This article was first published by The Witness on 26 August 2026
There is a persistent claim in South African public discourse that the National Health Insurance (NHI) scheme is necessary because the state simply does not spend enough on healthcare. According to this narrative, our public hospitals and clinics are in crisis primarily due to a lack of funds; more money through a centralised NHI Fund will magically deliver quality care for all. This is untrue. The numbers tell a different story, and the ideology behind NHI reveals something far more dangerous than a funding shortfall.
Public health expenditure has risen substantially over the years. In 1995/96, total public-sector health spending stood at roughly R18.7 billion. By 2019/20 it had climbed to over R220 billion. Growth was particularly strong in the years after the mid-2000s as the HIV programme expanded.
More recent consolidated figures continue the pattern of year-on-year nominal increases. Treasury estimates put consolidated health expenditure at a revised R267.3 billion, rising to R271.9 billion in 2024/25, R281.1 billion in 2025/26 and R295.2 billion in the next year. Provincial health expenditure grew from R231.6 billion in 2021/22 to R250.6 billion in 2023/24, with further projected increases to around R280 billion by 2026/27.
One recent budget overview put total consolidated government health spending at R310.4 billion. The 2025 budget speech signalled growth from R277 billion towards R329 billion by 2027/28. National Department of Health allocations have also risen in successive Estimates of National Expenditure documents, even as real growth has sometimes lagged inflation and population increases.
These are not the numbers of a neglected sector starved of resources. Staff numbers and budgets have expanded over decades. Yet outcomes remain poor: long queues, medicine stock-outs, collapsing infrastructure, and repeated scandals of waste and corruption.
Tembisa Hospital alone saw billions looted. The problem is not that the state spends too little; it is that the state spends badly, prioritises control over competence, and faces no real market discipline for failure.
NHI does not fix this; it doubles down on the same model. The Act creates a single national fund that will purchase care for all eligible residents, largely crowding out private medical schemes for the services it covers. It expands the very bureaucracy that has already failed to deliver.
Proponents frame it as social solidarity and universal coverage. In reality it is a power grab: more centralisation, more ministerial discretion, less individual choice, and the effective criminalisation of private arrangements that currently work for millions.
The philosophical foundations are revealing. NHI treats healthcare as a positive right that the state must deliver by compelling others to pay and by restricting alternatives. This sits uneasily with a free society.
Negative rights protect individuals from coercion; positive rights require the state to take from some to give to others. When the taker is an inefficient, capture-prone administration, the results are predictable. South Africans already experience state failure in electricity, water, and local government. Expanding that model into life-and-death decisions is reckless.
Critics of NHI are often painted as defending inequality or private profit – that is a distraction. The private sector exists because public facilities cannot meet demand or quality expectations. Medical schemes are voluntary associations of people pooling risk.
Destroying or severely limiting that option does not improve public hospitals; it simply removes an escape valve and concentrates more patients into a system that already cannot cope. Preparatory NHI grants and indirect funding continue to flow even while the Act faces multiple court challenges, showing the state’s determination to push ahead regardless of fiscal realism or legal process.
Year-on-year budgetary growth has not translated into corresponding improvements in service quality for the majority who rely on the public system. That is the core indictment. Throwing more money at the same institutional arrangements, or consolidating them under an even larger central fund, will not change the incentives.
Corruption, cadre deployment, weak management, and the absence of competition remain. Real reform would focus on deregulating the health sector in general so that private insurers can create products for low income individuals without state mandated prescribed minimum benefits as one example.
Another area of reform should be greater provincial and facility autonomy, transparent contracting with private providers where it works, and most importantly protecting the right of individuals to spend their own money on their own health.
The claim that state health spending has stagnated is false. Spending has risen. The crisis persists because the model is broken. NHI is not the solution; it is an intensification of the problem.
South Africans deserve better than another ideological experiment that prioritises state power over patient outcomes and individual liberty. South Africans need liberty, especially in healthcare, lest we continue on the road down to serfdom.
