NHI bill offers scant detail on how it will achieve its vision without overtaxing our systems

Imagine a South Africa where the wealth of one’s wallet does not dictate the quality of health care they receive – a nation where every citizen is guaranteed not just care, but care that upholds dignity and promotes health

Professor Terrence Kommal

Published Feb 9, 2024


Imagine a South Africa where the wealth of one’s wallet does not dictate the quality of health care they receive – a nation where every citizen is guaranteed not just care, but care that upholds dignity and promotes health.

This is the promise of the National Health Insurance (NHI) Bill. Yet, as a medical doctor and professor, I see the bill through the lens of reality, where good intentions must be met with robust planning and transparent governance.

The alluring vision of universal access

At its heart, the NHI bill seeks to provide equitable health-care access to all South Africans. It’s a commendable goal that mirrors the stories of my patients who face a daily struggle for care.

However, the bill offers scant detail on how it will achieve this vision without overtaxing our systems.

In envisioning universal access, the NHI holds the potential to reshape narratives of health-care disparities. However, a critical analysis reveals that the bill lacks the granular details needed to navigate the intricacies of our health-care infrastructure. The allure of universal access, while compelling, requires a roadmap for practical implementation.

The solidarity question: More than just a concept

Social solidarity should be more than just a feel-good term in policy documents; it should manifest in clear strategies that outline how the wealthy will support the health needs of the less fortunate. Yet, the bill leaves us guessing how the financial streams will flow.

Delving into the concept of social solidarity, the NHI’s intent to bridge economic gaps in health care is admirable. However, the lack of a concrete plan to channel financial support from the affluent to the less privileged raises concerns. The question of solidarity demands answers: How will financial contributions be structured, and how can we ensure a fair distribution that serves the health needs of all citizens?

The elusive path to universal coverage

The NHI aims to be a careful buyer of health services for the population, but without a clear plan, it risks becoming a clumsy giant, tripping over red tape. For example, Mr Dlamini, a retiree I know, worries about whether he will still see his trusted heart specialist or be lost in a maze of referrals under the NHI.

Navigating the path to universal coverage requires meticulous planning, especially in a landscape burdened by bureaucratic complexities. Consider the case of Mr Dlamini who has specific health needs. Will the NHI streamline his access to specialised care, or will he become entangled in a convoluted web of referrals and bureaucracy? The lack of clarity poses a tangible threat to the seamless health-care experience envisioned by the NHI.

The cost conundrum: Reducing out-of-pocket expenses

Reducing direct payments for patients is essential. However, without a transparent funding plan, the goal seems as distant as the horizon on a misty morning in the Drakensberg Mountains.

Addressing the cost conundrum is paramount for the NHI’s success. While the goal of minimising out-of-pocket expenses is commendable, the bill falters in outlining a concrete funding mechanism.

The misty uncertainty surrounding financial sustainability begs the question: How will the NHI bridge the gap between aspirations and fiscal realities?

Specific objectives: A cry for clarity

The NHI bill lists ambitious objectives – protecting against financial risk and providing equitable and efficient care. But how? The bill needs to paint the picture in more than broad strokes. The ambition inherent in the NHI’s objectives resonates with the need for transformative change in health care.

However, the devil lies in the details, and the bill falls short in providing a clear blueprint for translating objectives into tangible outcomes. The cry for clarity echoes: How exactly will the NHI navigate the complexities of financial risk protection and ensure the delivery of efficient and equitable care?

Primary health care: The cornerstone

A sturdy primary health-care system is crucial. Yet, we need to know how this will be achieved when many community clinics are struggling under the weight of demand.

Elevating primary health care to the cornerstone of the NHI underscores a commitment to preventive and community-centred care. However, the strain on community clinics raises a pertinent question: How will the NHI fortify the foundational pillars amid the challenges? A robust strategy is indispensable to prevent the risk of collapse under increased demand.

