Tag: NHI

Categories : Ethics and LawTags :

On Which Legal Arguments Are the NHI Court Cases Set to Turn? Part 1: Affordability

On By ModernMedia

By Jesse Copelyn

Since President Cyril Ramaphosa signed the NHI Act into law last year in May, eight different groups have challenged it in court. One common argument is that it is irrational and unreasonable to restructure the health system when there’s no money to do so. In this feature, Spotlight dissects how the argument is being applied, and whether it has any chance of success.

Earlier this month, the Western Cape Government filed papers with the Constitutional Court challenging the validity of the National Health Insurance (NHI) Act. In doing so, it became the eighth group to litigate against the Act, which aims to provide the same state-funded medical cover for all South Africans.

Not only are there now numerous litigants, each with their own distinct set of arguments, but some have also launched multiple applications, challenging different steps that led to it becoming law.

In this context, figuring out on which legal questions the future of the NHI Act will ultimately turn is difficult. Thus, Spotlight combed through some of the founding affidavits and spoke with legal experts to get a sense of the arguments litigants are betting on. A first key argument relates to the affordability of the scheme – in part two of this series we will turn to whether the NHI leads to an unreasonable regression in health services for certain groups.

Rationality and reasonability

Section 1(c) of the Constitution of the country holds that South Africa is a state governed by the rule of law. One of the implications of this is that governments can’t simply introduce laws arbitrarily without any justification. Instead, when an Act is passed, there has to be some aim behind that legislation, and some logical reason as to why passing it would advance that aim.

In other words, laws have to be rational.

Not only this, but Section 27 of the Constitution states that when it comes to the advancement of certain social rights like healthcare, government must act “reasonably”. This is a more demanding requirement than “rationality”. It doesn’t just require that an Act be logically related to its purpose but that it is practically feasible, and that it meets a range of other criteria (for instance, costs and benefits have to be fairly weighed).

A central argument of several litigants is that the NHI simply doesn’t meet basic standards of rationality or reasonability. One of the reasons for this, they argue, is that the government is unable to finance the NHI, and thus the Act has no hope of achieving its goals.

There are at least two ways in which this argument is being advanced. The first is as part of a series of applications seeking to invalidate the NHI Act itself. The second is as part of a procedural challenge to President Cyril Ramaphosa’s decision to sign the NHI Act into law. Here, the focus is on the rationality of the President’s decision, rather than the Act.

Challenging the act itself

The first party to take legal action against the NHI was the conservative trade union, Solidarity, which launched its application in the North Gauteng High Court in Pretoria on 24 May 2024.

In its founding affidavit, Solidarity argued that for the NHI to achieve its stated aim of universal access to quality healthcare services, the “requisite level of funding” must be available to establish the NHI Fund and its various mechanisms. But according to Solidarity’s application, it has already been shown that the government is incapable of raising enough tax revenue to support the scheme.

For instance, Solidarity references the position of the Davis Tax Committee, which was a group of experts chaired by Judge Dennis Davis that used to advise the government on how it could raise money to advance various policy goals. In 2017, the committee released a 48-page report on the NHI, which found that the state couldn’t cover the full cost of the NHI unless there was “sustained economic growth”.

Solidarity stated that this, in combination with its own research, showed that the NHI simply can’t be rolled out comprehensively. Thus, there was a “complete absence of a rational relation between the means selected and the objective sought to be achieved”.

Similarly, in February, a separate challenge was brought by the Hospital Association of South Africa (HASA), which argued that the NHI should be set aside because it is “fundamentally unreasonable and therefore unconstitutional”.

HASA’s submission argued that the burden of proof lay with the government to show that the NHI was financially feasible before passing the Act. This is particularly important given that the scheme involves a radical restructuring of healthcare with potentially detrimental knock-on effects for the private sector. The government thus had a duty to show that the scheme could lead to material benefits that justified these harms.

However, HASA argues that “no recent comprehensive and accurate financial feasibility and affordability assessment was conducted” by the government before pushing through the NHI, rendering “the passing of the legislation unreasonable and irrational”.

For its part, the National Department of Health has argued in court papers that trying to work out the full cost of the NHI would be a futile exercise. For instance, the health department’s NHI lead, Nicholas Crisp, filed an affidavit in response to Solidarity which stated that “attempts to conduct a once-off accounting exercise” were “not useful”.

He said: “The outcome of such an exercise is inevitably inaccurate, misleading and does not support informed decision making for reform.” Crisp argued that this was already evident from the “extremely wide range of figures that various parties have claimed to reflect the cost of the NHI in the public domain”.

Instead, Crisp stated that the World Health Organization (WHO) had advised the department to conduct an “ongoing costing approach for specific steps of the NHI implementation process”, which is something they were already doing, he said.

Nonetheless, many of the litigants have pushed back against this, arguing that this approach still leaves us without any evidence that the NHI can be funded in the medium to long term. In its affidavit, HASA argues: “In the context of constrained public finances and very challenging economic conditions… it is wholly irrational to commence the wholesale restructuring of the healthcare sector without long-term costing, and only with short-term piece-meal analysis”.

Challenging the President’s decision

While the above applications have sought to review and set aside the NHI Act itself, a separate set of challenges has instead focused on the decision of Ramaphosa to sign the Bill into law.

Section 79(1) of the Constitution states that if the President “has reservations about the constitutionality of the Bill”, then he should refer it back to Parliament for reconsideration.

If it can be proved that Ramaphosa had good evidence that the NHI may have been unconstitutional, but signed it anyway, then his decision can potentially be overturned by a court. In this case, the NHI wouldn’t be completely invalidated and set aside, but the President’s decision to sign it into law would be. Therefore, the NHI would go back to being a Bill, and would likely need to be reworked by Parliament.

President Cyril Ramaphosa holds a copy of the NHI Act after publicly signing into law in May 2024. (Photo: GCIS)

The Board of Health Funders (BHF), which represents medical insurance companies, is one of the litigants taking this approach. In addition, the South African Private Practitioners Forum (SAPPF) has a two-part application challenging both the Act itself and Ramaphosa’s decision to sign it.

Once again, the affordability argument has been central in these cases. In particular, the BHF and SAPPF have both highlighted a number of documents that were sent to Ramaphosa before he signed the NHI Act, which they argue should have caused the President to reconsider whether the Act was affordable.

For instance, the parties note that in 2018, the Office of the Presidency received a letter from the acting director-general of Treasury which expressed several concerns about what was then the NHI Bill. One of them was that the “financial implications are not costed”. As a result of issues such as this, the acting director-general felt “unable to support the bill in the current form submitted to cabinet”.

The BHF affidavit points out that the version of the Bill that Treasury had commented on was “not materially altered” later on. It further states that the letter from Treasury “was before the president when he assented to the NHI Bill and it is unclear at this stage the basis on which the president disagreed with the views of Treasury”.

In order to properly evaluate the rationality of Ramaphosa’s decision, the applications by BHF and SAPPF have been seeking to have the full record of his decision made public. The record refers to any information he would have had before him when signing the bill into law, as well as any minutes of correspondences he had which related to the Act.

