The success of universal healthcare coverage in South Africa will require the responsibility to be shared between the public and private sectors, argues Dr Katlego Mothudi, managing director of the Board of Healthcare Funders, in response to an article in MedicalBrief last week, NHI, public tenderness and what we owe each other while we wait.
Mothudi writes:
Sipho Mthathi’s article NHI, public tenderness and what we owe each other while we wait is not comfortable reading. It should not be. The suffering she describes is real. The moral weight she places on it is appropriate. And the frustration she directs at both the private healthcare sector and the state carries genuine force.
The Board of Healthcare Funders (BHF) does not dispute the diagnosis. The public health system is under severe strain. Clinics are under-resourced. Healthcare workers are carrying burdens that exceed what any person should be asked to sustain. Families are navigating a system that too often fails them before illness becomes catastrophic.
While the state remains the primary provider of healthcare in South Africa, longstanding capacity constraints have led employers and households to seek supplementary forms of cover through medical schemes and private care. Over time, this has created a fragmented system in which access is uneven and collective pressure for systemic reform has weakened.
But it is a misconception that medical aid is for the wealthy elite. Private healthcare is diverse, comprising both for-profit and not-for-profit entities, reflecting the complexity of the system. The BHF represents not-for-profit medical schemes across the SADC region.
Schemes in South Africa serve nearly 10m beneficiaries, of whom 67% come from previously disadvantaged groups. These include teachers, nurses, civil servants, factory workers, people who have made a deliberate choice to fund a portion of their own healthcare, reducing pressure on the public system in the process.
The BHF fully supports the attainment of universal health coverage (UHC) and believes that together with government, the private healthcare sector can and should play a far greater role in achieving this goal.
Government already has policy tools available to expand access to private healthcare for millions more South Africans through reforms such as enabling schemes to offer low-cost benefit options, enabling collective tariff negotiations between schemes and willing healthcare providers to reduce pricing opacity, and modernising prescribed minimum benefits to reflect today’s disease burden.
Importantly, all of these reforms could be introduced immediately and do not depend on the outcome of ongoing litigation.
What they do require, however, is the political and regulatory commitment from government needed to implement meaningful reform.
We have been calling for exactly this kind of action while the larger NHI reform debate proceeds because we recognise that patients need access to quality, affordable healthcare right now.
Whilst we wait for government reforms, medical schemes can play a more active role in improving affordability and reducing out-of-pocket payments for their members. Medical schemes need to reposition themselves from financial risk management vehicles to organisations whose core business is the health of their beneficiaries.
This requires a shift away from overly complex benefit structures designed primarily around utilisation management and towards benefit designs that prioritise essential healthcare services, preventative care, chronic disease management and long-term health outcomes.
The focus should be on keeping populations healthy, intervening earlier, and reducing the need for more costly care later.
A more efficient, prevention-oriented and affordable private funding environment can reduce pressure on the public health system and contribute meaningfully to the broader national objective of universal health coverage.
These are not positions adopted in response to litigation pressure. They are the substance of the reform agenda the BHF has advanced in research, in regulatory submissions, and in advocacy.
Importantly these reforms are not opposed to the proposed NHI framework, even in its current form, but are intended to strengthen and enhance it. Concerns around profit extraction and market distortion will not disappear in an NHI environment; if anything, they will require stronger oversight. This is why mechanisms such as tariff regulation and a supply-side regulator, as recommended by the Health Market Inquiry, remain essential. The NHI Fund itself would benefit from such reforms.
UHC will require the public system to be strengthened significantly. It will require governance that can manage a fund of enormous scale without the failures the Auditor-General has documented persistently across the health sector.
But, it is about more than the amount of funding available to public healthcare, it is how existing resources are managed and deployed. Government has repeatedly argued that fiscal constraints limit its ability to increase health expenditure materially. Yet even within these constraints, there remain serious concerns about the management of available funds.
Gauteng examples illustrate this clearly. In 2024, funds allocated for oncology services went unspent, despite backlogs in cancer treatment. Civil society ultimately took the provincial government to court. More recently, a Public Protector Report highlighted funds earmarked for repairs at Charlotte Maxeke Johannesburg Academic Hospital were left unspent while critical healthcare infrastructure remained compromised from the fire.
These are governance and implementation failures that undermine public confidence and directly affect patient care.
One of the major flaws of the NHI Act is that the legislation does not set out how government plans to finance, administer and operationalise a system of this scale in a manner that is transparent, accountable and capable of sustaining public trust over time.
The public and private sectors are not opponents in the goal of UHC. They are both under strain, and both are needed. Weakening one before the other is ready to absorb the demand does not serve patients. It serves no one.
What we owe each other, while we wait for the Constitutional Court judgment, is honest engagement with the complexity of reform and a commitment to the practical improvements within reach right now, that can expand access to quality healthcare without waiting for the courts to decide.
If universal health coverage is to succeed, all stakeholders, public institutions, private funders, civil society and policymakers, will need to accept shared responsibility for building a system that is workable, accountable and sustainable.
Dr Katlego Mothudi – Managing Director, Board of Healthcare Funders (BHF).
See more from MedicalBrief archives:
Public ‘tenderness’ shrinks as private sector and state drag out NHI battle
NHI a means towards – not an alternative – improved public healthcare
Profit-driven healthcare threatens NHI