An Empty Promise? Why Losing Specialists Could Sink South Africa’s NHI Dream

South Africa’s ambitious plan for universal healthcare, the National Health Insurance (NHI), faces a potentially fatal threat before it even gets off the ground: the accelerating exodus of the very specialist doctors the system is meant to be built upon. While the government pushes forward with the policy framework, medical professionals are issuing a stark warning: without fixing the public health system first, NHI is a plan without a foundation.

According to Dr. Rebonethato Lesupi of the South African Medical Association Trade Union (Samatu), the loss of specialists does not affect NHI’s primary care rollout but poses a “serious risk” to its success at the tertiary hospital levelthe backbone of complex medical care. “NHI is premised on a strong, functional public health system with adequate specialist capacity,” Lesupi states. “When specialists leave state hospitals, the system loses clinical expertise, supervision for trainees and institutional memory.”

A Financing Reform Without a Foundation

The warning cuts to the core of the NHI challenge. The scheme is, at its heart, a financing model designed to pool funds and purchase services. But as specialists continue to emigrate or move to the private sector, the crucial “service” side of that equation is evaporating. Lesupi argues that without urgent action on working conditions, staffing shortages, and healthcare worker morale, “NHI risks becoming a financing reform without the clinical capacity to deliver quality care.”

The implication is a nightmarish scenario: a system with a funding mechanism in place, but without the skilled hands to perform the surgeries, lead the cancer treatments, or manage the intensive care units it promises to fund.

The Prescription for Success

For NHI to have any chance, the union says the government must first stem the bleeding. The prescription is clear: the public sector must become a place doctors want to work. This means:

• Fair contracting and adequate remuneration that recognises skill and prevents burnout.

• Safe working environments where doctors have the tools and support to do their jobs.

• Respect for the profession and meaningful engagement in policy decisions.

The current trajectory suggests the opposite. Doctors speak of crumbling infrastructure, dangerous staff-to-patient ratios, and administrative burdens that overshadow patient care. Until these systemic issues are addressed with the same urgency as the NHI’s legislative process, the scheme’s rollout at the specialist level could be critically delayedor worse, become a theoretical promise that the country lacks the practical capacity to keep.

The message from the frontline is unequivocal: you cannot build a world-class healthcare system on top of a system experts are fleeing. For NHI to be more than words on paper, the government must first prove it can retain the people who make healthcare happen.