South African health financing reform 2000–2010: Understanding the agenda-setting process

Health Policy 109 (2013) 321–331

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South African health financing reform 2000–2010: Understanding the agenda-setting process Timesh D. Pillay a,∗ , Jolene Skordis-Worrall b,c,d a b c d

University College London Medical School, United Kingdom Health Economics and Global Health and Development, UCL Centre for International Health & Development, United Kingdom Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, United Kingdom Health Economics Unit, University of Cape Town, South Africa

a r t i c l e

i n f o

Article history: Received 28 March 2012 Received in revised form 25 September 2012 Accepted 22 December 2012 Keywords: Health financing Reform Agenda setting Politics Framework Class South Africa

a b s t r a c t Governments around the world are struggling to address persistent disparities in health care access. However, this priority competes with many others for support in moving onto and up the political agenda. In this paper, a novel method of agenda-setting analysis is developed by merging and modifying the Hall and Kingdon models. As a case study, this method is used to explore how health financing reform reached the policy agenda in South Africa between the years 2000 and 2010. Certain factors are identified that could have determined the agenda-setting process: a change in government, increase in the cost of private medical schemes, and increase in support for reform from various stakeholders. Further analysis, using a conceptual framework of interacting trends and shocks, identifies the growing middle class, the private sector, and workers unions as powerful actors and outlines further factors that may have contributed to the process: a broad political shift in the second half of the decade and the changing prioritisation of HIV/AIDS. Study findings have relevance to academics and policy makers in South Africa and beyond. © 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction As the deepening financial crisis and persistent economic recession continues to shape public policy globally [26], within-country health inequities are growing [49]. However, there appears to be little literature exploring how health finance agendas are shaped, and priorities emerge, especially outside the US [9]. This article uses health finance reform in South Africa as a case study to test a novel method that explores the agenda-setting process. South Africa is an upper-middle income country (MIC) at the tip of Sub-Saharan Africa. Home to an ethnically diverse population, the country has eleven official languages and an equally diverse portfolio of economic

∗ Corresponding author. Tel.: +02072429789 ext 2779. E-mail address: [email protected] (T.D. Pillay). 0168-8510/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.healthpol.2012.12.012

activity – ranging from agriculture to mining, manufacturing and tourism among others. The ruling African National Congress party has been in power since 1994, however challenges remain, especially in health and health care. South Africa is currently facing a quadruple burden of disease [50]: high HIV/AIDS prevalence; rising noncommunicable disease; diseases of poverty and the highest global rates of violence and injuries [17,69,70,76]. Health inequality in South Africa is among the worst in the world [5], the country has a gini coefficient of 63.1 (2009) [86]. 17 Years after the end of apartheid, there are still very significant differences in health between black and white communities, as well as substantial inequalities between the populations of richer and poorer provinces, urban and rural populations and urban middle class and informal settlement dwellers [17]. South Africa currently has a two-tiered healthcare system, with personnel and financing disproportionately

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concentrated in a private sector that serves a wealthy urban minority, whilst the public sector serving the majority is under-resourced. 16% Of the population has private medical insurance coverage, with a further 16% using private primary health care on an out-of-pocket basis while depending on public hospitals for tertiary care. Within the private insurance sector, fragmentation reduces riskpooling and income cross-subsidisation [4]. 68% Of the population is fully dependent on public sector healthcare. In 2008, out of a total of 8.5% of gross domestic product (GDP) spent on health [89], ZAR 10,000 (approximately $1253) per capita was spent in the private sector while ZAR 1,900 (approximately $238) was spent in the public sector [4]. Human resources in the healthcare system are also biased towards the wealthy; 79% of doctors work in the private sector [17]. This is not a significant improvement from the healthcare inequalities the apartheid regime left behind, more than 18 years ago [69]. Though the public sector is theoretically open to all, perceived lack of quality means that many of those who can afford private insurance do not use the public system [54]. While there is broad academic consensus in South Africa that comprehensive reform of the health care sector must take place to address persistent health inequalities, comprehensive health financing reform has only recently reached the government’s agenda. This paper aims to explore the agenda-setting process, in order to understand why it has recently become a priority.

