Universal health coverage cannot succeed with fragmented systems, weak data, and largely symbolic participation, so a recent court-ordered pause to NHI implementation offers a chance to build the foundations properly, argue Dr Haseena Majid and Professor Mogie Subban in Spotlight.
Implementation of the NHI Act has been delayed after High Court order, by agreement between the parties, prohibiting the proclamation or implementation of its provisions until the Constitutional Court rules on challenges related to public participation.
But beyond the legalities, the pause reveals something more consequential. Universal health coverage cannot succeed on fragile administrative foundations.
If the NHI is to deliver equity, efficiency and quality care, the state must first confront the structural weaknesses that continue to shape large parts of South Africa’s health system.
These include fragmented governance across national, provincial and local levels that weakens co-ordination and accountability; persistent shortages of health professionals that leave facilities understaffed and overburdened; and weak information systems that limit the state’s ability to track performance, allocate resources effectively and plan services based on reliable data.
The NHI Act can mandate pooled financing and new purchasing arrangements, but financing reform alone cannot fix fragmented governance, uneven data systems or inconsistent co-ordination between stakeholders.
When reforms are layered onto unstable administrative systems, the result is not transformation but increased risk.
The eye health example
Eye health illustrates this challenge clearly. This is because it depends on co-ordination across many parts of the health system including clinics, skilled cadres such as optometrists and ophthalmologists, hospitals, NGOs and screening programmes. When these stakeholders do not work together effectively, patients fall through the gaps.
South Africa’s burden of chronic disease is rising, and with it preventable vision loss. The International Diabetes Federation estimates that around 2.3m people in South Africa aged 20-79 have diabetes, which can affect the eyes and lead to vision loss and blindness if not detected early.
Studies in South Africa have reported high rates of diabetic eye disease, including prevalence estimates of 39%, in a tertiary diabetes clinic in Durban and around 25% in primary care settings in Tshwane.
These figures are not simply about eye disease. They reflect gaps in chronic disease co-ordination, screening coverage and referral systems. When diabetic eye screening is inconsistent, when referral pathways are unclear and when health data are incomplete, preventable vision loss becomes far more likely.
Cataract surgery, one of the most effective medical procedures available, is rightly prioritised. Yet provincial reporting continues to show significant surgical backlogs. While numbers fluctuate, the pattern remains consistent: demand continues to outpace co-ordinated capacity.
Vision challenges are also increasing as the population ages. A KwaZulu-Natal study reported presbyopia prevalence of 77% among examined adults. As the population grows older, near-vision impairment becomes not only a clinical concern but also one that affects productivity, mobility and independence.
Combined, diabetes-related eye disease, cataracts and age-related vision decline illustrate a predictable and growing demand for eye-care services. The burden is clear, but the health system response remains uneven.
Only around 6%-7% of optometrists practise in the public sector, while the majority work in private urban settings. Across the country, eye-care services are delivered through a mix of public facilities, private practitioners, NGOs, outreach surgical programmes and school screening initiatives.
Yet there is no single national picture showing who is providing which services, where those services are located, and how well they are functioning.
Government therefore does not consistently have a clear view of which partnerships are active, which communities are over-served or neglected, what equipment is functioning at facilities, or how the workforce is distributed relative to need. This is not a minor administrative gap, instead it is a governance failure with real consequences.
No clear view
Government cannot plan for what it cannot see. Data gaps and poor system visibility are creating blind spots that will paralyse even the best financing reforms. Without clear stakeholder mapping and infrastructure audits, planning becomes reactive. Procurement decisions become distorted and workforce deployment misaligned.
Funding reform under the NHI may change how services are purchased, but if the underlying service network remains fragmented, inefficiencies will simply be redistributed.
The consequences extend beyond clinics. Children with uncorrected vision problems struggle at school. Adults with untreated diabetic eye disease risk losing income and economic stability. Older people waiting for cataract surgery may lose mobility and independence.
When health systems fail to co-ordinate care, the costs are first absorbed by households and later by the state through disability, preventable complications and lost productivity.
The NHI Act aims to improve equity and purchasing efficiency. But efficiency depends on knowing where services exist and where they are missing. Equitable access depends on understanding how infrastructure and human resources are distributed. Quality oversight depends on reliable data that allow performance to be monitored.
What the NHI pause ultimately exposes is unfinished work in health-system governance. South Africa does not lack policy ambition. The country is widely recognised for progressive health policy. The challenge lies in fragmented implementation, limited visibility of service networks and uneven co-ordination across institutions.
A strategic choice
The Department of Health now faces a strategic choice. It can wait for the courts to resolve the legal process, or it can use this moment to strengthen the operational foundations needed for equitable reform.
Eye health presents a practical place to begin. It may not command the urgency of oncology, emergency medicine or infectious disease management, but that is precisely why it offers an opportunity to test workable solutions. Even under the best financing model, sustainable eye care depends on co-ordinated collaboration between public facilities, private practitioners, NGOs and community networks.
A focused national pilot could map eye-care services geographically, combining stakeholder mapping with infrastructure audits and workforce distribution analysis. This would strengthen planning in eye health while providing the system visibility on which large-scale purchasing reforms like NHI depend.
The efficiency gaps are already known. What is needed now is co-ordinated implementation. If government can demonstrate that fragmented service environments can be mapped and co-ordinated within eye health, it will create a practical reform model for other strained areas of the health system.
Universal health coverage will not be secured simply by moving money differently. It will be secured by making the system visible, co-ordinated and accountable. The current pause has given us more time. What matters now is whether it is used to build the governance foundations that real reform requires.
*Dr Majid is a Postdoctoral Research Fellow at the College of Law and Management Studies, University of KwaZulu-Natal. Professor Subban is Academic Mentor and Public Governance Expert, at the College of Law and Management Studies, University of KwaZulu-Natal.
Spotlight article – NHI pause should be used to build stronger healthcare foundations
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