Finance Minister Enoch Godongwana’s appeal for parties challenging the National Health Insurance (NHI) Act to “meet and craft a settlement” has drawn a cautious – and in some cases sceptical – response from organisations pursuing litigation against the law.
Godongwana made the remarks during the National Assembly plenary debate on the Special Appropriation Bill on 13 January, arguing that South Africa needs to move with greater urgency towards universal access to healthcare, and that prolonged litigation will delay the implementation of the NHI for years. While acknowledging the multiple court challenges facing the Act, he said he believed a solution could still be found.
He told Parliament that both the state and those opposing the NHI Act “proclaim that they support universal coverage and access”, and on that basis urged the parties to engage with one another to craft a settlement that would allow implementation to proceed.
Godongwana framed access to healthcare as a socio-economic right that must be progressively realised under the Constitution, adding that the government was committed to translating this constitutional obligation into practice.
The minister’s intervention comes as at least nine active court applications challenge various aspects of the NHI Act, which was signed into law in 2024 but has not yet been brought into effect. Two significant matters are scheduled for hearing in February, including proceedings related to the consolidation of several constitutional challenges and a case before the Constitutional Court concerning procedural issues around the Act’s adoption.
Responses from litigants indicate that although there is broad support for the principle that no one should be denied healthcare because they cannot afford it, there is far less agreement that the NHI Act provides a workable or acceptable route to achieving that goal.
Board of Healthcare Funders
The Board of Healthcare Funders (BHF), which represents medical schemes, said it has “consistently and unequivocally” supported the objective of universal health coverage (UHC) and agrees that no South African should be denied access to healthcare on the basis of affordability. However, it warned that broad consensus on the objective masks deep disagreement about the policy mechanism proposed in the NHI Act.
Charlton Murove, the BHF’s head of research, told Moonstone that the Act in its current form risks dismantling a healthcare financing system that already delivers care to millions of South Africans, including a majority of beneficiaries from previously disadvantaged communities. He cautioned that replacing this system without a carefully sequenced transition could undermine continuity of care and financial sustainability, rather than accelerate progress towards UHC.
Murove said any settlement process would need to be grounded in “practical, evidence-based solutions that demonstrably expand access, improve affordability, and protect continuity of care”. He said the BHF has, over several years, submitted detailed proposals aimed at advancing UHC in a more incremental and sustainable manner, including allowing medical schemes to offer low-cost benefit options and enabling collective tariff negotiations with healthcare providers. These proposals, he said, were not taken forward.
In that context, the BHF said it approached the courts to obtain legal clarity on matters of constitutionality and implementation. Litigation, it emphasised, was not an end in itself.
Asked whether the BHF regarded Godongwana’s remarks as representing a meaningful shift in the government’s approach to the NHI, Murove cautioned against interpreting the minister’s statements as a substantive policy shift in the absence of concrete legislative or regulatory change.
“A meaningful shift would be reflected in openness to alternative pathways to UHC, regulatory reform that enables affordability and innovation, and clear plans for how existing public and private healthcare capacity will be integrated rather than displaced.”
Health Funders Association
The Health Funders Association (HFA) said it agrees that UHC is a shared objective and a constitutional imperative, and welcomed Godongwana’s call for engagement, collaboration, and the possibility of negotiated solutions rather than prolonged court processes.
It told Moonstone that the Association has consistently supported health reform aimed at making South Africa’s healthcare system more equitable, accessible and sustainable, and has long maintained that litigation should be a last resort rather than a substitute for meaningful engagement.
The HFA’s decision to challenge the NHI Act followed years of constructive submissions, technical proposals and repeated requests for engagement that did not result in substantive policy change.
The court action is not aimed at the government per se, but at safeguarding South Africans against an NHI framework that the HFA believes, in its current form, is unworkable, fiscally unfeasible, and risks unintended harm to access, affordability and system stability.
While welcoming the finance minister’s call for collaboration, the HFA said any reconsideration of litigation would depend on whether a credible, structured process emerges that demonstrates genuine commitment to reform, evidence-based policymaking, and practical outcomes that protect households and the health system.
On whether Godongwana’s remarks signal a meaningful shift in the government’s approach, the HFA said it is encouraged by the emphasis on collaboration and cross-sector engagement, but that a substantive shift would need to be assessed through policy action rather than statements alone. This would include structured engagement with stakeholders, willingness to refine the NHI model to ensure fiscal sustainability, transparency around costing, sequencing and workforce capacity, and interim reforms that expand access in the near term rather than only over a 10- to 15-year horizon.
