medicines and Health Technologies: The chapter focuses on three key areas of national policy and implementation, in particular: the South African Health Products Regulatory Authority (SAHPRA) and reengineering the regulatory framework for health products; Scaling differentiated service delivery models for chronic medicines; and Antimicrobial Resistance - Policy solutions for effective governance.

Chapter 7: Hospital Services: The chapter provides an update on relevant national legislation and polices, including the role of hospitals envisioned under NHI. It then goes on to assess in more detail the increased governance responsibilities at hospital level in the context of the NHI purchaser/provider split and the different roles that will be played by Provincial and District management. The chapter then explores the need for adherence to the King 4 Governance principles, covering ethical Organisational culture and the Protocol on Corporate Governance in the Public Sector. Sections then focuses on community engagement and accountability and Strengthening Financial and Supply Chain Management, and Decentralisation of Management through Functional Business Units. The chapter discusses progress with Hospital Governance and Policy and Patient Centred Care and Clinical Governance.

Chapter 8: Covid-19 and Emergencies. In this chapter, we evaluate why disaster risk reduction and preparedness foster health system resilience.  We reflect on the global context and review South African preparedness efforts, drawing extensively from South Africa’s participation in, findings and outcomes of the joint external evaluation of adherence to the International Health Regulations (IHR) 2005. We identify health emergencies that took place from 2015-2020 and discuss in some depth two South African health emergencies that unfolded over this time. We reflect on health system responses to the unfolding COVID19 pandemic over 2020, illustrating how these drew on experience gained by stakeholders in earlier South African emergencies. Finally, we offer pointers to support strengthening South Africa’s emergency preparedness and response over the next five years.

Chapter 9: Non-communicable diseases. The chapter provides an overview of the rise in the noncommunicable disease burden in South Africa, and the main drivers of this major epidemic. The chapter provides a detailed analysis of some of the main NCDs in the country – coronary heart disease, diabetes, hypertension, cancer and asthma – with details of the trends in recent years and the key initiatives in the five-year period aimed improving prevention, cure and rehabilitation. Conclusions include recommendations on the way forward.

Chapter 10: Mental Health. In this chapter we highlight the various successes in the mental health sector for the period 2015-2020, but also raise areas of concern that require urgent attention. The chapter embraces a dimensional approach to mental health, i.e. that mental health exists on a continuum from severe disability to well-being. The chapter covers five areas, starting with two recent crises in South African mental health, namely, the Life Esidimeni tragedy and the Covid-19 pandemic. The second section addresses service organisation. We highlight the importance of making optimal use of scarce resources and bring into focus the need for a comprehensive approach to service provision, including mental health promotion and prevention.

Chapter 11: Occupational Health: The chapter provides an outline of progress the world of work in South Africa and the Governance, Legislation and Policy on Occupational Health and Safety, including the health systems response. The chapter covers the demography of work and a summary of the epidemiology of occupational injuries and disease, and the progress with occupational health services, including relevant human resources and professional societies. The remaining challenges facing South Africa are described with recommendations for the future.

Chapter 12: Infrastructure. The chapter provides and overview of the health infrastructure needs of the country, taking into consideration the health needs, and what is available through the public and private sectors. The chapter then reviews progress with various national initiatives aimed at responding to current challenges including the Ideal Clinic Realisation and Maintenance (ICRM), The Office of Health Standards Compliance, Infrastructure Unit Support Systems, Draft 10-Year Health Infrastructure Plan, The Accelerated Health Infrastructure Roll-Out Programme, Framework for Infrastructure Delivery and Procurement Management, Draft Maintenance Strategy and the National Infrastructure Asset Maintenance Management (NIAMM). For each we review the achievements and remaining challenges, before looking at non-infrastructure related challenges such as from the Covid-19 pandemic and climate change.

