- The NHI was signed into law in May 2024, planning for a large state-run fund that purchases health services from both the public and private health care sectors. But at least 12 court cases now challenge its constitutionality and the way the act was signed into law.
- In February, Ramaphosa announced that he would not promulgate any part of the Act until the Constitutional Court ruled on the two applications in May, meaning the NHI could not be implemented in the meantime.
- In an agreement between the president, the health minister and other major organizations involved in the NHI court challenges, these applications have been temporarily put on hold until the top court's May decision.
Less than two years after President Cyril Ramaphosa signed the National Health Insurance Act (NHI) into law in May 2024, South Africa's most ambitious health reform since the end of apartheid is effectively stalled – caught between a government committed to pushing it forward and a growing group of opponents who say it is impractical, ineffective and unconstitutional.
The Act proposes a centrally controlled state fund that would purchase health services from both public and private providers, eliminating the existing form of private medical aid, for which only about 15% of South Africans pay, while promising better care for the 85% who rely on public health services.
To fill that fund, it will rely on taxes and, essentially, redirecting medical aid premiums, since the Act makes it illegal for private medical aid to cover the same services as the NHI.
But as soon as Ramaphosa put pen to paper, cases started piling up.
At least 12 court cases now challenge the constitutionality of the act, with allegations ranging from procedural flaws and inadequate public participation to an unrealistic funding structure and blocking access to treatment for asylum seekers and undocumented immigrants. A South African case study in Global Health Watch, a Lancet-published analysis of global health reform released in January, raised similar concerns.
Read | Despite pending court decision, preparations for NHI continue in full swing – Motsoaledi
In late February, Ramaphosa announced that he would not promulgate any part of the Act until the Constitutional Court ruled on two applications related to the public participation process in May – meaning the NHI could not be implemented in the meantime. Also sitting before the Constitutional Court: his appeal against an earlier decision, which required him to show that he had taken the public submissions seriously before signing them.
In an agreement between the President, Health Minister Aaron Motsoaledi and other key figures involved in the NHI court challenges, these applications have been temporarily put on hold until the court's May decision. This includes the South African Medical Association (Sama)'s own High Court challenge, as well as a challenge brought by Solidarity, the Hospital Association of South Africa, the Health Funders Association (HFA), the South African Private Practitioners Forum and Sakelliga.
However, Business Day reported on Thursday that Motsoaledi told MPs in Parliament that at least some NHI plan preparations are underway in the meantime.
Motsoaledi defended the single-fund model, arguing that it was easier to protect one central pot from corruption than nine provincial budgets. But critics – including groups like Section 27 and the HFA – say that's exactly the problem: the Act gives the minister too much power, allowing him to appoint and dismiss board and committee members at large as he sees fit, with very little independent scrutiny.
On a recent episode of Bhekisisa's TV programme, Health Beat, Motsoaledi said he was prepared to vote in parliament for the changes, and acknowledged that it would be better to negotiate with organizations taking the Act to court than to wait for decisions. “But that's in an ideal world,” he says, “and we don't live in an ideal world.”
Read | NHI impasse: Court temporarily suspends implementation of NHI and further litigation against it
Susan Cleary, health economist at the University of Cape Town, spoke to Mia Malan about what's working – and what's not – about South Africa's current public health system, and whether the NHI is really a sensible way forward. The following is an edited version of their conversation.
Mia Malan (MM): NHI is stuck in slow motion. What should the government focus on now?
Susan Cleary (SC): The idea of universal health coverage has been on our agenda since the time of democracy and it is a good thing. But we already have the beginnings of a universal health system – our public sector covers about 80% of the population. The obvious thing to do is to continue to strengthen the system that will be the backbone of any future system. There's plenty to do in the meantime.
