South Africa currently utilises 8.7% of its Gross Domestic Product (GDP) on health services, with 4.2% of the GDP used for covering 84% of the population within the public health sector, and the private sector serving 16% of the population spending 4.5% of the GDP [1]. Despite South Africa’s high healthcare expenditure, the health outcomes are inferior compared to most middle- income countries [2].

South Africa is saddled with a quadruple burden of illness, specifically, the extraordinary prevalence of HIV and Aids, maternal and child morbidity and mortality, non- communicable disease and violence, injury and trauma [3]. Risk factors such as unsafe sex, interpersonal violence as well as alcohol abuse and malnutrition exacerbate the quadruple burden of disease [3]. Compounding the ever-increasing burden of diseases, institutions in the public sector have been prone to poor management, deteriorating infrastructure, insufficient resources, inferior quality of care and a shortage of key medical staff [4].

Universal Health Coverage (UHC) has emerged as a key reform for the health sector in order to provide access to quality and affordable health services for all [5]. The three dimensions of UHC include financial protection (what do people have to pay out of pocket), services (which services are covered) and population (who is covered) [5].

The South African Government has embarked on a number of initiatives to implement UHC. To improve population health coverage and quality of services, the National Department of Health has introduced the ideal clinic model and primary health care re-engineering that aims to move health care closer to the people whilst simultaneously addressing curative and preventative health [6]. To provide financial protection, to reorganize the funding of health care in pursuit of monetary risk shield, safeguarding efficiency in how funds are pooled and used thus eliminating fragmentation, thereby creating a unified health system implementing National Health Insurance (NHI) [7].

The NHI Fund will be the single strategic, publicly owned purchaser that will buy healthcare services [7]. The Office of the Health Standards and Compliance () will approve, certify and hire service providers. Beneficiaries are expected to utilize designated General Practitioners as main health care providers whilst still adhering to a referral pathway [7].

The NHI Bill lays the legal context for the implementation of NHI and recommends the creation of the National Health Insurance Fund as well as its control and advisory organizations. The NHI Bill sets out a three-phase timetable for the implementation of the NHI. Phase one between 2012 and 2017 entailed an analysis of health system and initiation of pilot sites. Phase two, between 2017 and 2022, will see the establishment of institutions, which will be the basis for an entirely efficient fund. The Minister will establish interim committees and there will be introduction of legislative reforms and provisional procuring of personal healthcare services for susceptible people [7]. Phase three, between 2022 and 2026,will involve extension of health system consolidation undertakings, deployment of added resources permitted by Cabinet and choice of commissioning of health services from private suppliers [7].

The envisaged impact of the NHI is that South Africans will receive comprehensive health care in both public and private health services near where they live, without payment at the area of service provision. This will result in households having increased disposable income. Individuals who have private cover will also benefit from the NHI [7].

Health care workers are at the centre of the healthcare delivery system. The success of implementing the NHI depends on health care workers understanding the key principles of the NHI [8]. The way health care workers perceive NHI will influence their contribution to the effective application of the NHI [9]. Anecdotal evidence suggested that health workers in general are not familiar with NHI or the content of the NHI Bill. This study aims to determine the knowledge, perceptions and attitudes of healthcare workers in Ugu towards the NHI.

Three hundred and seventy-nine respondents participated in the study. Eighty-three percent of the respondents were hospital-based employees, with the other 17% based at large community health centres. Most of the respondents were nurses (40.9%, 155) with a further quarter of the sample being administrative staff (25..0%, 95). Doctors (3.7%, 14) and pharmacists (6.3%, 24) comprised one-tenth of the sample. Of the sample of respondents, 48% (179) had beyond 10 years of service, 31% (118) had fewer than 5 years of service and 21% (82) had 5 to 10 years of service. A large number of the respondents (60.7%, 230) reside in urban areas as compared to (38.3%, 149) that reside in rural areas. One hundred and eighty-six (65.3%) of the study population were between 20 to 45 years of age, compared to ninety-nine (34.7%) who were between 46 to 65 years of age. There were three times more females (74.9%, 284) as compared to males (25.0%, 95) (Table 1).

3.3. Attitude Towards NHI

Seventy-eight percent (296) of respondents were willing to adhere to the requirements of NHI. There were nearly as many respondents who believed that the responsibility lay with health facilities (47.76%) as there were those who believed that the responsibility lay with the individual (52.24%) (Table 3).

Table 2. Frequency table reflecting knowledge on NHI.

-	Frequency (Correct response)	Percent
a) NHI stands for National Insurance System	245	66.6
b) NHI is a government initiation
c) The government wants to provide an equitable health care for every South African citizen through NHI
d) All South African have to contribute towards NHI depending on how much they earn
e) NHI means that I don’t have to pay when I am cared for in a private facility	123	33.4
f) NHI has not started in public health facilities
g) NHI will expand public clinics and General Practitioner's clinics so that everyone has a health provider next to them
h) NHI will ensure that people get treatment before they get very sick and hence get treated at a clinic level effectively
i) NHI is now at a pilot phase being piloted at Umzinyathi, Amajuba and Umgungundlovu
j) Private health sector and medical aids are an important part of NHI

Fig. (1). Respondents perceptions on NHI.

