Maverick Citizen


Let’s be pragmatic — the NHI has constructive and contentious aspects

Let’s be pragmatic — the NHI has constructive and contentious aspects
Professor Susan Cleary delivers her inaugural lecture as part of a lecture series by the University of Cape Town. (Photo: Supplied / Spotlight)

Professor Susan Cleary argues that the NHI is a wide-ranging reform with both positive and controversial aspects. The key will be to find a middle ground in order to continue the journey to universal health coverage.

President Cyril Ramaphosa signing the National Health Insurance (NHI) Act on the eve of the elections is a smart move from the perspective of a political party seeking to shore up its base. The concern, though, to those of us working to strengthen the health system is whether the NHI will enable the country to move closer towards universal health coverage.

For the NHI naysayers, perhaps it would be important to alleviate some fears and concerns. The NHI is a long-term project. In the 2024 budget, Treasury reduced the conditional grant allocations to the NHI in comparison with what was allocated in the 2023 budget. While signing the NHI Bill into law is a step forward, the reduction in resources towards NHI implementation reminds us that this is a long-term project. In addition, it is likely that there will be legal challenges which will lead to considerable delays for the scheme to be fully implemented.

The NHI is a wide-ranging reform, with many positive aspects sitting alongside some key controversial aspects. Positive aspects include the opportunity to enable greater use of evidence and transparency in priority-setting through the further institutionalisation of health technology assessment processes (akin to “NICE” in the UK), as well as the opportunity to use national-level purchasing power to drive down the prices of commodities such as medicines. The role of private multidisciplinary practices (GPs, nurses, health and rehabilitation professionals, etc) in the future NHI also holds some promise to improve access to healthcare, particularly to parts of the country with limited access to public clinics.

On the other hand, there are two key controversial aspects. The first is related to what may or may not happen to medical schemes and medical scheme administrators once the NHI is fully implemented. My sense is that there is no short-term concern in this regard. A bigger concern is whether a single pot of money in the NHI fund will present a larger or a smaller corruption risk than the current situation of many pots spread across provincial treasuries and medical aid schemes.

Another concern is that the NHI reform might disrupt our ongoing progress towards universal health coverage within our existing public sector. Our public sector is not perfect, but it is a system that has equity at its heart. The common definition of universal health coverage is to provide all individuals and communities with access to needed promotive, preventive, resuscitative, curative, rehabilitative and palliative health services of sufficient quality to be effective, while ensuring that the use of these services does not expose users to financial hardship.

The two main goals of universal health coverage are: (1) The provision of quality healthcare services to those in need and (2) The avoidance of financial catastrophe in this process. Clearly healthcare is far from free – indeed it is very expensive – and so the goal of avoiding financial catastrophe is about implementing prepayment and risk-pooling mechanisms, whether these are tax or insurance based.

Let’s first look at how we are doing on the provision of quality services. The figure below plots countries according to their achievements on the Universal Health Coverage Service Coverage Index. In this context, coverage of essential health services is measured based on indicators that include reproductive, maternal, newborn and child health, infectious diseases, noncommunicable diseases and service capacity and access, among the general and the most disadvantaged populations.

On this index, South Africa’s achievement is at just over 70%, similar to many other middle-income countries. While there would be room for improvement, our performance is in line with our global peers.


Global comparison of countries in terms of service coverage and quality. (Source: World Health Organization – Global Health Observatory, 2024) processed by Our World in Data. Accessed May 2024.

The second indicator is financial risk protection. The figure below plots countries against the percent of total health expenditure that is paid out of pocket at the point of use. On this indicator, we score 5.7%, indicating extremely high levels of financial risk protection.


Global comparison of countries in terms of the percent of total health expenditure that is paid out of pocket. (Source: World Health Organization, via World Bank, processed by Our World in Data. Accessed May 2024)

This does not mean there are no instances of financial catastrophe. Undoubtedly there would be, particularly for those seeking treatment for certain types of cancers. That said, over the past two decades I have studied this issue extensively. Across a wide range of conditions in diverse settings, we have interviewed tens of thousands of people to understand the costs they face in using health services – everything from transport to food, shelter or accommodation, childcare, lost income, under-the-counter payments to public sector providers (which we never found), fees paid to private providers or money spent at pharmacies. This research consistently showed that the level of catastrophic spending was very low. Our performance on financial risk protection is outstanding. I celebrate the work of those colleagues who shepherded in the removal of user fees in our national health system during the dawning of our democracy. We should all be thanking them.

