Transparent and honest debate is essential and should be encouraged. However, advancing a narrative that ostensibly seeks to address challenges affecting the broader population, while in reality promoting a particular agenda aimed at preserving a status quo that marginalises the majority for the benefit of a few, is fundamentally disingenuous.
The opinion piece published in Daily Maverick titled “Is the National Health Insurance just a distraction from urgent healthcare issues?” exemplifies this concern. While it presents itself as pragmatic, its underlying logic and policy implications are deeply flawed. At its core, the article constructs a false and misleading dichotomy between addressing immediate health system challenges and pursuing necessary structural reform through the National Health Insurance (NHI). This framing is analytically weak and ultimately counterproductive, as it ignores the reality that meaningful, long-term improvements in equity, efficiency and sustainability within South Africa’s healthcare system require both immediate interventions and systemic transformation.
The central premise of the article is that the NHI distracts from urgent service delivery failures. This premise rests on what is clearly a misunderstanding of how health systems function. South Africa’s “urgent healthcare issues” are not merely a product of operational inefficiencies or isolated governance failures. The mix of issues is rooted in the structural design of a deeply unequal system. As the article itself acknowledges, access to healthcare remains uneven and quality inconsistent. However, it fails to recognise that these are not problems that can be resolved independently of health financing reforms. The fragmentation between a well-resourced private sector and an overburdened public sector is not merely incidental, it is systemic and structural. To ignore the rationale that the NHI is explicitly designed to address this fragmentation through pooled funding and strategic purchasing, and instead conveniently opt to suggest that one can fix service delivery without addressing the underlying financing architecture, is to treat symptoms while actively ignoring the disease.
Moreover, the article’s key fault line is that it explicitly prioritises short-term administrative and sectoral fixes over long-term systemic transformation, as though the two are mutually exclusive. This is a false and inherently dangerous trade-off. In reality, meaningful improvements in infrastructure, workforce distribution and quality of care require a financing mechanism that aligns incentives and performance outcomes across the system. Without the NHI, South Africa will continue to operate two parallel systems that duplicate costs, entrench inequality, enforce fragmentation and undermine efficiency. Far from being a distraction, NHI is the policy instrument through which many of the “urgent issues” identified in the article can be adequately and sustainably addressed.
A deeper reading reveals a more concerning bias, which is the implicit defence of the current medical schemes environment, which primarily serves a minority of the population while consuming a disproportionate share of total health expenditure. The critique of the NHI that permeates the opinion piece is framed in a manner that suggests the preservation and expansion of medical schemes as a preferable and safe alternative. Yet this position is fundamentally misaligned with the health needs of the majority of South Africans. The current system allows those with the ability to pay to disproportionately access key health professionals and resources, while the rest must be exposed to long waiting lists and unattended health needs merely because private care is unaffordable for them. This is not merely inefficient, it is inequitable, an affront to the spirit of Ubuntu and, of course, constitutionally untenable.
By focusing on the risks that the NHI may pose to private sector actors, the author appears to conflate the sustainability of medical schemes with the sustainability of the entire health system. These are not the same. A health system should be designed to maximise population health outcomes, not to guarantee the growth or profitability of private financing mechanisms. The suggestion that expanding or protecting medical schemes, for instance through allowing low-cost benefit options or fragmented collective tariff negotiations, is a viable solution ignores the structural exclusion embedded in such an approach. Medical schemes, by design, pool risk within a limited and relatively affluent segment of the population. They cannot, and were never intended to, achieve universal health coverage (UHC), even within a prescribed minimum benefits framework. Therefore, to elevate their interests above broader systemic reform is to prioritise sectional benefit over national need.
It is surprising how underplayed is the extent to which the current system itself is a source of inefficiency and cost escalation. Private healthcare costs in South Africa are among the highest relative to income levels, driven in part by a lack of effective purchasing and regulatory fragmentation. More so, many of the interventions that the state has tried to implement to assist with effective costs control and to bring greater predictability to the system have been stalled through litigious behaviour. Without a single, strategically empowered purchaser such as the NHI Fund, the system lacks the leverage to control prices, standardise quality, emphasise performance and allocate resources rationally. In this context, defending the status quo is not a neutral position, but is an endorsement of a model that has already failed to deliver equitable outcomes.
Importantly, framing risks in a manner that perpetuates a narrative that reform is inherently destabilising and must thus be branded “a distraction from urgent healthcare issues”, while insinuating that the current system is implicitly stable and functional, is demonstrably incorrect. The public health sector faces chronic underfunding, workforce shortages and infrastructure backlogs, while the private sector remains inaccessible to the majority. These are not temporary challenges; they are structural reflections of a system that it is inappropriately configured and must be reformed in earnest. It is important to also note that the NHI does not create these problems, it seeks to resolve them through a more integrated and equitable approach.
What is even more concerning is that there appears to be no meaningful engagement with the constitutional and ethical imperatives underpinning the NHI. Access to healthcare is a right in South Africa, and the state is obligated to take reasonable measures to progressively realise this right within available means. A system that entrenches disparities based on income cannot be reconciled with this obligation. The NHI represents a deliberate policy choice to move towards a more just and inclusive system, grounded in principles of solidarity and risk sharing. To dismiss this as a distraction is to conveniently sidestep the fundamental question of how South Africa intends to meet its constitutional commitments.
A final reflection is that the critique presented is not only incomplete but equally counterproductive. To frame the NHI as a diversion from urgent issues is to obscure the reality that those very issues are symptoms of a deeper structural problem that the NHI is designed to holistically address. Furthermore, its implicit alignment with the interests of the medical schemes sector raises questions about whose interests are being prioritised in the analysis. The argument is disingenuous in that it selectively promotes measures that would sustain the medical schemes industry in its current form, while overlooking compelling evidence that meaningful reform must be systemic rather than piecemeal.
Achieving UHC can never be realised through piecemeal reforms that tinker at the margins of a fundamentally unequal system. Incremental fixes may address isolated inefficiencies, but what they also do is leave intact the structural fragmentation, inequitable financing and misaligned incentives that define the status quo. The current dichotomy between a well-resourced private sector serving a few and an underresourced public sector serving the majority is both inequitable and fundamentally indefensible in a constitutional democracy committed to the progressive realisation of the right to health. UHC, by its very nature, requires a coherent, system-wide approach that pools risk, integrates resources and aligns public and private actors towards a common goal. Without comprehensive reform, efforts remain disjointed, costs continue to escalate and inequities deepen. In this context, piecemeal change is not only insufficient, it risks entrenching the very problems it seeks to solve.
While undeniably complex, the NHI remains the most coherent policy pathway towards achieving a health system that is equitable, efficient and sustainable; one that advances the health rights of all South Africans, not just those of a privileged minority. DM