National Health Insurance Act: a single public fund to buy health care for all, adopted in 2024 but not yet in force
The National Health Insurance Act 20 of 2023, assented to by President Ramaphosa on 15 May 2024, creates a National Health Insurance Fund meant to become the single purchaser and single payer of health care services, funded through mandatory prepayment, with medical schemes limited to complementary cover once the scheme is fully implemented. The Act only takes effect on dates the President fixes by proclamation, and no section has been put into operation: on 24 February 2026 the President agreed to delay any proclamation until the Constitutional Court rules on challenges by the Board of Healthcare Funders and the Western Cape government to the public participation process. The Court heard the cases on 5 to 7 May 2026 and has reserved judgment. The Democratic Alliance, a partner in the Government of National Unity, opposes the Act in its current form.
Key points
Sections of the Act in force
0
at 11 November 2026 · Observed
commencement « to be proclaimed » according to the government’s legislation page; the President undertook not to proclaim any section before the Constitutional Court rules[1][13][12]
People without private medical insurance relying on provincial health services
53,400,000
2026 Budget Review · Estimate
according to the National Treasury (Budget Review, 25 February 2026)[14]
Written submissions received by Parliament on the bill
338,891
2019 to 2023 · Observed
according to Parliament (« approximately », press release of June 2023)[3]
Whether this participation was meaningful is the question before the Constitutional Court.
Out-of-pocket health spending
6.7%
2023
- Status: Adopted since February 24, 2026. No section has been put into operation (commencement « to be proclaimed »). The President agreed to delay the proclamation of any section until the Constitutional Court has ruled on the public participation challenges heard on 5 to 7 May 2026; judgment is reserved.[13][1][11][16]
- Next milestone: 2028, End of Phase 2 in the Act’s transitional timetable
At a glance
Reference text
National Health Insurance Act, 2023 (Act No. 20 of 2023), assented to on 15 May 2024[1][2]
No. Act No. 20 of 2023 (Government Gazette No. 50664, 16 May 2024) · May 15, 2024
Read the text ↗Carried by
- National Department of Health[7][3]Designed the NHI: Green Paper published for public consultation in 2011, pilot projects from 2012, White Paper, then the bill tabled in Parliament in August 2019 · 2011-2019 · Initiator
- Joe Phaahla[4]Minister of Health when the National Assembly passed the bill in June 2023 · 2023 · Initiator
- Cyril Ramaphosa[6][2]President of the Republic: signed the bill into law on 15 May 2024; holds the power to bring the Act into effect by proclamation · 2024 · Initiator
- Cyril Ramaphosa[13]President of the Republic: agreed, after consulting the Minister of Health, to delay the proclamation of any section until the Constitutional Court hands down its judgments · since February 2026 · Suspension
- Aaron Motsoaledi[9][13][8]Minister of Health in the Government of National Unity: responsible for regulations under the Act and for the preparatory work before commencement · 2025-2026 · Implementation
Implementation
- National Department of Health
- National Health Insurance Fund (to be established): autonomous public entity governed by a Board of at most 11 members appointed by the Minister
- National Treasury: funding of the Fund through money appropriated by Parliament, and the NHI conditional grants
- Office of Health Standards Compliance: inspection and certification required for providers to be accredited by the Fund
Stated objective
Achieve universal access to quality health care services in accordance with section 27 of the Constitution, through a fund financed by mandatory prepayment that acts as the single purchaser and single payer of health care services, so that care is distributed equitably and funding is sustainable.[2][7]
According to the National Health Insurance Act (long title and section 2)
Phase 1 of implementation (health system strengthening, establishment of the Fund)
4 years
2023 to 2026 · according to section 57 of the Act[2]
Phase 2 (Fund operating as purchaser through mandatory prepayment, selective contracting of private providers)
3 years
2026 to 2028 · according to section 57 of the Act[2]
Main measures
- A National Health Insurance Fund is established as an autonomous public entity (Schedule 3A of the Public Finance Management Act), governed by a Board of at most 11 persons appointed by the Minister and accountable to the Minister; it is exempt from the Competition Act so it can act as single purchaser and single payer.[2]
- The Fund purchases health care services on behalf of South African citizens, permanent residents, refugees, inmates and categories of foreigners determined by the Minister of Home Affairs. Asylum seekers and illegal foreigners are entitled only to emergency medical services and services for notifiable conditions; all children are entitled to basic health care services. Users must register with the Fund at an accredited provider.[2]
- Benefits are determined by a Benefits Advisory Committee; to be accredited, providers must be registered with their professional council and certified by the Office of Health Standards Compliance. Central, provincial and district hospitals are paid by global budget or diagnosis-related groups.[2]
- Once National Health Insurance has been fully implemented, as determined by the Minister through regulations, medical schemes may only offer complementary cover for services not reimbursable by the Fund (section 33).[2]
- The Fund’s chief income is money appropriated annually by Parliament from general tax revenue (including funds shifted from departments and provincial allocations), the reallocation of medical scheme tax credits, a payroll tax (employer and employee) and a surcharge on personal income tax, introduced through a money bill by the Minister of Finance.[2]
- The Act is to be phased in « using a progressive and programmatic approach based on financial resource availability », over two phases (2023-2026 and 2026-2028), and takes effect on dates fixed by the President by proclamation, which may differ by provision (sections 57 and 59).[2]
- Meanwhile, the 2026 budget carries two NHI conditional grants to provinces: the NHI grant (R467 million in 2025/26, adjusted budget, rising to R513 million in 2028/29) and the NHI indirect grant (R3,315 million in 2025/26, then R2,560 million in 2026/27 and R2,678 million in 2028/29).[14]
In data
Health expenditure
8.7% GDP
2022
Current health spending, public and private, as a share of GDP: the envelope the Fund is meant to pool.