The HFA said it has already placed workable alternatives on the table, including a hybrid, multi-fund model that builds on the NHI Fund, incorporates international best practice, and preserves effective elements of South Africa’s mixed healthcare system.
The Association believes South Africa can move faster towards UHC by prioritising the expansion of affordable, good-quality primary and preventive healthcare, particularly for the “missing middle”, and by leveraging existing private-sector expertise and capacity during a phased transition.
Hospital Association of South Africa
The Hospital Association of South Africa (HASA) said it would not have embarked on litigation if the government had been willing to engage constructively during the development of the NHI legislation.
HASA chief executive Dumisani Bomela said the association remains open to working with the government to improve access to healthcare, but that such engagement would require the state to “fundamentally revisit” its approach to the NHI.
Sakeliga
Business lobby group Sakeliga directly challenged the premise underlying Godongwana’s appeal, disputing the claim that all litigants support universal healthcare.
Russell Lamberti, Sakeliga’s executive director, said the term “universal healthcare” is ambiguous and capable of accommodating fundamentally different and often incompatible policy positions. Even where there may be agreement on improving access to healthcare, he said, there is deep disagreement over whether universal healthcare – as defined and pursued by the state – is desirable, and over the means proposed to achieve it.
Lamberti told Moonstone that when the state refers to universal healthcare, it is advancing a policy model centred on extensive state control and stringent regulation of independent private and community healthcare providers. By contrast, he said, other litigants who express support for universal healthcare are often articulating a general aspiration rather than endorsing the state’s regulatory model.
He said Sakeliga would not forgo litigation unless the NHI Act is repealed or amended to render it effectively inoperative. As long as the state’s policy objective remains placing itself at the centre of healthcare delivery, he said, opposition – rather than compromise – remains the responsible course of action.
Lamberti said it is apparent that National Treasury has come to regard the NHI as unaffordable. Godongwana’s remarks were therefore “not surprising” and likely reflect a desire to avoid a legislative proposal that entails substantial tax increases for already heavily taxed citizens.
His remarks, Lamberti said, “confirm what Sakeliga already knew: that Treasury is alarmed by the NHI’s exorbitant cost implications and that the state will eventually concede the need to walk back such an irrational proposal for healthcare regulation”. At the same time, he said, the comments “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 Godongwana may be expressing a willingness among some parts of the executive to retreat on the NHI, Lamberti said it is not yet clear that this translates into broad-based support within the executive to do so, or into an abandonment of the principle of state control over healthcare.
Solidarity
Trade union Solidarity rejected the idea of settling litigation on the basis of the NHI Act, making clear that it will not abandon its opposition to the legislation.
Theuns du Buisson, an economic researcher affiliated with the Solidarity Research Institute, said Solidarity remains open to constructive dialogue and engagement, but only if a sustainable alternative is seriously considered – and not any version or reconfiguration of the NHI. In early 2025, Solidarity submitted an alternative piece of legislation, the Healthcare Funding Reform Bill, to Parliament.
“No form of the NHI is acceptable to us,” Du Buisson said, adding that as long as the NHI remains the government’s point of departure, reconciliation is not possible. He said Solidarity supports universal healthcare in principle but insists that reform must not leave anyone worse off or strip people of existing rights, benefits or access to care.
Du Buisson argued that the NHI would remove meaningful choice from patients and practitioners and place healthcare delivery in the hands of an already underperforming public system. In the absence of serious consideration of Solidarity’s alternative framework, he said, the organisation would continue litigation.
South African Medical Association
The South African Medical Association (SAMA) adopted a more conciliatory tone, while emphasising that its support is directed towards a reconfigured NHI rather than the Act as currently framed.
SAMA reaffirmed its commitment to working collaboratively with the government to ensure that the NHI achieves UHC in a sustainable and equitable manner. It emphasised that litigation was pursued only as a last resort, after repeated attempts to engage through parliamentary submissions, petitions to the National Council of Provinces, and correspondence with the President failed to elicit meaningful responses.
The Association confirmed that it recently met with Health Minister Dr Aaron Motsoaledi (on unrelated matters), and that the parties agreed to schedule a dedicated engagement on the NHI.
SAMA said real progress would depend on continued, meaningful engagement with stakeholders across the healthcare ecosystem, and reiterated its willingness to contribute expertise towards a framework that is evidence-based, fiscally sustainable, transparently governed, and informed by developments in health technology.
Moonstone asked the South African Private Practitioners’ Forum for comment, but none was received by the time of publication.
