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2025 healthcare dilemmas: Will South Africa embrace NHI reforms amid worker shortage challenges?

2025 healthcare dilemmas: Will South Africa embrace NHI reforms amid worker shortage challenges?
Marcus Low
By Marcus Low
21 Jan 2025
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From the ongoing political and legal battles over National Health Insurance (NHI), to the far-reaching health impacts of political change in the United States, it is set to be another tumultuous year for healthcare in South Africa and around the globe.

Here are Spotlight’s top four healthcare questions for 2025.

Will we see a change of course on NHI? 


Arguably, the biggest healthcare question for this year is whether we will see any substantial changes to the government’s NHI plans. 

The NHI Act, signed into law last May (but not yet promulgated), foresees a massively reduced role for all medical schemes — essentially, schemes will only be allowed to cover things not already covered by the NHI fund. The Democratic Alliance, the second largest party in the Government of National Unity, is vehemently opposed to restricting the role of medical schemes in this way. 

A compromise option has emerged in recent months, first through the Hospital Association of South Africa and Business Unity South Africa, and more recently through a large coalition of healthcare worker groups under the banner of the Universal Healthcare Access Coalition. Broadly speaking, the compromise option is to make medical scheme membership mandatory for people earning above a certain threshold and then to have something like NHI for the rest. 

This is actually the type of system South Africa was slowly heading toward until the tide turned at the ANC’s Polokwane conference in 2007. The argument for a system like this is that the burden on the state will be reduced since millions more people will become members of medical schemes and thus shift pressure away from public sector facilities. (While Business Unity South Africa and Universal Healthcare Access Coalition agree on mandatory medical scheme cover, they differ in some other areas.) 

We put the chances of such a compromise option winning out well below 50%, given that internal ANC politics will make any change of direction perilous for President Cyril Ramaphosa. The more likely trajectory is that the NHI Act stays as is and that 2025 is the year in which the first few batches of NHI regulations are published and we start getting a clearer picture of what the eventual system will look like.

How will health-related changes in the US cascade around the world? 


The contribution of the US government to healthcare around the world is massive. The US has contributed more funds to the World Health Organization than any other country. Through the President’s Emergency Plan for Aids Relief, the US supports HIV and related programmes in many countries, including South Africa. Much medical research around the world, including in South Africa, is funded by the US National Institutes of Health. For many around the world, approval by the US Food and Drug Administration remains a trusted sign that a new medicine or vaccine is safe and effective. 

Though much is still uncertain regarding how things will play out under the second Trump administration, early indications are that to some extent all of the above are at risk. 

Should they come, large cuts to the President’s Emergency Plan for Aids Relief funding will be a significant setback for South Africa’s HIV response — and the impact in countries that rely more heavily on donor funding could be catastrophic. A return of the Mexico City Policy, which prohibits the use of US funding on abortion or the “promotion” of abortion, seems inevitable. Cuts to National Institutes of Health funding and a proposed move away from funding infectious disease research would be bad news for many researchers in South Africa — it could also mean that the brakes are put on research looking for an HIV cure and new TB treatments and vaccines. A weakened World Health Organization would hit developing countries the hardest, given that they are most dependent on its support and guidelines. 

But maybe even more concerning is the potential impact around the world of evidence-based medicine being rejected at the highest levels of the US government. As we know all too well from the years of state-sponsored Aids denialism under former president Thabo Mbeki, the cost of medical science being rejected in the corridors of power are likely to be counted in lives lost.

How many more people will have access to the latest HIV prevention products? 


The biggest HIV story of 2024 was that an HIV prevention injection that provides six months of protection per shot was found to be highly effective in two pivotal studies. Lenacapavir, the antiretroviral in the jab, was named the “breakthrough of the year” by the journal Science. 

The question now is when the lenacapavir injection will be registered for use in South Africa — we expect it to happen this year — and then when it will become available to the people who most need it. 

Another injection, one that contains the antiretroviral cabotegravir and that provides two months of protection per shot, has already been registered for use in South Africa, though it is only available to a relatively small number of people participating in operational research studies.

Will we finally see real leadership on the problem of healthcare worker shortages? 


One of the biggest problems in South Africa’s public healthcare system is that we don’t have enough healthcare workers. As shown in our previous reporting, the problem is not that we aren’t training enough healthcare workers, though there are problems there too, but that we aren’t absorbing enough of those who we do train into the system. The main reason for this is that provincial health budgets have for some years been shrinking in real terms, while workers have got pay rises that had not been budgeted for. 

The issue has got some attention, most notably in the 2030 Human Resources for Health Strategy, but beyond that there has been little sign of a comprehensive solution emerging from the Presidency, the Treasury or the health department. 

Some would of course argue that NHI is a comprehensive solution, but it will take many years to implement, and we need solutions right now. It is also not clear how far the redistribution of healthcare workers under NHI will take us. Switching to NHI would not in itself ensure that we train and employ sufficient numbers of healthcare workers. Establishing an NHI system also won’t ensure the kind of grand bargain that is needed with labour unions — for example to prioritise increasing staff numbers over increasing salaries. 

The questions we didn’t get to 


Apart from the above, some other questions we will keep an eye on this year include:  

  1. Whether South Africa’s ramping up of TB testing will gather momentum this year, or fizzle out.

  2. Whether important new diabetes and obesity medicines like semaglutide and tirzepatide will become substantially more widely available in South Africa and around the world.

  3. Whether the government will start taking the country’s growing diabetes and obesity crises as seriously as it takes HIV (currently we don’t even have a clear picture of how many people in the country have diabetes).

  4. Whether we will see greater accountability for corruption in South Africa’s public healthcare sector, and particularly for the widely reported alleged corruption at Tembisa Hospital.

  5. Whether the chronically dysfunctional Gauteng Department of Health will finally show signs of meaningful improvement.

  6. Whether progress in the fight against antimicrobial resistance will gather momentum and move beyond policy into widespread action. DM 


Low is the editor of Spotlight.

This article was first published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.

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