The BHF and SAPPF have already made some progress with their case. In May, the North Gauteng High Court in Pretoria ruled that it was able to review Ramaphosa’s decision to sign the NHI Bill into law, and gave the President 10 days to provide the full record of his decision to do so.

Neil Kirby, who heads the healthcare and life science practice area at Werksman’s Attorneys, which represents BHF, told Spotlight that after the ruling, “both the [health] minister and the president made application for leave to appeal that judgment which is a process that’s supposed to happen before the original judge. They also then proposed that they appeal directly to the constitutional court.”

He adds: “At this point in time the high court has taken a step back on the basis that the high court wants to wait for the constitutional court via the chief justice to see what to do about those direct applications.”

Thus, until the Chief Justice provides direction, Kirby says “everything is in limbo”.

In the meantime, the BHF has also launched a separate application at the Constitutional Court, which challenges the public participation process prior to Ramaphosa signing the NHI Act. The focus here is on the rationality and reasonability of Parliament’s consideration of the NHI Bill, which they argue failed to consider input from various parties. As with the other application, the affordability argument plays a role.

Kirby explains: “If you’re sitting in the National Assembly and you’re being asked to vote on a Bill that proposes a significant financial burden on the state in due course and you don’t have the figures in front of you to understand what that burden actually is, then you’re not in a position to say that such a thing is a good idea… It’s grounds for review based on the reasonableness and the rationality of [that] decision”.

How powerful is the affordability argument?

According to Kirby, the argument about affordability is by no means the only strong line of attack that the BHF possesses against the NHI, but it is easily one of the most powerful.

According to Dr Larisse Prinsen, a medico-legal expert at the University of the Free State, who is not involved in the litigation, the affordability argument is more likely to be successful as a line of attack against the President’s assent to the legislation (as with the BHF’s case). Though it would be unlikely to suffice on its own, she says.

Prinsen explains that if the “record shows that the President ignored massive red flags, such as the warnings by the [Davis Tax Committee] and Treasury regarding concerns about the sustainability of the NHI, unresolved costing, provincial power concerns etc., this could support the claim of irrationality in the decision-making process”.

However, she says when it comes to the legal challenges to the Act itself, the argument about affordability is less likely to be successful.

“Courts often defer where a law creates a framework with a phased roll-out and which leaves fiscal choices to later money bills,” she says. “The government might use annual appropriations or future revenue decisions or phased progressive implementation to argue the NHI scheme is in fact capable of reasonable realisation over time. This means that outright invalidation on ‘infeasibility’ alone is a harder battle to fight.”

Similarly, another attorney who is also independent of the litigation, told Spotlight that rationality reviews are typically aimed at procedural steps in the formation of an Act. Thus, the challenge to the President’s decision to sign the law, would likely carry more weight, he said.

Note: In part two of this series, we will turn to whether the implementation of NHI, as set out in the NHI Act, will lead to an unreasonable regression in health services for certain groups.

Republished from Spotlight under a Creative Commons licence.

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Categories : Expert Opinion HospitalsTags :

A Lament for South African Healthcare: There Is Another Way

On By ModernMedia

By Dr Dumisani Bomela, Chief Executive Officer of the Hospital Association of South Africa

There’s an old African idiom: “When elephants fight, the grass suffers.” The “elephants”, however, are two interdependent players in healthcare: the government, which is pushing for the National Health Insurance (NHI), and private healthcare providers and funders, who have long raised serious concerns about the initiative.

At the heart of the dispute is whether a single-fund NHI is constitutional, viable, and sustainable. The legal conflict is shaping up to be unlike anything we have seen in this country.

Dr Dumisani Bomela, CEO of HASA

Some legislators argue that the private healthcare sector opposes reform because it is driven by profit and harbours anti-poor sentiments. But no one in the private healthcare sector is opposed to the objectives of the National Health Insurance. We are in favour of healthcare reform that works. There is a crucial difference.

It is a difference dismissed by those determined that only their view matters. The result is that not only has the country spent nearly two decades in a fruitless debate about the NHI, but it appears that those in charge of the healthcare system have prioritised stagnation over progress. When alternatives could have been explored, expert advice considered, research examined, and insights heard, none were.

Instead, constructive dialogue leading to a positive compromise benefiting patients is perceived as a weakness to be denied and overcome. Perspectives have become so entrenched that mutual understanding seems out of reach. Consequently, energy, effort, and resources will be spent in courts rather than on designing solutions.

Meanwhile, the country’s healthcare users are not getting the attention they deserve. South Africans continue to suffer in under-resourced facilities or struggle to afford medical coverage.

Current legislation and regulation already allow for immediate reforms that could lower healthcare costs and ease pressure on the system and public hospitals. We could complete the reform pathway that would support the affordability of medical aid for millions more South Africans, a move that experts and the Health Market Inquiry have recommended.

Through public–private collaboration and innovation, we can upgrade healthcare infrastructure and develop a stronger base of critical healthcare skills, particularly in nursing, ultimately creating jobs and strengthening the national fiscus. These are realistic and achievable solutions that would deliver real progress in the short term and better position us to move more confidently towards universal healthcare coverage.

Our greatest achievement as a nation has been our ability to unite in times of crisis. We can do it again, but only if all role players are meaningfully involved in healthcare reform – including the private sector – and are willing to listen, consider, and compromise with each other to meet the needs of all healthcare users. To begin with, the government must view private healthcare as a strategic partner, a national asset that can offer significant ideas to resolve the national health delivery crisis. Private healthcare, on the other hand, faces challenges, some of which were identified in the Health Market Inquiry, and others that will undoubtedly be raised in the roundtable debates accompanying the collaborative initiatives crucial to strengthening the system.

If we don’t change course, patients waiting in overcrowded facilities will continue to suffer, and families will continue to struggle to afford care. Dedicated doctors and nurses already working under increasingly difficult conditions will face a darkening future, and the entire system will creak more ominously.

The path to reform does not have to be adversarial. We can redesign healthcare together, combining the strengths of both public and private sectors in the spirit of recognising our shared humanity and interdependence. We can still choose collaboration over confrontation, practical solutions over political battles, and progress over passivity.

But we must act now. Time is running out, and every day spent fighting in courtrooms rather than sitting eye to eye and exchanging ideas is another day that South Africans suffer without the healthcare they deserve. The choice is ours: Will we fight each other, or will we fight together for a healthcare system that serves everyone?

Categories : Healthcare Politics and RegulationsTags :

Warnings of ‘Fiscally Impossible’ Tax Hikes, Slashed Healthcare Under NHI

On By ModernMedia
Photo by Jp Valery on Unsplash

The Health Funders Association (HFA) has launched a legal challenge against the National Health Insurance (NHI) Act. The organisation filed its application on the 4th of June in the Pretoria High Court, challenging the Act on constitutional grounds. This marks the sixth legal challenge against the Bill, with others being brought by professional medical associations and other healthcare funding associations.

“South Africa needs a healthcare system that delivers equitable, quality care to all. We fully support that vision,” said Thoneshan Naidoo, the HFA’s chief executive. “However, in its current form, and without private sector collaboration, the NHI Act is fiscally impossible and operationally unworkable, and threatens the stability of the economy and health system, impacting everyone in South Africa.”