MM: What are the advantages – or disadvantages – of a large central fund?
scheduled caste: The advantage is purchasing power – the ability to negotiate good prices and contracts. Our current public sector already has this available to about 80% of the population. NHI will increase this to 100%. The disadvantage is that if that one pot of money is not managed well, there will be no alternative. Right now, various provincial departments of health and the private sector all offer options. Under the NHI, they largely disappear.
MM: Are there adequate safeguards against corruption in the Act?
scheduled caste: There are real concerns. The Minister has great authority to appoint the Board Chair, the CEO of the Fund and the members of the Appeal Tribunal. There are not enough checks and balances. What people want to see is a greater separation between the political and administrative spheres – and Parliament should play a greater role in approving key positions rather than ministers and cabinet.
MM: How should South Africans think about what the NHI can actually deliver?
scheduled caste: If the NHI provides similar services to the current public sector – about Rs 5,000 per person per year – then scaling it up from 80% to 100% of the population is probably massively cost-effective.
But if it means the private sector is expected to spend around Rs 15,000 per capita, we are expected to spend around 30% of our GDP on health care. This is absolutely not possible. The honest answer is that we don't know what it will cost, because we still don't have a defined benefits package. We can't put a price until we know exactly what services will be covered.
MM: So private sector users will get less, public sector users will get something better – somewhere in between?
scheduled caste: Yes – there is a lot of complexity hidden behind it. But broadly, yes.
MM: What needs to be decided before the NHI can work?
scheduled caste: Two things come to the fore. First, electronic patient information systems. We have seen significant improvements in the quality of care since the introduction of the public health care system in the Western Cape. This needs to happen at a national level, and it does not require the NHI – this should have happened a decade ago. We need such a system in the private healthcare system also. Second, priority setting: being clear and honest about the package of services that the public sector can actually provide equitably. Right now, we are not clear about this, and it is possible that what is in our standard treatment guidelines is not cost-effective – otherwise we would not see stockouts and poor quality of drugs.
MM: Is it realistic to fund the NHI through taxes with a 30% unemployment rate?
scheduled caste: At our current economic growth rates, covering 100% of the population in a single health system – and making it better than the current public sector – is very ambitious. Many countries making good progress on universal health coverage have plural systems: public and private sectors, or different social health insurance models co-exist.
MM: What is the most evidence-based path – the big bang or the phases?
scheduled caste: Definitely phase. We must be wary of losing the strength of our current public sector. Our model is actually very similar in some ways to the United Kingdom's National Health Service, and I don't think we've done enough to justify replacing it with something more sophisticated and harder to manage – especially given that governance is not our strong point. Universal health coverage does not require a unitary system. We are already scoring relatively well on universal health coverage metrics. We should not assume that everything is terrible.
MM: Where do we perform well and where do we fall short?
scheduled caste: Universal health coverage is about access to services – services that don't land you in financial disaster. This means how much you will have to pay when you get care. Obviously, you have to make payments, but if you are paying in advance as a prepayment, you have what is called financial security. Our financial security in the public sector is very good. People who have private health insurance are provided financial protection through that insurance system.
Where we perform less well is in terms of quality. We have areas of excellence, and then areas where the quality is quite poor; We also do not perform well in terms of the overall package provided to our population. We are concerned that we have inequality between the public and private sectors, but this is not part of the definition of universal health coverage.
MM: What about the private sector – is it ready for the NHI of the future?
scheduled caste: There is a real risk that the private sector is being ignored when we debate the NHI. It is becoming increasingly expensive and increasingly offers poor value. The Healthcare Market Inquiry produced a widely supported package of reforms – reforms that many private sector players actually want. Bringing them forward now will keep the private sector viable and provide a strong foundation for any future universal system. Instead, the reform agenda has been put on hold awaiting the NHI. And I think that's a serious mistake.
This story is based on an interview broadcast on Bhekisisa's TV program Health Beat in March. Additional support from the Health Beat team, including Jessica Pitchford, Albert Tibben, Tim Wege, and Jeanine Snyman.