NHI is bugbear of the upper crust

Some of South Africa’s most powerful business lobbies, private healthcare interests and affluent constituencies have turned to the courts to challenge the national health insurance (NHI) Act. 

They are determined to protect profits and their exclusive access to quality healthcare. Behind the legal arguments lies a determination to preserve a longstanding imbalance in which access to quality healthcare remains heavily determined by income, medical aid status and private purchasing power.

The NHI debate is fundamentally about whether South Africa is ready to shift from a deeply unequal two-tier system, where healthcare is a market privilege for those who can afford it, towards a more just and inclusive model that treats healthcare as a social right for all citizens.

It is no coincidence that the fiercest and most vocal resistance to the NHI does not come from the poor. Instead, it comes from those with the most to lose in a more equitable system, such as business interests, private hospital groups, medical scheme administrators, brokers reliant on substantial profits and upper-class individuals whose privileged access to superior care has long been secured through financial means.

While these opponents often frame their objections in terms of feasibility, governance shortcomings and fiscal risks, the underlying issue is their anxiety that the NHI will dismantle a healthcare hierarchy that has served them well for generations.

But what kind of healthcare system does South Africa need? The answer cannot be found in market forecasts or the anxieties of private healthcare shareholders. It must be found in the Constitution, the lived realities of the poor and the democratic imperative to dismantle structural inequality.

NHI forces South Africa to confront a moral question it has postponed for far too long: Will healthcare remain a class privilege or will it finally become a fundamental right?

NHI is not an ideological experiment, as its critics claim. It is not a war on doctors or private hospitals. For too long, South Africa has lived with a healthcare system that mirrors the worst features of society.

NHI is a constitutional and social justice intervention designed to ensure that access to healthcare is determined by need, not income.

South Africa suffers from a profound crisis of inequitable allocation and inefficient financing. The country spends approximately 8.5% of GDP on health — a level more than enough to support a pathway towards universal health coverage if organised rationally and fairly.

Yet despite this substantial national spend, outcomes remain deeply unequal because of South Africa’s two-tier healthcare system: heavily resourced for a privileged minority in the private sector, while chronically overburdened for the majority in the public sector. That is the central contradiction the NHI seeks to resolve.

Evidence shows that more has been spent in the private sector than in the public sector since 2008, even though the public sector serves the majority of South Africans. The per capita disparity is even more revealing. In 2021-22, private spending per person was approximately five times higher than public spending per person. This financing structure entrenches inequality.

This is precisely why the language of “choice,” so often invoked by NHI opponents, is misleading. In a country where millions have no meaningful purchasing power, “choice” is a euphemism for class privilege. 

The current system offers selective protection to those who can afford medical aid contributions, co-payments and out-of-pocket expenses. In such a system, the market does not allocate healthcare according to need; it allocates it according to wealth. In practice, money determines who gets healthy, who lives and who dies.

The NHI intervenes in healthcare financing and resource pooling, exactly where injustice resides. It proposes a single publicly funded health financing system that pools resources into one NHI Fund, which then purchases quality health services on behalf of all South Africans, based on need rather than ability to pay. 

This is the essence of universal health coverage, whose premise is that every person should receive the healthcare they need, when they need it, irrespective of their wealth.

So why, then, the ferocious opposition? Because NHI threatens privilege and profit built on fragmentation. It threatens the pricing power of dominant private hospital groups. It threatens the bloated administrative overheads of medical schemes.

The department has exposed the scale of this problem. At the start of 2024, there were 71 medical schemes offering 311 options, with 833 trustees, gross administration costs of nearly R21 billion and principal officers costing almost R140 million, some earning more than R6 million a year.

This administrative complexity is a symptom of fragmentation. It creates duplication, inflates transaction costs, encourages perverse incentives and makes fraud easier to conceal. Reported fraud, waste and abuse in the medical scheme environment in 2023 amounted to R28 billion in a single year.

The above debunks a persistent myth that private financing is inherently efficient. South Africa already spends enough collectively to build a far more equitable system. What it lacks is not money but a financing architecture aligned to social solidarity rather than market segmentation.

Opposition to NHI represents a coalition of the privileged against the poor’s right to decent healthcare. It is the political and economic fightback of those who have long enjoyed the luxury of world-class care where wealth buys life, dignity and speed, while the poor are forced to queue, wait and too often die in silence. At its core, the battle over NHI is between the constitutional promise of equality and the entrenched privilege of those who continue profiting from exclusion.

Opponents of NHI are mobilising South Africans to fear change. But what South Africans must fear most is the acceptance of inequality and the humiliation of being regarded as less worthy because one cannot produce proof of payment. 

NHI is opposed so fiercely because it asserts that the life of a domestic worker, a farm labourer, a child in Stinkwater and a professional in Sandton must carry equal claim on the nation’s health resources.

South Africa’s democracy was not built to protect privilege. It was built to improve the lives of South Africans. NHI is part of the unfinished work of the 1994 promise. It gives practical expression to section 27 of the Constitution and to the broader struggle for social justice.

It will be a betrayal of the dream of 1994 to accept that a deeply unequal market should continue deciding who gets quality care and who must be excluded.

Critics raise weaknesses in the public health system and corruption as ammunition against NHI. These are legitimate concerns. Governance matters. Corruption must be fought ruthlessly. Administrative capacity must be built. But these are arguments for doing NHI properly, not for abandoning it. No one suggests dismantling public education because schools are imperfect or abandoning policing because crime exists. Yet when it comes to NHI, the privileged demand perfection as a precondition.

International experience supports this direction. Britain’s National Health Service (NHS) was founded on the principle that healthcare must be free at the point of use and financed through public means. It has endured because that principle is morally sound. Cuba, despite severe economic constraints, has demonstrated the power of a primary healthcare-centred system to deliver strong outcomes through equity, prevention and community-based care. South Africa’s NHI is not a copy of either model but it shares the same ethical foundation: health is a right, not a privilege for the few.

History will not judge us by how effectively we protect profit. It will judge us by whether we had the courage to ensure that no South African is denied care because they lack money. NHI demonstrates that courage.

Cornelius Monama is a public servant and writes in his personal capacity (X: @cmonama).