Prior to this, the Board of Health Funders had launched its own legal effort to have President Cyril Ramaphosa make public his decision-making process for approving the NHI Bill. So far, he has refused, arguing that opponents would lead to a courtroom “fishing expedition” in search of flawed reasoning.

HFA pointed to research that it had commissioned from economic consultancy Genesis Analytics. The Genesis report showed that unsustainable tax increases were necessary to fund NHI, while also reducing healthcare access for members of medical schemes.

NHI unaffordable even with generous assumptions

Assuming a cost efficiency of 45.5% from state-centralised healthcare funding, R15 432 per capita expenditure would be required, which works out to R941 billion for South Africa’s 61 million. (For comparison, the 2024 budget for US space agency NASA was R440 bn.) This is a 77% increase over SA’s total of R532.2bn for public and private healthcare expenditure in 2022, making healthcare 33% of the budget. Personal income tax rates would rise to over 40% for even the lowest income bracket – more than doubling from 18.5%. The highest income bracket would increase from 45% to 68.4%. Those earning R92 000 a year would have R10 000 less income – if they were already paying for medical aid. If not, that would be R21 000. [One wonders how South Africa can afford this when we cannot easily replace the US$500 million worth of US aid for HIV and other healthcare programmes under PEPFAR. – Ed.]

“Such tax increases are fiscally impossible, particularly given South Africa’s narrow personal income tax base of 7.4 million taxpayers,” the HFA said.

The HFA also argued that the NHI is not a reasonable solution to the constitutional requirement for progressive realisation of the right to healthcare. By making private healthcare only valid for conditions not covered by the NHI, its much-maligned Section 33 infringes on individuals’ healthcare access. Legislative authority is delegated to the Minister of Health, violating the constitutional separation of legislature and executive power. It is fertile ground for tenderpreneurs, as discussed by Jeff Wicks in a News24 article (paywalled). The HFA also notes that the government has admitted in legislation brought by Solidarity that no thorough NHI costing was performed.

Healthcare quality impacted

Even if South Africa were to find the money for NHI between the couch cushions, there have to be skilled people who can provide the services. Nearly 300 000 healthcare professionals would be required, and given the time needed to train new ones, there would be a huge strain.

Worse, analysis shows that the NHI will make things even worse than they currently are. According to Naidoo, “what NHI will do actually is worse than healthcare for the uninsured because combining your medical scheme population, who are older, within a single risk pool, will actually usurp more funds and actually disadvantage the vulnerable.”

But the country is not without options and inherent advantages, Naidoo says, citing the strengths of its private healthcare system. “We can bring to the table the skills, the knowledge and experience on how to build a sustainable funding solution for the entire country. So that’s what we can bring, and we want to make sure we build this country for everyone.”

Categories : General Interest HospitalsTags :

My Five-hour Wait for Treatment at Mamelodi Hospital

On By ModernMedia

Gauteng Health MEC has said Mamelodi Regional Hospital meets National Health Insurance standards, but my experience was not good

The writer waited five hours for treatment for a broken wrist and head injuries at Mamelodi Regional Hospital in Tshwane. Photo: Warren Mabona.

By Warren Mabona

I waited five hours to get medical treatment at Mamelodi Regional Hospital in Tshwane, with a broken wrist and an injured head.

On 19 February 2025 at about 4pm I was walking in Mamelodi West. I was on a journalism assignment, heading to informal settlements that are prone to flooding.

The street was quiet, but I felt safe because I had walked there before. Suddenly, a car stopped in front of me, and two men got out of it and tried to rob me. I ran away and jumped into the stormwater passage, but slipped and fell, hitting my face against the concrete.

When I managed to stand up, I was dizzy and my vision was blurred. I was drenched in dirty water and my belongings — my cell phone, my wallet and my camera bag — were wet.

The men who attacked me were no longer on the street. My right wrist was swollen and painful, an injury above my eye was bleeding profusely, and my head was aching. But I was relieved that I was still alive and I still had all my belongings.

I decided not to call an ambulance, but to walk about 800 metres to Mamelodi Regional Hospital.

I went to the casualty unit, expecting that I would receive treatment quickly. At the front desk, a clerk took more than 20 minutes to fill in my file. He said the hospital’s computer system was offline and he had to fill in the file with a pen. I then went to sit at the reception area. My head was aching and I repeatedly requested headache tablets from the nurses, who gave me two tablets after 30 minutes. But my pain lingered.

The wound on my face was still bleeding and my wrist was swollen and bent. About 40 minutes after my arrival, a nurse cleaned my wound and wrapped it with a bandage, stopping the bleeding.

At about 8pm, a man sitting next to me said he had arrived at the hospital at 2pm after falling from scaffolding at a construction site. He was still waiting for his X-ray results.

I went for X-rays and long afterwards, at about 10pm, I had a cast put on my wrist. I was given injections which helped with the pain. I was discharged at 11pm and went home.

In September last year, the Gauteng MEC for Health Nomantu Nkomo-Ralehoko said that Mamelodi Regional Hospital was the first hospital in Gauteng ready to meet National Health Insurance (NHI) standards.

In response to GroundUp’s questions, Gauteng Department of Health spokesperson Motalatale Modiba said a triage priority system is followed at the hospital, meaning that four patients with critical wounds that required life-saving emergencies were attended to first. He said this affected my waiting time for wound care and the application of a cast.

“You were classified as Orange P2, that is a person who is in a stable condition and is not in any immediate danger, but requires observation,” said Modiba.

“At the time of your arrival, the casualty unit had 31 other patients to be seen. These include four critical cases in the resuscitation unit, ten trauma cases, 16 medical cases and four pediatric cases,” he said.

Modiba confirmed that the hospital’s computer system was offline when I arrived.

I asked Modiba whether the Gauteng Department of Health can still confidently regard this hospital as NHI-ready despite the slow delivery of medical services I experienced. Modiba said: “Mamelodi Regional Hospital remains committed to provide best healthcare services.”

Republished from GroundUp under a Creative Commons Attribution-NoDerivatives 4.0 International License.

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Categories : Healthcare Politics and Regulations Medical IndustryTags : 1 Comment

ANC and its Ministers Reject Reports of NHI ‘Concessions’

On By ModernMedia
Photo by Hush Naidoo Jade Photography on Unsplash

By Chris Bateman

Recent media reports over the future of NHI have been contradictory and hard to make sense of. Spotlight chased up those in a position to know where things stand – it seems the ANC has not in fact made any major concessions on NHI. There is however agreement that medical schemes won’t be phased out in the next few years, something that likely wouldn’t have happened in any case given the poor state of the economy and the long timeline for NHI implementation. 

The ANC is holding firm on the NHI Act with Health Minister Dr Aaron Motsoaledi and the National Health Department “unaware of any compromise deals”, and the President’s office saying engagement with Business Unity SA (BUSA) is “ongoing”.

In spite of recent media reports to the contrary, neither President Cyril Ramaphosa nor Motsoaledi have conceded to any BUSA proposals on amending sections of the NHI Act. BUSA is the country’s apex business association and represents the banking, mining, and retail sectors, including the Health Funders Association, the Hospital Association of South Africa, and the Innovative Pharmaceuticals Association of South Africa.

BUSA, and several other critics of the Act, have argued that provisions should be removed that prohibit medical schemes from covering any health services covered by the NHI fund. The NHI Act has not yet been promulgated. If promulgated in its current form, the role of medical schemes will be dramatically reduced.

The DA’s spokesperson on health, Michele Clarke, told Spotlight that at the establishment of the recent GNU-convened Medium Term Development Plan (MTDP), agreement was reached that the health department would “not de-establish medical aids during the current government’s term of office”.

Spotlight understands that this amounts to a commitment not to promulgate the relevant sections of the Act in the next few years – it does not amount to a commitment to remove those sections from the act.

This is a pyrrhic victory, given that the implementation of NHI was always going to be a long-term project and that even in the most pro-NHI scenarios, the effective phasing out of medical schemes in the next few years was highly unlikely. There are also four legal challenges being brought on procedural and constitutional grounds that may further delay things.

Mist of confusion

Last week’s mist of confusion lifted when both the Presidency and Dr Stavros Nicolaou, speaking to Spotlight on behalf of BUSA, said no concessions have been made on NHI. Motsoaledi’s office also flatly denied reports that there had been any ANC or GNU compromise to remove parts of the NHI legislation that would render medical aids almost obsolete. The Spokesperson for the National Department of Health, Foster Mohale, added that he was unaware of any MTDP agreement on medical aids.

Vincent Magwenya, a spokesperson for the president, told Spotlight he was “unaware of any process leading to the amendment of the NHI Act”, claiming that Maropene Ramokgopa, Minister in the Presidency responsible for Planning, Monitoring and Evaluation, was misquoted last week.

She was quoted in news reports as saying the ANC and the DA had reached an “unofficial understanding on the NHI” following an ANC compromise to remove parts of the NHI legislation that would collapse medical aids. “Ms Ramokgopa tells me she was misreported,” said Magwenya.

Chris Laubscher, the DA’s communications head, told Spotlight: “There was never confirmation by [DA leader who is also Minister of Agriculture] John Steenhuisen that the NHI in its entirety had been excluded from the government’s Medium Term Development Plan.”

The new MTDP has not yet been made public.

Charity Ophelia McCord, the spokesperson for Steenhuisen, said the MTDP had yet to be completed and passed, but was on the Cabinet agenda for Wednesday, February 12. Spotlight was not able to verify if this was discussed.

Meanwhile, Mohale said both the health department and the minister were unaware of any compromise deal, “thus the implementation of the NHI Act continues as per the plans”.

Cannot be changed over night

If at some point the NHI Act is to be amended, the process is likely to take several years, according to Professor Olive Shisana, Social Policy Special Advisor to Ramaphosa on the NHI and health systems strengthening.

“Any process for changing an enacted law normally goes through Parliament, including an amendment from the executive,” Shisana explained. “There would first have to be consultation with the public before it even got to Parliament. Then, when it gets to Parliament there’s more consultation, this time in each of the provincial legislatures, after which it goes to the Portfolio Committee on Health which also takes written submissions. The committee then decides whether to submit it to the National Assembly. If the National Assembly passes it, it goes to the National Council of Provinces which considers each province’s input. Government took five years to get this NHI Act in place, so you can imagine it might take about as long to get parts of it excised or reversed. That’s the normal route it would have to take, I’m afraid.”

However, both the DA and BUSA are adamant that the Act needs to be changed.

Clarke said the DA remained of the view that “multiple parts of the [Act] remain problematic and dangerous for the future of healthcare in South Africa”.

She added: “The DA wants the model underpinning the NHI to be completely reworked and multiple problematic clauses amended by Parliament to ensure that the healthcare model is protected and strengthened.”

BUSA met with Ramaphosa in September last year and tabled a proposal which included striking Section 33 – which effectively collapses private medical aids as they now exist, creating a single national fund – from the NHI Act. It also calls for the implementation of mandatory health insurance which it is argued will take pressure off the public health system and bolster existing medical aids. The president has since passed it on to Motsoaledi’s office.

Neither BUSA nor the responding government parties have given any indication of when they might next meet or pronounce on the proposal.

Rejection of NHI

Meanwhile, the United Healthcare Access Coalition (UHAC), a grouping claiming to represent 80% of all private healthcare stakeholders, lodged a detailed alternative proposal with the president’s office. This entirely rejects the NHI and focuses on rehabilitating the healthcare system based on a synthesis of far-reaching recommendations which various commissions and experts have made over several decades, including the Taylor Commission and the more recent Health Market Inquiry (HMI).

In January this year, Motsoaledi promised to pronounce on the implementation of the HMI recommendations from 2019 “within weeks”. As reported by Business Day, there indeed seems to now finally be some movement on the HMI recommendations with Minister of Trade Industry and Competition Parks Tau having gazetted an exemption that newly opens the door for tariff setting in the private health sector – a move that may help rein in runaway healthcare costs.

UHAC spokesperson Dr Aslam Dasoo described their report as “everything that the NHI is not”.

“Our health pathway requires easy legislative changes and is within current fiscal constraints. We can start the process immediately. It requires a change in governance structure of the provincial health systems where politicians relinquish all direct authority over health care institutions and instead focus on strategic policy,” he previously told Spotlight.

In an online briefing launching the UHAC on Wednesday, February 12, Dasoo warned all parties in the GNU to “consider their options” as they would be “held jointly responsible” should the NHI be implemented to the detriment of South Africa.

Another UHAC executive member and CEO of the SA Private Practitioners Forum, Dr Simon Strachan, said the focus of their universal healthcare plan was on providing equitable, implementable, and sustainable healthcare.

“We need to ensure that those who can look after themselves, do (financially), while subsidising those who cannot afford to. It’s one hundred percent dependent on improving health service delivery within the public sector and creating a competitive market for people to decide where and how they access healthcare,” he said.

The UHAC coalition includes NGO’s, patient advocacy groups, the SA Medical Association, the South African Private Practitioners Forum, and the Progressive Healthcare Forum.

Asked what UHAC’s “Plan B” was if they “hit a brick wall” on their detailed proposals, Dasoo said the GNU was obliged to respond to such a widely representative proposal “otherwise they’re not fit to govern”.

Referring to the ANC, he said the party “neglected the two major healthcare systems, allowing real degradation of the public sector and an unregulated private sector with no market growth, resulting in prices going up”. He added: “If there’s any brick wall, it’s the one they’ve built.”

Republished from Spotlight under a Creative Commons licence.

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Categories : Ethics and Law HospitalsTags :

HASA Launches NHI Legal Challenge

On By ModernMedia
Photo by Bill Oxford on Unsplash

The Hospital Association of South Africa (HASA) remains unequivocally committed to working with all stakeholders to build a healthcare system that sustainably benefits all citizens of South Africa and urges all involved parties to engage in a solution-oriented approach.

HASA believes the National Health Insurance is neither sustainable nor affordable and that dialogue and collaboration between all stakeholders is critical to finding and developing solutions to achieve universal health coverage. 