Information System was accessed online for data on government health expenditure. Following a variation on the ‘snow-balling’ methodology, once important events, individuals and stakeholder groups were identified in the above search, further related searches were made. Secondary data extracted from the literature, was supplemented with primary data from a small number of key informant interviews. These interviews were conducted by email with academics selected for their special knowledge of South African politics and health.2 Informally conducted conversations with key stakeholders, though not constituting primary data per se, provided additional insight into the context and process of agenda setting in this context. Blog posts have also been used with caution. 3. Findings This section first identifies when health finance reform reached the political agenda in South Africa using findings from the literature search described above. The time period for subsequent analysis is thus defined. Second, using the modified Hall model, a primary analysis of the factors that contributed to the agenda-setting process is conducted. Finally, a deeper analysis is performed using a model of trends and shocks interacting in a causal web. 3.1. Describing the agenda-setting process

For the purposes of this paper the policy agenda is defined as “[a] list of issues to which an organisation is giving serious attention at any one time with a view to taking some sort of action” ([16]: p. 63). The analysis is split into three parts. The first identifies the time period to be analysed and shows that reform has reached the government’s agenda. The second describes the agenda-setting process using a modified form of the Hall model that adopts the temporal dimension of the Kingdon model [36,47]. The third and final part of the analysis uses a novel approach, where by factors identified are defined as either ‘trends’ or ‘shocks’, assisting in the description of a causal web. This approach has been applied in the form of a case study to South African health care reform. The analysis used secondary information obtained from a number of literature sources including academic literature, media coverage and government and NGO reports among others. Searches were conducted in Eldis, Web of Knowledge, PubMed and JSTOR search-engines, as well as in online databases of the main South African national newspapers: The Business Day, The Mail & Guardian, The Sunday Independent, The Sunday Times and The City Press. Die Burger was not included, as its content was not available in English. A set of appropriate search terms was used to ensure consistency.1 The WHO Statistical

Comprehensive health financing reform was discussed in the final years of apartheid. Reform became a key African National Congress (ANC) manifesto pledge during the 1994 election, although the details were not confirmed at that time [78] and debate about the desired nature of reform continued after the ANC gained power [52]. The Broomberg and Shisana Committee of Enquiry into health financing, set up shortly after the general election in 1994, recommended social health insurance (SHI) to be implemented as part of the comprehensive Reconstruction and Development Programme (RDP) [72]. General support from policy analysts and politicians at that stage meant health finance reform was seen by many as already on the agenda [78]. Indeed, two financing policies were implemented between 1994 and 1999: free primary health care for all in 1996 [17] and the Medical Schemes Act in 1998, which facilitated the stricter regulation of the private insurance industry [65]. However, there was no significant progress towards comprehensive reform, with the debate around SHI continuing into the new millennium [78]. This article is timed to coincide with the final stage of the two implemented reforms, following the policy agenda from that point forward. Fig. 1 tracks the initial movement of health financing reform onto the policy agenda. After Health Minister Manto Tshabalala-Msimang (MTM) made a promising statement in 2000 about the future of SHI (IOL 2000), experts continued to explore ways to shape its potential implementation [30], but none were adopted. In 2002, the Committee on

1 The reference list of newspaper articles used in the results is available in Supplementary Document 1, along with a table presenting the number of online newspaper articles found in the data search.

2 Where their responses have informed the analysis, their email correspondence – including their written consent to being cited or quoted – can be found in Supplementary Document 2.

2. Methodology

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Fig. 1. Timeline of media coverage: when did National Health Insurance reach the Government’s Agenda in South Africa? Sources: 1, IOL [95]; 2, Smetherham [103]; 3, SAPA [121]; 4, Green [94]; 5, SAPA [104]; 6, IOL [96]; 7, SAPA [105]; 8, SAPA [109] 9, IOL [98]; 10, SAPA [108]; 11, Stewart [119]; 12, IOL [99]; 13, Kgosana [100]; 14, [90]; 15, IOL [122]; 16, SAPA [109]; 17, Khumalo [102]; 18, SAPA [113]; 19, Comins [93]; 20, SAPA [117]; 21, SAPA [118]; and 22, SAPA [114].