Affordability and sustainability: An economic balancing act

Discussing affordability and sustainability is one thing; demonstrating it is another. The bill needs to go beyond mere words and offer a clear economic blueprint.

The discourse on affordability and sustainability forms the linchpin of the NHI’s viability. Yet, the bill’s narrative lacks the substantive backing of a concrete economic blueprint. How will the NHI strike a delicate balance, ensuring accessibility without compromising long-term economic sustainability? South Africans await more than rhetoric – they await a tangible plan that secures the economic foundation of a transformative health-care system.

A phased approach: The need for a clear roadmap

Phased implementation is sensible, but it demands a detailed roadmap. Health-care workers want assurance that each step is planned and practical.

The notion of a phased approach acknowledges the complexity of health-care transformation. However, a roadmap is indispensable to illuminate the path forward. Health-care workers, integral to the implementation, seek more than theoretical phases; they yearn for a practical, step-by-step guide, ensuring that each phase is not merely a conceptual construct but a tangible and pragmatic progression.

Financial implications: The price of reform

The state’s financial role in implementing NHI is critical. Yet, without clear costs for quality improvement and fund administration, we risk flying blind into a storm.

The financial implications of NHI implementation constitute a critical pivot point. The absence of transparent costings for quality improvement and fund administration leaves a void in understanding the depth of financial commitment. South Africans need a comprehensive financial roadmap to navigate the potential storms of reform, ensuring that the lofty goals of the NHI are not undermined by fiscal uncertainties.

Power dynamics: A double-edged sword

Centralising power with the minister raises alarms, especially given experiences of mismanagement within our public health-care system. How will the NHI escape the historical shadow?

The concentration of power in the hands of the minister introduces a nuanced concern rooted in historical mismanagement. Addressing this apprehension requires more than assurances; it demands a robust governance framework that safeguards against the shadows of the past. How will the NHI dismantle the spectres of mismanagement and cultivate a transparent, accountable, and efficient system that serves the best interests of the public?

Private sector pitfalls: A cautionary tale

Even our private health-care sector is flawed. It’s no secret that some specialists charge exorbitant fees, with allegations of kickbacks from medical device suppliers tarnishing the industry’s reputation.

Practices like these and undeclared “file opening fees”; highlight the need for rigorous regulation and ethical oversight within any new system.

While critiquing the private sector’s pitfalls, the NHI must not merely position itself in opposition but articulate a collaborative engagement. The cautionary tale of exorbitant fees and questionable practices should propel the NHI to establish stringent regulations and ethical oversight. Crafting a system that addresses the flaws and fosters a partnership with the private sector is imperative for a comprehensive and effective health-care overhaul.

The implementation puzzle: Seeking specifics

We crave specifics on how the NHI will roll out its plan. Without this, it’s like handing patients a prescription without instructions – confusing and potentially dangerous. Embarking on the implementation journey without specifics is akin to a patient receiving a prescription without instructions. The NHI must recognise the urgency of clarity in execution.

How will the plan be operationalised, and what are the specific milestones that South Africans can anticipate? Offering specifics is not just a procedural formality but a prescription for a clear, comprehensible and safe health-care transformation.

Funding mechanisms: Show us the money

Where will funding for the NHI come from? South Africans deserve to know how the financial leap will be made without leaving them in economic free fall.

The question of funding mechanisms stands as a pivotal enquiry in the minds of every South African.

The NHI’s transformative promise is only as robust as its financial foundation. South Africans rightfully demand transparency in understanding how the financial leap will occur without casting them into economic uncertainty. Revealing the funding mechanisms is not just a matter of fiscal transparency but a commitment to ensuring that the pursuit of health-care equity does not inadvertently jeopardise the economic stability of the nation.

Integrating systems: A delicate dance

How will NHI dance with public and private providers without stepping on toes? Patients fear being caught in the crossfire of the complex tango. The integration of systems is a delicate dance that demands finesse. Patients, caught in the crossfire of conflicting interests, fear disruptions to their health-care continuity. The NHI must provide more than a vision – it must orchestrate a harmonious collaboration between public and private providers.

