South Africa

  • South Africa has a two-tiered (private and public) health system for its 56 million inhabitants, which has had challenges with fragmented funding, risk pools and subsequent huge inequities in healthcare access and quality.

    iDSI has supported the South African government since 2011 on institutionalising Health Technology Assessment (HTA) as part of ongoing National Health Insurance (NHI) reforms, as the country moves towards Universal Health Coverage (UHC).

Our Impact

iDSI has supported:

Contributed to South African’s government decision to establish national HTA agency, as part of 2018-2021 budget of R368m (US$27.3m) towards an interim NHI Fund

Provided pivotal input to the NHI process through policy dialogues and capacity-building workshops related to evidence-based priority-setting

Mapped out frameworks for health benefits design; clinical guidelines; legislation and policy; and HTA topic selection to inform the move towards NHI

The 2018 NHI Bill details the legislative measures needed for the next phase of NHI reforms, which will include establishing an NHI Fund as a mandatory single public purchaser and financier of health services. The Bill also specifies the use of priority-setting and forming an HTA agency to support the efficient and equitable use of the NHI Fund.

Institutionalising HTA under NHI

iDSI has been advising on the institutionalisation of HTA and evidence-informed priority-setting as part of the ongoing NHI reforms, by participating in the Health Services Benefits advisory working group, under the auspices of the Minister of Health; and working with the Council for Medical Schemes to strengthen private sector regulation. Our input has included detailed costed, short and long-term options for the National Department of Health to incubate an HTA unit, with a view to establishing a standalone HTA agency in the long term. Other iDSI analysis included a framework for health benefits design, a review of South African clinical guidelines, a legal and policy framework and a topic selection framework to inform the move towards NHI.

In partnership with PRICELESS SA, an academic unit based at the University of Witwatersrand with technical expertise in health economics and policy influence, iDSI has also undertaken activities to build increased understanding and capacity for priority-setting among policymakers. For example, in March 2017 PRICELESS hosted a three-day training event on Health Benefits Package design and economic evaluation for South African policymakers. This was followed by a policy dialogue specifically for those involved with the NHI benefits package design. Finally, a health economics module was included as part of the Masters in Public Health at Wits University for the first time in 2018.


iDSI input and support for policy dialogue have been pivotal to the NHI planning process with a HTA agency and supporting committees specifically identified in the NHI Bill, and funding committed for an HTA Unit to be incubated within the National Department of Health as part of the 2018 Budget of R368m (US$27.3m) dedicated towards an interim NHI Fund. A national HTA agency could ultimately help to inform the listing, pricing, reimbursement of medicines and health services, and the regulation of public and private providers.

iDSI estimates that for a national HTA agency in South Africa, an annual investment of US$1.5m to finance 20 full-time staff to produce 20 HTA studies and 5 clinical guidelines (for high-burden diseases such as diabetes) could generate approximate savings of US$200m, based on return-on-investment trends of HITAP in Thailand (US$133 per dollar) – or up to an equivalent 91,633 disability-adjusted life years (DALYs) averted , through evidence-informed price negotiations and improved clinical care pathways.



iDSI has formed links with networks such as the Collaborative Africa Budget Reform Initiative and the African Health Economics and Policy Association; and begun engaging with Tanzania and Zambia to introduce evidence-informed principles and methods into Essential Medicines List review and fiscal policy, nurturing the political will for HTA and broadening the impact of iDSI expertise. An important development has been the Master’s level educational programmes at Wits University where a health economics module was included as part of the Masters in Public Health for the first time in 2018. The majority of the 120 applicants were from South Africa and other sub-Saharan African countries, demonstrating demand for formal education in this area.

Key reads

Strengthening health technology assessment systems in the global south: a comparative analysis of the HTA journeys of China, India and South Africa MacQuilkan K, Baker P,  Downey L, Ruiz F, Chalkidou K, Prinja S, Zhao K, Wilkinson T, Glassman A & Hofman K (2018)  Global Health Action, 11:1, 1527556, DOI: 10.1080/16549716.2018.1527556 Full article: