South Africa’s National Health Insurance (NHI) reform was enacted in May 2024. It is the country’s most ambitious effort to achieve universal health coverage (UHC). South Africa has one of the most unequal healthcare systems globally. NHI debates are often framed in technical terms, focusing on cost and feasibility. This analysis shows that power relations and stakeholder interests fundamentally shape the reform’s design. This study draws on policy documents, parliamentary records, and stakeholder submissions from 2011 to 2024, with the political background from 2007 and legal documents to 2026. It applies Walt and Gilson’s policy triangle framework to examine how context, actors, and policy content interact. Key design provisions were embedded in the policy from its inception. These include the continuing voluntary role of medical schemes and accreditation frameworks for private healthcare providers. They reflect the private sector’s structural influence and fiscal constraints rooted in South Africa’s political economy. These are not concessions made during legislative passage. Public-interest civil society organizations were substantively engaged in the NHI process. These include health rights groups, trade unions, and rural health networks. Their influence was limited by restricted access to decision-making forums. The analysis draws lessons for policymakers pursuing UHC reform in contexts where the private health sector is powerful and governance is fragmented. Effective implementation requires governance capacity before or alongside financing. Sustained civil society engagement is an essential mechanism of accountability.

Background
The Swedish healthcare system is tax-funded and universal with low copayments, governed by politicians at national, regional and local levels. Since the early 1990s, the healthcare system has gradually been transformed from a mainly public system to an increasingly private for-profit driven, but still tax-financed system. This article describes the main driving forces and their effects.
Methods
The marketization of healthcare is contrasted to the legal and ethical framework established by the Swedish parliament for the healthcare system. The Swedish Health and Medical Services Act states that care should be provided solely according to need and on equal terms for the whole population, prioritizing those with greater need.
Results
Since the 1990s private enterprises and lobbyists have argued for market-oriented reforms where for-profit private providers can freely locate and operate outpatient services on public funding. A so-called choice reform (LOV) was implemented in 2010, mandatory in primary healthcare but optional in specialist care. This led to an expansion of for-profit private providers. In 2024, 52% of primary care visits and 22% of specialist care visits were to private providers. LOV has greatly reduced the power of regions to govern healthcare. It favours patients with limited rather than those with greater and more complex needs; it increases inequities in access between rural and urban areas, and between urban high- and low-income areas. The increase in private specialists has also enabled an increase in private healthcare insurance coverage, allowing the insured faster access to specialist care within the tax-financed healthcare system. This is inconsistent with the Health and Medical Services Act.
Conclusion
Marketization has increased inequalities in access to care in Sweden. Studies are needed on how to strengthen the primary healthcare system and to address inequalities in healthcare services related to increased privatization and marketization.

Background
Japan’s postwar welfare state developed around the universal Statutory Health Insurance System (SHIS), a complex public–private arrangement involving diverse insurers, providers, and government actors. Because most healthcare providers operate outside direct government control, the regulation of healthcare organizations and the setting of SHIS payment rates have remained central concerns in Japanese healthcare politics. However, the diversity of institutional arrangements and policymaking processes across different healthcare policy arenas has received limited systematic attention.
Methods
This paper conducts an institutional analysis of policy documents, media reports, and scholarly literature to examine Japanese healthcare politics over the past three decades.
Results
The paper begins by outlining the institutional structure of the SHIS and the key actors involved. It then examines four major arenas of healthcare policymaking: consensus-building in national councils, biennial revisions of medical fees and drug prices, system-wide health insurance reforms, and healthcare delivery reforms involving complex central–local relations. The analysis further considers how these arenas are affected by recent political transformations. These transformations include stronger political leadership, shifts in party competition, and intensifying conflicts over cost containment and cost-sharing. The analysis also highlights the emerging but uneven influence of patient voices and public opinion; while these forces remain structurally limited overall, they can occasionally prove decisive.
Conclusion
Rather than constituting a single unified process, contemporary healthcare politics in Japan is best understood as a differentiated system in which multiple policy processes coexist across distinct arenas. At the same time, changing political structures are reshaping distributive conflicts—increasingly centered on patient cost-sharing—within a healthcare system historically committed to universal coverage.

Citations

• Health Systems as Contested Ground
  Haejoo Chung, Carles Muntaner
  Health Politics.2026; 1(2): e006.     CrossRef