How will the delicate dance unfold, ensuring that the interests of patients remain at the forefront and the complexities of integration do not compromise the quality of care?

Encouraging provider participation: A fair exchange

Doctors and nurses need to know how they fit into the NHI landscape. They need incentives that respect their expertise and encourage their participation. Provider participation is the linchpin of the NHI’s success. Engaging doctors and nurses requires more than a token acknowledgement; it demands a fair exchange that respects their expertise. What incentives will be in place to ensure active and enthusiastic participation?

The NHI’s success hinges not only on structural reforms but on fostering a collaborative environment where health-care providers feel valued and integral to the transformative journey.

Quality control: Non-negotiable standards

Quality care is non-negotiable. We need a system that ensures high standards across the board, from Limpopo to Cape Town.

In the pursuit of transformative change, maintaining non-negotiable standards of quality care is paramount.

The NHI must transcend geographic disparities, ensuring that from Limpopo to Cape Town, every citizen receives care that adheres to the highest standards. How will the NHI institute and uphold the standards, bridging the gaps that have historically left certain regions underserved?

Accessibility for all: Beyond words

The NHI must do more than talk about equity; it must walk the talk. It must not just open doors but also pave paths so that every citizen can walk through them without barriers. Beyond rhetoric, the NHI’s commitment to accessibility must manifest in tangible actions. Opening doors is only the initial step; the NHI must pave paths that eliminate barriers preventing citizens from walking through. How will the NHI address the multifaceted challenges of accessibility, ensuring that it is not merely an aspirational slogan but a lived reality for every South African?

Public awareness: Knowledge is power

An informed public is an empowered public. The NHI must commit to educating South Africans about their rights and responsibilities under the new health-care regime.

Knowledge is the cornerstone of empowerment. The NHI’s success hinges on more than structural reforms; it requires an informed public. How will the NHI embark on a comprehensive public awareness campaign, ensuring that every South African understands their rights and responsibilities in this new health-care paradigm? A commitment to knowledge is not just a nicety but a powerful tool in fostering a sense of collective responsibility and ownership.

Governance with integrity: Building trust

To gain public trust, the governance structure of the NHI must be watertight against corruption. We need transparency and accountability at every turn. Trust is the bedrock of the NHI’s success. Building and maintaining trust necessitate a governance structure that is impervious to corruption. How will the NHI establish a watertight system that upholds transparency and accountability at every turn? The journey toward equitable health care demands not just good intentions but an unwavering commitment to integrity in governance.

Legal and ethical safeguards: The backbone of trust

The bill must consider the legal and ethical implications of managing sensitive health data. Patients must trust that their most private information is safe. As the custodian of sensitive health data, the NHI bears the responsibility of ensuring legal and ethical safeguards.

Patient trust hinges on more than promises; it requires robust measures to safeguard the privacy and integrity of health information. How will the NHI fortify the backbone of trust, assuring South Africans that their most private information is not just secure but ethically managed?


The NHI bill stands at a crossroads, with the health of millions in the balance. Our journey towards a more equitable health-care system is fraught with complexities.

To realise the dream, the bill must evolve from a skeleton of good intentions to a fleshed-out plan, capable of withstanding the realities of implementation. It must not shy away from the hard questions nor waver in the face of necessary scrutiny. For it is only through meticulous planning, transparent governance, and an unwavering commitment to quality and equity that we can truly transform our health-care system for all South Africans.

Professor Terrence Kommal is a medical doctor, CEO of the Medical Expert Consulting Group, and Extraordinary Professor of Practice at North West University, Shaping Innovations in Healthcare. Connect with Prof Kommal on LinkedIn (linkedin.com/in/terrencekommal) to explore his expertise and impactful contributions to the medical field.