The characterisation of NHI as a form of centralised state control that will undermine clinical autonomy and effectively nationalise healthcare provision is misleading, argue senior health officials in response to a commentary by RW Johnson published last week in MedicalBrief.
Dr Olive Shisana, Dr Adiel Chikobvu and Moremi Nkosi write:
The article titled “Why does the ANC cling to the clearly disastrous NHI?” presents itself as a critique of NHI, but on closer examination, it is better understood as an ideologically driven argument rather than an informed and evidence-based policy analysis. The central weakness of the article is that it assumes, from the outset, that NHI is an inherently flawed policy destined to fail.
This assumption is not rigorously demonstrated through comparative data or empirical evaluation but rather asserted and then reinforced through the selective use of concerns about cost, governance, the health workforce, and system capacity. In doing so, the article dismally fails to engage meaningfully with the substantial body of international evidence supporting Universal Health Coverage (UHC), nor does it grapple with the structural deficiencies of South Africa’s current two-tier health system.
A key mischaracterisation in the article is the depiction of NHI as a form of centralised state control that will undermine clinical autonomy and effectively nationalise healthcare provision. This framing is nothing short of misleading.
Modern UHC systems, including the model envisaged for South Africa, are based on the principle of strategic purchasing rather than direct state provision of all services. Under the NHI system, the NHI Fund acts as an active purchaser of healthcare services from appropriately accredited and contracted public and private providers, who remain operationally independent and continue to exercise clinical judgment within evidence-based parameters.
The shift that NHI introduces is not one of operational and clinical control, but rather one of financing and integrated risk pooling, aimed at ensuring that access to care is based on need rather than on one’s ability to pay. This approach is consistent with UHC systems in many countries, including those that successfully combine public funding with private provision.
The article’s treatment of workforce concerns, particularly the suggestion that large numbers of doctors will emigrate as a direct consequence of NHI, is similarly not evidence-based. Such claims are typically based on sentiment surveys rather than observed behavioural trends and fail to account for the complex set of factors that drive health worker migration.
These include, in South Africa, working overseas to repay medical education costs, as well as working conditions, safety, career opportunities, and remuneration structures, many of which are already problematic within the current health system. Indeed, the existing inequities between the public and private sectors contribute significantly to dissatisfaction among healthcare professionals.
Properly implemented, NHI has the potential to improve resource distribution, reduce pressure on the public sector, and create more predictable and equitable contracting arrangements for providers across the system.
To attribute potential emigration primarily to NHI is, therefore, to overlook the deeper systemic issues that the reform seeks to address. It is also important to note that the continued assertion that NHI will trigger a mass exodus of healthcare professionals is highly questionable.
Many of the countries these professionals are said to be considering emigrating to already operate under universal health coverage systems, suggesting that such claims are largely unfounded and amount to fear-mongering.
Cost is another area where the article advances arguments that appear overstated and insufficiently grounded in realistic policy modelling. Figures cited in the article, ranging from hundreds of billions to more than a trillion rands annually, are speculative and not derived from official or phased costing frameworks.
Importantly, the article itself acknowledges that no definitive costing has yet been finalised. This undermines the credibility of its conclusion that NHI is unaffordable.
A more accurate framing would recognise that South Africa already spends substantial resources on healthcare across both the public and private sectors, about 8.5% of GDP, far higher than some of the countries that implement NHI.
The central challenge is not the absolute level of expenditure, but rather the misallocation of resources, fragmentation, duplication, and inefficiency inherent in maintaining parallel systems. NHI is designed to address these inefficiencies through pooled funding and more strategic purchasing, which international experience suggests can lead to better health outcomes at comparable or even lower cost over time.
The argument that the government should focus on improving public hospitals rather than pursuing NHI reflects a fundamental misunderstanding of the relationship among financing, service delivery, and desired population health outcomes.
Strengthening public healthcare infrastructure is undoubtedly necessary, but it cannot be achieved sustainably without reforming the way in which the health system is funded and organised.
NHI is not an alternative to improving public services: it is the mechanism by which such improvements can be financed, co-ordinated, and sustained more effectively. Without addressing the underlying fragmentation in our health system, efforts to improve public hospitals are likely to remain constrained by limited resources and systemic inequities.
The article also misrepresents the role of the private sector under NHI, suggesting that the policy is inherently hostile to private healthcare providers. In reality, the NHI framework, as outlined in the White Paper and the NHI Act, explicitly incorporates private providers as essential partners in service delivery.
The intention is not to eliminate private healthcare, but to integrate it into a unified system where services are accessible to all citizens, rather than restricted to those who can afford private insurance.
This represents a shift towards a more equitable distribution of healthcare resources, addressing the current imbalance in which a relatively small proportion of the population consumes a disproportionate share of total health expenditure. This is not a legacy that a country with a history such as ours should be proud to continue.
Perhaps most concerning is the article’s dismissal of the equity rationale underpinning NHI, which it characterises as mere political rhetoric.
This seems to reveal the author’s reticence about having an equitable health system. This is because the perspective offered fails to acknowledge that equitable access to healthcare is not simply a policy preference, but a constitutional obligation in South Africa. The persistent disparities in access to quality care, driven largely by income and insurance status, represent a structural injustice that the current system has been unable to resolve.
NHI seeks to address these disparities by ensuring that all individuals, regardless of socioeconomic status, have access to a comprehensive package of healthcare services.
While the article raises legitimate concerns regarding governance and the risk of corruption, it draws an unwarranted conclusion that these challenges render NHI unviable. Governance weaknesses are indeed a serious issue, but they are not unique to NHI: they affect multiple sectors and existing health system arrangements, including the private sector that the author seems to vaunt.
Does the author also believe that, because some of the police departments have been found to be corrupt, South Africa should not have police departments? In fact, a more fragmented system with multiple funding streams and limited co-ordination is more difficult and administratively costly to regulate effectively.
A well-designed and integrated system, as planned under the NHI framework, with strong institutional safeguards, transparent procurement processes, and robust data systems, has the potential to enhance accountability, manage costs more effectively, and strengthen oversight, rather than diminish it.
A final reflection is that the article presents NHI as an ideologically driven project, yet this critique overlooks the reality that all health systems are shaped by contextual issues, underlying values and policy choices.
The private health system is characterised by a market-oriented model in which access to quality care is largely determined by one’s ability to pay.
This dynamic diverts critical resources from the public sector, thereby undermining the health and well-being of those most in need, for the benefit of a relatively small segment of the population. It is neither equitable nor sustainable to maintain a system in which the most vulnerable are effectively excluded from care, while those with financial means exert disproportionate influence over the allocation of health resources.
NHI, by contrast, is grounded in principles of solidarity, risk pooling, and universal access to needed care.
Therefore, the policy debate should not be framed as one between ideology and pragmatism, but rather as a question of which values should guide the organisation of the health system.
In conclusion, while the article highlights certain risks and challenges associated with NHI, it does so in a manner that is selective and intentionally disproportionately negative, failing to engage with the broader context and necessity of reform.
Alarmist rhetoric is neither constructive nor solution-oriented, because the status quo is both inequitable and inefficient, and maintaining it is not a viable option. NHI should be understood as a complex, long-term reform process aimed at addressing these structural issues.
The appropriate response is not to abandon the policy, but to focus on its careful, phased implementation, supported by strong governance, stakeholder engagement, and ongoing evaluation.
Dr Olive Shisana, Honorary Professor, UCT, writing in her personal capacity.
Dr Adiel Chikobvu, Director of Strategic Operations, Department of Health (GP).
Moremi Nkosi, Chief Director of Healthcare Benefits (NHI), Department of Health.