Bianca Visagie - Healthcare Specialist

27/08/2026

Die Departement van Gesondheid en farmaseutiese vervaardigers gaan die reëls vir private medisynepryse hersien ná jare se klagtes oor toepassing.

23/08/2026

Better Healthcare Comes at a Price. Provider Networks Help Keep It Affordable
06 August 2026 | Healthcare | General | Thoneshan Naidoo, CEO at Health Funders Association

South Africans rightly expect access to the latest medicines, advanced technology and world-class healthcare.

Every year brings new treatments that improve and extend lives. Robotic surgery, precision medicine, advanced cancer therapies and sophisticated diagnostic tools are transforming patient care.

The difficult question is not whether these innovations are valuable, but who ultimately pays for them.

Healthcare has never been more advanced, but it has also never been more expensive. Every new medicine, breakthrough treatment and additional healthcare benefit comes at a cost. There is no magic pot of money that funds medical innovation. Every rand spent on healthcare ultimately comes from medical scheme contributions, taxes or patients' own pockets.

Medical schemes therefore face an increasingly difficult balancing act. They must provide members with access to high-quality healthcare while ensuring that cover remains financially sustainable. Achieving this balance requires careful purchasing decisions and funding mechanisms that maximise value for money rather than simply reducing costs.

The objective is not to purchase the cheapest healthcare. It is to achieve the best possible health outcomes for every rand contributed by members.

Prescribed Minimum Benefits
This challenge becomes particularly important when viewed against South Africa's Prescribed Minimum Benefits (PMBs).

PMBs are a defined set of health services, including emergency care and treatment for serious medical conditions, that every medical scheme is legally required to cover in full, regardless of the benefit option a member has selected. This provides essential financial protection, ensuring that members can access life-saving care without facing catastrophic healthcare costs.

Meeting this obligation requires medical schemes to purchase healthcare as efficiently as possible without compromising quality or access. Unlike many countries, South Africa does not regulate the prices that most private healthcare providers may charge. Yet medical schemes remain legally obliged to fund PMBs in full. The ability to negotiate reimbursement rates is therefore one of the primary mechanisms that enables schemes to meet this obligation while keeping contributions sustainable.

Every health system, whether publicly or privately funded, must decide how to purchase healthcare within finite resources. Some negotiate medicine prices. Others negotiate hospital tariffs or provider contracts. South Africa's medical schemes use provider networks as one of the principal mechanisms to purchase healthcare more efficiently and deliver better value for members. Without these purchasing mechanisms, healthcare costs inevitably rise.

One of the most important tools available to schemes is the Designated Service Provider (DSP) network.

Why provider networks matter
A Designated Service Provider is a hospital, doctor, pharmacy or other healthcare provider contracted by a medical scheme to deliver care at negotiated reimbursement rates.

These arrangements align the interests of members, healthcare providers and medical schemes by creating value for all three. Members benefit through lower contributions, lower out-of-pocket costs and protection from unexpected balance billing. Providers agree to negotiated reimbursement rates and benefit from network participation that delivers greater patient volumes, faster payment and lower administrative and bad debt costs.

Although provider networks improve affordability, they are about far more than price. Providers generally need to meet agreed quality and service standards before joining a network. Networks support coordinated care for conditions such as cancer, HIV and other chronic diseases, allowing schemes to promote evidence-based treatment, monitor quality and improve health outcomes.

Importantly, provider networks do not deny members access to essential healthcare. Existing legislation already protects members where a designated provider is not reasonably available, where treatment is an emergency or where care cannot reasonably be delayed. Provider networks therefore improve affordability without compromising access to essential care.

What the data shows
Contrary to some perceptions, almost every PMB claim is already paid in full.

Data from our member schemes in 2025 shows that approximately 97.7% of PMB claims are already paid without any co-payment, while co-payments account for just 2.3% of total PMB claim values.

