What happens to healthcare while NHI is being resolved?

South Africa’s path to attain universal health coverage has seen the enactment of the National Health Insurance (NHI) Act, which represents one of the most significant health policy shifts in the country’s democratic history.

As this reform unfolds, legal clarity is both necessary and appropriate. While the courts deliberate, healthcare delivery continues. Every day, patients arrive at clinics and hospitals seeking care. Healthcare workers continue to manage pressure, often with limited resources. Decisions still need to be made, even when the path ahead is not fully clear.

It is critical, in other words, that the system remains stable and functioning.

In practice, however, there is policy uncertainty translating into hesitation, uncertainty and confusion across the system. Investment decisions are difficult to make. Planning becomes more complex, and alignment between national ambition and provincial execution can begin to shift. The system is neither stable in its current form nor clearly transitioning to any future state.

For patients, these dynamics are not abstract. They are felt in waiting times, in access to services and in the quality of care received. Public sector facilities continue to face high patient volumes and resource constraints, while disparities in access and quality persist. In this context, even small disruptions or delays can have real consequences.

At the same time, progress is not on hold. Infrastructure investments are being made, service delivery programmes are ongoing, and collaboration between public and private stakeholders continues to evolve. In many parts of the system there is a shared commitment to finding practical ways to improve care, often under difficult conditions. These efforts matter. They are the foundations on which any future system will depend.

The risk lies in allowing this moment to become a holding pattern. If the system shifts into a posture of waiting for legal outcomes before acting, there is a danger of losing momentum where progress is both possible and necessary. Over time, this can lead to frustration among those working within the system, and uncertainty for those who rely on it.

Continuity of care

This moment also presents an opportunity to take a more pragmatic view of reform. Strengthening healthcare delivery does not need to be deferred until all legal questions are resolved. There is scope to accelerate improvements within existing systems, deepen collaboration where it already works, and focus on interventions that directly impact patient outcomes.

Continuity of care must remain the central priority. This means ensuring that services remain accessible, that facilities are supported, and that operational challenges are addressed in real time. It also means recognising that progress is often incremental. Meaningful change is built step by step, through consistent effort and practical improvements.

There is also a need for clarity and communication. In periods of uncertainty, consistent and transparent messaging is essential to maintain confidence among stakeholders and the public. This is not about promoting a policy, but about ensuring that the system remains understood, predictable and responsive.

Importantly, this is not a question of being for or against NHI. It is about recognising that responsibility for healthcare delivery is shared. Government, healthcare providers and broader stakeholders all have a role to play in ensuring that the system continues to function effectively, regardless of where the legal process ultimately lands.

The outcome of the court proceedings will shape the future trajectory of reform. But the present requires equal attention.

Because for those who depend on the system, and those who work within it, healthcare is not something that can be deferred.

The challenge, and the opportunity, is to ensure that while the future of NHI is being decided, the health system continues to move forward.

Dumisani Bomela is CEO of the Hospital Association of South Africa.

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