There is broad agreement on the goal, a healthcare system that provides access to quality care for all, without financial hardship. But agreement on the destination should not obscure the need for honesty about the path.
Image: PEAKSTOCK / SCIENCE PHOTO LIBRAR / LDA / Science Photo Library via AFP
South Africa’s National Health Insurance (NHI) debate is increasingly being shaped by assertion rather than evidence. That is a risk the country can ill afford.
There is broad agreement on the goal, a healthcare system that provides access to quality care for all, without financial hardship. But agreement on the destination should not obscure the need for honesty about the path.
A central claim in support of NHI is that South Africa already spends about 8% of GDP on healthcare, and that this funding can simply be pooled into a single system. It is a compelling narrative but it is also incomplete.
Only about half of that spending flows through government. The remainder is paid voluntarily by approximately 4.5 million South Africans through medical schemes, using income that has already been taxed. This is not a technicality; it is fundamental to the feasibility of NHI.
There is no R500bn pool of public money waiting to be reorganised. Government is effectively starting with around R250bn in public health expenditure. The rest is private spending, belonging to individuals who have made a deliberate choice to fund their own healthcare. Any credible NHI proposal must therefore explain, in concrete terms, how the additional funding required will be raised.
But the funding debate is only part of the issue. A number of persistent narratives about the private healthcare sector continue to shape public discourse on NHI in ways that warrant closer examination.
One is that the private sector is “stealing” healthcare professionals from the public system.
This characterisation oversimplifies a complex workforce challenge.
Healthcare professionals move between sectors for many reasons, including working conditions, infrastructure, career opportunities and management stability.
Retention challenges in the public sector are more closely linked to systemic constraints within facilities than to the existence of a private alternative.
Another is that government subsidises private healthcare.
Medical scheme tax credits are often framed in this way, yet this does not fully reflect their purpose.
These credits recognise that individuals who fund their own care reduce demand on the public system.
They are a policy tool that supports self-provision and alleviates pressure on state resources. Removing or repurposing them would not create new fiscal space; it would shift costs back onto an already strained public sector.
Similarly, employer contributions to medical schemes, including those for public servants, are sometimes presented as funds that could be redirected to NHI.
In practice, these are negotiated employment benefits, embedded in contracts and labour agreements. They are neither discretionary nor easily reallocated.
Concerns about the cost of private healthcare are also frequently reduced to the issue of provider remuneration.
While costs are a legitimate concern, this framing overlooks broader drivers such as regulatory constraints, hospital infrastructure, technology and the absence of mechanisms like collective tariff negotiation.
South Africa also competes globally for scarce clinical skills. Competitive remuneration is part of retaining that expertise.
Taken together, these narratives risk reinforcing a false binary between the public and private sectors. In reality, South Africa’s health system depends on both. The question is not which should prevail, but how they can be better aligned to deliver improved outcomes.
Both sectors are under pressure.
The public system carries the bulk of the disease burden under constrained conditions, while the private sector faces rising costs that limit affordability.
Treating this as a zero-sum contest obscures the need for a more integrated approach.
At the same time, the governance and implementation risks associated with NHI require careful consideration.
The proposed NHI Fund will be one of the largest public entities in the country, managing substantial financial flows.
In a context where public sector governance has faced well-documented challenges, it is reasonable to expect safeguards that are stronger, not merely comparable, to existing frameworks. Recent findings by the Auditor-General highlight persistent weaknesses in financial management, internal controls and infrastructure delivery within the health sector, all of which have direct implications for service delivery.
Legal uncertainty adds a further layer of complexity. The growing number of court challenges to the NHI Act reflects unresolved concerns about both process and substance. The BHF’s cases, in particular, focus on whether constitutional requirements, including meaningful public participation, were met.
These proceedings will shape the trajectory of the legislation.
None of this detracts from the importance of universal health coverage. It remains a shared national objective. But achieving it requires more than ambition. It requires credible funding pathways, institutional capability, and policy choices that are responsive to evidence.
There are practical reforms available now, within the existing regulatory framework, that could expand access and improve affordability without waiting for NHI.
Enabling collective tariff negotiations between medical schemes and willing healthcare providers, modernising prescribed minimum benefits, and permitting schemes to offer low-cost benefit options could extend coverage to millions while reducing pressure on public facilities.
The greater risk is not that reform is attempted, but that it is deferred in favour of a future system that remains uncertain.
If South Africa is serious about healthcare reform, the debate must shift from assertion to evidence. It must engage directly with the realities of funding, governance and implementation.
Because in the end, healthcare reform will be judged not by its intentions, but by whether it delivers access to care - reliably, affordably and at scale.
Dr Katlego Mothudi is the Managing Director of the Board of Healthcare Funders (BHF).
Dr Katlego Mothudi is the Managing Director of the Board of Healthcare Funders (BHF).
Image: Supplied.
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