Chapter 13: Quality. This chapter reviews developments in the quality of health care in South Africa since 2015. We highlight important policy developments, and several initiatives in the public and private sectors to improve the quality of care. We also describe the key findings and recommendations of the 2019 South African Lancet National Commission report, ‘Confronting the right to ethical and accountable quality health care in South Africa’, and discuss barriers and opportunities for achieving a high quality health system in South Africa post COVID-19.

Chapter 14: Legislative Framework and Right to Health: The chapter provides a summary on the relationship between law and the right to health, explaining why does law matter and a human rights approach to health. It then covers the legal framework and how it has changed between 2015 and 2020, covering legislation, policy and regulations, intellectual property policy, notifiable conditions regulations, emergency medical services regulations, control of sugar, tobacco, and alcohol products, and legal advocacy and legal processes. A review is provided of the Life Esidimeni crisis, when law and policy is implemented badly, and the Health Market Inquiry. A review of the key litigation includes Emergency Medical Treatment, Physician assisted suicide and euthanasia, and medical negligence claims. A case study covers ‘what COVID-19 teaches us about the NHI’ and the chapter ends with conclusions on the way forward. 

Chapter 15: Governance, Management and Leadership. Following a brief overview of the governance, leadership and management successes and challenges in the past, we clarify the governance and leadership concepts that underpin the chapter and describe the key governance interfaces and relationships within the South African health system. We then examine the experience of frontline (district level) governance and then focus on provincial and national levels – considering how they support or constrain frontline governance in the multi-level public health system. We then summarise the critical issues of leadership and management highlighted in earlier sections and close by drawing out key conclusions for the future about the action needed to strengthen governance, leadership and management.

Chapter 16: Information, Indicators and Systems. This chapter describes and evaluates advances in the availability of accurate and timely local health information in South Africa between 2015 and 2020 against the backdrop of calls for more community participation, improved health system responsiveness to community needs and priorities, and enhanced provider accountability. The chapter deals with both the public and the private health sectors, although most routine data sources predominantly cover public sector provision of healthcare services.

Chapter 17: Human Resources. The chapter reviews the previous national HRH strategy, launched in 2011, and reviews progress with implementation, and the likely implications for HRH of future reforms, in particular the NHI Bill. The chapter then reviews the problems related to inadequate HRH data for planning and monitoring progress, with comparisons to other countries. The implications for formalisation of CHWs are considered, and progress in strengthening leadership across the health system. A summary of the recently completed HRH strategy is provided and some of the main challenges outlined, including dealing with the implication of the Covid-19 crisis.

Chapter 18: Health Financing. This chapter examines trends, problems, challenges and progress in a selection of public and private financing domains. In general, despite some progress on the policy front, inadequate progress was made on the sector’s key reform, National Health Insurance (NHI), and the chapter attempts to explore why this is the case. In addition, the policy focus on NHI detracted focus from several other areas including medical scheme reform, which despite the Health Market Inquiry, made limited progress. At the end of the period, a large health security crisis emerged in the form of COVID19, which had major implications for sectoral funding. Budget allocations were initially positive to counter the epidemic in 2020/21, but then increasingly negative from 2021/22 as the effect of prolonged lockdowns on the economy worked its way through to public sector revenue and spending. Final conclusions include that the proposed NHI model proposed in the NHI Bill may require some reevaluation of aspects of the model to get NHI reforms back on track.

Chapter 19: Global and Regional Health: The chapter provides an overview of the global regional health architecture and the main actors and institutions that are linked to South Africa. An update is given on the main initiatives that have been undertaken of importance fro South Africa, and their relative success. The chapter then reviews the role of international actors and donors in South Africa, and the role of South Africa in supporting other countries in the region.  The current challenges, including cooperation during the Covid-19 crisis is reviewed with lessons and conclusions drawn out for the future.

Chapter 20: The way forward:  The editorial committee led the completion of this chapter, using the suggestions and recommendations made by the authors for the different chapters.  This provides a comprehensive set of ideas for the next 5 years, building on the identified challenges and success es of the period under review.


