Ramaphosa pauses NHI implementation pending Constitutional Court ruling

President Cyril Ramaphosa has paused the implementation of the National Health Insurance (NHI) Act until the Constitutional Court rules on legal challenges to the law.

In a letter dated 20 February, the Office of the State Attorney in Pretoria confirmed that Ramaphosa will not commence any sections of the Act before the apex court delivers judgment on the “public participation challenges”.

The letter follows correspondence sent a day earlier by Health Minister Aaron Motsoaledi, in which he stated that he would not request the president to promulgate any sections of the Act while the Constitutional Court cases are pending.

The challenges were brought by the Board of Healthcare Funders (BHF), an industry body representing medical schemes and by the Premier of the Western Cape, Alan Winde last year. They contend that parliament did not follow constitutional requirements for public participation during the legislative process that led to the adoption of the NHI Act.

The legal challenges seek to prevent any sections of the law from being implemented until the court has ruled and argue that procedural irregularities may render parts of it invalid.

Earlier this month, the apex court issued directions removing separate applications for leave to appeal and direct access filed by the president and Motsoaledi, known as the “presidential assent challenges,” from the court roll. The court postponed those applications pending its decision on the public participation cases.

The Constitutional Court has scheduled hearings on the public participation challenges for 5 to 7 May 2026

The letter from the Office of the State Attorney notes that the president’s decision to bring legislation into force is influenced by requests from the minister of health and factors including the readiness of the department responsible for implementation.

“The president undertakes not to promulgate any provisions of the NHI Act prior to the Constitutional Court handing down judgment in the public participation challenges. We reiterate that this is in line with the undertaking previously given by the president that he would not promulgate or bring into operation any provision of the Act until requested to by the minister,” it said.

“As previously stated, the president does not act in isolation in considering and determining whether to bring legislation into effect or in determining whether to implement the legislation.”

The NHI Act, passed by parliament in 2023 and signed into law by Ramaphosa in May 2024, aims to establish a single, state-run fund to purchase healthcare services on behalf of all South Africans. It proposes changes to healthcare financing and delivery, including limiting the role of medical schemes once fully implemented.

The latest development clearly indicates that sustained pressure against the Act is having the intended effect, said Theuns du Buisson, an economic researcher at the Solidarity Research Institute.

“It is now time to maintain this pressure, and it provides the department of health with an opportunity to reconsider,” Du Buisson said.

“It should, of course, never have progressed this far, as Solidarity has long indicated how unworkable, irrational and unaffordable the NHI scheme is. Even the Treasury recognises this, and we hope that this realisation is now also reaching the president and the minister of health.”

The union pointed to its Healthcare Funding Reform Bill, tabled in Parliament in 2025, and said it would continue pursuing legal challenges, including upcoming proceedings on the consolidation of multiple cases against the state.

“There is a viable alternative to consider, rather than destroying the lives of millions of South Africans through the NHI. “Now is the time for the country’s leaders to exercise sober judgement and to consider proposals such as our alternative bill. We urge them to abandon the NHI now, as it is not workable,” Du Buisson added.

Solidarity said the pause creates space for the government to reconsider what it calls an unaffordable and unworkable policy. 

The pause comes as rights group AfriForum this week served summons on Ramaphosa and Motsoaledi, challenging the constitutionality of the Act. The organisation said the law limits provincial powers, patient choice and clinical independence, describing it as economically unworkable. 

AfriForum is asking the high court to declare the Act unconstitutional and return it to Parliament. 

The Democratic Alliance has continued to oppose the NHI, despite now being part of  Ramaphosa’s government of national unity, arguing that the scheme is unaffordable and will weaken private healthcare.