When South Africans talk about healthcare, the answer is always the same: people want care that is reliable, timely and of good quality. That is the promise many hope the National Health Insurance (NHI) Act will deliver.
But for the millions of working South Africans who pay tax, contribute to medical schemes, and depend on employer-supported healthcare, the act in its current form could take away more than it gives.
A persistent myth is that medical schemes are a luxury for the wealthy. The reality is, however, very different. Most scheme members are not rich – they are ordinary workers: teachers, nurses, mineworkers, clerks, and factory staff, whose employers subsidise their membership.
After paying income tax, VAT, fuel levies, and rates, these workers choose to allocate a portion of their net income to medical schemes because they want predictable, reliable care. For many, it is not about luxury, but necessity. It’s a decision made to avoid long queues, unpredictable service, and the uncertainty that comes with relying solely on a strained public system.
This choice is not a privilege; it is protected by the constitution. Yet under the current NHI framework, this freedom is at risk. The act restricts medical schemes from covering services included in the NHI basket. That means workers will have no choice but to rely on an already overstretched public system for basic services. Even if they are willing to pre-pay for their healthcare through their medical scheme, they will be left with no choice but pay from their own pocket for quicker or better care.
It removes agency from people who have taken financial responsibility for their healthcare and forces them into a single system – one that is not yet ready to meet the needs of millions more users.
Public healthcare is not free for working people. A day spent queuing at a clinic is a day’s wages lost for shift workers. For the self-employed, it is income gone. Employers also pay the price in the form of absenteeism, reduced productivity, and higher sick leave costs.
If millions more people are forced into the same system without an increase in clinics, staff, or operating hours, these delays will grow. Experience from other countries shows that waiting months for specialist appointments becomes the norm under such arrangements. But illness does not wait, and neither can workers who keep the economy running.
People who rely on daily wages or limited leave days are particularly hard hit. Taking time off work to sit in a queue for hours just to collect chronic medication or get a referral is not just inconvenient, it can be financially devastating.
SA’s competitiveness depends on healthy, productive employees. The NHI Act, as signed, provides no costed plan for how the public system will absorb additional demand. There's no budget for extending clinic hours, no framework for ensuring consistent medicine availability, and no staffing plan to meet the inevitable surge in patients. In addition, certain health services currently covered by the Compensation Fund, which all employers contribute to, will be shifted to the NHI Fund.
This is not just a healthcare issue; it’s an economic one. Employers who currently benefit from the stability provided by restricted medical schemes in industries such as mining, transport, and education will lose a vital support system that ensures employees stay healthy and productive.
Without a reliable healthcare alternative, companies may find themselves dealing with increased downtime, more workplace illnesses, and rising indirect costs, all of which threaten operational efficiency.
Universal health coverage is an essential national goal. But achieving it should not mean dismantling what works.
The medical scheme industry has been ready to implement low cost benefit options for nearly a decade, but regulatory inaction has stalled progress. The Board of Healthcare Funders has taken this to court because we believe affordable care should be expanded, not restricted.
There is no need to throw the entire system into disarray to reach universal health coverage. A layered approach, one that preserves functioning models while extending coverage to more people, is not only possible, but practical.
SA’s workers are the backbone of our economy. They keep the lights on, the classrooms open, the mines running, and the hospitals staffed. They deserve more than promises. They deserve healthcare that respects their choices, protects their productivity, and strengthens, not weakens, the system they rely on.
The bridge to universal healthcare must be built strong before the old one is torn down. Until then, government should focus on reforms that expand access without taking away what is already working for millions of workers.
- Dr Mothudi is managing director of the Board of Healthcare Funders.
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