The current framework is therefore already delivering the financial protection it was designed to provide and the value created by provider networks is substantial.
Members benefit from between R8.8 billion and R11.5 billion in annual savings because medical schemes negotiate lower reimbursement rates through provider networks. Those savings are ultimately reflected in lower contributions for members.

Without these savings, medical scheme contributions could increase by an additional 3% to 4% over and above normal annual increases.

Why this matters
The medical scheme population is predominantly made up of lower- and middle-income households. Around 83% of beneficiaries earn less than R40 000 a month, while almost half earn less than R16 000.

These are the members who rely most heavily on affordable, network-based benefit options. Those options remain sustainable because medical schemes can negotiate favourable reimbursement rates through strong provider networks. If these networks are weakened, it is households with the least room in their budgets that will feel the impact first through higher monthly contributions.

The principle worth protecting
Healthcare will continue to evolve. New treatments will emerge and expectations will continue to rise. The challenge is ensuring that these advances remain financially accessible.

Provider networks are one of the most effective mechanisms medical schemes have to purchase healthcare strategically, negotiate fair reimbursement rates and build coordinated systems of care that improve both quality and affordability.

Healthcare innovation is only meaningful if people can afford to benefit from it. Preserving strong provider networks is therefore not simply about protecting contractual arrangements between medical schemes and healthcare providers. It is about protecting affordable access to high-quality care for millions of South Africans.

Ultimately, the future of healthcare will depend not only on medical innovation, but on our ability to keep that innovation affordable.

22/08/2026

22/08/2026

Medical Shortfalls & Gap Cover – What You Need to Know

Many people believe their medical aid covers everything — until the bills arrive. From orthopaedic surgeries to maternity costs and gastrointestinal treatments, unexpected shortfalls can run into thousands.

🔹 Always understand your financial risk before treatment
🔹 Some procedures can’t be delayed — plan ahead
🔹 Speak to a financial advisor or broker to find the right Gap Cover for your needs
🔹 More specialists are now upfront about costs and will ask if you have Gap Cover.

Catch the full discussion with Brian Harris and Jeremy Maggs on Hot 91.9 FM 🎧 — it’s an eye-opener for anyone who wants to stay financially protected. https://app.marketiq.co.za/topics/article_full_text_public?id=2080974350&org_id=742&source_type=broadcast

👉 082 309 7012

𝘛𝘶𝘳𝘯𝘣𝘦𝘳𝘳𝘺 𝘔𝘢𝘯𝘢𝘨𝘦𝘮𝘦𝘯𝘵 𝘙𝘪𝘴𝘬 𝘚𝘰𝘭𝘶𝘵𝘪𝘰𝘯𝘴 (𝘗𝘵𝘺) 𝘓𝘵𝘥 𝘪𝘴 𝘢𝘯 𝘢𝘶𝘵𝘩𝘰𝘳𝘪𝘴𝘦𝘥 𝘍𝘪𝘯𝘢𝘯𝘤𝘪𝘢𝘭 𝘚𝘦𝘳𝘷𝘪𝘤𝘦𝘴 𝘗𝘳𝘰𝘷𝘪𝘥𝘦𝘳 (𝘍𝘚𝘗 𝘯𝘰. 36571). 𝘜𝘯𝘥𝘦𝘳𝘸𝘳𝘪𝘵𝘵𝘦𝘯 𝘣𝘺 𝘓𝘰𝘮𝘣𝘢𝘳𝘥 𝘐𝘯𝘴𝘶𝘳𝘢𝘯𝘤𝘦 𝘊𝘰𝘮𝘱𝘢𝘯𝘺, 𝘢𝘯 𝘈𝘶𝘵𝘩𝘰𝘳𝘪𝘴𝘦𝘥 𝘍𝘪𝘯𝘢𝘯𝘤𝘪𝘢𝘭 𝘚𝘦𝘳𝘷𝘪𝘤𝘦𝘴 𝘗𝘳𝘰𝘷𝘪𝘥𝘦𝘳 (𝘍𝘚𝘗 1596) 𝘢𝘯𝘥 𝘐𝘯𝘴𝘶𝘳𝘦𝘳 𝘤𝘰𝘯𝘥𝘶𝘤𝘵𝘪𝘯𝘨 𝘯𝘰𝘯-𝘭𝘪𝘧𝘦 𝘪𝘯𝘴𝘶𝘳𝘢𝘯𝘤𝘦 𝘣𝘶𝘴𝘪𝘯𝘦𝘴𝘴. #𝘛𝘶𝘳𝘯𝘣𝘦𝘳𝘳𝘺𝘎𝘢𝘱𝘊𝘰𝘷𝘦𝘳 #𝘎𝘢𝘱𝘊𝘰𝘷𝘦𝘳 #𝘕𝘢𝘷𝘪𝘨𝘢𝘵𝘪𝘯𝘨𝘵𝘩𝘦𝘞𝘢𝘺 #𝘔𝘦𝘥𝘪𝘤𝘢𝘭𝘌𝘹𝘱𝘦𝘯𝘴𝘦𝘴 #𝘔𝘦𝘥𝘪𝘤𝘢𝘭𝘌𝘹𝘱𝘦𝘯𝘴𝘦𝘚𝘩𝘰𝘳𝘵𝘧𝘢𝘭𝘭

