Consultation or governance for universal healthcare?
- Lem Chetty
Senior academics in Public Health and Governance weigh in on where rebuilding trust should begin in the contentious National Health Insurance debate.
South Africa’s universal healthcare plan remains entangled in court challenges and fierce public debate. To the sceptical public, the National Health Insurance (NHI) blueprint sounds illusory. How will authorities convince us that they can manage this gargantuan beast, when the public and private health sectors are worlds apart? Every South African is asking: “Can we trust the government to do this?”.
For Adjunct Professor Precious Matsoso, trust is not a soft public relations concept. It is the foundation upon which major health reforms either succeed or fail.
A pharmacist and former Director-General of the National Department of Health, Matsoso recently concluded one of the most complex diplomatic assignments in global health governance. As Co-Chair of the World Health Organization's Intergovernmental Negotiating Body, she helped steer 194 countries in negotiations which started during the Covid-19 pandemic and which culminated in May 2025 in the adoption of the WHO Pandemic Agreement. Her experience offers important lessons for our NHI journey.
"We, too, started with a trust deficit during the pandemic," she says.
Trust assumptions
The negotiations unfolded during a period marked by deep divisions between wealthy and developing nations. Many lower-income countries felt abandoned as richer nations secured and stockpiled vaccines while others waited for access. People died.
"The issue was equity," Matsoso says. "There were countries that strongly supported equity and others that were either opposed or remained silent. The polarisation was palpable."
Despite those divisions, nearly 200 countries eventually reached agreement, an outcome which Matsoso says was only possible because negotiators recognised an uncomfortable truth from the outset: trust could not be assumed.
"It was very clear that there was no way we would succeed without addressing the trust issues up front, by building bridges and confidence,” she says.
Difficult dialogues
There was much talk which, for those seeking action, might have been frustrating, but Matsoso says that the process required sustained dialogue, difficult conversations and a willingness to confront contentious issues.
The parallels with South Africa's NHI debate are difficult to ignore.
"Trust is foundational, but it is also fragile," Matsoso says. "You can't simply present something to people, saying you've consulted and that is sufficient. It requires a conscious effort to engage in dialogue and build bridges, not walls."
She recalls similar tensions during her tenure in government when health policy reforms were being developed. "While we were engaging with multiple stakeholders across the public and private sectors, there were headlines suggesting we had been captured by the private sector."
Such accusations, she argues, undermine meaningful engagement.
"We need to dispel the notion that dialogue with different stakeholders is somehow inappropriate. Trust is also about listening."
For Matsoso, consultation must go beyond formal meetings and public submissions. It requires genuine engagement with dissenters.
"If you coordinate different groupings, working towards different goals, you won't succeed," she says. "You need meaningful dialogue."
The current impasse over the NHI, she argues, cannot be resolved solely through litigation. "We need to sit around the table and start talking – and listening. What are the concerns? As long as these issues remain in court, nothing will move."
Rebuilding trust, she adds, requires humility.
"Where mistakes have been made, parties must acknowledge them. Trust is reciprocal. It takes commitment to build bridges."
The engagement process should extend beyond government and traditional stakeholders, she argues, to include scientists, health experts and private sector actors whose experience may help strengthen implementation.
"You need to engage detractors and find ways to deal with their concerns."
Her emphasis on consensus-building echoes calls from several prominent health and governance figures who have advocated for broader stakeholder engagement around health reform.
The opposing view
Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at the µÚÒ»³Ô¹ÏÍø , argues that the trust issue is not only about what the public believes is possible, but that the NHI framework itself has failed to earn public confidence.
"Trust follows credible design," he says. "It follows competence, accountability, legality and protection against abuse. The NHI Act and policy framework fail these tests."
Fundamentally flawed design
Van den Heever argues that trust cannot be created through consultation alone if the underlying institutional design remains flawed.
“As framed in law, the NHI is institutionally weak, fiscally unrealistic and practically unimplementable,” he says. “It cannot deliver on its promises.”
He warns that the current framework risks undermining existing forms of healthcare coverage without adequately addressing longstanding weaknesses in the public health system.
“That is not reform,” he says. “It is institutional overreach masquerading as universal healthcare.”
For van den Heever, South Africa's challenge is not creating universal coverage from scratch but deepening coverage by improving the access, quality, equity and effectiveness of a system that already provides some level of healthcare access for all.
Structural corruption
Central to his critique is governance. He argues that South Africa's history of state capture and corruption demands stronger institutional safeguards than those currently contained within the NHI framework.
“A core problem is structural corruption,” he says. “Once networks of extraction are embedded in operational leadership, procurement systems, and regulatory bodies, corruption is no longer an exception to the system. It becomes the system.”
In his view, concentrating purchasing and regulatory authority within a single NHI fund creates new risks rather than solving existing ones.
“A credible universal health system would move in the opposite direction,” he says. “It would disperse power, hardwire transparency and create real checks and balances.”
That would include independent regulators, merit-based appointments, transparent procurement systems, formula-driven funding mechanisms and stronger accountability measures.
Robust governance required
Van den Heever, too, points to the pandemic as evidence that public and private sectors can work together when required. However, he believes that the deeper lesson learned was not the value of trust-building alone but the importance of robust governance and institutional structures.
He says, “The issue is not mistrust between sectors. It is that no serious actor can place confidence in a public system still primed for capture.”
There is time for the government and state institutions that lost public faith to correct, he adds. “South Africans will believe in universal healthcare when abuse is made difficult, performance is visible and accountability is unavoidable. The answer is not to market the NHI more aggressively. It is to build institutions worthy of public belief.”
The difference in the two arguments lies in where they believe the trust process should begin. For Matsoso, trust is the prerequisite for reform. For van den Heever, reform is the prerequisite for trust.
The question is whether South Africa can build both before the opportunity for meaningful health reform slips beyond reach.
- Lem Chetty is a freelance writer.
- This article first appeared in CURIOS.TY, a research magazine produced by  and the .
- Read more in the 21st issue, themed #Trust — the invisible glue binding society, science and technology.