Read more in Daily Maverick: NHI fund will take decades to roll out — we answer your burning questions

Read more in Daily Maverick: Everything you ever wanted to know about the NHI but were afraid to ask

Despite these successes on universal health coverage, there are areas of concern for the South African health system. We do not achieve health outcomes commensurate with our level of investment. My sense is that this is driven by our relatively high burden of disease; for example, we continue to have the world’s largest HIV treatment programme. While our average life expectancy steadily increased with the introduction of antiretroviral therapy (although note the downturn from 2020 which coincides with the Covid-19 pandemic – see the figure below), the HIV epidemic has been a cruel setback that needs to be considered when we seek to make global comparisons on life expectancy and avertable mortality.


Global comparisons of life expectancy: 1970-2020. (Source: United Nations World Population Prospects, 2022, processed by Our World in Data. Accessed May 2024)

Now that the NHI Bill has become the NHI Act, it is time to move on from debates about whether we need NHI or not, and rather focus on how we can make the NHI work for us.

Our public sector will be the backbone of our future NHI and so we should seek to continue to strengthen this system. It would also be wise to put in place measures to strengthen our private system given that private providers are intended to play a key role in the NHI. We should be pragmatic.

The NHI includes many exciting opportunities for leveraging big data and artificial intelligence in health systems strengthening, but at this stage we hardly have any electronic health data. A clear step forward would be the further implementation of the National Digital Health Strategy (2019-2024) which includes the establishment of a patient electronic health record, among other needed developments.

In addition, the NHI places emphasis on the achievement of a purchaser-provider split via establishing “Contracting Units for Primary Health Care” (CUPS). These new entities will contract with both public and private providers within a defined geographic area, on behalf of a particular population. The establishment of CUP “proof of concept” sites is therefore a priority, but must be done in a way that generates learning and enables adaptation to different contexts.

Let’s continue to push forward on many of these complex undertakings. It is going to take time, but it is needed, irrespective of the name that we choose to give to our health system. DM

Cleary is professor of health economics and the head of the School of Public Health at the University of Cape Town.

This article was published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.


Comments - Please in order to comment.

  • Fanie Rajesh Ngabiso says:

    Many I believe are not opposed to the broad intention.

    However the ANC’s track record of breaking and stealing from everything they touch makes the odds of “the implementation” failing very very high indeed.

    And failure of either the intention or the implementation will be catastrophic for all South Africans.

  • drew barrimore says:

    I think the Professor/author of this writing imagines we are in Switzerland. Here we deal with people appointed in management and procurement that have no skills in that regard other than political fealty. Here we deal with people bent upon milking tax-funded entities and systems for their own benefit. Now this author wants all that money in one centralised pot. I don’t understand what she has not noticed or seen over the past 30 years. Her argument that our attitude should be “let’s just move on, NHI is here and we must work with it” is naïve. The idea that NHI is good is not bad in itself, but it is just an idea. If there is no-one prepared to look at who we are dealing with in the public sector, no-one prepared to look at the history of repeating corruption, no-one who will even mention how hospitals have been fleeced, how the nursing training system has been degraded, how dysfunctional the medical councils or whatever thousand regulatory bodies there are, which serve as sheltered employment entities rather than the real thing. I have not heard a single strident voice saying: “Let’s fix the public health system, and this is how we can do it”. We’re in a short-attention-span Twitter world, we’re in a silver bullet forest where we want that one magic thing to fix everything. But that is the realm of myth and hope, and can never translate a good idea into a brilliant working system.

  • Shaun Pastor says:

    Go see how many doctors and nurses have left this year.

  • Trenton Carr says:

    Glaring data point missing in this analysis.


  • Carolyn Fryer says:

    Let’s be “pragmatic”, has this professor ever worked in a public hospital and heard of the horror stories and neglect. Doctors working in impossible conditions with unqualified management. So let’s destroy the private hospitals too and cause a massive exodus of doctors. Rather fix the current system, unlikely with our current government. With the current state of affairs in universities around the world I honestly don’t have much faith in the opinion of woke professors that have never worked in the “real” world

  • Thinker and Doer says:

    This article makes interesting and informative points, but it does not deal at all with the rampant corruption and maladministration in the public sector, and which a centralized NHI Fund will be an incredible magnet for. It also does not touch at all on the affordability of the programme in its current proposed form, which will require 200bn or more to implement, and there is not even a proper funding model that has been developed. The incapability of the government to implement such a massive programme effectively is also not considered.

  • John Lewis says:

    Let’s be pragmatic and fight this damn thing in every way possible until South Africa has a government that is not too corrupt and incompetent to run it. Fix public healthcare as it stands first–then we can talk about this whole bondoogle.

  • Vincent Britz says:

    Funny that the author of this article doesn’t mention the ANC track record of handling state funds.

    Maybe the author has also been bought by the ANC government!

