The state must abandon the NHI and its mission for central control over healthcare

During the National Assembly plenary session on 13 January 2026, finance minister Enoch Godongwana suggested that litigants opposing the NHI Act engage with the government to craft a negotiated settlement rather than continue with litigation. In support of this idea, the Minister asserted that litigating parties, in agreement with the government, already support the principle of universal healthcare coverage.

The Minister’s remarks reveal concern and division within the executive over the feasibility of the NHI Act, but ultimately cannot yet be taken as a serious sign that the state is truly willing to negotiate in good faith.

On the one hand, these remarks confirm what Sakeliga already knew: that Treasury is alarmed by and likely desperate to avoid the NHI's exorbitant cost implications and, therefore, that the state would eventually concede the need to walk back such an irrational proposal for healthcare regulation. It has been fairly apparent throughout recent years that the finance ministry regards the NHI as unaffordable and therefore, at the very least, infeasible. Mr Godongwana would want to avoid the substantial tax increases that would be required to fund the NHI. National Treasury is well aware that further tax increases will place households and businesses under severe economic stress, undermine tax compliance, and - as the 2025 VAT debacle showed - be extremely politically unpopular.

On the other hand, these remarks lack specificity and clarity, and are incongruous with the Department of Health, which apparently remains committed to forging full-steam ahead with the NHI. While the Minister is clearly expressing greater realism among some parts of the executive on the NHI, it is not at all clear yet that this translates into broad-based executive branch support for meaningful concessions and an abandonment of the goal of state control over healthcare in principle (by any means).

Universal Health Coverage

The Minister also falsely gives the impression that litigants support the principle of universal health coverage. Whether this is a genuine mistake or a tactic to control the framing of possible future negotiations remains to be seen.

There are two problems with the concept of "universal health coverage." The first is the term's ambiguity and abstractness, which invite multiple interpretations. The second is that even if there were general agreement on a definition, there is vast disagreement over whether it is a good to be pursued or over the means and approach to achieving it.

The critical question, then, is: what does the state mean by the term universal health coverage?

In Sakeliga's view, when the state refers to universal health coverage, it is a public health policy proposal that aims to equalise healthcare services through extensive state control and stringent regulation of independent private and community healthcare services.

While there appears to be a division between Treasury and the Department of Health on the feasibility of the NHI, it is not clear that there is a division between the two departments on the primacy of the state in healthcare and the statist interpretation of universal health coverage.

Several of the litigants opposing the NHI Act who have publicly stated their support for universal health coverage, or universal healthcare, most likely do not have the state's definition in mind. Rather, they appear to be expressing, in good faith, a wish that all people could one day obtain adequate healthcare services. And even where there is an acknowledgement of a role for the state in serving the poorest communities, it does not necessarily imply alignment with the state on how to achieve such a future in the real world.

The South African government has clearly stated its intention to place the state at the centre of healthcare, prioritising standardisation, redistribution, and regulatory coercion over patient and doctor autonomy, economic growth, and medical innovation. This is reflected in the NHI Act and in various regulatory efforts aside from the Act.

But the widespread availability and affordability of healthcare is not possible without first creating the means to both provide and afford quality healthcare services. Only a thriving and productive economy absorbing millions more people into productive employment, together with greater freedom for healthcare businesses to trade, invest, and innovate, can furnish the means required to scale up quality healthcare supply to most people, and perhaps one day to nearly all people.

Policies that genuinely enable and advance this realistic type of healthcare abundance would find support from Sakeliga.

Implications for litigation

Sakeliga will not forgo litigation based on a vague, unspecified concession by the Minister of Finance - for at least two reasons.

Firstly, the NHI Act has been signed by the President, and the Department of Health has begun preparations for the NHI, even though the Act has not yet come into force. Unless or until the Act is repealed or amended so as to render it effectively inoperative, litigation efforts opposing it must continue.

Secondly, as long as the NHI Act remains legislation and the state's goal remains state-controlled healthcare, opposition – not compromise – remains the responsible course of action. The NHI Act and the state’s desire to place itself at the centre of healthcare are completely unreasonable, irrational, and harmful proposals, and therefore cannot legitimately serve as the anchor point for a negotiated settlement on healthcare regulation.

For such an indicative concession to impact the course of litigation, the government would have to demonstrate its seriousness in proposing a settlement with its legal opponents by tabling, through existing legal channels, a formal, departmentally unified, and clear set of terms for consideration and discussion among the parties and their legal representatives.

Should formal negotiations between the state and representative groups over healthcare regulation take place in the future, it would be important to ensure the state not only abandons the NHI Act and any other single-payer healthcare system framework but also abandons designs on central state control over healthcare by any means.

Good prospects for resisting the NHI

The finance minister's remarks reveal that, fortunately, the NHI is not inevitable. Opponents must challenge it staunchly, and the prospects for success from these challenges – if sustained and resolute – are promising.

Healthcare industry representative groups should avoid making premature concessions and harmful settlements while the state’s hand is much weaker than it pretends.

In the same vein, Healthcare businesses should also, as far as possible, steer clear of overcompliance and pre-compliance with the NHI, and instead prioritise a business-as-usual, value-adding customer focus for as long as feasible.

We must protect the independence of healthcare providers to ensure they can continue delivering and expanding quality care.

Further Reading

• Resisting the NHI and health-shedding - article by Sakeliga CEO, Piet le Roux, and Chief Economist, Russell Lamberti.

• Sakeliga launches Case to oppose the NHI Act - Application lodged with the High Court to oppose the nationalisation of healthcare

• Sakeliga files NHI court application to oppose the state's delay tactics - Sakeliga’s application ensures that if legal challenges are paused, so too must the NHI’s implementation