Comprehensive Social Security for South Africa (CSSSA Committee) suggested that a universal pooling of funds should be adopted, rather than a pool only for contributors [30], effectively shifting the focus from SHI to National Health Insurance (NHI). After the CSSSA Committee, the idea of comprehensive reform appeared to fall off the political agenda [54] for almost six years. Only in 2008 and early 2009, did health finance reform again begin to achieve media prominence [100,119]. However, Minister of Finance, Trevor Manuel, omitted NHI from his budget in February 2009 [99]. The first hard evidence that comprehensive reform had again reached the government’s agenda came in June 2009, when President Jacob Zuma announced not only the importance of health financing reform but also his commitment to NHI as his chosen strategy in his ‘state of the nation’ speech [90]. This was followed, in July 2009, by a statement from Health Minister Aaron Motsoaledi, expressing his commitment to NHI [109]. Since then, statements from various politicians have confirmed that health financing reform and NHI are a government priority. Indeed, judging from recent Department of Health (DoH) announcements, steps have been taken to facilitate the implementation of a NHI scheme (see Fig. 1). In August 2011, the government published their argument for NHI in a green paper [63] and in March 2012, 10 pilot districts were named as the first participants in an estimated 14-year roll-out period [7]. At the time of writing, a

government white paper on NHI is being drafted [22]. This confirms that comprehensive health financing reform did indeed reach the policy agenda in South Africa in 2009. The following section explores how this came about.

3.2. Primary analysis The Hall model suggests legitimacy, feasibility and support for political action determine the likelihood of an issue reaching the agenda [36]. Kingdon’s [47] focus on changes in the agenda-setting process over time has informed the decision to use the Hall model (usually used to assess one point in time) over the time period identified above, 2000–2010. Findings are summarised in Tables 1–3, while this section provides the key definitions required to interpret the findings, and a brief summary of each theme.

3.2.1. Legitimacy Determining legitimacy requires asking: ‘is this an issue with which the government considers it should be concerned?’ ([36]: p. 475). A change in government often brings new perceptions of legitimacy as the government receives a fresh mandate from the electorate [32]. It is also proposed here, that a government’s perceptions of the legitimacy of reform depend on the perceived severity of the problems in the current system (see Table 1).

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Table 1 Changes in legitimacy of health financing reform in South Africa 2000–2010. Factors increasing legitimacy

Factors decreasing legitimacy

Change in leadership and government – Mbeki was replaced by Zuma in 2009 (see Fig. 1) Private sector costs increasing substantially over decade [18]

No crisis in public sector: Spending in public sector has steadily increased [27,84,89] Geographical health inequalities have been partially addressed [12] User fees have been reduced [104]

Table 2 Changes in feasibility of health financing reform in South Africa 2000–2010. Factors increasing feasibility

Factors decreasing feasibility

• Financial burden of more recent policy option (NHI)lower than previous one (SHI) [57] • Support for change from health workers [74]

• Economic crisis makes public spending harder [61] • International donor funding is increasingly for specific diseases [11] • HIV became a costly challenge as HIV denialism waned [24,29] • Less popular methods of funding NHI as compared to SHI: through taxes and out-of-pocket payments rather than by individuals [58] • Human resource depletion in public sector [17] makes health system expansion difficult [1] • NHI would require substantial improvements in health system [4] • Confidence in public system – necessary for NHI implementation – has decreased [21,56]

Table 3 Changes in support for health financing reform in South Africa 2000–2010. Groups for reform

Groups against reform

For • Public [21,56,73] • ANC [59,109,119] and South African Communist Party [91] • [74] and National Education, Health and Allied Workers Union (Nehawu) [107,123] • Private sector [30,54,101,106] Non-health unions [25]: Federation of Unions of South Africa (FEDUSA) [111], Congress of South African Trade Unions [112] and National Union of Metalworkers of South Africa [115] • Civil Society Organisations (CSOs): AIDS Law Project [10], Institute for Democracy in South Africa [42] and Black Sash [92] • Majority of academics [13,48,56,60,64,73,87,89]