HASA has thus far deferred filing a legal challenge to the NHI Act as it firmly believes that sustainable and affordable solutions, to achieve universal health coverage for all South Africans, are within reach. However, the government’s lack of response to several constructive and practical proposals, including those of Business Unity South Africa (BUSA), and the Minister of Health’s recent public statements concerning the NHI, including regarding the imminent publication of NHI regulations, have necessitated that HASA move forward with its legal challenge to the NHI legislation. 

Even though HASA has decided to proceed with legal action, it remains hopeful that the Presidency will respond positively to the constructive proposals that have been made. 

HASA remains open to engaging with the Government on the way forward in parallel to the legal process. Reiterating the time-critical nature of the matter, Melanie Da Costa, Chairperson of HASA, today said, “We remain firmly committed to participating constructively while the legal process unfolds. As an organisation, we have always preferred to resolve matters through dialogue, and we believe that effective healthcare solutions are urgently needed and achievable through a reasonable and collaborative approach.” 

Categories : Healthcare Politics and RegulationsTags :

Pressure Grows for NHI Compromise Ahead of Cabinet Lekgotla

On By ModernMedia

By Chris Bateman

Whether or not the ANC and DA can find common ground on the future of medical schemes is set to be a major test of South Africa’s Government of National Unity. Ahead of a Cabinet lekgotla where the issue is expected to be on the agenda, momentum has been gathering behind a compromise option. 

Little more than a month after President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law in May last year, the ANC entered into a government of national unity (GNU) following a large drop in their share of the vote in South Africa’s 2024 elections. This raised questions over the future of NHI, given that the second largest party in the GNU, the DA, is vehemently opposed to NHI.

The NHI Act has not yet been promulgated and could be amended if the ANC and DA agree to do so. But whether the parties can agree to a compromise remains unclear, especially since there appears to be a hardline faction in the ANC that is committed to NHI as currently encapsulated in the NHI Act. As it stands, the Act foresees a dramatically reduced role for medical schemes whereby they will not be allowed to cover services that are already covered by the NHI fund.

Also in play are at least four High Court challenges to NHI legislation – by the Board of Healthcare Funders (BHF) challenging Ramaphosa’s assent to the NHI Bill just before the elections last year, Solidarity, and the SA Private Practitioners Forum, both claiming government overreach which impacts on people’s right to choose their own health cover and run their own businesses. The South African Medical Association (SAMA) is also preparing a legal challenge.

Two proposals

Meanwhile, momentum has been growing with two compromise proposals: one from Business Unity South Africa (BUSA), the country’s apex business organisation broadly representing the banking, mining and retail sectors, but more pertinently here, the Health Funders Association, the Hospital Association of South Africa, and the Innovative Pharmaceuticals Association of SA. The other is from the United Healthcare Access Coalition (UHAC), a large coalition of healthcare worker groups including, among others, SAMA, the South African Private Practitioners Forum, and the Progressive Healthcare Forum.

BUSA last year met with Ramaphosa and, on his request, provided a detailed yet currently “confidential” proposal, wanting key sections of the NHI Act amended and/or thrown out to enable medical schemes to remain in play by punting mandatory health insurance.

“The BUSA proposal is being processed by the Department of Health and National Treasury. Once processed, a response to BUSA will be formulated accordingly,” presidential spokesperson Vincent Magwenya told Spotlight this week.

The fundamental difference between the two objecting groups is that the UHAC thinks the NHI Act should be thrown out completely and replaced with their detailed blueprint, while BUSA wants the existing Act amended to accommodate private funders. In its proposal, the UHAC urges implementation of long delayed fundamental systemic reform in both healthcare sectors to enable what they say would be efficient, pragmatic and more politically neutral, consultation-driven universal healthcare measures.

We understand that in a meeting between the two groups, shortly before BUSA lodged its proposal with the Presidency, not enough common ground could be found to join forces.

But there are significant overlaps in their proposals. Both groupings embrace mandatory health insurance and dismiss a single central fund as envisaged under NHI as dangerous and financially unfeasible.

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DA spokesperson for health, Michelle Clarke, said her party backs mandatory insurance. She also said the party agrees with the UHAC proposals – and would not hesitate to mount a legal challenge should the NHI go ahead without substantial amendments.

Mandatory health insurance was part of government’s longer term health reform plans until the pendulum swung in favour of NHI at the ANC’s national conference in Polokwane in 2007 when Jacob Zuma became president of the party. The idea was placed back in the spotlight last September when Dr Richard Friedland, immediate past CEO of the Netcare Hospital Group and a key member of BUSA’s health delegation, made the case for it at the HASA conference.

Under mandatory health insurance, everyone who is in formal employment, or who earns above a certain threshold, would be forced by law to be a member of a medical scheme. This, it is argued, would result in medical scheme membership swelling substantially and pressure being taken off the public healthcare system. It is also expected to result in medical scheme premiums being reduced because more healthy, younger people will join the schemes. People who are unemployed or who cannot afford health insurance will still be taken care of by the public healthcare system, which would also take paying medical aid members.

Friedland said at the time that mandatory healthcare insurance would triple the medical scheme market from 9.2 million to potentially 27.5 million beneficiaries over time and reduce those dependent on the state from 53.8 million to 35.5 million.

This week Friedland declined to reveal the contents of the BUSA proposal, saying it was with Ramaphosa and thus confidential.

Meanwhile, Health Minister Dr Aaron Motsoaledi last week rubbished media reports that the cabinet lekgotla scheduled for month end would be taking on board the BUSA proposal. He did however confirm that he will shortly announce which of the far-ranging and long-outstanding recommendations of the Competition Commission’s Health Market Inquiry (HMI) into the private healthcare sector will be implemented, something many have been calling for in recent years.

Far-reaching reforms

Adjunct Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand, who with Dr Aslam Dasoo, founder and chair of the Progressive Health Forum, forms part of the UHAC, said their fundamental point of departure is that the status quo is unacceptable.

According to the UHAC report, irregular provincial health expenditure levels provide a proxy indicator for corruption. The combined irregular expenditure for eight of the nine provinces from 2017/18 to 2022/23 consistently averages around 12.3% (around R9 billion per annum) of non-personnel expenditure compared to 0.1% for the DA-run Western Cape.

“The difference in performance between the Western Cape and the other eight provinces is reasonably attributable to governance differences,” the report reads.

Observes Van den Heever: “We’re losing an enormous amount of performance in the public sector because of political appointments into the system. It compromises leadership and results in a massive waste of resources. The Western Cape shows you the difference governance can make.”

He said that in the “dismally” regulated private sector, funding the pooling system was identified as a problem even before 1994, “but you don’t now disrupt the system to amalgamate into a monopoly fund to solve this (i.e. NHI). Risk equalisation would force medical schemes to compete on the value of what they cover, and nobody would be discriminated against in accessing healthcare.”

Van den Heever says the NHI intention to increase taxes and move funding money from the private to the public sector is “unworkable”.

He added: “The way to address pooling problems is to separate pooling from purchasing. The NHI process has pooling and purchasing in the same organisation, centralising everything – which is highly inefficient, unworkable and with negative consequences all the way through.

