The article locates current South African government proposals for establishing a national health service (referred to as National Health Insurance) in its historical context. The attempt to create a national health service in South Africa is not a new policy idea, having been preceded by two prior unsuccessful attempts, in the 1940s and the 1990s. The institutional and political obstacles to re-distributive health policy achieving its egalitarian outcomes are examined. The article argues that the current ‘third NHI moment’ for health care reform in South Africa will need to resolve key concerns if it is to be successful. These include vested interests in the private sector, severe problems of capacity to deliver on quality health care in the public sector, the problem of drawing the middle class back into public forms of health care provision, availability of fiscal resources to sustain a universal system of provision and the ‘gate-keeping’ function of the Treasury in regards such fiscal resources, and provincial opposition to central government control of health care provision. Not least political support for a universal health care service beyond championing by the Department of Health and its minister of Health will be a vital element in achieving a universal system of health care it is argued.