Read the Conversation
Meeting highlights:
- Severe funding disruption – The sudden termination of US aid (PEPFAR, CDC, NIH) coincided with domestic budget delays, causing major cash flow issues for HIV programs, research, and staffing, severely straining the health sector.
- NHI implementation hurdles – Since the NHI Act was signed in May 2024, the department has faced seven court cases from stakeholders with vested financial interests, political resistance from new coalition partners, and slow budget approvals, delaying staffing and operations.
- Defense of universal health coverage – Crisp stresses the distinction between universal health coverage and universal health care, rejecting parallel systems and advocating for a single-payer model to address South Africa’s extreme inequality in health spending.
- G20 and African health sovereignty – South Africa used its G20 platform to push for African self-reliance in pharmaceuticals, regulatory capacity, and primary healthcare, stressing the need for continental cooperation to reduce donor dependency.
- Patient-centered reform – Crisp emphasizes that health reform must prioritize patients over profit, requiring stakeholders to move beyond defending the status quo and engage in constructive dialogue to achieve equitable, sustainable healthcare access.
EF: There’s been a lot of geopolitical shifts this year—from the threat of tariffs to the withdrawal of certain aid streams. How do you assess the outlook for 2025 in South Africa?
NC: There’s a lot of uncertainty in every market and society. It’s been especially tough since January 20th, when we received the stop order from the President of the United States regarding the termination of funding. The speed and scale of the funding termination were the issue.
Our minister and government have been clear: we accept that no country is entitled to donor money. But when you’ve received consistent support for so long, you’d expect some advance notice. Governments are not agile—they’re cumbersome systems. And all of this coincided with our domestic challenges: a change in government, delays in budget approval, and cash flow issues.
At the same time, PEPFAR’s USAID funding stopped, the CDC money slowed, and we had no approved national budget. It was a perfect storm. We were trying to maintain the HIV program while researchers had their NIH grants abruptly terminated. Some felt targeted—there’s no other way to put it. It’s been an onslaught on everything we’ve tried to achieve.
EF: When we spoke to you last year, the NHI Act had just been signed into law. Now, a year later, how have things progressed?
NC: As expected, we’ve since been taken to court—seven cases so far. Most were lodged quickly after the Act was signed. While the plaintiffs differ, the content overlaps: all are stakeholders with significant financial interests in maintaining the status quo. Interestingly, we are not being challenged by unions or patient rights groups—those groups want to support NHI.
All initial cases went to the High Court. The latest is a second case by the same applicants, but filed in the Constitutional Court. Defending ourselves is hugely expensive and time-consuming. These stakeholders have far more resources than we do, which significantly slows us down.
Then, of course, there was the election. It resulted in a government of national unity. Some of the new parties in Cabinet are not in favor of NHI, and they’ve expressed their dissatisfaction—not just with NHI but with many policies of the previous administration. We have a new Minister and reshuffled portfolios. It’s taken months to brief the new team—even though the Minister had held the portfolio before, a lot had changed.
In parallel, the budget was rejected twice before finally passing a week ago. The health sector received a modest 3% increase—about R6.7 billion—but it was not allocated as we would have liked. Funds have been allocated to the provinces, but it remains unclear whether they’ll prioritize spending or settle debts. We’ve only now, five months into the fiscal year, been allowed to start recruitment. Until now, we couldn’t advertise posts.
The public sector is running on a cracked shaft. Meanwhile, private providers have increased tariffs by 9%–13%. They’re not struggling—only the people who rely on medical schemes are, and one more increase like that may push many out of coverage.
As for NHI implementation, we published the draft regulations on March 6. Public comment closed June 6. We’ve just finalized the incorporation of that feedback and hope to request the President’s proclamation of the first sections and the publication of final regulations by the end of this week. Of course, that will trigger another round of legal action, I’m sure. But this is where we are: panic from those who resist change, and heavy defense from those of us pushing for reform.
EF: Many contributors say they support universal health coverage in principle, but are concerned about the NHI roadmap to implementation. What would you say to those people?
NC: I would first ask them to define what “universal” means. Because they seem to be using two different universes, they also often confuse universal health care with universal health coverage—there is no WHO definition for the former. Universal health coverage (UHC) is a United Nations commitment, signed by our country and over 150 others.
So if they claim to support UHC, they need to be clear about what they mean. Most are advocating for a social health insurance model with two parallel systems—the very setup we have now. It maintains high costs and unequal access. They argue that removing some low-income workers from the public burden is beneficial, but overlook that many people with medical aid still rely on public services. Medical schemes don’t cover everything—not even the prescribed minimum benefits (PMBs). Many beneficiaries pay out of pocket or through costly gap cover.
We are working toward a single-payer model, but every country’s single-payer model is unique. Ours is designed to address the most unequal health system in the world. Over 50% of health spending benefits just 15–16% of the population. That level of disparity requires a bold solution.
South Africa has done difficult things before. People once told me we’d never dismantle the homelands—but we did. We consolidated provincial health systems. So I ask again: what exactly are these opponents defending? If it’s profits and privilege, they should say so. I didn’t study medicine to serve a privileged few. My job is to make sure everyone gets care when they need it, where they need it, without suffering financial hardship.
EF: You were involved in the G20 this year. UHC was a major topic. Can you tell us more about your role and what it means for South Africa?
NC: The G20 is a significant platform for wealthier nations. South Africa and the African Union having seats at the table is meaningful. While we speak as a sovereign nation, we do our best to represent Africa.
COVID taught the continent a harsh lesson: the world will look after itself first. We were last in line for vaccines, last for staff, last for support. The recent US aid cuts reaffirmed that message—countries like Malawi and Mozambique are now in an even tougher position.
So our focus at G20 was to assert Africa’s place. We want to stop being perpetual aid recipients. We aim to establish a domestic pharmaceutical market, collaborate on API production, and ensure that regulators are taken seriously. For that, we need harmonized standards and regional collaboration. South Africa’s market alone, 63 million, is too small. We need all 1 billion Africans to work together.
UHC was one of the health agenda pillars. We discussed how to escape dependence on donor funding. South Africa is in a better position than many peers—I’ve worked in seven African countries, so I’ve seen the difference. We want to strengthen primary healthcare as the foundation for everything—pandemic preparedness, vaccine delivery, digital surveillance.
We’ve also deepened bilateral ties through the G20. For example, we met with the UK around the release of their 10-year plan, which also focuses on primary care and digital transformation. Our starting points are different, but the goals are similar.
We’re also watching global health threats, like climate change and antimicrobial resistance, closely. TB remains a major issue for us. It all ties into the One Health agenda. These are the priorities we’ve been pushing on the global stage.
EF: Is there any final message you’d like to leave with our readers?
NC: We will defend the patient at all costs. That’s our job. If we start prioritizing providers, suppliers, or profits, then we’ve failed in our duty.
Reform is hard, and change brings uncertainty. But if we want a truly universal system, everyone must leave their comfort zones and come to the table—not to argue philosophy or defend market shares, but to talk about how we achieve this. From our side, those other arguments aren’t valid anymore. We’ll keep doing everything in our power to build a better, fairer healthcare system.