22/08/2026

Martin Rimmer, CEO of Sirago Underwriting Managers

Women’s Month is a timely reminder to reflect on one of the most crucial aspects of financial wellbeing: healthcare financial planning. While this matters for everyone, women face unique challenges that make strategic, professionally guided health planning particularly important.


Martin Rimmer, CEO of Sirago Underwriting Managers, a gap cover provider underwritten by GENRIC Insurance Company Limited, says: “Women generally have longer life expectancies and may experience career interruptions due to caregiving responsibilities, which can influence lifetime earnings and retirement savings. Combined with elevated risks for certain health conditions, these factors underscore the importance of having appropriate healthcare cover in place.”


Independent financial advisor, Janette Rooney of Le Forge Financial Consultants, adds that women are often also the ones managing the family’s health administration. “From medical aid claims to children’s check-ups to caring for ageing parents, much of this load falls on women’s shoulders, often alongside full-time work. Women drive healthy habits across the whole family, yet their own health checks are often the first thing pushed down the to-do list. This Women’s Month is a reminder that the same care women extend to their families deserves to be turned inward too, starting with a proper review of their own healthcare planning,” says Janette.



As the gap between income, savings and rising costs widens, many people are forced into trade-offs between immediate needs and planning for an unknown future health event. Getting professional advice from a qualified healthcare broker is one of the most effective ways to strike the right balance in your healthcare plan.


Top considerations for your healthcare financial plan



1. Medical scheme benefit: your foundation


Given the high cost of private care, many consumers prefer private healthcare because of accessibility and service considerations. For many consumers seeking access to private healthcare, medical scheme membership is an important consideration. Choosing the right benefit option requires careful thought. Work with a professional healthcare broker who can assess your healthcare expenditure, family and personal medical history, and any pre-existing conditions, to strike the right balance between cost, benefits and needs. A professional broker can also help you identify opportunities to earn better rewards and coverage simply by being more proactive about health checks and healthy lifestyle habits.


It is important to remember that medical scheme membership and insurance products serve different purposes and are regulated under different legislation. Gap cover and other insurance products are not substitute for medical scheme membership and are intended to complement qualifying medical scheme cover.



2. Get gap cover: protecting against unexpected shortfalls


Even with a comprehensive medical scheme benefit, gap cover may be appropriate for consumers depending on their medical scheme option, healthcare needs and affordability. It covers the shortfall between what your scheme pays and what specialists charge, and specialist and in-hospital fees can run up to 400% above scheme tariffs. If your scheme pays out at 100% or 200% of tariff, you carry the remaining 200–300% yourself if you don’t have gap cover. Many schemes also carry deductibles and co-payments, especially on lower-tier options. Based on internal claims experience, Sirago’s average “large loss” gap claim currently sits at R40,000–R60,000, which makes the case for gap cover on its own.

3. Plan for a health crisis

A serious illness or disabling event can affect both your health and your ability to earn. Cancer, for example, may mean months away from work and income. For stay-at-home mothers, a health crisis also disrupts childcare, schooling support and care for ageing parents, responsibilities that carry real financial cost if a caregiver needs to step in. Speak to a qualified and authorised financial adviser or healthcare adviser.


4. Prevention, prevention, prevention

Preventative care is a benefit worth using, not leaving on the table. Commit to annual screenings – early detection can reduce both the health and financial impact of serious conditions. Make sure your plan covers essentials such as mammograms, pap smears, bone density tests and cardiovascular screening.


5. Reproductive health and maternity planning


If you’re planning to have children, prioritise a plan with strong maternity and reproductive health benefits. Childbirth is costly, and significantly more so with complications. Check for adequate cover for prenatal visits, screenings and postnatal care for both mother and baby. Sticking to your scheme’s maternity programme can meaningfully ease both the health and financial load during this period.


6. Managing a chronic condition

Many people live with chronic health conditions that require ongoing medical care and treatment. Having appropriate healthcare cover in place can help reduce the financial impact of specialist consultations, diagnostic tests and long-term medication. When planning your healthcare needs, it is important to ensure that your cover aligns with your personal health circumstances, so that managing a chronic condition does not result in significant out-of-pocket expenses.


7. Lifestyle as financial strategy

Small, consistent changes pay off, in health and in rand terms. Eat well, move daily even if only briefly, limit alcohol, cut out smoking and va**ng, manage stress, and prioritise sleep. These habits help you avoid costly chronic conditions later and can reduce your long-term healthcare spend.


8. Maximise available resources


If you have access to group employee benefits, use them. Just make sure your individual and employer-provided cover work together, without gaps or unnecessary duplication.

9. Get professional advice


Healthcare financial planning is genuinely complex, which is why professional guidance is so valuable. A qualified advisor can help you identify coverage gaps, understand potential out-of-pocket costs, plan for shortfalls, and balance affordability against comprehensive cover, cutting through the complexity of how different insurance products work together.


Healthcare financial planning is important for everyone, but women may encounter certain health, life-stage and caregiving considerations that make proactive planning particularly valuable. It is not only about managing costs when you are unwell, but also about giving yourself the confidence and financial flexibility to prioritise your health and wellbeing throughout your life.


This Women’s Month, take the opportunity to review your healthcare and financial plans to ensure they remain aligned to your needs, priorities and budget. Speaking to a qualified adviser can help you make informed decisions and adapt your plans as your circumstances evolve.

20/08/2026

Did you medical aid only paid a portion of your claim?

👇

Say no more. Make Gap cover part of your financial planning.

☎️ Contact me today for a quote on Gap cover. (Liberty Zestlife. Turnberry, Sirago, Stratum & Zestlife Dental Gap Cover)

https://nexus.profileme.app/biancascholtz

Is the NHI feasible?

“The President has made an undertaking, sanctioned by court, that he will not sign any sections into law until the Constitutional Court has ruled on current [NHI-related] cases; and the Minister of Health has also undertaken not to implement any part of it,” said Roseanne Harris, Executive Head of Policy and Regulatory Affairs for Discovery Health, during the brand’s inaugural Retirement Fund Forum.

Harris was challenged by Discovery Health’s Chief Product Officer, Yashtil Moodley, on the feasibility of the plan. Her first observation was that stakeholders should not deflect from the core problem the Act seeks to address, being access to quality healthcare for all South Africans. She then conceded that “the single fund model inherent in the current version of the NHI was not feasible”. To explain why required a multi-category dissection of how people funded and participated in the private and public healthcare sectors.

