South Africa spends more on healthcare per capita than any other sub-Saharan African nation. Its health outcomes — maternal mortality, life expectancy, child nutrition — are among the worst of any upper-middle-income country on Earth. The problem is not a shortage of resources. It is where those resources go. A private health system of world-class quality burns through 51 percent of total health spending to serve 16 percent of the population. The remaining 84 percent use a public system that is chronically underfunded, understaffed, and running on fumes.

The National Health Insurance system pools all health financing — employer contributions, general taxation, the former private insurance premium base — into a single fund that buys healthcare from both public and accredited private providers on behalf of every South African resident. The private insurance industry challenged the legislation in court three times. Lost the final appeal in February. Has spent the two months since in what industry analysts are calling an existential business model renegotiation. That is a polite way of putting it.

Implementation is rolling out district by district. The 22 million South Africans being enrolled first are predominantly rural, predominantly in the former homeland areas, and previously had access only to the overwhelmed public system. Their enrolment means, for the first time, access to the accredited private GP network in their districts — a doctor who is not working through a 60-patient daily queue.

Fiscal sustainability is the live debate. Health economists at the University of Cape Town have modelled outcomes ranging from successful long-term cost containment to structural deficit within eight years, depending on utilisation rates and the government's ability to hold pharmaceutical and specialist fees to the fund's schedule. The programme is working. Whether it can keep working is the question nobody has answered yet.

"Healthcare in this country has always told you who you were," said Health Minister Aaron Motsoaledi. "It is time for it to tell you something different."