Key points
- South Africa runs a mixed, two-tier system: a public sector serving 84% of the population and a private sector serving 14%, described by the National Department of Health as fragmented.
- The National Health Insurance (NHI) Act was signed into law on 15 May 2024, legislating universal coverage through a tax-funded NHI Fund that will buy services from public and private providers — but the Fund is not yet operational.
- Medical aid covers only 15.7% of individuals (2023), yet the private sector absorbs a large share of spending; medical schemes must pay Prescribed Minimum Benefits in full, though co-payments are often pushed to patients.
- Households paid only 6.7% of health spending out of pocket in 2023 (WHO Global Health Expenditure Database) — the lowest share stated in any profile in this set.
- Life expectancy at birth was 66.0 years in 2023, and health spending was 8.9% of GDP in 2023 (WHO Global Health Estimates; World Bank, WHO Global Health Expenditure Database).
Direct answer: South Africa runs a mixed, two-tier system: a public sector serving 84% of the population and a private sector serving 14%, described by the National Department of Health as fragmented. The National Health Insurance (NHI) Act was signed into law on 15 May 2024, legislating universal coverage through a tax-funded NHI Fund that will buy services from public and private providers — but the Fund is not yet operational, and accreditation and contracting requirements are still being developed. Medical aid covers only 15.7% of individuals. Households paid only 6.7% of health spending out of pocket in 2023 — the lowest share stated in any profile in this set. Life expectancy at birth was 66.0 years in 2023 — and healthy life expectancy 56.2 years — and health spending was 8.9% of GDP in 2023 (WHO Global Health Estimates, October 2026; World Bank, WHO Global Health Expenditure Database).
At a glance
| Item | Detail |
|---|---|
| Model | Mixed — two-tier public/private; NHI legislated, not yet operational |
| Who pays | General taxation (public sector) + medical scheme contributions (private sector); government and compulsory schemes accounted for 61.6% of health spending in 2023. The NHI Fund will be paid predominantly from general revenue, supplemented by a payroll tax and a surcharge on taxable income |
| Who delivers | Public clinics and hospitals, the first port of call for 73.1% of households (2023), and private providers; the NHI Fund will buy services from both |
| What is free at the point of use | Public-sector care, funded from general taxation, for the 84% of the population it serves; under the NHI Act, covered services will carry no co-payments or user fees once the Fund is operational |
| Life expectancy at birth | 66.0 years (2023, WHO Global Health Estimates) |
| Health spending | 8.9% of GDP (2023, World Bank, WHO Global Health Expenditure Database) |
| Source for the model and coverage | National Department of Health — National Health Insurance FAQ |
Figures are a snapshot checked 7 November 2026, not a live feed. No country is ranked as best.
How the system works
South Africa’s health system is fragmented and two-tiered. The public sector serves 84% of the population, with constrained budgets and underservicing, while the private sector serves 14%, with rising costs and overservicing and no demonstrated improvement in outcomes. The Department of Health derives its mandate from the National Health Act of 2003, which requires a structured and uniform health system and sets out the responsibilities of the three levels of government. In 2023, 73.1% of households said they would first go to public clinics, hospitals or other public institutions, while 25.4% said they would first consult a private doctor, private clinic or hospital.
The National Health Insurance Act, signed into law on 15 May 2024, is meant to unify the system. NHI is a Fund paid by taxes from which the government will buy services for all who live in the country, from public and private providers. Its benefits are comprehensive — primary, secondary, tertiary, specialised and quaternary care, with a referral system, an Essential Medicine List and an Essential Equipment List — and a Benefits Advisory Committee determines which benefits are medically necessary. The Fund purchases on behalf of citizens, permanent residents, refugees, inmates and specific categories of foreign nationals; asylum seekers and illegal foreigners are covered for notifiable conditions and emergency care, and all children are covered regardless of nationality. Registration happens at the first visit to a contracted clinic, GP or hospital, with an identity document or passport and a biometric record, and there is no registration fee.
But the Fund is not yet operational. Transitional arrangements run from 2023 to 2026, including establishing the institutions and the Fund as a Schedule 3A public entity, and the NHI Fund’s accreditation and contracting requirements are still being developed — the Department says it will take some time for all health care providers to obtain certification. The Act will be implemented in phases, and the Fund itself is expected to take 6 to 12 months to establish once the relevant sections are proclaimed.
Who pays, and what people pay
General taxation pays for the public sector, and medical scheme contributions pay for the private sector. Government and compulsory schemes accounted for 61.6% of health spending in 2023 (World Bank, WHO Global Health Expenditure Database). The NHI Fund will be funded predominantly from general revenue allocations, supplemented by a payroll tax on employers and employees and a surcharge on taxable income; there is no opting out. What patients pay is small by the standards of this set: households paid only 6.7% of health spending out of pocket in 2023 — the lowest share stated in any profile in this set. Medical aid covers only 15.7% of individuals (2023, down slightly from 15.9% in 2002), with over 71 registered medical schemes and over eight million beneficiaries by August 2024. Medical schemes must pay Prescribed Minimum Benefits in full — 26 chronic conditions and 271 medical conditions — yet co-payments are pushed to patients.
What is free, and what is not
Free at the point of use: public-sector care, funded from general taxation, for the 84% of the population it serves — and, once the NHI Fund is operational, covered services will carry no co-payments or user fees. What is not free is the margin: private care outside the public sector, paid for through medical schemes, and the co-payments that schemes push to patients even on Prescribed Minimum Benefits. The two tiers are the story: the public sector is under-resourced for the share of the population it serves, while the private sector is expensive for the share it serves.
How it compares
South Africa spends 8.9% of GDP on health (2023), just below the OECD average of 9.3% (2024), and its life expectancy of 66.0 years is 15.1 years below the OECD average of 81.1 years (2023) — the second-lowest in this set after Nigeria (62.9 years). South Africa is not in the OECD tables, so its figures come from WHO and World Bank sources for 2023 rather than the OECD’s 2024 dashboards. Its distinguishing feature is the contrast between the money and the outcome: spending close to the OECD average, the lowest out-of-pocket share stated in any profile in this set (6.7%), and yet the second-lowest life expectancy in the set — with a National Development Plan target of raising life expectancy to at least 70 years by 2030, and an NHI Act that legislates universal coverage but is not yet in operation. Compare countries side by side in the Health System Comparison tool, or read the other profiles in the country index.
Frequently asked questions
Is healthcare free in South Africa?
Public-sector care, funded from general taxation, is the first port of call for 73.1% of households — and under the NHI Act, covered services will carry no co-payments or user fees once the Fund is operational. Private care is paid for through medical schemes.
What is NHI?
National Health Insurance: a tax-funded Fund, legislated by the NHI Act signed on 15 May 2024, that will buy comprehensive health services for everyone who lives in South Africa from public and private providers. It is being implemented in phases and is not yet operational.
Do I still need medical aid?
Medical aid covers 15.7% of individuals (2023). Once the NHI Fund covers a benefit, medical schemes may not cover the same benefits — but until the Fund is operational, schemes remain the route to private care.