Is NHI Bill’s signing a defining moment in SA’s healthcare system?

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While the National Health Insurance (NHI) Bill is laying on President Cyril Ramaphosa’s desk, hours before he’s expected to sign it into law, it remains unclear how much longer it will take to for a collective consensus regarding the road ahead in addressing the systematically flawed issues embedded in South Africa’s healthcare system.

The NHI aims to ensure that everyone has access to comprehensive quality healthcare services at the point of need, without financial hardship. This is in line with target 3.8 on Universal Health Coverage (UHC) within the United Nations Sustainable Development Goals (UN SDGs) on health. As part of the global health agenda, UHC seeks to tackle the factors driving inequality in health systems and further widening the gap to accessing equitable quality healthcare worldwide as a human right.

One of the major barriers to accessing healthcare is affordability and the cost of healthcare. South Africa is not exempt from this global occurrence.

In fact, the Competition Commission’s Market Inquiry into the Private Healthcare Sector stated among its recommendations in September 2019, that the private healthcare sector was characterized by high and rising costs of healthcare and medical scheme cover. With these revelations in hand, it is clear at close range, that high costs of healthcare in the private healthcare sector invertedly makes healthcare increasingly inaccessible.

Meanwhile, budgetary constraints in the public health sector are among the contributing factors to some of the sector’s viability shortfalls to provide quality and equitable health service delivery. This, coupled with other persisting issues such as wasteful expenditure, the alarmingly high cost of medico-legal claims and corruption are sinkholes in the public health sector’s financial feasibility to meet the demands of an increasing population size needing to access healthcare.

A small percentage of people afford medical insurance in South Africa. According to the latest Medical Scheme Industry Report conducted by the Council for Medical Schemes (CMS), only about 9 million beneficiaries were on record in 2022.

When juxtaposed with the Statistics South Africa (STATS SA) 2020 General Household Survey findings, that an estimated 80% of the population in the country access healthcare through the public healthcare sector, the disparity is evident.

The current administration aims to change this phenomenon through NHI — A single national fund that will cover the medical costs of all those residing in South Africa. These funds will be raised through taxes.

Once fully implemented, NHI will provide health services through the purchasing of a set of health packages from health facilities and service providers contracted to the NHI-fund. Health services that are not included in the NHI, can be insured privately through medical schemes. This means that when one is ill or needs medical attention, one can present at any health facility of their choice within the NHI contract and will not be required to pay; regardless of private or public health. The health service or procedure for the patient will be paid for from the NHI-fund.

To date, there have been widespread concerns from various spheres of the health fraternity, civil society, and opposition parties about the NHI Bill in its current form. Some of these include Section 9 of the Bill which establishes the National Health Insurance Fund as an autonomous public entity. It has been noted that this may place the fund vulnerable to fraud and corruption as a high risk.  The dire state of many public entities has been used as examples to illustrate the reasons for the push-back on the NHI fund as a public entity. While other apprehensions on the Bill have cited discomfort with the extent of power the Minister of Health will have, such as appointing the NHI Board.

Meanwhile, the Medical Scheme industry has vocalized its reservations over the precise role it will play in the sector should the Bill be signed in its current form. The Bill says medical aid will only cover health services that will not form part of the NHI-bought set of health packages. However, the Bill in its current form while on the Presidents’ desk, does not provide clarity on what these packages are exactly. This seems to be inducing worry among those in the medical insurance industry, that perhaps they will be reduced to play somewhat of a minimized auxiliary role in the health sector — a major concern for the sustainability of the medical schemes industry in the country. Furthermore, the funding model of NHI has been a contentious issue. The fund will be raised through taxes, yet another financial burden to taxpayers.

With May 29th fast approaching, many people are preparing to cast their vote, they will in part, also be voting for better healthcare services and with whom they are entrusting that responsibility.

According to the Parliamentary Monitoring Gorup, President Ramaphosa has on average taken about 70 days to assent a bill since taking office in 2018.

Breakdown of average calendar days the President took to assent Bills passed by Parliament 2018 – 2020


Number of Bills signed Number of average calendar days Year
23 Bills 84 days 2018
16 97 days 2019
11 31 days 2020


At the core of this, are questions on what implications will the Bill signed in its current form have on the future of the country’s health system wholistically as South Africa heads to polls and what impact will the imminent transitions that come with a new dispensation post the National and Provincial Elections (2024 NPE) this year mean for the NHI Bill after receiving the green-light from the President come election-day.

Ahead of the elections, some political parties have made their stance on the NHI clear in their manifesto.

  • The African National Congress (ANC) says it is committed to implementing the National Health Insurance (NHI) in quest to achieve quality health care that is affordable and accessible to all people
  • The Democratic Alliance (DA) opposes the NHI.
    It proposes its Universal Healthcare Coverage model instead. The model sets out to increase access to services in both the public and private health sectors, improve the existing healthcare system, and guarantee a basic level of care to all people.
  • Inkatha Freedom Party (IFP): aims to spearhead a process that will review the NHI and its funding model. The IFP says while executing this, it will also clearly define the role of public and private health service providers and that of medical aid schemes.
  • ACTION SA: opposes the NHI Bill in its current form, citing that the Bill is not aligned with the realities of the country’s public healthcare system.

Political parties have different ideologies on healthcare and post-election, there will be competing priorities such as the economy and fiscal-related matters, job creation, crime, the impact of ongoing power cuts and education to name a few. So, it is unclear how far up the priority-to-do-list will healthcare reform and NHI feature. The NHI is a health system reform and policy change process, and with any reform comes teething problems, which in this case, includes a sense of mistrust in the Bill in its current form. A more consultative and inclusive process in reviewing some of the major concerns raised regarding the NHI Bill in its current form may cushion its implementation in a quest to ensure that South Africa provides equitable quality healthcare while improving population health outcomes as a basic human right.

The signing ceremony of the Bill is scheduled for 15 May 2024 by President Cyril Ramaphosa at the Union Building in Pretoria.