“The UHAC proposal separates them out with the provinces and medical schemes remaining as purchasers while strategic pooling or resource allocation is a national function. So, risk equalisation and taxation form part of strategic national pooling functions, while the purchasing and provision of health services are protected from political appointments – including national ministers and provincial MECs.”

Dasoo, who is also a founder member of trade union NEHAWU, said the UHAC collaborative proposal draws on all the research developed over several decades including the Taylor Commission, which made recommendations on an effective social security system for South Africa, the HMI, and numerous other official inquiries.

Dasoo described the UHAC report as “everything that the NHI is not. This health pathway requires easy legislative changes and is within current fiscal constraints. We can start the process immediately. It requires a change in governance structure of the provincial health systems where politicians relinquish all direct authority they have over health care institutions and instead focus on strategic policy.”

BHF hearing in March

A spokesperson for the BHF, Zola Mtshiya, confirmed their NHI legal challenge, set for hearing in March, but said the BHF was only invited to sign up to the UHAC proposal after it was made public. The BHF represents most medical aid schemes – except for the largest, Discovery Health.

BHF Managing Director, Dr Katlego Mothudi, said his organisation is “engaging the association [UHAC] on the document”. he added: “We welcome the willingness to collaborate as an industry as strengthening health systems is everybody’s business.”

Cabinet lekgotla next week

Despite all these developments, whether the ANC is open to a potential compromise on NHI remains unclear. On the one hand, the presidency says they have asked Treasury and the Department of Health to consider the BUSA proposal, on the other, Motsoaledi has rubbished suggestions that the ANC’s position on NHI has shifted and appears committed to an NHI system that dramatically limits the role of medical schemes. His position is thus incompatible with that of the DA.

According to media reports, things got very heated between Motsoaledi and DA ministers when NHI and the future role of medical schemes were discussed at a Cabinet meeting last October.

The matter is likely to again be on the agenda at the Cabinet lekgotla set to take place next week.

Asked about how the GNU might eventually influence universal healthcare, Clarke said: “ANC arrogancy has tapered down a lot compared to what I’m used to. There’s a lot more transparency – but we cannot allow for a very badly written law with huge implications for people’s lives and the economy to go ahead.”

Foster Mohale, spokesperson for the national health department, declined to provide comment for this article, referring Spotlight to the Presidency and Motsoaledi. “What I can say is we’re still working on the Health Market Inquiry recommendations and will let you know when there’s an announcement,” he said.

Magwenya did not provide responses to most of Spotlight’s questions, other than saying that both Treasury and the health department are considering the BUSA proposal and confirming that the President had met with BUSA.

Republished from Spotlight under a Creative Commons licence.

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Categories : General Interest Medical Research & TechnologyTags :

Healthcare Trends to Watch in 2025

On By ModernMedia
AI image made with Gencraft using Quicknews’ prompts.

Quicknews takes a look at some of the big events and concerns that defined healthcare 2024, and looks into its crystal ball identify to new trends and emerging opportunities from various news and opinion pieces. There’s a lot going on right now: the battle to make universal healthcare a reality for South Africans, growing noncommunicable diseases and new technologies and treatments – plus some hope in the fight against HIV and certain other diseases.

1. The uncertainty over NHI will continue

For South Africa, the biggest event in healthcare was the signing into law of the National Health Insurance (NHI) by President Ramaphosa in May 2024, right before the elections. This occurred in the face of stiff opposition from many healthcare associations. It has since been bogged down in legal battles, with a section governing the Certificate of Need to practice recently struck down by the High Court as it infringed on at least six constitutional rights.

Much uncertainty around the NHI has been expressed by various organisation such as the Health Funders Association (HFA). Potential pitfalls and also benefits and opportunities have been highlighted. But the biggest obstacle of all is the sheer cost of the project, estimated at some R1.3 trillion. This would need massive tax increases to fund it – an unworkable solution which would see an extra R37 000 in payroll tax. Modest economic growth of around 1.5% is expected for South Africa in 2025, but is nowhere near creating enough surplus wealth to match the national healthcare of a country like Japan. And yet, amidst all the uncertainty, the healthcare sector is expected to do well in 2025.

Whether the Government of National Unity (GNU) will be able to hammer out a workable path forward for NHI remains an open question, with various parties at loggerheads over its implementation. Public–private partnerships are preferred by the DA and groups such as Solidarity, but whether the fragile GNU will last long enough for a compromise remains anybody’s guess.

It is reported that latest NHI proposal from the ANC includes forcing medical aid schemes to lower their prices by competing with government – although Health Minister Aaron Motsoaledi has dismissed these reports. In any case, medical aid schemes are already increasing their rates as healthcare costs continue to rise in what is an inexorable global trend – fuelled in large part by ageing populations and increases in noncommunicable diseases.

2. New obesity treatments will be developed

Non-communicable diseases account for 56% of deaths in South Africa, and obesity is a major risk factor, along with hypertension and hyperglycaemia, which are often comorbid. GLP-1 agonists were all over the news in 2023 and 2024 as they became approved in certain countries for the treatment of obesity. But in South Africa, they are only approved for use in obesity with a diabetes diagnosis, after diet and exercise have failed to make a difference, with one exception. Doctors also caution against using them as a ‘silver bullet’. Some are calling for cost reductions as they can be quite expensive; a generic for liraglutide in SA is expected in the next few years.

Further on the horizon, there are a host of experimental drugs undergoing testing for obesity treatment, according to a review published in Nature. While GLP-1 remains a target for many new drugs, others focus on gut hormones involved in appetite: GIP-1, glucagon, PYY and amylin. There are 5 new drugs in Phase 3 trials, expected variously to finish between 2025 and 2027, 10 drugs in Phase 2 clinical trials and 18 in Phase 1. Some are also finding applications beside obesity. The GLP-1 agonist survodutide, for example have received FDA approval not for obesity but for liver fibrosis.

With steadily increasing rates of overweight/obesity and disorders associated with them, this will continue to be a prominent research area. In the US, where the health costs of poor diet match what consumers spend on groceries, ‘food as medicine’ has become a major buzzword as companies strive to deliver healthy nutritional solutions. Retailers are providing much of the push, and South Africa is no exception. Medical aid scheme benefits are giving way to initiatives such as Pick n Pay’s Live Well Club, which simply offers triple Smart Shopper points to members who sign up.

Another promising approach to the obesity fight is precision medicine, which factors in many data about the patient to identify the best interventions. This could include detailed study of energy balance regulation, helping to select the right antiobesity medication based on actionable behavioural and phsyiologic traits. Genotyping, multi-omics, and big data analysis are growing fields that might also uncover additional signatures or phenotypes better responsive to certain interventions.

3. AI tools become the norm

Wearable health monitoring technology has gone from the lab to commonly available consumer products. Continued innovation in this field will lead to cheaper, more accurate devices with greater functionality. Smart rings, microneedle patches and even health monitoring using Bluetooth earphones such as Apple’s Airpods show how these devices are becoming smaller and more discrete. But health insurance schemes remain unconvinced as to their benefits.