Against • Democratic alliance [110] • Private sector [15,39] • South African Institute of Race Relations [116]

3.2.2. Feasibility Government’s perception of feasibility depends on the economic cost, the human resources available, the expected level of collaboration of stakeholders and the feasibility of different policy options ([36]: p. 479). The shift in government focus over time from SHI to NHI, may have affected the perceived feasibility of action for a number of reasons. SHI involves a system of mandatory contributions from formal sector employees, which ‘buys’ them coverage in either the public or private sector. It does not involve providing healthcare for those outside of the formal sector. NHI, on the other hand, aims to provide a package of care to the whole population funded from a central government pool [57] (see Table 2).

3.2.3. Support Hall et al. ([36]: pp. 484–485) also emphasise the importance of support for the proposal from civil society. In this section we consider public support, party-political support, civil society support, private sector support and academic support for policy. The position of key civil society

• Economists [77,83]

stakeholders are summarised in Table 3.3 However, findings for academic and private sector support require further explanation. Academics have largely supported the principle health financing reform in South Africa (press review, Table 3 and Supplementary Document 3). That said, support for SHI from this sector waned in the middle part of the decade, due in part to concerns over the type of SHI that might be implemented in South Africa [53,54]. Studies showed that the multiple risk pools associated with SHI lead to the potential for risk-selection by schemes and less risk pooling overall [120] and concerns were also voiced that SHI may act as a barrier to formal employment [120] in a country battling persistently high unemployment rates of approximately 25% [75]. Such critiques logically pointed towards the need for a larger risk-pool to maximise income and risk pooling. NHI achieves this, and the majority of academics publishing in this area appear to support recent NHI proposals. This is demonstrated by various studies providing evidence of the efficacy of reform [56,73] and numerous comment pieces

3

And in more detail in Supplementary Document 3.

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advocating reform [13,60,64]. However, some do oppose the idea due to the potential negative impact on the private sector [77,83]. For much of the decade, the private sector has given little direct insight into their perspective on financing reform (press review, see Table 3 and Supplementary Document 3). However, academic literature (McIntyre [54], Gilson [30]) suggests the private sector was largely opposed to reform while SHI was being debated (2000–2002). Grey literature is also available from later in the decade, though it gives conflicting messages regarding the position of the Hospitals Association South Africa (HASA) and the private health insurance sector – suggesting the private sector response to reform may in fact be heterogeneous across the various actors in the sector. 3.3. The ‘trend’ and ‘shock’ approach Two broad questions follow the results of the modified Hall Model: “Which stakeholder groups supporting reform had the power to move it on to the agenda?” and “Which factors influenced these powerful groups?” With these in mind, we now use a synthetic approach, whereby factors from the Hall model – along with others found in the literature review neither related to legitimacy nor feasibility nor support – are defined as either trends or shocks, and are linked together to form a web of influence. An overview is best demonstrated with a diagram (see Fig. 2), since the interactions are not linear. However, the detail must be conveyed with narrative, which starts by identifying the stakeholder groups with potential power over the agendasetting process. 3.3.1. Potentially powerful stakeholders A theory of agenda setting proposed by Grindle and Thomas [32] states that the status quo is maintained in the absence of a ruling class ‘crisis’. It is notable that, since the fall of apartheid, health sector reforms had not challenged the position of any powerful stakeholders – whether the ruling elite or the private sector [6]. The literature notes a rapid expansion of the middle class in South Africa post-apartheid [40,62]. Economic policies adopted by the ANC in the late 1990s provided the environment for individuals from the previously suppressed black majority to become successful in private business [40]. Mbeki’s policy of Black Economic Empowerment, implemented from 1999, further consolidated the process [62]. The Bureau of Marketing Research at the University of South Africa estimates that this group grew from 6.3 million South Africans in 2001, to 9.3 million in 2007 [80]. However, access to the new middle class does not seem to have been open to all. Some evidence suggests that economic opportunities were more likely to be open to those with political connections, mainly through the ANC [62]. These party links suggest the group may have more direct influence over the policy agenda than in other settings. In the period under review, the new growing middle class will have started to experience rapidly rising medical costs [57], stimulating their support for reform. As possible evidence of this ‘crisis’ we note that the

