NHI at a crossroads: how practical, systematic reform can make the NHI work for all

The National Health Insurance (NHI) Bill was signed into law in May 2024. Since then, the process of implementation has been shrouded in controversy. With nine active court applications being brought against NHI Act, it is undoubtedly one of the most hotly contested pieces of legislation in South Africa. However, improving access to healthcare does not mean dismantling what works. With practical, phased reform of the NHI, the system can be used to coordinate care, rather than divide the national healthcare system.

Medical aid schemes are among several institutional bodies that have raised direct challenges to the NHI Act. In South Africa, they have played a pivotal and long-standing role in developing a private healthcare sector that is well-resourced, highly regulated and internationally competitive.

It stands to reason, then, that medical schemes would seek to protect both the sustainability of the sector and the interests of their members. Thus far, the ratification of the NHI Act has driven a wedge between private and public sector stakeholders. That division is a hurdle to true progress.

It’s important to remember however, that for all parties involved, the objective is the same: universal access to quality healthcare and the preservation of life and dignity for all South Africans. On this, we can all agree. Constant disputes and lengthy court proceedings serve only to undermine progress towards this goal and ultimately, to prevent positive change from taking shape.

his gaping divide doesn’t need to become the status quo. With a few incremental, evidence-based reforms, all industry stakeholders can be supported in building a more accessible, reliable and stable healthcare system.

The most sustainable path forward lies in repositioning NHI as a coordinating framework that strengthens access to care through collaboration across public and private health resources.

Medical aids have a role to play in reform

Centralising healthcare funding and purchasing under a single entity introduces significant operational, financial, and accountability risks that have yet to be taken into account. As it currently stands, centralisation is more likely to serve as a divisive force, rather than enabling collaboration.

To remedy this, medical aid schemes – as bastions of the country’s thriving private healthcare system, need to be a part of the picture. A reformed NHI framework must provide unambiguous clarity on the role of medical aid schemes to ensure system stability and continuity of care.

Large-scale reforms are inherently disruptive, and uncertainty in policy design can lead to unintended consequences for patients, providers and funders.

Therefore, clearly articulating how medical schemes will coexist with the NHI – particularly during transitional phases – will reduce instability, prevent gaps in coverage, and protect access to care for millions of South Africans who currently rely on private funding mechanisms. 

A hybrid future for the NHI

In addition, allowing medical schemes to cover services beyond the defined core NHI benefit package would strengthen, rather than undermine, universal health coverage. With a clearly thought-out plan, medical aid schemes can be brought into the process of transformation by operating as a complement to the NHI rather than an exclusion from it.

A complementary model would enable the NHI to focus finite public resources on essential services and vulnerable populations, while preserving patient choice, continuity of care and innovation in service delivery. A hybrid system could enhance overall system resilience, especially when roles are clearly defined and duplication is managed responsibly.

Professional development and training as key investments

No health reform succeeds on policy design alone. Effective implementation depends on strong leadership, capable management and a well-trained health workforce at every level of the system.

Investment in professional development, particularly in clinical leadership, hospital management and health system administration is therefore critical to translating NHI reforms into improved patient outcomes. Without this foundation, even well-intentioned reforms risk faltering at the point of delivery.

Independent governance and accountability mechanisms

Furthermore, robust, independent governance structures are essential to building public trust in the NHI and ensuring value for money. Clear accountability mechanisms can improve efficiency, reduce waste and ensure that public funds are directed toward strengthening frontline service delivery rather than expanding administrative complexity.

Transparent oversight will also provide taxpayers, healthcare workers and patients with reassurance that the system is truly being managed in the public interest.

A realistic, phased implementation process

There is a strong case to be made for claiming that the scale of NHI reform demands a phased approach that aligns with South Africa’s fiscal and economic realities. Gradual implementation will allow for course correction, institutional learning and capacity building, while protecting existing services from disruption.

Importantly, it could also reduce the risk that vulnerable populations may be exposed to gaps in care during periods of legal, policy or funding uncertainty, which could otherwise undermine the very goals of universal coverage.

An investment into collaborative, primary healthcare

Strengthening primary healthcare must be at the centre of NHI reform. Investment in clinics, community health workers and preventive services could go a long way to reduce pressure on hospitals, improve population health outcomes and bring care closer to where people live.

Where public capacity is constrained, contracting private clinics, pharmacies and general practitioners can rapidly expand access and improve service quality. A well-functioning primary healthcare system is not only cost-effective, but foundational to a sustainable NHI.

Together, these reforms would position the NHI as a strategic purchaser and coordinator of healthcare services, enabling collaboration across public and private providers, pharmacies and medical schemes. Let’s work together to promote the smarter use of existing healthcare capacity rather fixating on ideological divisions.