The first task was to segment people into medical scheme members; other income taxpayers not on medical schemes; the informal sector; and the unemployed. This exercise revealed that 14% of the population were beneficiaries of medical schemes, while up to two-thirds were unemployed or informally employed. “We have a very small proportion of people who are funding the tax base for healthcare benefits,” Harris said, noting that the 14% were chipping in around 74% of personal income tax.

Dissecting tax revenue shares

The next step was to show how the four segments participated in healthcare financing and utilisation. Discovery Health estimates the ratio of tax benefits to tax payments in the healthcare financing realm as 7.2 times for the unemployed; 1.6 times for those in the informal sector; 2.3 times for taxpayers not on medical schemes; and 0.1 times for medical scheme members, mostly through the medical tax credit mechanism. The bulk of private funding, which is contributed by the medical scheme members, is used by them.

“One of the big challenges with the healthcare financing debate is that private funding and public funding are just sort of conveniently put into a single pot,” Harris said. “But private funding, the medical scheme contributions being the biggest component of that, largely comes from after-tax, out-of-pocket household expenditure”. She argued that raising tax collections to fund NHI would lead to a significant drop in healthcare cover for more than half of taxpayers. The solution demands that current taxpayers pay much more in taxes in return for an even smaller portion of the total healthcare pot.

Moodley echoed the uncertainty among intermediaries, medical scheme providers and various other stakeholders in the private healthcare sector, asking: “What is the current status of the NHI? We know now it is not feasible; is this eventually going to be forced upon us in 10 years, or do our medical schemes still have 20 to 30 years as going concerns?” Harris reminded the audience that there were eight or nine litigants involved in taking legal action against the NHI.

Court challenges ongoing

FAnews has reported on these in the past, notably in ‘NHI leaves your clients with 43% less cover at 1.5 times the tax’. An up-to-date summary shared during the presentation confirmed two procedural and one substantive challenge against the law. Harris said that the Western Cape Government and Board of Healthcare Funders (BHF) case against Parliamentary procedure had gone before the Constitutional Court from 5-7 May 2026, and that rulings were expected in October. “Those rulings could lead to the NHI Act being sent back to Parliament, which would be quite a positive thing,” she said.

Substantive challenges have been brought by a long list of organisations including the Health Funders Association (HFA); Hospital Association of South Africa (HASA); South African Medical Association (SAMA); South African Private Practitioners Forum (SAPPF); Solidarity; and Sakeliga. A consolidation and deferral case was held late in February this year, and these actions are ongoing. A separate BHF and SAPPF challenge against Presidential procedure is postponed indefinitely pending the Court ruling on Parliamentary procedure.

One of the substantive issues that will be tested is how government could push ahead with an uncosted solution. Harris showed some sympathy for government’s reticence here; but said that any health reforms should at least be costed on a scenario basis. She referred the audience to a report by Genesis Analytics, which includes detailed costing and analysis on various scenarios. This is the same report that informed the aforementioned FAnews article, which concludes that medical scheme members will pay 1.5 times more tax for 43% of their current cover. And that was for one of the most affordable hybrid scenarios included in the research.

A fiscally impossible solution

Genesis noted that even under the most optimistic assumptions, factoring in as much as 45% in savings from present private sector healthcare cost levels, government would not be able to raise the necessary funds. To quote from the report: “for NHI to fund a level of care equivalent to what medical scheme members currently receive, personal income tax would need to increase by 2.2 times from the current average rate of 21%.” That explains why the report labelled the implementation of the NHI Act as fiscally impossible.

So, what happens next? Harris said there was “a robust engagement process happening” while industry awaited clarity on the various legal actions. She believes that this process will lead to a workable model that is unlikely to resemble the current NHI solution. As an aside, whatever solution the private sector eventually thrashes out with government will likely require another 10 to 15 years to implement. To wrap the conversation, Moodley asked the expert what healthcare brokers and medical scheme members should do in the interim.

