MOREMI NKOSI: Setting the record straight on NHI

The article titled “Sleight of hand” (FM, March 26-April 1) reflects a familiar wave of scepticism towards National Health Insurance (NHI), raising overhyped concerns that, while not new, warrant careful clarification.

Public debate on reform on the scale of NHI is necessary and welcome. However, it is equally important that such debate is grounded in fact, context and a fair reading of both the policy intent and its design.

NHI is not a sudden or untested idea; it is the product of more than a decade of policy development, consultation and refinement aimed at addressing one of the most enduring structural challenges in South Africa: inequality in access to and affordability of quality health care.

The article inaccurately repeats the claim that the views of doctors and health-care professionals have been ignored in the development of NHI. This assertion does not withstand scrutiny. The government has engaged extensively with stakeholders, including professional associations such as the South African Medical Association, specialist groups, hospital networks, academics and health-care worker unions. These engagements have taken place through formal submissions, parliamentary hearings, technical working groups and ongoing consultations on implementation mechanisms.

What is often characterised as “ignored input” is, in reality, a divergence of views, particularly where stakeholder positions do not align with the broader public interest objectives of equity, affordability, sustainability and universal health coverage. Policymaking in this context requires balancing competing interests, not privileging one constituency that is opposed to change because the status quo benefits it.

Another common misconception in the article is that NHI can be funded only through significant increases in personal income tax or VAT. This reflects a misunderstanding of the fundamental purpose of health financing reform. South Africa already spends 8%-9% of its GDP on health, an amount comparable to many countries with universal health systems. The problem is not the quantum of spending, but how it is distributed. Nearly half of total health expenditure serves a small minority of the population through private medical schemes, while the majority rely on a constrained public sector. NHI seeks to address this imbalance by pooling funds more effectively, reducing fragmentation and improving purchasing efficiency.

Funding will be introduced progressively and will draw on a combination of existing public resources, reallocation and carefully calibrated revenue measures. There is no basis for the claim that NHI necessitates an immediate or disproportionate increase in specific taxes; rather, it is a long-term restructuring of how health resources are mobilised and used, for the benefit of the entire population.

To argue that recent allegations of corruption in the health sector show that NHI is destined to fail is misleading and flawed. Corruption risk is not unique to NHI or to the public sector. It is a systemic challenge that affects public and private health-care environments globally. Importantly, the identification and investigation of possible wrongdoing reflect the functioning of oversight and accountability mechanisms, not their absence. NHI, in fact, strengthens governance relative to the current fragmented system by introducing centralised strategic purchasing, standardised contracting and enhanced digital verification systems. Oversight institutions such as the auditor-general will continue to play a critical role in ensuring transparency and accountability. The appropriate response to corruption risk is not to abandon reform but to design systems that are more resilient, transparent and enforceable than those now in place.

Concerns about excessive powers vested in the health minister similarly overlook the broader governance framework within which the NHI Fund will operate. While the minister does have a role in appointing key structures, this is consistent with governance arrangements across public entities in South Africa and is subject to legislative oversight and applicable safeguards. These include compliance with the Public Finance Management Act, parliamentary oversight, fiduciary duties of the board and administrative justice requirements. Authority is not exercised in a vacuum; it is bounded by law, transparency requirements and institutional checks and balances. The framing of this issue as an unchecked concentration of power is therefore inaccurate and disregards the legal architecture designed to prevent precisely such an outcome.

Oversight institutions such as the auditor-general will continue to play a critical role

The assertion that NHI is unaffordable or fundamentally flawed also rests on a set of assumptions premised on a worst-case scenario as the only outcome. South Africa’s dual health-care system is characterised by stark inequities, rising costs in the private sector and persistent underresourcing in the public sector. Without reform, these challenges will deepen, placing increasing pressure on households and the fiscus alike. NHI introduces mechanisms such as strategic purchasing, price certainty and risk pooling, all of which are internationally recognised tools for improving efficiency and controlling costs. Evidence from a range of countries demonstrates that universal health coverage systems achieve better health outcomes at lower or comparable cost growth over time. The question, therefore, is not whether South Africa can afford NHI, but whether it can afford to maintain a system that delivers unequal outcomes at significant economic and social cost, with the profit-driven protagonists continuing to argue that those with the most health needs must be offered some minimalist package of health benefits.

Finally, the suggestion that the government has failed to engage with alternative proposals from business, including those put forward by Business Unity South Africa, does not fully reflect the reality of ongoing dialogue. The government has engaged business stakeholders across multiple platforms and continues to do so.

However, the proposal for a multipayer system offering a limited package of benefits raises substantive policy concerns. Chief among these is the risk of perpetuating fragmentation and inequality by maintaining separate funding pools with varying levels of coverage. The core principle of NHI is solidarity, ensuring that access to health care is based on need rather than ability to pay. A single, unified purchaser strengthens bargaining power, enhances equity and allows for a more coherent and efficient allocation of resources. While constructive engagement is essential, any alternative must be assessed against these foundational objectives.

The authors could have done a better job of presenting a more balanced view of the issues, rather than merely eliciting opinions from people who have expressed anti-NHI sentiments previously. Good journalism requires good balance in opinion as well.

Nkosi is the chief director: health care benefits and provider payment design in the department of health