Table 3. Frequency table of attitudes towards NHI.

	Number	Frequency
Are you going to adhere to all the requirements of NHI that may be required from you?	296	78.1%
Responsibility of NHI
Health facility	181	47.8%
Individuals	198	52.2%

The profile of respondents in the current study of a majority of nurses (409%, 155) having more than 10 years of service (48%; 179), more females (7493%, 284) and the majority being between 20 to 45 years of age (186; 653%) is reflective of the profile of the health workforce of in the public health sector of South Africa (Table 4).

The findings of this study indicate that most health care workers in Ugu (968%) are familiar with the basic concept of NHI, of which 70% heard about NHI from their health facility and 85% were aware of NHI services to be offered at the health facility. This potentially implies that basic training or seminars on NHI in the facilities have yielded positive results of creating awareness on NHI. The high level of awareness is consistent with previous studies conducted amongst healthcare professionals in Mthatha General Hospital), OR Tambo district, that showed 90 of the 100 respondents surveyed were aware of NHI [10]. A previous study from EThekwini Metro and Ugu districts in Kwazulu-Natal province documented 91% level of awareness among health professionals [11].

Two-thirds (666%) more participants had basic information on NHI, whereas only one-third (33%) of the participants were familiar with details regarding the objectives of NHI. This may be attributed to the lack of detail of the training program. Concurring with these results a cross - sectional study (n=253) conducted of health care staff in a tertiary hospital in Limpopo showed that although 64% of respondents knew what NHI is about, 48% did not know about policy content [12]. It is worth noting that both these studies were at non-NHI pilot sites. Corroborating with the results of poor knowledge on objectives of NHI by health care staff, was a cross-sectional survey regarding awareness of health care workers on NHI in Tshwane (n-480), where 58% of respondents were not familiar with the objectives of NHI [13] In contrast to these findings, a study conducted in the three KZN NHI pilot districts showed that 93% of health workers had good knowledge of the NHI, whilst in Mtata General Hospital 81% of the respondents knew the objectives of NHI

The statistically significant relationship between younger ages (< 45 years) and better knowledge and attitudes towards NHI could be because of younger health workers having more opportunities for exposure to seminars and training programs. In addition, younger age groups are more technologically savvy and have internet access and engage on social media platforms. In contrast to these findings, a study of private Doctors in Ethekwini indicated that older people are more inclined to favour redistribution and hence have a positive attitude towards NHI, as one of the key objectives of NHI is redistribution and sharing of resources [11].

More than half (606%) of the respondents believed that NHI was not well communicated by the government and 546% believed they will have to pay more money because of NHI. Nevertheless more than half of the respondents (619%) still believed that NHI will help them a lot and they will benefit from NHI (554%). Similar findings of support for NHI were established in Mthatha General Hospital on the awareness, knowledge and perception of health care staff on NHI, where 79% supported the implementation of NHI, although more than half of the respondents believed that they would be taxed more to fund the program [10]. Ambivalent perceptions were reported from a study of private doctors in KwaZulu-Natal where only 21% of doctors had a good perception of NHI. The poor perception was attributed to the lack of clarity and control mechanisms regarding risks [14]. This is further exasperated by the constant reports of fraud and corruption in the media by South African Government Departments, politicians and Parastatals. This suggests that the NHI Policy and NHI Bill is not clear in terms of risk mitigation strategies and requires further clarity during stakeholder engagements.

A study on the three pilot districts in KwaZulu-Natal found that more than 50% of health care workers were optimistic about NHI [11]. However, the inference is that the balance of the health care workers in the said study had a poor perception of NHI and believed NHI will not help them. Similarly, a study of health care workers in Limpopo revealed that only 40 percent of respondents had the perception that their facility was ready to implement NHI due to lack of sufficient resources [12]. Some of these health care workers are under the impression that there is a serious lack of resources within public health. This insinuates the need to increase resources in order to improve credibility in the effective application of NHI.

Although only a handful of studies have documented the perceptions on NHI, it is evident that the responses of health care staff on their perception of NHI are varied. However, negative perceptions can hinder success. On the other hand, a good knowledge of the objectives of NHI could inspire an optimistic perception and, therefore successful implementation.

The study found that most (778%) of the respondents were willing to adhere to the requirements of NHI and more than half of the respondents believed that NHI will help them a lot. Similarly, a cross sectional study in Nigeria regarding knowledge and attitude of health professionals towards the National health insurance scheme indicated that health workers had a positive attitude towards the NHI [15]. On the contrary, in the study of private doctors in Ethekwini and Ugu, less than 50% of the respondents indicated that they are ready to implement NHI, citing lack of resources as a challenge [11]. Similarly, lack of staffing and infrastructure were cited as challenges to implementation of NHI [16].

This study has revealed that majority of the respondents know about NHI but they are not familiar with the details regarding the implementation of NHI. In addition, the lack of clarity and control mechanism regarding risk have served to perpetuate the negative perceptions toward the NHI. The impression of a serious lack of resources within public health sector continues to perpetuate a negative perception and attitude towards the NHI. In order to improve knowledge, attitudes and perceptions towards the NHI, it is imperative that a modified approach is adopted for communicating and training about the NHI and an increased investment could improve credibility in the effective application of NHI