Public health spending (% of GDP)
4% GDP
2022
Government and compulsory schemes only.
Out-of-pocket health spending
6.7%
2023
Payments made directly by patients, which the NHI aims to replace with no payment at the point of care.
Timeline
- Announced
NHI Green Paper published for public consultation[7]
NHI Green Paper, then pilot projects from 2012[7]
According to the Department of Health, the NHI Green Paper was published for public consultation in 2011, followed in 2012 by NHI pilot projects focused on strengthening the health system.
- Under debate
National Health Insurance Bill tabled and referred to the Portfolio Committee on Health[3]
Bill tabled in Parliament[3]
The bill was tabled and introduced to the Portfolio Committee on Health on 8 August 2019; the committee received its first briefing from the Department of Health on 29 August 2019.
Public hearings in all nine provinces[3]
According to Parliament, the hearings were attended by 11,564 members of the public and stakeholders across 33 district municipalities, and 961 oral submissions were heard. Virtual hearings with 114 stakeholders followed from 18 May 2021 to 23 February 2022, and the committee received about 338,891 written submissions.
National Council of Provinces passes the bill[5]
- Adopted
President Ramaphosa signs the National Health Insurance Act into law[6][2][3][5]
Passed by the National Assembly in June 2023 and by the National Council of Provinces on 6 December 2023; published in Government Gazette No. 50664 of 16 May 2024. The Act takes effect only on dates fixed by the President by proclamation, possibly different for different provisions.
Democratic Alliance declares a formal dispute within the Government of National Unity over the NHI and the Expropriation Bill[8]
DA leader John Steenhuisen said he had written to the President with proposals on the NHI Act and that the DA had objected to the inclusion of NHI targets at the previous Cabinet Lekgotla.
Draft regulations on the governance of the Fund published for comment[9][10]
Department of Health notice No. 5950 in Government Gazette No. 52224 of 6 March 2025; comments were invited until 6 June 2025. The Western Cape provincial cabinet decided to oppose the draft regulations in their entirety, calling them premature and invalid.
Board of Healthcare Funders applies directly to the Constitutional Court[11][12]
Notice of motion dated 29 July 2025 (case CCT 251/25, against the Speaker of the National Assembly and twenty-three others). The Premier of the Western Cape brought a separate application (CCT 269/25); both concern public participation in the making of the Act.
- Adopted
Commencement put on hold pending the Constitutional Court[13][1][11][16]
No section has been put into operation (commencement « to be proclaimed »). The President agreed to delay the proclamation of any section until the Constitutional Court has ruled on the public participation challenges heard on 5 to 7 May 2026; judgment is reserved.
President agrees to delay any proclamation until the Constitutional Court rules[13][15]
The Presidency said the undertaking, given after consultations with Minister Motsoaledi, would not affect the timetable for implementing the NHI, and that the agreement was expected to be made an order of court on 24 February 2026. According to press reports, parties challenging specific sections of the Act in other cases agreed to pause them pending the Constitutional Court.
Constitutional Court hears the public participation challenges[11][12][16]
The Board of Healthcare Funders asked the Court to declare the whole Act invalid; the Western Cape government asked for the public participation process to be redone in two provinces. Parliament maintained that proper processes were followed.
- Upcoming: the outcome is not known
End of Phase 2 in the Act’s transitional timetable[2]
Section 57 sets Phase 2 « from 2026 to 2028 », with the operationalisation of the Fund as a purchaser through mandatory prepayment as its objective. That timetable assumes the Act is in force; whether it can still be met is not known.
