The NHI is coming, says Ramaphosa
President Cyril Ramaphosa says that South Africa’s private healthcare sector cannot continue to operate in parallel to the public sector, and that the National Health Insurance (NHI) scheme will ensure that the two become one.
Writing in his weekly letter to the public, the president continued to tout the NHI as the single solution to South Africa’s healthcare issues, almost five weeks after he agreed to put the rollout of the laws on hold.
The NHI Act was signed into law in May 2024, but it was not commenced.
Amid a flurry of legal challenges, the president agreed not to promulgate any of the outstanding sections of the Act until fundamental constitutional challenges had been resolved.
Key challenges relating to the public participation process during the drafting of the laws will be heard in May 2026.
However, despite the hold, Ramaphosa has been adamant that the NHI rollout timelines would not be affected and that the government would not abandon the scheme.
He has repeatedly stated over the past month that foundational work on the NHI would continue, particularly to improve public healthcare facilities and implement core systems.
On an ideological level, the president said the current healthcare system is fundamentally flawed, and that the NHI would resolve this.
“Our Constitution guarantees every person the right of access to healthcare services. That right cannot depend on where you were born, how much you earn or where you live,” he said.
“A child in rural Limpopo has the same right to quality healthcare as a child in the suburbs of Johannesburg or Cape Town.”
Ramaphosa said that South Africa has a well-equipped and well-funded private healthcare sector, with some of the finest hospitals, specialists and medical technology on the continent.
“Yet only around 16% of South Africans have access to these facilities. By contrast, the majority of the population, some 84%, uses public health facilities,” he said.
“On average, the amount of money spent each year on a person who uses private health care is around five times what is spent on someone in the public sector.”
“These two parts of our health care system cannot continue to operate in parallel, as if serving two separate nations. They must work together in service of one nation.”
Opposition to government control
In his letter, Ramaphosa argues that the NHI is more than just a funding mechanism.
“It is a commitment, grounded in our constitutional values, that every South African will have access to quality health services without suffering financial hardship.”
“It is the instrument through which we will ensure that the skills and dedication on display [in South Africa] are available to all our people, regardless of their ability to pay.”
He said the country needs “genuine and sustained partnerships between the public and private health sectors”, as well as academic institutions, medical professionals, pharmaceutical companies, non-governmental organisations and communities.
“We should be doing more to share skills and knowledge across the public-private divide, as happens when private specialists contribute time to public hospitals,” he said.
“It means investing in the training and retention of healthcare workers so that public facilities do not continue to lose their best people to private employers or to opportunities abroad.”
Notably, most opponents of the NHI are not against the principle of universal healthcare or greater collaboration between the public and private sectors.
At the core of the criticism of the NHI are the centralisation of healthcare under the national government, uncertainties around funding, and corruption in the healthcare sector.
Under the NHI, the state will become the lone purchaser of healthcare services in the country. This will be done through the NHI Fund, which will ultimately be financed through taxes.
This includes removing medical aid tax credits and redirecting to the scheme, and introducing new taxes, such as payroll taxes and surcharges.
When the scheme is fully in effect, medical aids will also no longer be able to fund any services paid for by the NHI.
They will only be allowed to provide complementary cover, effectively killing the sector and establishing a state monopoly on healthcare funding.
Private healthcare providers, meanwhile, will have to contract with the NHI, accept regulated fee structures, and cannot deny services to users.
These limitations are being challenged in court, along with questions about the various parliamentary and public consultation processes used to draft the laws.
A core argument among opponents is that the government has not considered any alternatives to the NHI that could deliver greater access to healthcare without the drawbacks flagged.
Another is affordability—that, because of the steep cost of quality healthcare, the NHI would burden South Africa’s already stretched tax base to extremes to meet its aims.
The National Department of Health has responded to some of these criticisms in the past.
Despite these issues, Ramaphosa said the state is not moving away from the NHI, but rather leaning into it.
“As we prepare to implement the NHI, we are already making significant investments to strengthen our public health infrastructure,” he said.
“We are building and refurbishing clinics and hospitals, expanding our community health worker programme, working to ensure the availability of essential medicines, introducing digital systems and improving the management of facilities.”
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