Can SA rescue its health system?

A healthcare system in which private and public systems work together for the benefit of all could be on the cards if we get our act together. Picture: Thulani Mbele/Sowetan
A healthcare system in which private and public systems work together for the benefit of all could be on the cards if we get our act together. Picture: Thulani Mbele/Sowetan

Four scenarios are suggested for our health sector; all show how key proper leadership is to a positive outcome

In just 11 years, our country’s healthcare system could find itself in the intensive care unit, on life support.

This is the worst-case scenario that could occur if the highly fragmented health system – characterised by inequality and polarisation between the public and private healthcare sectors, and distrust between key industry players – persists.

However, we could also get a “clean bill of health” if there is proper leadership, along with clear policy and regulation.

Cohesion among all players and equitable, proactive healthcare will also be key factors in ensuring the success of the country’s universal health coverage.

These were two of the four scenarios presented at the Board of Healthcare Funders’ (BHF’s) 20th annual conference, held last week in Cape Town.

The scenarios were part of a session titled Scenario Planning 2030 – Next-Generation Health System.

Developed by Mind of a Fox scenario strategists, the four different theories highlighted both the challenges currently facing the system and what could still be achieved if there was unity and collaboration between the public and private health sectors.

The scenarios were presented as government continues with preparations to implement the National Health Insurance (NHI) scheme.

Last week, Cabinet approved and adopted the contentious NHI Bill, expected to be tabled in Parliament before year-end.

And on Thursday, President Cyril Ramaphosa signed the Presidential Health Compact, which aims to fix the country’s ailing public healthcare system and improve the quality of care.

Its mission statement is One Country, One Health System.

A healthcare system in intensive care, where patients receive poor treatment – this is, according to scenario planners, where we are right now. Picture: Moeletsi Mabe/The Times

The BHF conference, which brought together medical schemes, administrators and other private healthcare players, conducted its own deliberations on what a new future with NHI could spell.

Scenario strategist Chantell Ilbury said the 2030 timeline was chosen for each of the four situations because it pointed to a future where technology and artificial intelligence might have taken over, yet was a close enough date to understand what changes needed to be made currently.

She said the scenarios could serve as a starting point for debate as the sector worked towards collaboration.

“South Africa’s healthcare sector is not healthy. From a high-level, strategic perspective, it is a tale of two ecosystems: public and private healthcare,” Ilbury said.

“Approximately 80% of South Africans have no form of medical coverage. The popular demand for universal healthcare has increased, but at the same time, we have in the sector an increased trust deficit. So, collaboration is difficult and has to be a conscious decision for players.

“If you contextualise the state sector ... healthcare is declining and it has also become a political imperative. These are some of the reasons for implementing NHI.”

Ilbury said the cost of private healthcare had increased dramatically and there were questions about the value of medical schemes.

She added that the scenarios were underpinned by the fact that there were two pivotal uncertainties between now and 2030: the quality of leadership we will have by then, particularly within government; and whether or not there will be cohesion between government, administrators, funders, regulators and patients.

Ilbury said all four scenarios had the potential to be realised, and the current feeling among most industry players was that the health sector was in ICU.

She concluded by challenging the private sector stakeholders to move towards a “win-win” situation for all South Africans.



The doctor is on the ball, the treatment is solid and the patient follows the doctor’s guidance.

In this best-case scenario, positive leadership from senior government – especially the minister of health – has laid down the structural framework and the collaborative environment for key players within the healthcare sector. 

Clear guidance from regulators, with collaborative input from other players, provides a level playing field and a clear path to growth within the sector. There is wide access to quality and affordable healthcare. 

The NHI roll-out is successful, with provision made for the role of private funders.

Scenario strategist Chantell Ilbury summed it up this way: “A clean bill of health means we have good leadership; good, clear policy and regulation; and cohesiveness within the sectors. It is really a nation in step with itself. There is a structural framework and a collaborative environment among key players. Healthcare is equitable and proactive, and the NHI roll-out is successful.” 


The doctor provides healthy advice about what needs to be done, but the patient either ignores the advice or googles alternative therapies. The result: non-adherence.

In this scenario, despite positive leadership on the part of senior government, key players within the healthcare sector can find little ground for agreement and collaboration. 

A protectionist mind-set puts stumbling blocks in the path of the clear developmental initiatives that government provides. 

As a result, healthcare provision is patchy and the sector flounders. The NHI roll-out is driven by the state with little or no provision for private healthcare funders.

Ilbury said: “The non-adherence scenario would see the implementation of the NHI with leadership capacity, but the healthcare sector is still very fragmented.” 


The patient has an idea of what is wrong and has done all they can to help the situation. Now they are sitting and waiting for the necessary authorities to help.

In this scenario, key players in the healthcare sector, inspired by leadership within it, have gradually collaborated to provide the framework for growth and a better quality of healthcare for all.

All they need is buy-in from senior government structures to provide the momentum and pathways for it to succeed. 

But that leadership is not forthcoming. The result is increased frustration, especially within the private sector, and an overall healthcare sector marked by pockets of excellence but mainly poor delivery. 

The NHI roll-out stumbles, and private healthcare picks up the ball.

Said Ilbury: “The waiting room is where the health sector starts to work together and providers start to form relationships to optimise the sector. But still, the country has poor government leadership and, in terms of NHI, there are issues and the relationship between government and the private sector isn’t good.”


The patient is being kept alive by the occasional input of intensive resources. There is some hope of recovery, but it is a case of touch-and-go, and another nasty event could prove fatal.

In the worst-case scenario, the ongoing failure by senior government to provide positive leadership has exacerbated discord between key healthcare players. Without clear guidance through regulation, and the energy and resources of senior government, the healthcare sector has little hope of growth. 

Players distrust each other and a protectionist mind-set takes root. 

The result is a highly unequal provision of healthcare, with little innovation. Under this scenario, NHI is a failure.

Ilbury said this scenario could amount to a collapse of the healthcare system.

“Players distrust each other, there is unequal provision of healthcare, and the sector is beset with scandal – particularly NHI, involving millions of rands that are unaccounted for. NHI could become another state-owned enterprise such as Eskom or SAA,” she said.

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