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percentage of South Africans covered by medical schemes decreased between 2002 and 2006 [68]. The 2008 Household Survey [56] supports these data, and also highlights increased support for a new public system. It showed that 71% of those already with medical schemes or using private primary healthcare, agreed with the statement ‘[I] would join a publicly supported health insurance scheme if my monthly contribution was less than for current medical schemes’. It is difficult to determine the position of the private sector in relation to reform. One might expect that any comprehensive reform plan may pose a threat to the private market in South Africa by creating a system of effective public provision that would compete with the private sector. Already, increasing costs to private providers and a shrinking consumer pool [54] has led to stagnating profits, as shown by one private insurance company, Discovery Health, announcing falls in share prices in 2005 [97]. Indeed, the opposition of the private insurance sector between 2000 and 2003 has been clearly described in the academic literature [53]. However, evidence of private sector support for, or opposition to, reform after that period is scarce and less homogenous. No evidence was found of any stated position between 2003 and 2009. Public expressions of support for NHI then came five days after Zuma’s agenda-setting speech in 2009 [101] – although this timing may suggest that they were responding to an agenda rather than shaping one. Patrick Bond, an academic who has written about NHI in South Africa [13], suggests that the private sector expressed their support in order to engage with the process and influence reforms.4 For example, the private insurance sector may be lobbying for a proportion of NHI revenues to be channeled into existing medical schemes [57]. Though it is difficult to identify a single consistent position of the private sector over the course of the decade, it may have been that early opposition helped to dampen support for SHI, while their relative quiet regarding reform in the decisive agenda-setting period between 2007 and 2009, allowed the discourse around NHI to progress significantly. With matters so far advanced, the private sector appears in the latter part of the decade, to be seeking to maximise their gains from any reform. The position of South Africa’s workers’ unions appears to have been important in the agenda-setting process. Mbeki’s neo-liberal policies, including ‘flexible labour markets’ meant unions gradually lost their influence after 1999, having been an important part of the tripartite alliance in the first years post-apartheid [66]. However, Zuma’s rise to power brought with it a resurgence of the groups he had mobilised in support of his candidacy between 2005 and 2007, including the unions, who returned to the forefront of national politics [8]. Hence, union support for NHI in 2007–2009 – notably from the National Education Health and Allied Workers Union (Nehawu) [107] and the Federation of Unions of South Africa (Fedusa) [111] – may have had an important influence over Zuma’s dispensation. However, despite the increasing influence of

4

Bond, email correspondence, Supplementary Document 2.

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Fig. 2. Web of influence: explaining the agenda-setting process in South Africa.

workers’ unions, membership has steadily declined over the course of the decade as ‘democratisation’ and the perceived role of the ANC has brought with it less of a niche for political representation at a worker level [3]. Other groups within South African society appear to have had relatively little power over the agenda-setting process. Most of South Africa’s poor are in “non-standard”, i.e. informal, temporary or part-time employment suggesting that their interests are not represented by the Unions [23]. NGOs, a common nexus for civil society, have had some influence over the South African government in the past, most notably in the promotion of action against the HIV/AIDS epidemic [44]. However, like patient groups and healthcare workers, their support for NHI was expressed relatively late in the agenda setting process.5 Further factors were identified during the literature search that may have influenced key actors in the process, yet were not applicable to the Hall–Kingdon model. 3.3.2. Economic philosophy shifted left The first half of the decade was characterised by the Neoliberal economic policies of Mbeki’s regime. In this climate, the CSSSA Committee suggested a particularly progressive version of SHI in 2002, requiring substantial

5

See Supplementary Document 3.

