KATLEGO MOTHUDI

For many South Africans, accessing healthcare is not a single event. It is a process that can take days. It starts with finding transport to a clinic or hospital.

It continues with long waiting times, often in overcrowded facilities. It may involve being referred elsewhere, sometimes more than once, before receiving the care that is needed.

Along the way, there are delays, uncertainty, and gaps in the system. This is what access to healthcare looks like in practice in SA.

For the majority of the population, around 84%, who rely on the public health system, these challenges are not occasional.

They are part of everyday experience. They are shaped by whether there are enough healthcare workers on duty, whether systems are in place to guide patients efficiently, and whether facilities are functional and able to meet demand.

“If the delivery of care is not strengthened, changes to funding structures alone are unlikely to translate into better access.” — Katlego Mothudi

These are the factors that determine outcomes, and they should be the starting point for any meaningful healthcare reform.

SA has committed itself to achieving universal health coverage, a system where everyone can access quality care without financial hardship. That goal is both necessary and widely supported. But reaching it depends on more than how healthcare is funded. It depends on whether the system can deliver care reliably.

At present, many of the challenges facing patients are operational. They relate to how healthcare is organised, managed and delivered on the ground. Staffing shortages, infrastructure constraints, and weak referral pathways continue to affect the consistency and quality of care.

SA also faces a shortage of healthcare professionals relative to its population, with doctor-to-patient ratios below global benchmarks, placing further strain on an already overburdened system. These are not new issues, but they remain unresolved.

This is why it is important to consider whether current reform efforts are focused in the right place. The National Health Insurance (NHI) aims to transform how healthcare is funded and coordinated in SA.

However, in its current form, it places significant emphasis on centralising control over funding and decision-making. The risk is that this approach does not sufficiently address the underlying issues that patients experience every day. If the delivery of care is not strengthened, changes to funding structures alone are unlikely to translate into better access.

There is also a broader system impact to consider. SA’s healthcare system operates across both public and private sectors. While they function differently, they are interconnected. Medical schemes currently provide access to care for nearly 10 million South Africans, of which 67% come from previously disadvantaged groups, reducing demand on public facilities.

If this capacity is weakened before the public system is able to absorb additional demand, the result could be increased pressure across the system as a whole. For patients, this would mean longer waiting times and more limited access to care.

It is in this context that the Board of Healthcare Funders (BHF) has challenged the NHI Act in court. This legal action is focused not only on the potential impact of the Act, but also on the process through which it was passed.

The BHF has raised concerns about whether constitutional requirements were fully met, including the obligation for meaningful public participation by parliament and the duty to properly consider substantive concerns before the bill was signed into law by President Cyril Ramaphosa.

The objective of these court challenges is to ensure that healthcare reform is both constitutionally sound and practically implementable.

At its core, this is about ensuring reform that brings about a health system that can deliver consistent, reliable care to all patients. It’s not about protecting the privileged as is often said. This step has been taken to ensure that healthcare reform strengthens the system rather than placing it under further strain and that any changes are grounded in both constitutional principles and practical realities.

Importantly, there are also opportunities to improve access within the current system. While the government may dismiss these as not their ideal solutions, the undisputed fact is they will improve access to healthcare.

Reforms such as enabling collective tariff negotiations between medical schemes and willing healthcare providers could help manage healthcare costs more effectively. At present, pricing is fragmented and often opaque, contributing to rising costs across the system.

A structured and transparent negotiation framework would improve predictability for both funders and patients, while helping to bring greater discipline to pricing.

Updating prescribed minimum benefits would align cover with today’s health needs. The current framework is outdated and does not fully reflect changes in disease burden, treatment protocols, or healthcare delivery models.

Modernising these benefits would allow for more efficient, patient-centred care while reducing unnecessary cost pressures.

Permitting schemes to offer low-cost benefit options could expand access to primary healthcare for millions of South Africans who currently fall outside both medical schemes and often pay out of pocket to access care in the private sector.

These options could extend cover to an additional 10 million people, offering affordable, prevention-focused care and reducing out-of-pocket expenditure as well as pressure on overburdened public facilities.

These are practical interventions that can be implemented without delay. They also share a common objective, immediately improving access to quality, affordable private healthcare.

Healthcare reform is often discussed in terms of long-term transformation. But for many South Africans, the need for improvement is immediate. The effectiveness of any reform will ultimately be measured not by its structure but by its impact: shorter waiting times, better staffed facilities and clearer pathways to care.

These are the changes that define real progress. If healthcare reform is to succeed, it must start here.