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National Health Act, 2003 (Act No. 61 of 2003)


National Health Insurance Policy towards Universal Health Coverage

Chapter 5 : National Health Insurance Coverage

5.4 Cost coverage


133. Cost coverage refers to the extent to which the population is protected from direct costs as well as from catastrophic health expenditure. Improving financial protection can be achieved with64: (a) Increasing government expenditure on health; (b) reducing out-of-pocket payments (OOP) in the broader funding context; (c) Implementing national measures of financial protection; (d) Ensuring the poor are not left behind; and (e) Supporting positive trends in financial protection.


134. The covered population will be protected from financial hardships as they will not be required to pay directly at the point of accessing and utilising health care services. Services provided will be paid for through the NHI Fund. The covered population will not be expected to make any OOP.


135. To prevent inappropriate and excessive use of health services and to ensure long-term sustainability and affordability of the health system, gate-keeping, selective contracting, provider reimbursement strategies, through the use of clinical guidelines and protocols will be implemented at the primary care level with strict referral procedures, and providing suitable incentives to health care providers. By-pass fees will be imposed only for non-adherence to referral pathways whilst ensuring that they do not prevent rural communities from accessing health care. Nevertheless, careful attention will be paid to the process of introducing this policy to avoid potential adverse consequences for those accessing hospital-based services.


136. Services to which there is no coverage, such as elective cosmetic surgery, must be paid for in full by the user.