South Africa has entered 2026 facing a familiar but intensifying healthcare paradox. It is another election year, with local government elections due to take place from November and healthcare will remain a focal point of how citizens hopefully vote to change the politicking into tangible health service delivery. Once again National Health Insurance (NHI) is set to dominate the political debate however beneath the policy rhetoric, affordability remains the single biggest pressure point across both the public and private healthcare system.
While the long-term vision of universal healthcare is widely supported, the practical reality of NHI remains uncertain. Funding constraints, a shrinking tax base and unresolved constitutional questions mean that, in practical terms, South Africa is still far from a realistic implementation process. Without sustained economic growth of around 5% a year, and without additional tax revenues in the fiscus, the current NHI framework is simply not financially viable. In this context, the risk is that NHI becomes more of a political distraction than a catalyst for reform.
A system under pressure cannot afford to stall
Unless there are significant amendments to the NHI Act that address funding, freedom of choice and the role of medical schemes, legal challenges will continue for years. In the meantime, the healthcare system cannot afford to stagnate. Both public and private sectors are already carrying pressures that have been building for decades.
At the heart of these pressures is affordability. Internationally healthcare inflation continues to outstrip normal CPI, driven by a combination of higher utilisation (people using more healthcare services), limited numbers of healthcare professionals and the cost of new technologies. South Africa has too few general practitioners and specialists, many of whom are ageing and not being replaced at the required pace. At the same time, the country faces the contradiction of having unemployed doctors who are unable to find stable entry points into either the public or private sector.
At the same time, the country faces the contradiction of having unemployed doctors who are unable to find stable entry points into either the public or private sector. This is where platforms like finDR play a critical role. By helping early-career professionals gain meaningful work opportunities, finDR supports the development of the next generation of healthcare providers while easing staffing pressures in both public and private settings.
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These constraints ripple through the system, as long queues in public facilities lengthen and access to come specialists in the private sector can take more than 6 months to find an appointment. The demand and supply factors lead to an increase in costs and reduce access. According to StatsSA’s latest General Household Survey (GHS), 15.5% of South Africans had access to a medical aid scheme in 2024. Yet an additional 25.3% of households said that they would first consult a private doctor, private clinic or hospital over a public facility. In many cases where people have no medical scheme cover, people are forced to borrow money or sell assets to pay for this private care, highlighting the critical reality that healthcare affordability needs to be addressed across the board.
Expanding coverage through long-delayed reforms
One of the most effective levers to do so is expanding medical scheme coverage through long-delayed reforms such as low-cost benefit options. In the absence of these reforms which seem to be neglected by the relevant regulators and legislators, gaps have been filled by low-value insurance products that extract profit from healthcare without offering meaningful protection. Medical schemes, by contrast, do not profit from healthcare use, and any surpluses are owned by the members themselves.
Rising costs influence how members engage with healthcare. Utilisation plays a significant role in inflation, with even small year-on-year increases adding directly to cost escalation. As a result, medical schemes are increasingly focused on prevention, early detection and supporting healthier behaviour. Digital health assessments, accessed via smartphones, allow for upfront risk profiling and prompt targeted preventative screenings such as PSA tests or mammograms.
This shift is reinforced by the continued growth of telemedicine, supported by smart diagnostic tools which include wearable devices that share real time or historical risk information with clinicians. These models reduce unnecessary in-person visits, stretch limited clinical resources and improve access, particularly in a system constrained by specialist shortages.
At the same time, new medicines and technologies are extending lives, but at a significant cost. Profmed has seen average high-cost cases rise from around R550,000 to R1.2million in just four years, with some cases reaching as high as R12million. These technological advances are vital, but they emphasise the need for prevention and early intervention to avoid utilisation to keep the system sustainable.
Member behaviour, especially among younger professionals, will also shape the year ahead. Many younger people underestimate their healthcare risk, prioritising price over coverage and delaying entry into medical schemes. Yet shifts like rising mental health prevalence and increasing cancer diagnoses in younger age groups underscore the risks of this approach. Once a chronic condition is diagnosed, access to affordable cover becomes far more difficult and medical schemes will apply a 12 month waiting period to access benefits relating to pre-existing conditions.
Mental health as a defining issue for 2026
Mental health, in particular, will remain a defining issue in 2026. Over the past five years, diagnoses and treatment have increased by an average of 14% annually, especially among 15 to 35-year-olds. Economic pressure, unemployment and lingering post-pandemic effects are driving this trend, pushing schemes to focus more on early identification and treatment for stress and anxiety accompanied by holistic behavioural health support.
In the months ahead, progress will depend less on policy announcements and court cases and more on collaboration. Public-private partnerships, better use of existing public and private capacity will drive more pragmatic interventions at the cold face of health services. Healthcare cannot remain stagnant while waiting for NHI to be resolved. The system will only move forward if all stakeholders work together, pragmatically and urgently, to expand access, manage costs and build a healthcare system that truly serves all South Africans.
Written by Profmed CEO, Craig Comrie