It doesn’t look good for the NHI in South Africa
Most of South Africa’s public healthcare facilities are not compliant with the necessary standards to be considered ‘NHI- ready’, and will needs focus, skills and funding to get to the required levels.
In a written response to a recent RISE Mzansi parliamentary question, the Minister of Health, Dr Aaron Motsoaledi revealed that of the 3,092 public healthcare facilities inspected by the Office of Health Standards Compliance (OHSC) only 1,226 or 39.65% comply with the legislated standards.
This means that the balance – 1,866 or 60.35% of the facilities – do not comply with these standards and are thus not ‘NHI-ready’.
The worst performing province, which achieved an average rate of compliance of 15.89%, is the Northern Cape with Limpopo (17.88%), Free State (20.18%), and Eastern Cape (26.74%) not far behind.
“The figures should concern all of us, given that the majority of South Africans rely on the public healthcare facilities, which are evidently not up to the regulated standards; moreover, healthcare practitioners are not working in environments conducive to providing quality healthcare,” it said.
The party said that South Africa cannot build a quality and accessible healthcare system until multiple battles are won – specifically underfunding and resourcing, corruption, loss of skills to the private sector, and other personnel issues.
When asked what the costs to bring infrastructure back up to scratch, the minister said that this is unknown at this stage but the OHSC will spend a further R16 million in the 2024/25 financial year to cover the cost of inspecting 668 health facilities.
This is not the cost of bringing facilities up to standard – just inspecting them.
The health minister said that the direct health facility revitalisation grant is the largest source of funds for public health infrastructure and is transferred to provincial departments of health through the Health
Facilities Infrastructure Management (HFIM) sub-programme.
The idea of using funds from the Public Investment Corporation (PIC) (which holds assets of around R2.7 trillion, which mainly serves public sector entities) to finance public health infrastructure to prepare for the NHI remains an active point of discussion within the government.
The data gives credence to the widely stated ‘consolation’ to those worried about the impact of the NHI on private healthcare, that the scheme is nowhere near ready to be implemented or put into full effect.
This is despite the Department of Health moving ahead with its phased rollout of the scheme, which envisions funding mechanisms rolling out as soon as 2026.
Funding issue
A key question hanging over the NHI is the funding question. Not only the funding for the scheme itself – which is estimated at hundreds of billions of rands each year – but also the preparatory work to get the scheme going, such as upgrading public hospitals.
National Treasury recently addressed this in part.
According to the NHI Act, the first implementation phase of the NHI runs from 2023 to 2026, when the NHI Fund will be set up and other groundwork put in place.
The second phase—which would 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—runs from 2026 to 2028.
As indicated by the Act’s wording, this would ostensibly put the requirement for tax changes and other funding mechanisms into effect from 2026 onward.
In a parliamentary presentation on the MTBPS, Treasury noted that the “NHI act still needs to be promulgated, and NHI regulation needs to be gazette for comment.”
Importantly, the NHI fund—enabled by the NHI Act—will take two to three years at minimum to establish fully and list, Treasury said.
In the meantime, while the NHI is receiving some attention in the budget, it is mostly for foundational work that exists outside the scheme (ie, funding that would have been given regardless of the NHI).
Notably, the Treasury pointed out that the National Health Insurance Act has not yet been promulgated, and much of the financing towards the scheme is through indirect grants.
The country has budgeted just under R3 billion for the NHI over the 2025 Medium-Term Expenditure Framework (MTEF) period, R2.5 billion of which is indirect health spending and R460 million of which is direct NHI funding.
The direct grant relates to the National Department of Health’s preparations for the implementation of the NHI, including the testing of reforms, improving services of primary healthcare facilities and aligning infrastructure with national and provincial policy directives.
The indirect financing, which accounts for the bulk of the grant, relates to two projects: health facility revitalisation, and development of health systems. Both of these serve the NHI, but are also independent projects not directly tied to the NHI.
“Patient information systems, as one of the key focus areas of this grant, is allocated R112.5 million in 2024/25 to continue its work on implementing patient information systems.
“For general practitioner contracting, the department is allocated R103 million to develop and test strategic purchasing,” Treasury said.
Treasury said that it, along with other key departments, is part of the NHI Technical Work Group, which is looking for a “reasonable rollout of the NHI” while looking at various aspects like matters related to intergovernmental relations, strategic purchasing, and crucially, tax policy.
However, this is nowhere near ready for launch.
“A substantial amount of work still needs to be commissioned by the department, supported by other stakeholders, to enable the successful and effective implementation of NHI,” the department said.
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