  • Groot Koos says:

    To say that we should not worry because it will take a long time to implement is not very reassuring. The author wants us to sit back now and make it our children’s problem in 10 or 15 year’s time.
    The NHI will never work in South Africa. Human beings are not born equal (some are stronger, more intelligent, taller etc.) and the notion that all should be equal is a fallacy. One cannot expect of the productive (read working) section of our population to waste hours and days waiting in line for medical assistance. Those who can pay are the most productive and they should be allowed to look after their own needs.

  • T'Plana Hath says:

    I have no problem with the concept of universal healthcare. I do however have a huge problem with handing over the equivalent of a space shuttle to a bunch of toddlers that I wouldn’t trust to push a go-kart, let alone a Rolls-Royce.
    Stop trying to frame this as ‘the haves’ freaking out about losing their privilege to the ‘have-nots’. You want less have-nots? Go after the have-lots! Stop dismissing opposition to the NHI as ‘nay-saying’. Most of all, stop confusing the subject (NHI) for the target (ANC) and actually _listen_ to what people are saying.

  • John P says:

    There are two insurmountable problems with the whole NHI concept
    1 – the tax base is too small to support this grandiose concept
    2 – the governments track record with SOEs does not instill any confidence in it working.

    • T'Plana Hath says:

      I’d offer a third and quote Colin Powel.
      “No plan survives contact with the enemy”.
      And we all know who the enemy is.

  • Cape Doctor says:

    I am afraid that this represents a “Polyanna-Pie in the Sky view from a Public health boffin who is most unlikely to have spent much – if any – time at the clinical or administrative coalface in our public health sector. To state that our public health sector “… not perfect” is the understatement of the decade. To talk up the current situation with reference to selective indicators is frankly, disingenuous. I strongly recommend she take a weekend sabbatical and spend it in the Emergency Unit at Chris Hani Baragwanath Hospital.

    • Mike SA says:

      The fact that we have the worlds largest HIV programme as she says. is as a result of funding by the USA, the same country that our President has been wiping his feet on, but that could change in 2025 in Trump comes in.

  • Mike SA says:

    @John P You are 100% correct and that is we need full employment and everybody paying tax. None of this up to R 95,750 of earnings are not taxed, everybody pays tax.
    Furthermore the Prof needs to understand that the opposite of positive is negative, not a “contentious aspect” so she fails ab initio in respect of her impartiality.

  • Dellarose Bassa says:

    The best way to solve a problem is to ensure it doesn’t happen in the first place. Let’s start with PREVENTIVE Health Care. This hopelessly inept regime with all its lapdog supporters singing for their supper should look to stem the avalanche of preventable lifestyle diseases. We have an obesity epidemic in this country. What are the health authorities doing about that? When I see a physically fit looking policeman/woman or Govt employee or- God help us all- politician, I have to look to the nearest chair to sit down lest I fall over from shock. Even army personnel are carrying barrel boeps. Look at the junk sold in school tuck shops, loaded with salt and fat and sugar. Do something about that. GEMS should emulate the excellent preventive health care model of Discovery Health. But nooooo. All that takes personal responsibility and accountability and work. Rather go the quick, easy, populist route: offer expensive, sophisticated medical solutions, paid for by the already shrinking tax-base, to lie to the ‘have-nots’ that the failed ANC kleptocracy is making them ‘equal’ to the ‘haves’ as if by magic. That’s the go-to modus operandi of the ANCK (ANC Kleptocracy): instead of starting with the causes of the problems and addressing that, they start at the tail-end after sitting on their rear-ends for 3 decades doing nothing about anything with the requisite degree of efficiency, intelligence, honesty and real commitment to ‘a better life for all’. Shameless.

  • Rod H MacLeod says:

    We already have an NHI in effect – we have state run medical facilities – hospitals, clinics, you name it – which are with few exceptions managerially defunct. Seriously, how is the assimilation of private medical care into this huge messy swamp going to resolve the maladministration and corruption? By a ministerial council of 11, all state nominees prone to cronyism and graft? Never. Why doesn’t the President simply take a vacuum pump to this morass, suck all the rotten gunk out of the swamp, and fill it with properly remunerated experts instead of drunken cadres?

  • Confused Citizen says:

    I am confused. From the first 2 graphs it seems that we don’t really have a problem. On the delivery side, we score 70% – on par with other middle income countries. On the financial risk side, no one is really going bankrupt getting healthcare.
    So, why then do we need NHI?

    I also don’t understand the insinuation that there is rampant maladministration and corruption in the private health sector on the scale of the public sector that somehow needs intervention (the NHI). Please name examples and money involved.

    We cannot sit back and ‘not worry’ about the implementation of the disastrous NHI. Then it just becomes our children’s problem.

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