A Systematic Literature Review of the National Health Insurance (NHI) funding models: Insights fot the Financial Sustainability of the South African NHI

Abstract

As South Africa moves towards implementing National Health Insurance (NHI), concerns remain about how to fund the system in a way that is both sustainable and equitable. This study aims to review existing literature on NHI funding models across different countries to identify insights that can support the financial sustainability of South Africa’s NHI. A systematic literature review was conducted, focusing on low- and middle-income countries with socioeconomic conditions similar to those of South Africa, and following the PRISMA protocol to ensure a structured and transparent selection of studies. Relevant literature was organised and analysed using the Atlas—ti software, enabling thematic coding and the synthesis of key findings. The findings highlighted a range of funding models adopted by low- and middle-income countries and the challenges of implementing NHI. The study provides evidence-based insights to guide policymakers in developing a sustainable and inclusive NHI funding model. Limitations include a focus on literature published between 2015 and 2025, and between 2021-2025 for results analysis, predominantly in English, which may exclude relevant studies from other periods or regions. The government should try to implement a progressive, primary healthcare–focused NHI funding model while strengthening public participation to ensure fairness, sustainability, and trust. Kurt Lewin’s Change Management Theory should guide implementation to reduce resistance through clear communication, training, and phased reform. Future research should employ a qualitative research method to explore stakeholders' perceptions and experiences regarding the feasibility and acceptability of a progressive financing and primary healthcare investment funding model for South Africa's National Health Insurance (NHI).