After making a huge splash in 2024 as it rapidly evolved, AI technology is now maturing and entering a consolidation phase. Already, its use has become commonplace in many areas: the image at the top of the article is AI-generated, although it took a few attempts with the doctors exhibiting polydactyly and AI choosing to write “20215” instead of “2025”. An emerging area is to use AI in patient phenotyping (classifying patients based on biological, behavioural, or genetic attributes) and digital twins (virtual simulations of individual patients), enabling precision medicine. Digital twins for example, can serve as a “placebo” in a trial of a new treatment, as is being investigated in ALS research.

Rather than replacing human doctors, it is likely that AI’s key application is reducing lowering workforce costs, a major component of healthcare costs. Chatbots, for example, could engage with patients and help them navigate the healthcare system. Other AI application include tools to speed up and improve diagnosis, eg in radiology, and aiding communication within the healthcare system by helping come up with and structure notes.

4. Emerging solutions to labour shortages

Given the long lead times to recruit and train healthcare workers, 2025 will not likely see any change to the massive shortages of all positions from nurses to specialists.

At the same time, public healthcare has seen freezes on hiring resulting in the paradoxical situation of unemployed junior doctors in a country desperately in need of more doctors – 800 at the start of 2024 were without posts. The DA has tabled a Bill to amend the Health Professions Act at would allow private healthcare to recruit interns and those doing community service. Critics have pointed out that it would exacerbate the existing public–private healthcare gap.

But there are some welcome developments: thanks to a five-year plan from the Department of Health, family physicians in SA are finally going to get their chance to shine and address many problems in healthcare delivery. These ‘super generalists’ are equipped with a four-year specialisation and are set to take up roles as clinical managers, leading multi-disciplinary district hospital teams.

Less obvious is where the country will be able to secure enough nurses to meet its needs. The main challenge is that nurses, especially specialist nurses, are ageing – and it’s not clear where their replacements are coming from. In the next 15 years, some 48% of the country’s nurses are set to retire. Coupled with that is the general consensus that the new nursing training curriculum is a flop: the old one, from 1987 to 2020, produced nurses with well-rounded skills, says Simon Hlungwani, president of the Democratic Nursing Organisation of South Africa (Denosa). There’s also a skills bottleneck: institutions like Baragwanath used to cater for 300 students at a time, now they are only approved to handle 80. The drive for recruitment will also have to be accompanied by some serious educational reform to get back on track.

5. Progress against many diseases

Sub-Saharan Africa continues to drive declines in new HIV infections.  Lifetime odds of getting HIV have fallen by 60% since the 1995 peak. It also saw the largest decrease in population without a suppressed level of HIV (PUV), from 19.7 million people in 2003 to 11.3 million people in 2021. While there is a slowing in the increase of population living with HIV, it is predicted to peak by 2039 at 44.4 million people globally. But the UNAIDS HIV targets for 2030 are unlikely to be met.

As human papillomavirus (HPV) vaccination programmes continue, cervical cancer deaths in young women are plummeting, a trend which is certain to continue.

A ‘new’ respiratory virus currently circulating in China will fortunately not be the next COVID. Unlike SARS-CoV-2, human metapneumovirus (HMPV) has been around for decades, and only causes a few days of mild illness, with bed rest and fluids as the primary treatment. The virus has limited pandemic potential, according to experts.

Categories : General Interest Healthcare Politics and RegulationsTags :

Health in 2024: The Year in Fewer than 1000 Words

On By ModernMedia

By Marcus Low and Adiel Ismail

From the NHI Act to major advances in HIV prevention, it has been another busy year in the world of healthcare. Spotlight editors Marcus Low and Adiel Ismail recap the year’s health developments and identify some key trends in fewer than 1000 words. 

For a few weeks in June, it seemed that the surprising outcome of South Africa’s national and provincial elections would usher in far-reaching political and governance changes in the country. As it turns out, some significant changes did come, but not in the health sector. 

Rather than a new broom, it was déjà vu as Dr Aaron Motsoaledi returned as Minister of Health – he was previously in the position from 2009 to 2019. In both Gauteng and KwaZulu-Natal – the country’s most populous provinces – ANC MECs for health from before the elections kept their jobs. The ANC garnered well under 50% of the votes in both of those provinces and nationally and accordingly had little choice but to form national and provincial coalitions. 

To be fair, five of the nine MECs appointed after the elections were new, but these changes were mainly in the less populous provinces. 

Policy-wise, the trajectory also remains much as it was a year ago. Two weeks before the elections, President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law (though most of it has not yet been promulgated). While Ramaphosa has since then asked Business Unity South Africa (BUSA), the country’s largest employer association, for new input on NHI and while talk of mandatory medical scheme cover had a moment in the headlines, there is no solid evidence that the ANC is open to changing course – if anything, Motsoaledi has doubled-down in the face of criticism. The Act is being challenged in various court cases. 

The sense of discord in healthcare circles was further deepened in August when several organisations distanced themselves from Ramaphosa’s updated Presidential Health Compact. The South African Medical Association, the South African Health Professionals Collaboration—comprising nine associations representing over 25 000 public and private healthcare workers—and BUSA all declined to sign the accord. BUSA accused government of “unilaterally” amending the compact “transforming its original intent and objectives into an explicit pledge of support for the NHI Act”.  

Away from these reforms, a trend of health budgets shrinking year-on-year in real terms continued this year. This funding crunch, together with well-documented shortages of healthcare workers, has meant that even well-run provincial health departments are having to make impossible trade-offs – that while governance in several provincial health departments remains chronically dysfunctional. This was underlined by a landmark report published in July that, among others, highlighted leadership instability, lack of transparency, insufficient accountability mechanisms, and pervasive corruption. New reports from the Auditor General also didn’t paint a pretty picture. 

Gauteng health has again been in the headlines for the wrong reasons. The provision of cancer services in the province remains mired in controversy as the year comes to an end, with plans to outsource some radiation services to the private sector apparently having stalled, despite the health department having the money for it. A deal between the department and Wits University was also inexplicably derailed. With high vacancy rates, serious questions over senior appointments, reports of corruption at Thembisa Hospital, and much more, it seems that, if anything, governance in the province has gotten even worse this year. 

In a precedent-setting inquest ruling in July, Judge Mmonoa Teffo found that the deaths of nine people moved from Life Esidimeni facilities to understaffed and under-equipped NGOs “were negligently caused by the conduct of” former Health MEC Qedani Mahlangu and former head of the provincial health department’s mental health directorate Dr Makgabo Manamela. 

Outside our borders, Donald Trump’s election victory in the United States is set to have far-reaching consequences. A return of the Global Gag Rule seems likely, as does major changes to the Food and Drug Administration, the President’s Emergency Plan for AIDS Relief, and the National Institutes of Health – the latter funds much HIV and TB research in South Africa. 

Away from politics and governance, the biggest HIV news of the year came in late June when it was announced that an injection administered every six months was extremely effective at preventing HIV infection. It will likely be several years before the jab becomes widely available in South Africa.

Another jab that provides two months of protection per shot is already available here, but only to a small number of people participating in implementation studies. 

