Healthcare sector needs urgent reform, not political rhetoric

South Africa’s national healthcare debate tends to be dominated by sweeping ideological positions and big promises of structural overhaul. However, in a high cost-of-living environment, health care for most people is not an abstract policy discussion. Rising healthcare costs, access constraints and systemic reliability are very real concerns with real-world implications.

As the gap between a resource-constrained public sector and a high-cost private healthcare system continues to widen, industry experts warn that the current trajectory is unsustainable. The structural imbalance is being exacerbated by the erosion of private cover among middle-income earners.

Kevin Aron, principal officer at Medshield Medical Scheme, says the biggest pressure point in the local health ecosystem lies in the missing middle — working individuals and families who earn too much to qualify for free public healthcare but too little to comfortably afford private medical scheme premiums. Driven by sustained economic pressure and a loss of disposable income, many of these families are being priced out of the private sector by necessity rather than choice.

When members of the missing middle exit private cover, they don’t disappear from the healthcare system but shift into the public sector. — Kevin Aron, principal officer at Medshield Medical Scheme

“When members of the missing middle exit private cover, they don’t disappear from the healthcare system but shift into the public sector,” says Aron. “The consequences of this extends beyond individual households. It adds additional pressure onto a public system that already serves more than 84% of the population, while disrupting continuity of care and compromising long-term health outcomes.”

It is a dynamic, he says, and results in a lose-lose scenario for the country.

“Under financial strain, consumers will tend to delay seeking medical attention, which ultimately leads to more complex, severe, and expensive health issues down the line. This is a structural challenge that requires a deliberate and sustainable response,” he says, adding that, if left unaddressed, this dynamic will widen the gap between public and private health care, entrench inequality and reduce overall system resilience.

While the government continues to promote National Health Insurance (NHI) as an inevitable endpoint, the implementation path remains deeply entangled in multi-party constitutional litigation, fiscal constraints, and a narrow national tax base. The 2026 national healthcare budget revealed a degree of fiscal restraint rather than dramatic restructuring, leaving medical tax credits intact and omitting new NHI taxes.

Industry leaders, including Aron, argue that true universal care cannot be engineered on top of a fragile foundation and that the public sector must first address critical infrastructure backlogs, staffing losses, procurement failures, and governance vulnerabilities before centralisation can succeed.

“There is a narrative that medical schemes and public healthcare exist in opposition to one another. I reject that,” says Aron. “A well-functioning public healthcare sector is not a threat to medical schemes, but is instead essential to a stable national health ecosystem.”

Instead of adversarial positioning, he says the future of the sector depends on practical public-private partnerships.

“A revitalised and credible public health system could operate as a contracted provider for medical schemes. Members on entry-level options could use public facilities, with private schemes reimbursing the state at agreed tariffs, lowering overall systemic costs while expanding access,” says Aron.

For the private sector, the biggest challenge remains medical inflation outpacing general inflation driven by rising input costs, technological advancement, and increased utilisation.

Aron warns that the instinctive industry response to cut costs, such as stripping back benefits or increasing co-payments, is a short-sighted strategy that merely defers costs instead of containing them.

Instead, affordability must be engineered through smarter system design, network-based provider models, and aligned incentives that reward health outcomes rather than the volume of procedures performed. Furthermore, healthcare funding must adapt to modern employment patterns through more flexible, income-sensitive contribution models.

Crucially, industry leaders such as Aron are calling for a proactive, nationwide shift towards preventative care as a core financial strategy.

“Too often, healthcare systems are designed to respond once illness has already progressed, resulting in higher costs and poorer outcomes,” says Aron. “A more sustainable model is one that identifies risk early, supports intervention before conditions escalate, and empowers individuals to take a more active role in managing their health. Preventative care is not simply a clinical ideal. It’s an economic imperative in a high-cost environment.”

This transition requires the purposeful application of modern technology. Implementing data-driven insights allows funders to identify emerging health-risk patterns sooner, while user-friendly digital tools can substantially improve primary healthcare access. For instance, making use of virtual consultations lowers geographic and logistical barriers for the missing middle, while targeted care programmes help patients manage chronic conditions effectively before they require acute hospitalisation.

Cross-industry alignment is needed to address systemic waste. Under traditional funding frameworks, healthcare providers are often reimbursed through models that reward the volume of services rendered rather than the quality of care delivered. Curbing fraud, waste, and over-servicing requires proactive industry collaboration, clearer clinical care pathways, and transparent pricing structures. By equipping consumers with transparent information, schemes can guide members towards appropriate, cost-effective utilisation without diluting their legal healthcare rights.

To achieve this, all stakeholders across the healthcare ecosystem — including regulators, medical schemes, healthcare providers, and employers — must share the responsibility.

“Healthcare sustainability does not exist in an isolated vacuum; it is fundamentally dependent on the performance of the broader South African economy,” says Aron. “When the local economy achieves meaningful growth, formal employment expands, which naturally strengthens private contribution pools and enhances the entire system’s resilience. Conversely, prolonged economic stagnation places immense, compounding strain on both individual household budgets and institutional funding structures.”

Ultimately, the sustainability of the entire healthcare framework remains inextricably linked to South Africa’s broader economic performance. Real progress will be measured not by the grandeur of political promises but by the practicality of execution and disciplined fiscal planning. In an evolving landscape, maintaining the stability of existing infrastructure is the only viable foundation for meaningful, lasting reform.