Malebona Precious Matsoso, 

Position: Honorary lecturer Department of Pharmacy and Pharmacology, Director of the Health

Regulatory Science Platform, Wits Health Consortium and previously Director-General of the South African National Department of Health and served on WHO Executive Board for a three year term, Chaired for one year. Member of Independent Advisory Committee for the WHO Emergency Programme, Member of the Independent Panel on Pandemic Preparedness and Response, Cochair of the Intergovernmental Negotiating Body for the Pandemic Treaty. Address: University of the Witwatersrand, Johannesburg, South Africa. 

Telephone: +27523521279 

Email: pmatsoso@hrsp.co.za

Biography: Previously published in over 80 peer reviewed journals on pharmaceuticals, and on

South African health policy. Co-editor of The South Africa Health Reforms 2009-2014: Moving towards

UHC (Juta, 2015); Co-author of the Independent Panel for Pandemic Preparedness and Response (WHO,

2021). Over 80 peer reviewed journal articles including High-quality health systems in the Sustainable Development Goals era: time for a revolution (Lancet, 2018), Covid-19: how a virus is turning the world upside down (BMJ, 2020).

Lindiwe Makubalo 

Position: Assistant Regional Director, World Health Organization Africa Regional Office. Dr

Makubalo has served on numerous scientific and advisory boards, bodies and groups such as the South African Medicines Control Council, national ethics councils, several data systems boards, expert group on Oncocerciasis Control, Strategic advisory group on malaria eradication, and as African representative on the UNITAID Board. Most recently she held a diplomatic role as Minister, Health Expert for the South African Government to the United Nations in Geneva where she participated and led development of important policy and resolutions such as the NCD indicators monitoring and Ebola resolutions as chair along with other important activities to strengthen global policy for SDGs and health emergencies.

Address:, WHO AFRO, Brazzaville, Congo-Brazzaville

Email: lmakubalo@gmail.com

Telephone: +41788664390                                                                                                 

Biography: She has rich experience in disease surveillance and data management systems as well as research and innovation management related to tropical diseases and HIV.  She previously served at WHO HQ, as Director of the Alliance for Health Policy and Systems Research, as well as a sabbatical position in the Special Programme for Research and Development in Tropical Diseases.

Usuf Chikte

Position: Emeritus Professor in Health Systems and Public Health. The former Head of the Department of Global Health in the Faculty of Medicine and Health Sciences has been a dental practitioner and an academic during a long and very illustrious career, and served on various professional and educational bodies for many years as well. At SU, which he joined in 1996 as head of the Department of Community Dentistry, he has consistently tried to address such inequalities in healthcare. He became Associate Dean of the Faculty in 2000 and Executive Head of the Department of Interdisciplinary Health Sciences in 2006. Chikte has played a key role in helping to advance this process of transformation, both as an academic, a Senator and a member of the University Council.

Address: Department of Global Health, Faculty of Medicine and Health Sciences, University of


Email: umec@sun.ac.za

Telephone: +27828779522

Biography: Published extensively on public health and health systems issues in South Africa in particular on oral health and the health workforce.  

Yogan Pillay 

Position: Country Director: CHAI-South Africa and senior advisor on UHC, and previously Deputy Director-General: National Department of Health. 

Address: Country Director, CHAI-South Africa, 1166 Francis Baard St, Hatfield, Pretoria, 0028

Email: ypillay@clintonhealthaccess.org 

Telephone: +27825519437

Biography: Over 100 peer review journal articles on all aspects of public health and over 40 other publications, including book chapters and public articles. This includes co-author of the book

Mental Health Policy Issues for South Africa (MASA, Cape Town, 1997), Textbook of International Health, 3rd ed (Oxford University Press. NY, 2009), Textbook of Global Health, 4 th ed. (Oxford University Press. NY, 2017). Recent peer reviewed articles include lead author of Health benefit packages: moving from aspiration to action for improved access to quality SRHR through UHC reforms. (Sex Reprod Health Matters. 2020), Towards an AIDS-free generation by 2030: how are South African children, adolescents, caregivers and health care workers coping with HIV? (South African Journal of Psychology 2021) and coauthor of The impact of implementing the 2016 WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience on perinatal deaths: an interrupted time-series analysis in Mpumalanga province, South

Africa. (BMJ Glob Health. 2020)

Robert (Bob) Fryatt 

Address: Vice President Health Systems and Policy and Global Project Director of the USAID Local Health System Sustainability Project, Abt Associates, MD 20852, USA.