It is estimated that around 50 000 people died of HIV related causes in South Africa in 2023 and roughly 150 000 were newly infected with the virus (reliable estimates for 2024 will only be available in 2025). A worrying one in four people living with HIV were not on treatment in 2023. There was an estimated 56 000 TB deaths and around 270 000 people fell ill with the disease. While these HIV and TB numbers have come down dramatically over the last decade, they remain very high compared to most other countries. 

There are some concerns that a new TB prevention policy published in 2023 is not being universally implemented. We have however been doing more TB tests, even while TB cases are declining – as we have argued, this is as it should be. Also positive, is that a massive trial of an TB vaccine kicked off in South Africa this year. 

With both TB and HIV, South Africa is making progress too slowly, but we are at least trending in the right direction. With non-communicable diseases such as diabetes, there are unfortunately signs that things are getting worse. As we explained in one of our special briefings this year, our diabetes data in South Africa isn’t great, but the little we have painted a worrying picture. As expected, access to breakthrough new diabetes and weight loss medicines remained severely constrained this year, largely due to high prices and limited supply. 

Ultimately then, at the end of 2024, South Africa is still faced with chronic healthcare worker shortages, severe governance problems in several provinces, and major uncertainties over NHI – all while HIV and TB remains major public health challenges, though a shift toward non-communicable diseases is clearly underway. 

Republished from Spotlight under a Creative Commons licence.

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Categories : Expert OpinionTags :

Navigating the Road to Universal Health Coverage in South Africa

On By ModernMedia

By Dr Reno Morar, Director: Medical School, Faculty of Health Sciences, Nelson Mandela University

Dr Reno Morar

Johannesburg, 20 November: As Director of the newly established Medical School in the Faculty of Health Sciences at Nelson Mandela University, I am honoured to lead South Africa’s tenth and youngest medical school. Our medical students exude an infectious spirit of hope and enthusiasm as we progress toward graduating our first cohort of Mandela Doctors in 2026.

As we navigate our journey at the medical school and within the Faculty, our goal is to successfully graduate composite health professionals who are equipped to serve our communities.

This journey is inextricably linked to a larger national goal: achieving Universal Health Coverage (UHC) for South Africa.

With the signing of the National Health Insurance (NHI) Act into law, South Africa stands at a pivotal moment in its healthcare journey. Achieving UHC promises equitable access to quality healthcare for all South Africans, regardless of income or location. But transforming this vision of UHC into reality requires much more than policy reflected in the NHI, it calls for robust planning, thoughtful resource allocation, and, above all, collaboration across sectors.

Our nation’s medical schools and higher education and training institutions are essential to the UHC journey in their support of South African’s human resources for health strategy. This strategy provides a foundation for advancing universal health coverage by ensuring healthcare professionals are appropriately trained to meet the demands of a redefined healthcare system.

These institutions play an instrumental role in building a workforce ready to support the NHI system. Lessons from our response to the recent COVID-19 pandemic have already shown us the power of unity; as we move forward, this spirit of collaboration between the public and private sectors will be crucial in shaping a resilient and inclusive healthcare system that can achieve UHC.

The NHI Act sets out to provide universal access to quality healthcare services, bridging disparities and delivering equitable access to essential services for all South Africans. However, the path to UHC is about more than access, it requires quality, efficiency, and sustainability across a restructured healthcare landscape.

Photo by Hush Naidoo Jade Photography on Unsplash

The government’s role here is pivotal – responsible leadership, resource allocation, and effective oversight are critical to building public confidence. This transition poses complex governance and constitutional challenges.

Implementing the NHI Act requires establishing new accountability mechanisms, redefining roles, and reassessing funding streams. Addressing these structural challenges – especially in under-resourced and underserved regions – demands both strategic mindset and practical capacity to adapt quickly to evolving needs.

Many of South Africa’s rural and township communities face significant shortages in healthcare resources and access to quality services. For NHI to succeed in these settings, dedicated efforts in providing adequate healthcare infrastructure and equipment, staffing, and strong governance and leadership are essential.

Achieving the ambitious goals of NHI without a solid foundation in governance and accountability would be a costly misstep. The success of NHI demands careful, evidence-based planning with clear goals and accountability.

This approach will require decades of commitment, with the understanding that universal healthcare frameworks often take generations to mature fully. NHI will not be a quick fix, but with meticulous preparation, it has the potential to become a sustainable, far-reaching health system intervention.  

Government planning must also account for the rapidly changing landscape of healthcare needs and technology. South Africa’s healthcare system must prepare not only for current demands but also for future challenges, including digital healthcare infrastructure and data security.

Protecting patient information and ensuring uninterrupted services is paramount in a digital age where data breaches are a constant risk. Recent experiences with cybersecurity issues in the National Health Laboratory Services underscore the importance of proactive measures in this domain.

The pandemic has taught us the power of unity in times of crisis. During COVID-19, South Africa’s public and private healthcare sectors demonstrated resilience, adaptability, and a shared commitment to public health. This partnership was instrumental in resource-sharing, patient care, and vaccine distribution.

It serves as a powerful reminder that as the NHI system is implemented over the next 10 to15 years, the system will benefit from a collaborative model where the expertise and resources of the private and public sectors complement each other in the public interest and wider community access.  

Collaboration between the public and private sectors must focus on expanding healthcare infrastructure, enhancing service delivery in underserved areas, and integrating innovative technologies for more efficient patient care. By working together, public and private sectors can foster a healthcare environment that maximises strengths and mitigates gaps in service. 

To sustain the implementation of the NHI system, South Africa needs healthcare professionals equipped to handle both the scope and scale of this vision. Medical and health professions education must adapt and evolve to meet these challenges, training future healthcare providers not only in clinical skills but also in adaptability, empathy, and resilience.

At Nelson Mandela University’s Faculty of Health Sciences, we prioritise these qualities, embedding community-based learning and problem-solving into our curriculum to prepare graduates for a diverse and demanding healthcare landscape.

Students experience firsthand the disparities within South Africa’s healthcare system, and this allows our students to develop the necessary understanding of the realities their future patients face.

Our programme equips them to work in a wide array of settings – from rural clinics with limited resources to state-of-the-art urban facilities. This holistic training ensures our graduates are capable of addressing the multifaceted healthcare challenges with the empathy and innovation necessary to serve our communities across South Africa.

The journey toward UHC and the implementation of NHI system is both inspiring and challenging. It is a bold declaration of South Africa’s commitment to affordable universal access to quality health care services, healthcare equity – and must be approached with open eyes and a steady hand.

Our success will depend on a combination of strategic planning, effective governance, and a commitment to collaboration across sectors.

South Africa has a unique opportunity to build a healthcare system that is equitable and resilient. By prioritising these foundational steps, we can pave the way for a healthcare system that genuinely serves all South Africans, one that fulfils the promise of our constitution and reflects the spirit of our democracy. The future of our healthcare system is within our hands, but only if we approach it with responsibility, collaboration, and a deep commitment to the well-being of all our people.

It will be an intensely proud South African moment when we graduate our first 45 Mandela Doctors from our medical school in 2026! As South Africans, we also want to be proudly South African about the health system we build for and with our people.