The debate
Citoyen takes no position: arguments are reported as their authors put them.
According to its supporters
- President Ramaphosa argues that health care provision is « fragmented, unsustainable and unacceptable »: the public sector serves most of the population under budget constraints while the private sector serves a fraction at far higher cost, and the NHI would free resources in poor families and tackle the misallocation of health spending.[6]
- The Department of Health says the current system is fragmented with high levels of waste, and that buying care for the entire population through one fund would cut costs through economies of scale, with no payment at the point of care.[7]
- Minister Joe Phaahla stressed in 2023 that implementation would be gradual and phased, and that the groundwork was under way: budgets earmarked for facilities and training, and a Health Patient Registration System installed in over 3,000 public health facilities.[4]
- Parliament defends its process: hearings in all nine provinces, virtual hearings and about 338,891 written submissions; before the Constitutional Court it maintained that proper processes were followed and that the applicants are unhappy with the outcome.[3][16]
According to its opponents
- The Board of Healthcare Funders argues that Parliament never gave the public a credible account of what the scheme would cost, how it would be funded or what the basket of services would be, making participation a « ritual »; it asks for the Act to be declared invalid.[12]
- The Western Cape government says it supports the principle of universal health care but that the Act in its current form poses a risk to the functioning of the province’s health system, and that the National Council of Provinces did not give it a fair opportunity to submit its mandate.[10][16]
- The Democratic Alliance, the second party of the Government of National Unity, says it is committed to universal quality health care but that the NHI « in its current form is not the vehicle for this », as it risks undermining both public and private health care; it declared a formal GNU dispute in January 2025.[17][8]
Indicators to watch
- Constitutional Court judgment in CCT 251/25 and CCT 269/25 · Constitutional Court of South Africano Citoyen card yet
- Proclamations fixing the commencement of sections of the Act · The Presidency / Government Gazetteno Citoyen card yet
- NHI conditional grants to provinces (direct and indirect) · National Treasuryno Citoyen card yet
- Out-of-pocket health spending · OMS / Banque mondialeSee the card →
- Current health expenditure · OCDESee the card →
- Life expectancy at birth · Banque mondialeSee the card →
- Infant mortality · Banque mondialeSee the card →
Sources
- [1]National Health Insurance Act 20 of 2023 (English / Afrikaans): commencement « To be proclaimed » –South African Government (gov.za), May 16, 2024
- [2]Act No. 20 of 2023: National Health Insurance Act, 2023, Government Gazette No. 50664, 16 May 2024 (assented to 15 May 2024) –The Presidency, Government Gazette (via gov.za), May 16, 2024
- [3]Press Release: The National Assembly Passes The National Health Insurance Bill and The Land Court Bill –Parliament of the Republic of South Africa, June 2023
- [4]Minister Joe Phaahla on passing of National Health Insurance Bill by National Assembly –Department of Health (via gov.za), June 13, 2023
- [5]NCOP Passes the National Health Insurance Bill and Two other Bills –Parliament of the Republic of South Africa, December 6, 2023
- [6]President Ramaphosa signs NHI Bill into law –SAnews, South African Government News Agency, May 15, 2024
- [7]NHI: Background and history –National Department of Health
- [8]DA declares formal GNU dispute over Expropriation Bill and NHI –Democratic Alliance, January 25, 2025
- [9]National Health Insurance Act: Regulations: Governance of the Fund: Comments invited (Government Notice No. 5950, Government Gazette No. 52224) –Department of Health (via gov.za), March 6, 2025
- [10]Western Cape Government on National Health Insurance Act draft regulations –Western Cape Government (via gov.za), May 29, 2025
- [11]Board of Healthcare Funders NPC v Speaker of the National Assembly and Others; Premier of the Western Cape Government v Chairperson of the National Council of Provinces and Others (CCT 251/25, CCT 269/25), case record –Constitutional Court of South Africa (collections)
- [12]Board of Healthcare Funders NPC v Speaker of the National Assembly and twenty-three others, CCT 251-2025: Applicant’s written submissions –Constitutional Court of South Africa (case record)
- [13]Presidency on National Health Insurance Act litigation –The Presidency (via gov.za), February 24, 2026
- [14]2026 Budget Review (chapters 5 and 6, Table 6.3 Conditional grants to provinces) –National Treasury, February 25, 2026
- [15]Participatory democracy: What will be on the line when the country’s highest court turns to NHI in May? –Spotlight, April 23, 2026 · secondary source
- [16]ConCourt reserves judgment in NHI challenge –Eyewitness News (EWN), May 7, 2026 · secondary source
- [17]ConCourt precedent undermines NHI centralised model and relegates NHI as unworkable –Democratic Alliance, May 18, 2026