Email: bobfryatt@gmail.com;  

Telephone: +447904336561

Biography: Over 40 peer reviewed publications, chapters, editorials, and articles on topics covering health policy, health financing, health systems, HIV and TB; co-editor of The South Africa Health Reforms 2009-2014: Moving towards UHC (Juta, 2015); co-editor of Special Series Experiences in

Promoting Health Finance and Governance Reforms (Health System Reform, 2018). Author of chapter on Primary health care and international development assistance in ‘International perspectives to primary care research’ (CRC Press 2015). Recent peer reviewed articles include lead author of: editorial Tuberculosis control in South East Asia: vignettes from China, Cambodia and Myanmar (Health Policy and Planning, 2017); Commentary Financing health systems to achieve the health Sustainable Development Goals. (Lancet Global Health, 2017); Article Health sector governance: should we be investing more? (BMJ Global Health, 2017). 

3. Book details

Significance of publication: This is a follow up to the first publication, which was also written by teams of researchers and policy makers. It will be of interest to students of social and public health practice and policy nationally and around the globe.

Scope:, building on the insights and progress summarized in the previous publication (‘The South Africa Health Reforms 2009-2014: Moving towards UHC’).

Provisional length & format: (not including footnotes/endnotes): 130,000 words maximum (7,500 per chapter) and estimated 18 figures and 24 tables. No colour figures anticipated.

Timetable: A first draft manuscript will be ready by December 2021, and a final draft for submission to Publisher will be ready by April 2022. The book will be launched in by national and international VIPs later in 2022.

Readership: There is considerable attention on South Africa given the HIV/AIDS epidemic, the Covid19 response, and South Africa’s growing role in global and regional health. The first book was used extensively in universities across South Africa, including in Leadership and Management development courses. The book will be required in all major schools of public health that study international and global health, and in academic centres that hold courses and perform research on comparative social policies. In South Africa the participants at the annual public health conferences would be a target audience (eg PHASA https://www.phasa.org.za/ , AIDS https://www.saaids.co.za/ ). There are many thousands of schools of public health with perhaps up to about a thousand globally that provide courses and perform research on international public health or global health. Many of these are members of international networks and host their own conferences for example in Europe: https://www.aspher.org/, the USA: https://www.aspph.org/ . The international network of health systems researchers who will be a primary audience for the book; it will be launched at their next international symposium in Cape Town (https://healthsystemsresearch.org/ ).

Previous publication and copyright: no sections will have been published elsewhere and copyright will be with HSRC press agreed with editors in normal manner.

Publication date: To be ready for launch during the Public Health Association of South Africa Conference, in Durban on 11th September 2033. An international launch will take place at the Health Systems Research Symposium, Bogota, Colombia under the title 'Collaboration and accountability for health reform in South Africa' scheduled for November 3rd 2022,11:00 AM-12:30 PM.

Peer reviewers:


  • Japan International Cooperation Agency (JICA) South Africa Office
  • Wits Health Consortium (Pty) Limited (WHC), wholly owned by the University of the Witwatersrand
  • Foreign, Commonwealth and Development Office (South Africa), Government of UK
  • Board of Healthcare Funders

Electronic publication: To be made widely available as with previous publication.

Media interest: There will be interest in the South African popular press given the interest in the Covid19 response and the National Health Insurance.

If you would like a copy of this book please click here for the digital version or reach out to info@witshealth.co.za