UHAC proposal offers implementable solutions to reform SA's healthcare.

A pragmatic route to achieving universal access to equitable, quality and affordable healthcare in South Africa is gaining support amongst healthcare professionals, workers and patient advocacy organisations, as government sticks to its guns on continuing with the “unimplementable” and “unfixable” National Health Insurance (NHI) Act.

The Universal Healthcare Access Coalition (UHAC) says its proposed framework for healthcare reform is practical, evidence-based, capable of more immediate implementation and critically, is designed to work within the country’s fiscal constraints rather than raising the tax burden on citizens.

In response to President Cyril Ramaphosa’s State of the Nation address [Thurs, 6 Feb 2025] where he said government would proceed this year with “the preparatory work for the establishment of the NHI”, UHAC steering committee member Dr Aslam Dasoo said this signalled that the crumbling state of healthcare would continue “while government tries to figure out how to fund and implement an unworkable NHI”.

“Effectively, the SONA promised little more than policy stagnation and an untenable status quo. The UHAC has developed a concrete, workable reform pathway to address the very evident failures in the public and private healthcare systems and achieve a high-performing system of universal access and coverage in South Africa,” said Dr Dasoo, who is the convenor of the Progressive Health Forum (PHF).

The UHAC represents the majority of South Africa’s healthcare and related professionals and industry organisations, with more than 25 representative organisations as signatories to the proposed healthcare reform framework, and support growing. The group was formed following the President’s invitation in September 2024 for specific proposals of workable solutions to advance quality, affordable healthcare for all in South Africa.

The NHI Act is “deeply flawed”, said UHAC steering committee member Dr Mvuyisi Mzukwa, chair of the SA Medical Association (SAMA).

“The NHI does not materially depart from the weaknesses of the current system but instead centralises control without resolving fundamental problems. The Act as it stands is unworkable, lacking a clear implementation pathway and timeframes. Crucially, the NHI model of a single tax-financed fund to provide healthcare access and cover for the entire population is unfeasible and unattainable in the country’s current and foreseeable economic future.”

“UHAC proposes a mixed funding model of medical scheme contributions and general taxes, with some re-alignment of existing taxes, which better aligns with the country’s fiscal constraints and will ensure long-term sustainability,” Dr Mzukwa said.

UHAC steering committee member Dr Simon Strachan, CEO of the SA Private Practitioners Forum (SAPPF), said the coalition’s proposal draws on research and the recommendations of various commissions and related enquiries over the last three decades, updated and designed to account for the absence of healthcare reform over the last 20 years.

“The public system is failing due to institutionalised corruption enabled by flawed governance structures. Needed reforms to the private system, most recently outlined by the Health Market Inquiry in 2019, have inexplicably been put on indefinite hold – an apparent consequence of the irrational and counterproductive perspective that medical schemes would no longer exist.

“There have been contradictory statements recently on whether or not changes will be made to the Act to continue allowing private medical schemes to operate fully, but this is in any case insufficient to ‘fix’ the NHI,” Dr Strachan said.

He said UHAC aimed to build broad consensus across the healthcare and related sectors, civil society advocacy organisations, academia and the public, on a viable means to achieve healthcare reform and the Constitutional right of access to healthcare.

While the NHI would overhaul the entire healthcare system and its funding, the coalition’s proposals aim to build on the strengths of the existing system, while resolving weaknesses, and would deliver both immediate and incremental improvements over time.

“The UHAC proposed framework is adaptable and scalable, leading to sustainability and a path of progressive improvement over time, avoiding the systemic disruption of a complete one-time overhaul,” Dr Mzukwa said.

Dr Dasoo said the proposed strategic reform actions were within the capabilities of government to implement and not dependent on additional fiscal support.

“Implementing the proposed reforms could begin almost immediately and make a real and sustainable difference to improving access to healthcare,” he said.

He said UHAC was continuing to gather input and support for the proposal, “developed by highly capable minds drawn from across the diversity of health professionals and stakeholders”.

“As healthcare professionals, we serve and are accountable to the people, not the government. We want to put healthcare back in the hands of the people. We are your healthcare workers with your best interests at heart in optimising healthcare for all,” Dr Dasoo said.

The UHAC proposed healthcare framework has several key distinctions from the NHI.

“This is not an ‘NHI alternative’ as such, as the NHI is focused on the funding of healthcare. Our proposals go broader than funding:  into the governance, regulation and delivery of both public and private healthcare, and integrate the two systems rather than alienating private care as under the NHI,” Dr Strachan said.

The coalition believes that improving governance in the public system and better regulating the private system for cost efficiency and equity, will address the currently polarised system of “an underperforming public sector and an expensive private sector.”

Governance reform is a key element of the framework, which proposes retaining health as a provincial competency to keep management and decision-making closest to service delivery points.

“We propose addressing current governance failures by de-politicising healthcare management through independent supervisory boards to oversee operational decision-making for each public health facility. “This would improve accountability, reduce corruption, and enhance service delivery efficiency,” Dr Dasoo said.

Healthcare funding (taxes and medical scheme contributions) and risk management will be pooled at national level to ensure equitable distribution of resources, while it is proposed that purchasing of healthcare services be decentralised for more efficient, localised decision-making.

“The UHAC approach introduces multilateral tariff negotiations, independent regulation, and competitive alternatives to address rising costs in the private sector, which are more targeted and nuanced than the NHI’s reliance on centralised purchasing,” Dr Strachan said.

The UHAC proposes mandatory medical scheme coverage for higher-income groups, in order to leverage the strengths of the private sector. Unlike the NHI which bars the private sector from covering services offered under the NHI, the coalition’s proposal would see medical schemes continuing to offer the full spectrum of cover and services, albeit more tightly regulated for competitiveness and efficiency.

A publicly-sponsored medical scheme, to which individuals can choose to contribute instead of a private scheme, is also proposed, to increase competitiveness and affordability in the sector.

The UHAC has secured the support of most of the major formations of health workers and professionals, along with patient advocacy organisations, and is continuing consultations across the spectrum of business, academia and civil society, as well as organs of state.

“The purpose is to achieve a broad, public consensus on the critical reforms needed to take healthcare from a state of endemic crisis to one of coherence, stability and progressive improvement,” Dr Mzukwa said.

“These proposals, from a broad-based and consensus-driven coalition of healthcare professionals, hospital and medical scheme representative bodies, worker formations and patient advocacy organisations, would enable government to implement practical solutions that are supported by the South African public to meet their needs for affordable, accessible healthcare,” Dr Dasoo said.

Interested parties can find more information on UHAC and the proposals at https://progressivehealthforum.net/uhac/

About the Universal Healthcare Access Coalition (UHAC)

The Universal Healthcare Access Coalition (UHAC) is a collaboration of the majority of SA’s healthcare professional and business organisations and related institutions of patient advocacy, academia and society. Currently, 28 representative organisations have joined UHAC and are signatories to its proposal with more expressing interest to join.

The reform proposal was jointly developed by the South African Medical Association (SAMA), the Progressive Health Forum (PHF) and the SA Private Practitioners Forum (SAPPF), which then formed UHAC and gathered further input and signatories.

The coalition is committed to building a broad consensus by fostering open dialogue and inviting inputs to strengthen the proposals for healthcare reform in SA, pursuant to the constitutional entitlement to unimpeded access to healthcare for all who live in South Africa.