government funding (Ibid.). McIntyre reflected in 2003 [53], on the cooling of support for reform at the time: “It may be that current emphasis on promoting economic growth with relatively less emphasis on active redistribution measures . . . means that the window of opportunity for introducing an equitable and sustainable SHI has passed” (2003, p. 55). The second half of the decade however, saw a shift in South African politics within the ANC, in government and amongst the public. Disaffection with Mbeki’s policies grew, due to plans such as the Accelerated and Shared Growth Initiative for South Africa (AsgiSA), which favoured economic growth over redistribution ([33], Mooney 2009). Zuma was dismissed from the government by Mbeki in 2005 and hence became a high profile victim of the president. Zuma used this antipathy, and his role as victim, to mobilise a populist coalition consisting of important groups within the ANC as well as worker’s unions [8]. Zuma eventually replaced Mbeki as leader of the ANC in 2007 and became president of the country in 2009. The adoption of NHI, one of the ANC’s most progressive policies to date, at the 2007 ANC party conference was both a signal, and a result of this political transition [14]. It appears that a discourse of progressivism was created around Zuma between 2007 and 2009, which is likely to have influenced the government’s perceived validity of carrying out such a resource-intensive redistributive policy.

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3.3.3. HIV/AIDS could not be denied any longer The Hall model identifies increasing HIV/AIDS expenditure as a factor making health finance reform less feasible than it was earlier in the decade. However, this does not address the political position of HIV/AIDS during this period. HIV denialism amongst powerful politicians in South Africa – most notably Mbeki and the health minister from 1999 to 2008 Manto Tshabalala-Msimang [24] – hampered attempts to deal with the epidemic in the early parts of the decade [81]. However, international donors, global governance organisations [88] and domestic and international human rights movements [51] created a groundswell for action. A court ruling in July 2002, ordering the government to make ART available to pregnant women [28] showed progress in the fight for access to HIV/AIDS treatment in South Africa. Perversely however, the dominant focus on HIV/AIDS until 2007 may also have prevented the prioritisation of comprehensive finance reform in that period. The AIDS/STI strategic plan 2007–2011, widely praised as ‘good policy’ (Coovadia [17]), provided a strategy for dealing with HIV/AIDS in South Africa, resulted in an easing of international and domestic pressure. Hence may have provided the political space for ministers to prioritise comprehensive health finance reform.

3.3.4. Shocks Three key events, described here as shocks, characterise this period of agenda setting: the 2007 ANC conference, the economic crisis in 2008 and the change of government in 2009. Each is described in more detail below. The initial newspaper search identifies the 2007 ANC conference as an important time for NHI, since it provided the context for its first mention in the media since 2000. Furthermore, a report for the Health Systems Trust published just before the ANC conference – in early December 2007 – acknowledged that health finance reform was not being debated politically [55]. Therefore, the re-emergence of NHI as a policy option (having last been seriously considered in 1994) occurred not long before the conference, if not at the conference. When asked why, an academic with expert knowledge of health financing in South Africa commented: “I would say that the NHI has always been lurking in the background as a policy issue. But there have been many urgent issues to deal with; and some things simply fell off the agenda - sometimes because they didn’t have enough attention drawn to them; and I suspect sometimes by accident rather than design.” (David McCoy correspondence –Supplementary Document 2) Indeed, the attempt to find patterns in the agendasetting process may underestimate its chaotic nature, and this argument complements the proposed position of HIV denial as a barrier to the prioritisation of reform. However, the increasing concern of the ANC-connected middle class along with the broad political shift in the second half of the decade may have acted to drive the process forward outside of the conscious perceptions of those involved in it. Bond [14] argues that it was medical professionals within the ANC who pushed for NHI. These medical professionals are

