South Africa's National Health Insurance (NHI) scheme, signed into law by President Cyril Ramaphosa in May 2024, continues to face significant legal hurdles, with Health Minister Aaron Motsoaledi acknowledging that the process could be mired in court battles for up to 20 years.

The NHI Act, aimed at providing universal health access and equal care across public and private sectors, has not been promulgated or implemented, following an agreement by Ramaphosa not to enact any provisions until key court cases are resolved.

Currently, there are 14 ongoing court cases challenging the NHI, with a potential 15th from AfriForum, focusing on aspects such as the public participation process during its passage through Parliament.

Key challenges include applications from the Western Cape Government, led by Premier Alan Winde, and the Board of Healthcare Funders, alleging flaws in the National Council of Provinces (NCOP) and National Assembly's handling of public input before the bill reached the president.

The Constitutional Court is set to hear these matters from 5 to 7 May 2026, with litigants arguing that inadequate consideration of public views invalidates the legislative process.

Motsoaledi has criticized the Western Cape's direct approach to the Constitutional Court and warned of an "unending formula" of cases and appeals, potentially leading to inconsistent rulings if not consolidated.

Under a court agreement, other legal challenges have been paused until this ruling, but Motsoaledi emphasized that even a government victory would likely see resumed litigation, appeals, and further delays.

A adverse ruling could set aside the NHI Act entirely, necessitating redrafting and reprocessing, further extending timelines.

Despite these obstacles, the Department of Health is proceeding with preparatory work, including the rollout of the Health Patient Registration System developed by the CSIR to track patients across facilities.

Other ongoing efforts encompass building at least three new hospitals, establishing medical schools, modernizing digital systems, and regulating pricing in the private healthcare sector.

However, certain steps, such as forming the NHI Board and promulgating related regulations, remain on hold per the agreement.

The 2026 budget allocates approximately R9.3 billion to NHI-related initiatives, comprising R1.5 billion in direct provincial grants over the next three years (R475 million in 2026, R497 million in 2027, and R513 million in 2028) and over R7.8 billion in indirect funding focused on infrastructure and digital upgrades.

This funding supports reforms like improving primary healthcare facilities and aligning infrastructure with policy directives, reflecting an upward trend from 2025 expenditures of R467 million in direct grants and R3.3 billion indirectly.

Stakeholders, including parties in the Government of National Unity (GNU), have opposed the scheme, with warnings of legal challenges dating back to 2022 from former Health Minister Joe Phaahla.

Governance expert Professor Alex van den Heever has asserted that the NHI is unlikely to ever be implemented in its current form, citing the absence of a clear funding mechanism and flawed institutional design that fails to achieve its objectives.

Van den Heever argues that the government's pursuit of the NHI redirects resources, leading to deterioration in both public and private healthcare quality, without addressing underlying governance flaws.

He advocates for alternative reforms to enhance public sector care and private sector efficiency, noting that South Africa's healthcare outcomes have worsened in coverage and quality over the past two decades due to a lack of structural interventions.

According to van den Heever, ongoing litigation may compel the government to prioritize credible universal coverage programs, shifting focus from the NHI to practical improvements in the existing system.

Many litigants support universal healthcare but reject the NHI as an ineffective vehicle, emphasizing that even without opposition, the scheme's funding and design issues would prevent its realization.