There are some low-cost benefit option (LCBO)-type cover alternatives available to South Africa’s low- to mid-income earners. These solutions are based on primary care coverage that is consistent with the principles inherent in the NHI and broader healthcare policy; but they remain on the periphery of the medical scheme regulatory environment. Harris said that bringing such products into the medical scheme ‘fold’ could contribute to more affordable access for around 10 million people.

The primary cover solution already exists

“We are certainly pushing hard for primary care coverage to be accommodated in the medical scheme environment; these initiatives are entirely consistent with what the NHI is trying to achieve,” Harris concluded. “If we can get to the multi-payer environment that we envisage, then building this coverage will be part of that workable solution”. The more people you can lift out of public sector dependence, the more you can increase the per capita amount that is available for the unemployed.

Is the NHI feasible?

“The President has made an undertaking, sanctioned by court, that he will not sign any sections into law until the Constitutional Court has ruled on current [NHI-related] cases; and the Minister of Health has also undertaken not to implement any part of it,” said Roseanne Harris, Executive Head of Policy and Regulatory Affairs for Discovery Health, during the brand’s inaugural Retirement Fund Forum.

Harris was challenged by Discovery Health’s Chief Product Officer, Yashtil Moodley, on the feasibility of the plan. Her first observation was that stakeholders should not deflect from the core problem the Act seeks to address, being access to quality healthcare for all South Africans. She then conceded that “the single fund model inherent in the current version of the NHI was not feasible”. To explain why required a multi-category dissection of how people funded and participated in the private and public healthcare sectors.

The first task was to segment people into medical scheme members; other income taxpayers not on medical schemes; the informal sector; and the unemployed. This exercise revealed that 14% of the population were beneficiaries of medical schemes, while up to two-thirds were unemployed or informally employed. “We have a very small proportion of people who are funding the tax base for healthcare benefits,” Harris said, noting that the 14% were chipping in around 74% of personal income tax.

Dissecting tax revenue shares

The next step was to show how the four segments participated in healthcare financing and utilisation. Discovery Health estimates the ratio of tax benefits to tax payments in the healthcare financing realm as 7.2 times for the unemployed; 1.6 times for those in the informal sector; 2.3 times for taxpayers not on medical schemes; and 0.1 times for medical scheme members, mostly through the medical tax credit mechanism. The bulk of private funding, which is contributed by the medical scheme members, is used by them.

“One of the big challenges with the healthcare financing debate is that private funding and public funding are just sort of conveniently put into a single pot,” Harris said. “But private funding, the medical scheme contributions being the biggest component of that, largely comes from after-tax, out-of-pocket household expenditure”. She argued that raising tax collections to fund NHI would lead to a significant drop in healthcare cover for more than half of taxpayers. The solution demands that current taxpayers pay much more in taxes in return for an even smaller portion of the total healthcare pot.

Moodley echoed the uncertainty among intermediaries, medical scheme providers and various other stakeholders in the private healthcare sector, asking: “What is the current status of the NHI? We know now it is not feasible; is this eventually going to be forced upon us in 10 years, or do our medical schemes still have 20 to 30 years as going concerns?” Harris reminded the audience that there were eight or nine litigants involved in taking legal action against the NHI.

Court challenges ongoing

FAnews has reported on these in the past, notably in ‘NHI leaves your clients with 43% less cover at 1.5 times the tax’. An up-to-date summary shared during the presentation confirmed two procedural and one substantive challenge against the law. Harris said that the Western Cape Government and Board of Healthcare Funders (BHF) case against Parliamentary procedure had gone before the Constitutional Court from 5-7 May 2026, and that rulings were expected in October. “Those rulings could lead to the NHI Act being sent back to Parliament, which would be quite a positive thing,” she said.