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also likely to be part of the growing middle class identified above. The economic crisis in 2008and shrinking GDP in 2009 [43] is likely to have contributed to further stagnation of private healthcare markets, and so may have indirectly promoted the process of agenda setting by either distracting the private sector (who may have thought that NHI would have ultimately gone the same way as SHI proposals), or by shifting political ideology to the point where vocal opposition to reform would have created a very negative image of the private sector. Change in government in 2009 appears to have been crucial, both in terms of a broad political shift but also a change in the personnel of government. Manto TshabalalaMsimang, the health minister from 1999 to 2008, was opposed to NHI, as shown by her interference in the process in July 2008 [107]. On arriving in power, Zuma’s new appointment Aaron Motsoaledi expressed full support for NHI, aware that it was his ‘most important challenge’ [45]. A similar shift was seen in the treasury, where Pravin Gordhan replaced Trevor Manuel. In 2008, Manuel warned that ‘we need to disabuse people of the notion that we will have a mighty powerful developmental state’ [124] despite criticism that same year that the government was allowing developmental plans to be continuously ‘at the mercy of the treasury’ [91], On the other hand, Gordhan’s history of apartheid-era involvement in the Macroeconomic Research Group (MERG) rather than the GEAR strategy [79] suggests his support for NHI would be greater. 4. Discussion The above three-part analysis has revealed a complex agenda-setting process involving various factors and multiple stakeholders. Results of this multifaceted approach are best summarised in Fig. 2. They suggest that an appreciation of the position of certain powerful actors – the growing middle class, the private sector and unions – as well as broader changes in public discourse are of importance in understanding this agenda-setting process. South Africa is an interesting case study as it shares health systems characteristics with a range of other settings and as such, the empirical findings of this study may inform our understanding of agenda setting in other contexts. The well developed private sector is a feature common to many middle and high income countries including India [19], Brazil [46], Thailand [20] and the USA [37] among others. Indeed, similar challenges are faced by a number of countries that see disproportionate funding and personnel in the private sector and an under-resourced public sector [20,71]. Many of those settings are also facing rising health care costs and Van Niekerk et al. describe how the USA is currently experiencing ‘escalating healthcare costs, poor outcomes for expenditure on health and fragmentation of services’ (V [82]). Furthermore, the findings here support existing literature from the US that identifies the private sector as a powerful group that helped to push health care reform onto the agenda there in the early 1990s [34] and had to be incorporated into reform plans in 2008 [35]. Our findings suggest that in South Africa too, the private sector may exert some influence over agenda

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setting but must also cautiously tread the line of positive public opinion and may need to appear supportive of reform. This careful positioning as outwardly supportive of reform, appears to have given the private sector an ‘insider’ role in the agenda setting process and from that role has stemmed much of their opportunity for influence. Finally, the absence of a visible civil society presence in the agendasetting process in South Africa, is common to many settings including Ghana among others [2]. Aside from the general empirical contribution of this paper, we believe this analysis makes a general methodological contribution. The methodology applied in this paper has enabled a relatively thorough analysis of the agenda-setting process, with data that is largely publicly available. We believe that these methods could be used to explore the distinct processes dictating agenda setting in other contexts. In settings where more information is available online – with archiving stretching back further in time and more media diversity, civil society organisation websites or blogs – this approach would arguably be even more robust. That said, a noted limitation of a media search is the potential bias towards more current articles since they are more likely to be included in online archives. This is partly ameliorated by triangulating findings across a range of sources. Furthermore, this method is based on the assumption that all relevant changes to the agenda are recorded. Though this is likely to be true in the most part, further data, including interviews with senior civil servants, politicians and private sector representatives could strengthen the evidence provided, as has been done in other agendasetting studies [78]. A further limitation of this analysis may be the use of the Hall model itself, which has been criticized for its top down perspective [67]. We believe that adding the temporal dimension to the analysis may overcome this limitation to some extent, but it does not change the perspective of the Hall model. We would argue however, that these limitations, while important to note, do not detract significantly from the overall usefulness of the methodology and the analytical framework in exploring this complex question. By design, the scope of this study concludes in 2010, when health-financing reform in South Africa appeared to be firmly on the political agenda. As with any agenda setting analysis, this fails to address fully how implementation has proceeded from that point. We believe that a future study of this progress would be a source of great interest and considerable learning as the world continues to grapple with the challenges of universal access. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j. healthpol.2012.12.012. References [1] Abramovitz M, Zelnick J. Double Jeopardy: the impact of neoliberalism on care workers in the United States and South Africa. International Journal of Health Sciences 2010;40(1):97–117.

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