For healthcare brokers, the immediate task is not to predict the final shape of National Health Insurance, but to help clients make sound decisions in a changing and increasingly expensive healthcare environment.
South Africa’s National Health Insurance (NHI) debate has generated more heat than clarity. The NHI Act has been signed into law, but its practical implementation remains uncertain amid legal challenges, policy questions and the formidable task of strengthening the public health system. For medical scheme members, this uncertainty has translated into an understandable question: should I still be paying for private healthcare cover?
The short answer, according to those working at the coalface of healthcare advice, is yes.
Gary Feldman, executive head of health insurance at Jigsaw, says brokers should start by helping members understand the principle behind NHI. Universal access to quality healthcare is an important and necessary goal for South Africa. But supporting that objective does not remove the need for members to make realistic decisions about their healthcare needs today.
“NHI is envisaged as a central fund that purchases and pays for healthcare services on behalf of the population. Under the proposed model, patients would follow designated referral pathways. A person who chooses to bypass those pathways and use a provider of their own choice could find that the NHI Fund does not cover the treatment.”
That distinction is vital.
“Members need to understand that NHI is not simply a new version of their current medical scheme,” Feldman says. “It implies a different model of access, provider choice and funding.”
For now, however, medical schemes remain central to the healthcare landscape. Feldman’s view is that members, with the assistance of a healthcare broker, should remain on a medical scheme, selecting the most suitable plan to meet their needs until NHI is fully implemented — a process widely expected to take many years. During that transition, medical schemes will continue to operate alongside the public system. If NHI eventually reaches full implementation, schemes are expected to evolve towards complementary cover: Funding treatment, medicines or services not paid for by the NHI Fund.
Do not cancel your medical aid
That is why the idea that clients should cancel medical scheme membership in anticipation of NHI is misplaced. A future policy destination, however important, cannot meet a family’s current healthcare needs.
Greg Setzkorn, vice-president of the Financial Intermediaries Association of Southern Africa, believes the industry’s immediate focus should be sustainable, person-centred healthcare cover. In a high-inflation healthcare environment, he says, brokers (or “healthcare consultants” to be more precise) are often the first source of guidance for members trying to balance affordability against adequate protection.
That balance is becoming more difficult. Contribution increases place pressure on household budgets, while members remain acutely aware of the potentially ruinous cost of private hospital treatment and specialist care. The answer is not necessarily to abandon cover; it is to make sure the cover is appropriate.
Feldman advises members worried about rising contributions to speak to a qualified healthcare broker before taking action. Network options on a member’s chosen scheme can often reduce premiums while preserving similar benefits, provided the member is willing to use the designated network of doctors and hospitals. Depending on health status, family circumstances and risk tolerance, a member may also consider moving to a hospital plan and self-funding routine day-to-day expenses.
No universal answer
There is no universal answer. A plan that works well for a young, healthy individual may be entirely unsuitable for a family with chronic conditions, dependants or a history of frequent medical needs. The key is to understand what the member is giving up, what risk remains, and whether the savings are genuine rather than merely short-term.
Setzkorn argues that this is precisely where healthcare consultants can demonstrate their value. Their role extends beyond comparing contributions and benefits. They need to give members confidence through current knowledge of the policy environment, ensure that clients understand their options, and help them make choices that support better health outcomes over time.
That requires brokers to be clear about what is known and what is not. The NHI implementation roadmap is complex, with substantial operational and financial questions still to be resolved. Communication and transparency from policymakers will be essential if advisers, product providers and consumers are to plan responsibly. Feldman says public input must be meaningfully considered, particularly where concerns have been raised about provider capacity and the availability of funding.
The need for clear communication is not limited to government. Schemes, insurers and intermediaries also have a responsibility to avoid allowing uncertainty to become misinformation. Members should not be frightened into making hasty decisions, nor should they be given false certainty about a process whose timing and final structure remain unresolved.
For Setzkorn, the conversation should not be consumed entirely by NHI. The more immediate strategic shift in healthcare is towards prevention. He believes the sector is moving from a model that sees healthcare as a cost to one that recognises it as an investment. Prevention, wellness screening and early intervention are no longer peripheral benefits; they are becoming central to controlling long-term health risk.
Active management
This matters to members, employers and medical schemes alike. Regular health checks, screening programmes, appropriate chronic medication and active management of existing conditions can prevent a crisis or reduce its severity. It can also improve quality of life.
“Many conditions once viewed as inevitably life-threatening, including some cancers and cardiovascular diseases, can increasingly be managed over the long term when people engage early and consistently with treatment and preventive care,” he says.
For employers, the argument should extend beyond the annual contribution increase. A healthier workforce is likely to be more resilient and productive, with fewer avoidable disruptions from acute illness. Yet that long-term perspective can be difficult to maintain in an economy where finance directors and business leaders are under pressure to control immediate costs.
Brokers can help reframe the discussion.
“Rather than presenting wellness benefits as a nice extra, they can demonstrate how preventive care supports a longer-term financial and health strategy,” says Setzkorn. “They can also encourage members to use reward programmes, screenings and disease-management support that they may already have through their medical scheme but do not fully understand or use.”
The changing market may also create opportunities beyond conventional medical scheme membership. Setzkorn points to the large “missing middle”: an estimated 10 million South Africans who may not be able to afford comprehensive medical scheme cover but could access well-designed primary healthcare products. Broadening access to these products — while ensuring appropriate consumer protection and regulatory oversight — could offer more South Africans a structured route into private healthcare funding.
Wider public benefit
“Expanding this layer of cover could produce a wider public benefit,” he says. “If more people who can afford some form of private primary healthcare cover are able to use it, pressure on the public system may ease, potentially allowing more resources per patient for those who remain dependent on public healthcare.”
The precise policy mechanism will be debated, but the underlying goal is worth keeping in view: a healthcare system in which more people have meaningful access to care, rather than a system divided between comprehensive private cover and no cover at all.
The industry appears to be preparing for a range of possible outcomes. Setzkorn believes that medical schemes are not generally behaving as though the market is about to disappear. Instead, there is continued attention on product development, particularly in primary healthcare, as well as efforts by industry bodies and other stakeholders to engage the legal and policy process.
At Jigsaw, Feldman says, this preparation includes ongoing engagement with regulators and product providers so that its support for brokers and clients remains relevant, while continuing to uphold the principles of Treating Customers Fairly.
“That is the right posture for a period of transition: Remain alert, engage constructively and focus on decisions that are useful now,” he says.
For brokers, the message is straightforward: Educate clients about NHI without oversimplifying it. Reassure them that medical scheme membership remains important during the implementation period. Review affordability carefully and explore sensible alternatives, such as network options, without treating lower premiums as the only measure of value. Above all, help members understand that their healthcare decisions are not just about paying claims when something goes wrong. They are about building a sustainable path to better health.
NHI may ultimately reshape the funding landscape. But the need for informed advice, adequate cover and preventative care is not on hold while South Africa waits for greater certainty. It is more important than ever.