Substantive challenges have been brought by a long list of organisations including the Health Funders Association (HFA); Hospital Association of South Africa (HASA); South African Medical Association (SAMA); South African Private Practitioners Forum (SAPPF); Solidarity; and Sakeliga. A consolidation and deferral case was held late in February this year, and these actions are ongoing. A separate BHF and SAPPF challenge against Presidential procedure is postponed indefinitely pending the Court ruling on Parliamentary procedure.

One of the substantive issues that will be tested is how government could push ahead with an uncosted solution. Harris showed some sympathy for government’s reticence here; but said that any health reforms should at least be costed on a scenario basis. She referred the audience to a report by Genesis Analytics, which includes detailed costing and analysis on various scenarios. This is the same report that informed the aforementioned FAnews article, which concludes that medical scheme members will pay 1.5 times more tax for 43% of their current cover. And that was for one of the most affordable hybrid scenarios included in the research.

A fiscally impossible solution

Genesis noted that even under the most optimistic assumptions, factoring in as much as 45% in savings from present private sector healthcare cost levels, government would not be able to raise the necessary funds. To quote from the report: “for NHI to fund a level of care equivalent to what medical scheme members currently receive, personal income tax would need to increase by 2.2 times from the current average rate of 21%.” That explains why the report labelled the implementation of the NHI Act as fiscally impossible.

So, what happens next? Harris said there was “a robust engagement process happening” while industry awaited clarity on the various legal actions. She believes that this process will lead to a workable model that is unlikely to resemble the current NHI solution. As an aside, whatever solution the private sector eventually thrashes out with government will likely require another 10 to 15 years to implement. To wrap the conversation, Moodley asked the expert what healthcare brokers and medical scheme members should do in the interim.

There are some low-cost benefit option (LCBO)-type cover alternatives available to South Africa’s low- to mid-income earners. These solutions are based on primary care coverage that is consistent with the principles inherent in the NHI and broader healthcare policy; but they remain on the periphery of the medical scheme regulatory environment. Harris said that bringing such products into the medical scheme ‘fold’ could contribute to more affordable access for around 10 million people.

The primary cover solution already exists

“We are certainly pushing hard for primary care coverage to be accommodated in the medical scheme environment; these initiatives are entirely consistent with what the NHI is trying to achieve,” Harris concluded. “If we can get to the multi-payer environment that we envisage, then building this coverage will be part of that workable solution”. The more people you can lift out of public sector dependence, the more you can increase the per capita amount that is available for the unemployed.

20/08/2026

Is the NHI feasible?

“The President has made an undertaking, sanctioned by court, that he will not sign any sections into law until the Constitutional Court has ruled on current [NHI-related] cases; and the Minister of Health has also undertaken not to implement any part of it,” said Roseanne Harris, Executive Head of Policy and Regulatory Affairs for Discovery Health, during the brand’s inaugural Retirement Fund Forum.

Harris was challenged by Discovery Health’s Chief Product Officer, Yashtil Moodley, on the feasibility of the plan. Her first observation was that stakeholders should not deflect from the core problem the Act seeks to address, being access to quality healthcare for all South Africans. She then conceded that “the single fund model inherent in the current version of the NHI was not feasible”. To explain why required a multi-category dissection of how people funded and participated in the private and public healthcare sectors.

The first task was to segment people into medical scheme members; other income taxpayers not on medical schemes; the informal sector; and the unemployed. This exercise revealed that 14% of the population were beneficiaries of medical schemes, while up to two-thirds were unemployed or informally employed. “We have a very small proportion of people who are funding the tax base for healthcare benefits,” Harris said, noting that the 14% were chipping in around 74% of personal income tax.

Dissecting tax revenue shares

The next step was to show how the four segments participated in healthcare financing and utilisation. Discovery Health estimates the ratio of tax benefits to tax payments in the healthcare financing realm as 7.2 times for the unemployed; 1.6 times for those in the informal sector; 2.3 times for taxpayers not on medical schemes; and 0.1 times for medical scheme members, mostly through the medical tax credit mechanism. The bulk of private funding, which is contributed by the medical scheme members, is used by them.

