While the minister of finance made it clear there is no money for NHI, the minister of health goes about implementing NHI as if it is in operation.
While various aspects of Budget 2025 were identified and reviewed from all angles, one important aspect stood out because Finance Minister Enoch Godongwana did not mention it at all: NHI.
However, if you look closely at the medium-term expenditure framework released with the Budget 2025 documents, you will find references to the NHI.
Craig Comrie, CEO of Profmed, says the recent re-tabling of Budget 2025 made one thing abundantly clear: National Health Insurance (NHI) is still more of an aspiration than a reality.
“The absence of any direct mention of NHI in the speech is more telling than many South Africans realise.
“You have to search the accompanying medium-term expenditure framework to find references to NHI. It speaks volumes about the financial and practical roadblocks ahead.”
He points out that the private sector has long cautioned that any attempt at universal healthcare coverage must be rooted in feasibility, not just intent and empty political rhetoric.
“With no NHI in sight, now more than ever, we need a pragmatic approach to healthcare reform that builds on the healthcare assets we already have rather than chasing an unrealistic, unbound and unfunded ideal.”
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What the healthcare allocation budget shows about NHI
Comrie says the announced healthcare budget allocation prioritises maintaining the status quo rather than expanding into an NHI framework with a R52 billion increase in the healthcare budget allocation over the next three years aimed at stabilising the existing system, including retaining healthcare workers.
Budget 2025 also does not provide for the loss of USAid which is set to leave a R8 billion hole in critical services, he says.
“The increase in the healthcare allocation is a positive step to ensure continuity of care, but it does not set the foundation for NHI. If anything, the budget signals an acknowledgement of financial constraints rather than pushing ahead with unrealistic ambitions.
“The minister of finance made it clear. There is no money for new programmes, structures, or committees. The lack of an actual costing effort for NHI means the minister will not budget for any NHI services.
“According to the Department of Health’s initial estimation more than a decade ago, NHI requires at least R200 billion — a figure far beyond the depth of state coffers. Even if NHI is implemented in phases, without a carefully costed plan, it will remain a policy promise rather than a deliverable outcome.”
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The best way to improve healthcare is not NHI
Comrie says the best way to improve public healthcare is not through a massive, unfunded overhaul but through targeted reforms that enhance accountability, root out corruption, and improve service delivery, efficiency and accessibility.
He points out that South Africa is already making progress on this path, with Budget 2025 indicating the successes of Operation Vulindlela, in which the private sector participates in stabilising the energy and transport sectors.
“However, it is totally the opposite of the current health minister, who seems to ignore years of well-researched recommendations on how to partner with the private sector to bring about universal healthcare coverage. Why not replicate Vulindlela in healthcare? We could use some incremental but meaningful change right now.”
Comrie says another opportunity lies in making public sector facilities attractive to all South Africans, including medical scheme members. “In the past, many schemes willingly funded treatment in public hospitals when the quality of care was high. If incremental investments are made in public healthcare institutions where skilled staff are supported, well-managed and equipped, they could attract a significant portion of the R280 Billion medical scheme funding, creating a sustainable revenue flow that benefits all South Africans.
“Simply put, if we cannot reform the whole system, we can start by creating centres of excellence in the public sector to get the ball rolling.”
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Private healthcare is not opposed to universal healthcare, just NHI
In addition, Comrie points out that it is a massive misperception that private healthcare is universally opposed to universal healthcare. He says the private sector is ready to collaborate, but meaningful reform must go beyond the singular, politically motivated focus on NHI.
“Like every sector of our economy, healthcare must be built on financial sustainability, sectoral collaboration and governance structures that ensure quality outcomes for all.”
Comrie uses a home-building analogy to sum up NHI. “The NHI promise was designed like a grand mansion with ensuite rooms for everyone, but nobody figured out how to pay for it. It looks like a great house, and the architect (the minister of health) designed something aspirational, but the financier (the minister of finance and taxpayers) raises valid concerns about affordability and were not informed of what the budget is.
“It is like having a property owner trying to build a new house who gets a bond with a poor credit history (confirmed by the budget speech). It would never get off the ground if it were a construction project.”
As significant financiers within the current healthcare system, we cannot afford to waste time and money on structures that do not deliver services, Comire says.
“Instead, we should focus on reforms and partnerships which strengthen healthcare delivery … now.
“Healthcare reform is not about a single policy. It is about taking practical steps towards a system that works for all South Africans. It is time to drop the politicking and move forward with healthcare solutions that are realistic, funded and work. Let us move on expanding access to health in a more pragmatic approach which partners government and private sector.”
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Health minister goes about implementing NHI despite no legislation in operation and no budget
Despite no budget for NHI and the fact that the NHI Act that President Cyril Ramaphosa signed last year in May is not in operation yet, Health Minister Dr Aaron Motsoaledi published NHI regulations just over a week ago.
The South African Medical Association (Sama) says it notes the recently published NHI governance regulations and remains deeply concerned about several key aspects. “While we acknowledge the need for a well-structured governance framework, these regulations fail to address critical issues of transparency, accountability and operational independence.
“The concentration of decision-making power in the hands of the minister of health raises serious concerns about potential political interference, which could compromise the efficiency and fairness of the NHI system.”
No clear mechanism for stakeholder engagement on NHI
In addition, Sama says, the absence of clear mechanisms to ensure stakeholder engagement, particularly the involvement of medical professionals and independent oversight bodies, undermines the credibility of the governance structure.
“Sama reiterates that for the NHI to be effective and sustainable, its governance must be built on principles of good corporate management, free from undue political influence and guided by evidence-based healthcare policies that prioritise patient outcomes.
“We urge government to engage meaningfully with healthcare professionals and stakeholders to ensure that the governance of the NHI aligns with international best practices and serves the interests of all South Africans.”
