Abstract
<title>Abstract</title> <p>Background Governance is an important but under-assessed determinant of health system performance, particularly in low- and middle-income countries (LMICs). While a body of literature speaks to the impact of the ‘micro-practices’ of governance, there is limited literature examining the impact of ‘macro-practices’. This paper aims to develop and demonstrate the value of systematically evaluating the governance implications of health sector legislation, using South Africa's National Health Insurance (NHI) Act as a case study. Methods A bespoke governance assessment framework was developed using a combination of South Africa’s King IV Report on Corporate Governance and the Organisation for Economic Co-operation and Development (OECD) Guidelines on the Governance of State-Owned Enterprises. Four pillars of governance were defined, including (1) Leadership and composition; (2) Accountability and oversight; (3) Transparency and public engagement; and (4) Integrity and risk management. The governance design of the National Health Insurance Act 20 of 2023 (South Africa) was assessed using a qualitative framework analysis. Results Application of the framework to the Act highlights a concentration of authority in the Minister of Health, who is able to determine key senior appointments to the NHI, creating a structural risk for political interference and a reduction in operational autonomy. The analysis also foregrounds the lack of mandatory proactive public disclosure and an absence of independent citizen redress mechanisms. These results indicate key risks to health system performance. Conclusions The study illustrates how a governance assessment framework can be applied to understand the implications of the ‘macro-practices’ of governance. It highlights the possibility of developing a combined domestic-international framework for ex-ante analysis and provides a replicable methodology for governance assessment, offering a tool for LMICs legislating health financing reforms.</p>