“One of the big challenges with the healthcare financing debate is that private funding and public funding are just sort of conveniently put into a single pot,” Harris said. “But private funding, the medical scheme contributions being the biggest component of that, largely comes from after-tax, out-of-pocket household expenditure”. She argued that raising tax collections to fund NHI would lead to a significant drop in healthcare cover for more than half of taxpayers. The solution demands that current taxpayers pay much more in taxes in return for an even smaller portion of the total healthcare pot.

Moodley echoed the uncertainty among intermediaries, medical scheme providers and various other stakeholders in the private healthcare sector, asking: “What is the current status of the NHI? We know now it is not feasible; is this eventually going to be forced upon us in 10 years, or do our medical schemes still have 20 to 30 years as going concerns?” Harris reminded the audience that there were eight or nine litigants involved in taking legal action against the NHI.

Court challenges ongoing

FAnews has reported on these in the past, notably in ‘NHI leaves your clients with 43% less cover at 1.5 times the tax’. An up-to-date summary shared during the presentation confirmed two procedural and one substantive challenge against the law. Harris said that the Western Cape Government and Board of Healthcare Funders (BHF) case against Parliamentary procedure had gone before the Constitutional Court from 5-7 May 2026, and that rulings were expected in October. “Those rulings could lead to the NHI Act being sent back to Parliament, which would be quite a positive thing,” she said.

Substantive challenges have been brought by a long list of organisations including the Health Funders Association (HFA); Hospital Association of South Africa (HASA); South African Medical Association (SAMA); South African Private Practitioners Forum (SAPPF); Solidarity; and Sakeliga. A consolidation and deferral case was held late in February this year, and these actions are ongoing. A separate BHF and SAPPF challenge against Presidential procedure is postponed indefinitely pending the Court ruling on Parliamentary procedure.

One of the substantive issues that will be tested is how government could push ahead with an uncosted solution. Harris showed some sympathy for government’s reticence here; but said that any health reforms should at least be costed on a scenario basis. She referred the audience to a report by Genesis Analytics, which includes detailed costing and analysis on various scenarios. This is the same report that informed the aforementioned FAnews article, which concludes that medical scheme members will pay 1.5 times more tax for 43% of their current cover. And that was for one of the most affordable hybrid scenarios included in the research.

A fiscally impossible solution

Genesis noted that even under the most optimistic assumptions, factoring in as much as 45% in savings from present private sector healthcare cost levels, government would not be able to raise the necessary funds. To quote from the report: “for NHI to fund a level of care equivalent to what medical scheme members currently receive, personal income tax would need to increase by 2.2 times from the current average rate of 21%.” That explains why the report labelled the implementation of the NHI Act as fiscally impossible.

So, what happens next? Harris said there was “a robust engagement process happening” while industry awaited clarity on the various legal actions. She believes that this process will lead to a workable model that is unlikely to resemble the current NHI solution. As an aside, whatever solution the private sector eventually thrashes out with government will likely require another 10 to 15 years to implement. To wrap the conversation, Moodley asked the expert what healthcare brokers and medical scheme members should do in the interim.

There are some low-cost benefit option (LCBO)-type cover alternatives available to South Africa’s low- to mid-income earners. These solutions are based on primary care coverage that is consistent with the principles inherent in the NHI and broader healthcare policy; but they remain on the periphery of the medical scheme regulatory environment. Harris said that bringing such products into the medical scheme ‘fold’ could contribute to more affordable access for around 10 million people.

The primary cover solution already exists

“We are certainly pushing hard for primary care coverage to be accommodated in the medical scheme environment; these initiatives are entirely consistent with what the NHI is trying to achieve,” Harris concluded. “If we can get to the multi-payer environment that we envisage, then building this coverage will be part of that workable solution”. The more people you can lift out of public sector dependence, the more you can increase the per capita amount that is available for the unemployed.