The recent Constitutional Court ruling on South Africa’s Certificate of Need (CONS) provisions marks an important inflection point in the country’s healthcare debate.
The court found that the provisions failed the constitutional rationality test. While the objective of improving equitable access to healthcare and addressing historical imbalances cannot be faulted, the court concluded that the chosen mechanism had no rational connection to the outcome it sought to achieve.
This finding is significant because the government positioned the Certificate of Need as a “central pillar” for restructuring healthcare under the National Health Insurance (NHI) framework. The judgment therefore provides an opportunity to reassess how healthcare reform is approached. Future interventions must be evidence-based, constitutionally sound and capable of successful implementation in practice.
But the significance of the judgment extends beyond the legal outcome itself. It highlights the growing tension between aspiration and implementation in South Africa’s healthcare reform agenda.
The need for practical reform
There is little disagreement that South Africa’s healthcare system requires reform. Public healthcare facilities remain under strain.
Access to quality care remains uneven. Healthcare inflation continues to rise faster than economic growth. At the same time, households face increasing financial pressure. The question, therefore, is no longer whether reform is necessary. The real debate concerns how reform can be implemented and how quickly it can realistically happen. It also concerns which practical interventions can expand access to care while broader structural reforms continue to evolve.
By the government’s own estimation, full implementation of NHI may take more than a decade. But healthcare pressures cannot be put on hold for 10 years. They are unfolding now.
Healthcare reform is often framed as a choice between public and private healthcare. In reality, neither sector has the resources, infrastructure, skills or funding capacity to address South Africa’s healthcare challenges alone.
Most successful health systems evolve through practical, incremental reforms that build on existing strengths. In South Africa’s case, this means finding ways for the public and private sectors to work together more effectively. This collaboration can expand access to care while broader reforms continue to develop.
Leveraging existing healthcare infrastructure
Part of the infrastructure capable of improving healthcare access already exists within South Africa’s regulated healthcare financing system.
Medical schemes were created and are regulated as part of South Africa’s broader healthcare financing framework. They provide healthcare funding and financial protection for working people. In many respects, they already embody several of the core principles underpinning universal health coverage, including social solidarity, risk pooling and cross subsidisation.
While approximately 25 million South Africans utilise private healthcare services in some form, only around 9 million belong to medical schemes. Millions of working South Africans remain caught between comprehensive medical scheme cover and an overstretched public healthcare system. Instead, they rely on out-of-pocket payments for consultations, medicines and diagnostic services.
This is where the healthcare gap becomes particularly visible. As household finances come under increasing pressure, people often delay care. Chronic conditions remain unmanaged, and preventive healthcare falls away. The result is poorer health outcomes, higher long-term healthcare costs and greater pressure on already stretched public healthcare facilities.
A practical path to greater access
One example of the kind of practical collaboration the healthcare sector should pursue involves regulated medical scheme infrastructure. The sector could use this infrastructure more effectively to expand access to affordable primary healthcare for lower- and middle-income households.
Such options could provide access to GP consultations, medicines for common chronic conditions, preventive screening and maternity care. They could do so at a fraction of the cost of comprehensive medical scheme cover for an additional 10 million South Africans.
This would not resolve every structural problem in the healthcare system. However, it could meaningfully reduce the number of people currently left exposed between comprehensive private cover and an overstretched public sector.
More importantly, it would represent something the broader healthcare debate has often lacked: an incremental and implementable step towards universal health coverage.
In many respects, that may be one of the most important lessons emerging from the Constitutional Court judgment. Meaningful healthcare reform cannot succeed through legislation alone. It requires cooperation between the institutions, professionals and policymakers who collectively hold the future of healthcare in their hands.
Bridging the healthcare gap
Despite the healthcare gap that often dominates the debate, most stakeholders ultimately want the same thing: broader access to quality healthcare, better health outcomes and greater financial protection for South Africans.
The healthcare gap will not disappear through a single intervention. 
Instead, South Africa must combine broader structural reform with practical measures that can expand access in the near term.
South Africa does not need to choose between reform and pragmatism. The challenge before us is to build a healthcare system that expands access as quickly as possible. At the same time, it must preserve and leverage what already works.
Achieving this will require trust, collaboration and a willingness to pursue practical solutions. These solutions must deliver measurable improvements in people’s lives.
Thoneshan Naidoo | CEO | Health Funders Association (HFA) | mail me |
