Big NHI mystery for South Africa
While President Cyril Ramaphosa says the pause in promulgating the National Health Insurance (NHI) Act will not affect the scheme’s rollout, the target dates for the first phase have all but collapsed.
In addition, the National Department of Health has no clear implementation path and cannot indicate when the scheme will actually be up and running.
In a Parliamentary Q&A this week, Health Minister Aaron Motsoaledi was asked directly when he envisaged that the NHI Act would be finally implemented.
The minister did not provide any dates or timeframes, saying only that the Act provides for “progressive and programmatic introduction of the changes”.
He pointed out that, while the Act was assented to in May 2024, its contents have been caught up in the courts, which led to the February decision by Ramaphosa to pause the proclamation of the first sections of the laws.
The Constitutional Court is set to hear cases challenging the public participation processes on the laws from 5 to 7 May 2026.
“Once the judgment of these two cases is known, the Act will either revert to Parliament for amendment or proceed for implementation,” he said.
However, even if the Constitutional Court rules in favour of the state in this case, the government will still need to defend substantive content challenges brought by various parties on other grounds, he said.
This means there is no clear timeline for the NHI and no final date for its full implementation.
Despite this, Motsoaledi echoed Ramaphosa’s statements, saying that foundational aspects of the NHI will continue to be established.
These include “health systems strengthening initiatives and preparations for the implementation of the law”.
“It must be remembered that the Act provides for different dates for the proclamation of sections and for progressive and programmatic introduction of the changes,” he said.
NHI timelines already missed
The National Department of Health outlined a broad timeline for the rollout of Phase 1 of the NHI in November 2024.
At the time, the department was confident that it would issue draft regulations for the scheme for public comment by the end of November 2024, incorporate comments by the end of March 2025, and promulgate the regulations by April 2025.
The draft regulations were gazetted in March 2025—four months later—with comments closing in June 2025.
By this point, various industry stakeholders, including unions, business groups, private healthcare groups, and the Western Cape Provincial government, had begun launching their legal challenges.
Other notable timelines mentioned by the department in November 2024 include:
- Establishing foundation institutions – by April 2025 and beyond
- Establishing the NHI Fund as a Schedule 3A entity
- Appointing NHI Fund board members by November 2025
- NHI Fund entity in operation by April 2026
- Purchasing personal health care services for vulnerable groups – by 2026/27
With promulgation frozen and many court battles ahead, it is unlikely that any of these timelines can be met.
While the NHI Act defines the NHI Fund as a Schedule 3A public entity in law, it has not yet been fully constituted and operationalised in practice. As such, no board members have been appointed.
As the court case will only be heard in May 2026, having the NHI Fund operating by April 2026 is not possible.
In his latest Q&A response, Motsoaledi referred to the NHI Act itself and the timelines contained in the laws, but even these broad guidelines raise doubts.
Section 57 of the NHI Act refers to the timelines for implementing the laws, which run from 2023 to 2028.
The first implementation phase of the NHI runs from 2023 to 2026, during which the NHI Fund is supposed to be established and groundwork laid.
While the groundwork is being actively laid—and the president has tripled down on it in his most recent public statements—the NHI Fund is caught up in the promulgation freeze.
The second phase is the key phase, where funding and questions about costs come into play.
This phase will see the “mobilisation of resources” and “the establishment and operationalisation of the (NHI) Fund as a purchaser of health care services through a system of mandatory prepayment”, and runs from 2026 to 2028.
As indicated by the Act’s wording, this would ostensibly require tax changes and other funding mechanisms to take effect from 2026 onward.
Notably, these timelines and tax plans can only be implemented once the NHI Act is promulgated, with the financing measures to be put into motion by the National Treasury through Money Bills.
For the 2026 Budget, no such mobilisation is being implemented, with allocations to the NHI totalling around R9.3 billion.
This includes close to R1.5 billion in direct NHI grants over the next three years, as well as over R7.8 billion in “indirect” NHI funding.
The direct funding—provincial NHI grants—are relatively small, amounting to R475 million, R497 million and R513 million over the medium term (2026-2028).
The direct grant generally relates to the National Department of Health’s preparations for the implementation of the NHI on a provincial level.
This includes testing reforms, improving the services of primary healthcare facilities, and aligning infrastructure with national and provincial policy directives.
The indirect financing, meanwhile, is usually more focused on background public healthcare improvements that are part of the general NHI project, but not related to direct NHI healthcare services.
This includes infrastructure upgrades and the modernisation of healthcare systems, with a strong focus on digital.
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