If the government is serious about building trust in the health sector, it must start by fixing the way the National Health Insurance (NHI) will be governed. Adjusting the scheme’s governance framework would show that leaders are not only hearing, but acting on the loudest demand to come out of the country’s first national convention in August: better governance and real accountability.
- If the government is serious about building trust in the health sector, it must start by fixing the way the National Health Insurance (NHI) will be governed.
- Adjusting the scheme’s governance framework would show that leaders are not only hearing, but acting on the loudest demand to come out of the country’s first national convention in August: better governance and real accountability.
- That convention, held in Tshwane and attended by more than 1 000 delegates, was billed as the launchpad for a series of national dialogues called by President Cyril Ramaphosa to shape South Africa’s next democratic chapter.
- The concerns and proposals that emerged from the convention will be brought together at a second convention planned for 2026.
If the government is serious about building trust in the health sector, it must start by fixing the way the National Health Insurance (NHI) will be governed. Adjusting the scheme’s governance framework would show that leaders are not only hearing, but acting on the loudest demand to come out of the country’s first national convention in August: better governance and real accountability.
That convention, held in Tshwane and attended by more than 1 000 delegates, was billed as the launchpad for a series of national dialogues called by President Cyril Ramaphosa to shape South Africa’s next democratic chapter.
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The concerns and proposals that emerged from the convention will be brought together at a second convention planned for 2026.
Participants at the convention, hosted at the University of South Africa, repeatedly argued that the government must do more than stage consultations: there needs to be “substance over form”.
For the NHI to succeed , government actions must reflect this legitimate feedback.
But many consultation processes within South Africa to date have been seen by informed participants as formulaic — routine box-ticking, instead of genuine listening. These violate the governance principles of true consultation: hearing people’s concerns and thereafter changing the government’s strategy, so that the legitimate concerns are addressed.
What’s wrong with the NHI’s governance framework?
The governance structures stipulated in the NHI Act lack balance — and that needs to change.
Power is overly concentrated in the hands of the health minister: the minister appoints the people who advise on who should sit on the NHI board, but he also appoints the actual board and its CEO (with cabinet approval), and decides on the overall policy and direction of the Fund. If someone has a complaint about the NHI, it’s handled by an appeals tribunal — but the minister also ultimately decides who sits on that tribunal.
In short: the same person is the referee and player. That much power in one set of hands makes it hard to keep the system fair and accountable.
This is even more worrying, because the Act gives the appeals tribunal many of the same powers as the high court. But the health minister chooses who sits on it. That means there aren’t enough independent groups, like civil society or Parliament, to act as watchdogs to keep ministerial powers in check. This makes it harder to check the minister’s decisions or stop abuse of power.
The power issue transcends the health sector
These concerns are not limited to health.
Participants at the convention pointed out similar problems across other sectors — too much power in the hands of the executive, the erosion of institutional autonomy and the steady decline of public trust.
The way the NHI is currently designed mirrors these flaws. It does not meet South Africa’s own governance standards, like those set out in King IV guidelines for good governance , nor does it align with international principles backed by the World Health Organisation (WHO) and the Organisation for Economic Co-operation and Development (OECD).
As the Act stands, it creates systemic risks, which could lead to the entire health system breaking down.
What the government can do
The NHI gives the government a chance to prove it is listening and ready to act. To protect the Fund’s credibility and make it work, several reforms should be considered:
Put Parliament at the centre. Parliament must play a key role in keeping the NHI accountable, so that power does not rest almost entirely with the health minister and their appointees.
Appoint all governance structures independently and transparently. Introduce statutory requirements for open nomination and vetting, merit-based appointments, and clear rules for removal. Let the board appoint a competent CEO without needing ministerial and cabinet approval.
Abide by South African and global governance guidelines. The law should clearly separate the functions and powers of the health minister, department of health, the NHI Fund, relevant boards, purchasing entities, appeals tribunal and service providers to prevent conflicts of interest. Independent regulators and purchasing units should be created, in line with WHO and OECD standards.
Listen. Many of the voices opposing the current form/structure/governance of NHI are progressive voices that have deep insights into why the NHI in its current form might not work, with communities possibly ending up worse off.
“Tickbox” consultations will get us nowhere
If the NHI’s governance isn’t fixed, it could suffer the same fate as other state bodies that have been damaged by weak leadership. That means the Fund could become slow and inefficient, open to political interference, and too tightly controlled by the minister.
In the end, it risks losing the trust of the very people it’s meant to serve. Such a collapse wouldn’t just threaten South Africa’s plan for universal healthcare (UHC) — it could also fuel even greater public doubt about the government’s reform agenda.
Both the heated exchanges at August’s national convention and subsequent local and sectoral dialogues revealed deep frustration and anger among NHI supporters. Many progressive voices feel dismissed when they raise legitimate concerns about how the scheme is being built.
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UHC support is bigger than what government thinks
Too often, the government paints such criticism as “anti-transformational” or “anti-universal healthcare”. In reality, much of the critique comes from progressive South Africans who strongly support UHC, but who worry that flaws in the current NHI design could cause it to fail.
During the parliamentary hearings on the NHI Act, a wide range of groups — from doctors and nurses to civil society and the private sector — made detailed submissions. Yet the Act shows almost no real changes. It is hard to believe that the insights of so many public health experts and community members could be dismissed as unworthy of inclusion.
By sticking to procedure but failing to truly respond, government has weakened both the democratic process and the credibility of its flagship health reform. This was the warning raised at the convention: real democracy requires substantive accountability , not only process.
Mere box-ticking brings us nowhere.
Tim Tucker is CEO of the healthcare service provider Sead, consulting and honorary associate professor at the University of Cape Town Town’s ( UCT) school of public health ; Mina Haji is a researcher at the UCT School of public health; Susan Cleary is professor of health economics and head of the UCT school of public health; Geetesh Solanki is adjunct associate professor at the UCT school of public health, and principal consultant at NMG Consultants and Actuaries .
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter .
