South Africa’s NHI Rollout: What’s Actually Live vs Still a Plan

South Africa’s National Health Insurance (NHI) is legally established but not yet operating as a fully functional nationwide health insurance fund. The National Health Insurance Act 20 of 2023 was signed by President Cyril Ramaphosa on 15 May 2024, but the Act states that it will take effect only on a date proclaimed by the President in the Government Gazette. As of September 2026, no nationwide NHI benefit system has replaced the existing public healthcare system, private medical schemes or private cash-paying arrangements.

The government is continuing preparatory work, including healthcare-system strengthening, institutional planning, digital health development and work connected to the proposed NHI Fund. However, the proclamation of sections of the Act has been delayed while Constitutional Court challenges concerning the parliamentary public-participation process are considered.

This distinction matters. South Africa has an NHI law, but having an enacted law is not the same as having a fully operational fund that pays doctors, hospitals and pharmacies for all residents.

NHI Status in 2026

The clearest way to understand the rollout is to separate what has already happened from what remains conditional or incomplete.

The Department of Health describes NHI as a tax-funded Fund that would purchase healthcare services from contracted public and private providers. Its published FAQ explains that users would receive covered services from accredited providers without paying at the point of care. That model is a future operating framework rather than a service currently available across South Africa.

What the NHI Act Says

The National Health Insurance Act 20 of 2023 provides the statutory framework for a National Health Insurance Fund. Its stated objectives include achieving universal access to quality healthcare services, establishing the Fund, creating governance structures and providing for the strategic purchasing of healthcare services.

Section 2: Purpose of the Act

Section 2 sets out the purpose of the legislation. It provides for:

• Universal access to quality healthcare services in accordance with section 27 of the Constitution.
• Establishment of a National Health Insurance Fund.
• Powers, functions and governance arrangements for the Fund.
• Strategic purchasing of healthcare services on behalf of users.
• Equitable, effective and efficient use of Fund resources.
• Measures addressing unlawful, unethical and undesirable conduct connected with the Fund.

The Act therefore creates the legal architecture for a single public purchaser. It does not, by itself, mean that every South African can currently visit any private doctor or hospital and have the bill paid by NHI.

Section 4: Proposed users of the Fund

The Act provides for access categories that include South African citizens, permanent residents, refugees, inmates and specified categories of foreign nationals. Asylum seekers and undocumented migrants are addressed differently, particularly for emergency medical services and notifiable conditions. Children are intended to receive broader protection under the framework.

The Department of Health’s FAQ also explains that visiting foreign nationals would generally rely on mandatory travel insurance, while specific healthcare access rules would apply to other foreign-national categories.

Section 7: Functions of the Fund

The Fund is intended to act as a strategic purchaser. In practical terms, this means that the Fund would collect or receive public financing and use it to buy defined healthcare services from contracted providers.

This differs from the present arrangement, in which:

• Provincial health departments fund and operate public facilities.
• Medical schemes finance private healthcare for their members.
• Patients without medical cover may pay private providers directly.
• Employers may contribute to medical-scheme membership, but this is not an NHI contribution.

Section 39: Accreditation

The Act links access to NHI purchasing arrangements with accreditation and contracting. A healthcare provider would need to satisfy prescribed requirements before the Fund could purchase services from that provider.

The Department of Health explains that providers would generally need professional registration, certification by the Office of Health Standards Compliance and compliance with NHI requirements covering service quality, reporting, treatment protocols, referral pathways and pricing.

This means that the phrase “NHI will cover private doctors” requires an important qualification: the provider would need to participate in the NHI system and meet the applicable requirements. A private provider that has not contracted with the Fund would not automatically become an NHI provider.

Section 57: Transitional implementation

Section 57 requires the Act to be implemented in phases using a progressive and programmatic approach based on available financial resources. The Act describes:

• Phase 1 as covering the period from 2023 to 2026.
• Phase 2 as covering the period from 2026 to 2028.

The first phase focuses on health-system strengthening, human-resource planning, institutional development, legislative work and purchasing healthcare services for vulnerable groups. The second phase is intended to advance the Fund and its purchasing functions. Act 20 of 2023

The phase dates are statutory implementation planning periods. They do not mean that the entire NHI benefit package automatically became operational at the start of 2026.

Section 59: Commencement

Section 59 is central to the current status. It provides that the Act takes effect on a date fixed by the President through proclamation in the Government Gazette. The official government publication lists the commencement status as “To be proclaimed.”

This is why the NHI Act can be an enacted statute while many of its operational provisions remain inactive.

What Is Actually Live?

The law has been enacted

The NHI Act is an Act of Parliament and was assented to by the President in May 2024. This gives the government a statutory framework for developing the Fund and pursuing the policy objectives contained in the legislation.

However, enactment does not equal complete implementation. The Act’s commencement clause requires a proclamation, and various operational arrangements still depend on regulations, institutions, funding decisions, contracting systems and legal developments.

Existing public healthcare continues

Public clinics, community health centres and hospitals continue to provide services through the existing national and provincial health structures. Patients do not currently use a universal NHI card or NHI registration process to access the whole public health system.

South Africa’s existing public healthcare system remains separate from the future nationwide purchasing model described in the NHI Act.

Health-system strengthening is continuing

The Department of Health has identified infrastructure, human resources, information systems and service quality as part of the preparation process. Its 2024/25 annual report recorded development of an electronic medical record for primary healthcare, including a TB/HIV-focused version deployed in March 2025 across 37 pilot facilities.

This is relevant to NHI preparation, but an electronic medical-record pilot is not the same as a functioning national NHI Fund. It represents supporting infrastructure that may help a future system operate across facilities.

Government has published an implementation explanation

The Department of Health has published information explaining the proposed benefits, provider accreditation, registration, funding and transitional arrangements. These documents are useful for understanding government policy, but they do not create a live entitlement beyond what has been legally commenced and operationally implemented.

What Is Still a Plan?

Nationwide NHI-funded healthcare

The proposed model is that the Fund would purchase comprehensive personal healthcare services from accredited public and private providers. The Department’s FAQ lists primary, secondary, tertiary, specialised and quaternary services, as well as emergency care, rehabilitation, palliative care, mental-health services, medicines and diagnostic procedures.

That full package is not currently available nationwide under one operational NHI purchaser.

Free care at contracted private providers

The Department says users would not pay at the point of service for benefits purchased by the NHI Fund. This would apply to providers contracted with the Fund and services included in the Fund’s benefit package.

At present, a person cannot assume that a private general practitioner, specialist, pharmacy or hospital will provide treatment without payment merely because the NHI Act exists. Existing payment arrangements continue unless a specific facility operates under another public programme or funding contract.

A single national purchaser

The NHI model would consolidate or coordinate healthcare purchasing through the Fund. The Department describes the Fund as a single purchaser that would negotiate prices and contract with healthcare providers.

That structure is still being built. Establishing a board, administrative systems, information technology, provider contracts, payment mechanisms, audit controls and benefit rules is a substantial process. The existence of a statutory Fund does not prove that all these operational components are already working nationwide.

Dedicated NHI taxes

The NHI Act does not automatically create a new payroll deduction or individual surcharge simply because it was signed into law. The Department’s FAQ states that National Treasury will determine funding sources and that Parliament would approve tax measures.

Government has described possible funding sources as:

• General tax revenue.
• A payroll tax payable by employers and employees.
• A surcharge on individuals’ taxable income.
• Other mandatory pre-payment arrangements.

No dedicated NHI payroll-tax rate or NHI personal-income-tax surcharge is currently payable as a nationwide NHI contribution. Any new tax would require the applicable fiscal and legislative process.

NHI and Medical Schemes

Medical schemes continue to operate under South Africa’s existing legal and regulatory framework. A person who belongs to a medical scheme continues to deal with that scheme according to its rules, benefit option and applicable legislation.

The NHI Act proposes that, once the Fund covers a particular healthcare service, medical schemes may not cover the same service in the same way. The Department says medical schemes would eventually focus on services not covered by the NHI Fund.

That outcome is dependent on several future steps:

1. The NHI Act or relevant provisions must commence.
2. The Fund must become operational.
3. Benefits must be defined and funded.
4. Providers must be accredited and contracted.
5. Regulations and transition arrangements must be issued.
6. The legal position must survive ongoing court challenges.

Until those steps occur, existing medical-scheme arrangements remain in place. The NHI Act has not, by itself, cancelled medical schemes or immediately converted their benefits into NHI coverage.

How NHI Funding Would Work

The proposed funding model is based on public pooling. Instead of each patient paying separately at the time of treatment, public revenue would be collected and allocated to the Fund. The Fund would then pay contracted providers for covered services.

A simplified example illustrates the intended flow:

This is not a current calculation for an individual taxpayer. For example, a South African employee earning R30,000 per month cannot currently calculate a legally payable “NHI deduction” by applying a published NHI payroll percentage, because no nationwide NHI payroll-tax rate has been introduced.

The same applies to employers. An employer’s existing payroll obligations, including PAYE and UIF where applicable, should not be labelled as an NHI contribution unless a future law specifically creates that obligation.

NHI Implementation Timeline

The Presidency stated in February 2026 that no sections of the NHI Act would be proclaimed until the Constitutional Court had handed down judgments in challenges concerning the public-participation process. The statement also said preparatory work, including improvement of health services, was continuing.

Constitutional Court Litigation

Several organisations have challenged the NHI legislation. Some challenges concern whether Parliament adequately considered public participation before passing the Bill. Other disputes concern substantive provisions of the Act and their possible effect on healthcare providers, medical schemes, provincial powers and property or constitutional rights.

The February 2026 undertaking by the Presidency does not mean that the NHI policy has been abandoned. It means that the proclamation of sections is being delayed while the court process proceeds.

This creates three separate questions:

• Is the NHI Act legally enacted? Yes.
• Is the full NHI Fund currently operating nationwide? No.
• Can the government continue preparatory work? Yes, subject to the Constitution, court orders and applicable legislation.

The final practical position may depend on court judgments, further proclamations, regulations, budget decisions and implementation agreements.

What the Rollout Means for Businesses

South African businesses do not currently submit a separate NHI payroll levy merely because the Act exists. Payroll departments should distinguish between current statutory deductions and any future NHI-specific charge.

For HR and payroll records, the relevant distinction is:

Employers may monitor official publications from National Treasury, SARS, the Department of Health and the Government Gazette for any future tax proposals. A media report or policy statement is not, by itself, a payroll instruction.

Practical NHI Status Checklist

When checking whether a new NHI announcement changes the current position, look for the following:

1. A proclamation in the Government Gazette bringing the relevant section into operation.
2. Regulations issued under the Act.
3. An officially published NHI benefit package.
4. A confirmed provider-accreditation and contracting process.
5. National Treasury or SARS guidance on any new tax.
6. Official information on registration and user identification.
7. Court orders or Constitutional Court judgments affecting implementation.
8. A confirmed list of contracted facilities and services.

This checklist helps separate an announcement about policy direction from an operational change that affects patients, employers, providers or taxpayers.

ToolBase Application

A future NHI payroll levy would require updated payroll rules, tax rates and statutory thresholds before it could be calculated accurately. ToolBase’s salary and payroll calculation tools can be used for existing South African payroll components, while a future NHI calculator would need to wait for an enacted contribution formula and official implementation guidance.

For employers reviewing the effect of existing payroll deductions, a ToolBase PAYE calculator can help illustrate current income-tax withholding separately from any proposed NHI funding mechanism. The two calculations should not be combined unless an official law introduces an NHI-specific deduction.

Conclusion

South Africa’s NHI rollout is at a transitional and legally contested stage. The National Health Insurance Act 20 of 2023 has been enacted, but the full Fund, nationwide provider network, comprehensive benefit package, dedicated NHI payroll tax and replacement of existing medical-scheme arrangements are not currently operating as a completed national system.

What is live includes the enacted legal framework, government preparation, healthcare-system strengthening and supporting digital-health work. What remains largely planned includes national Fund purchasing, universal contracted private-provider access, detailed funding mechanisms, benefit implementation and the long-term relationship between NHI and medical schemes. The Presidency’s February 2026 position delaying proclamation of sections pending Constitutional Court judgments adds an important legal constraint to the rollout.

This article is for educational purposes only and does not constitute professional advice. Consult a qualified professional for your specific situation.