The R940bn NHI figure that wasn’t: What the Genesis report actually says

The figure R940 billion has become one of the most powerful weapons deployed against South Africa’s National Health Insurance (NHI) Act. It is routinely cited as proof that NHI is fiscally reckless, economically impossible, and constitutionally suspect.

Yet the Genesis Analytics report from which the figure originates tells a far more cautious story, one that is often lost once its caveats are stripped away.

A figure the authors repeatedly qualify

Genesis is explicit that its estimate is not a prediction of what NHI will cost. In its overview, the report states:

“Further downside risks in the above estimate of the impact on scheme beneficiaries is a best-case scenario.”

The authors go on to emphasise the limits of their analysis, noting that: “We are not able to say how Government will implement NHI or the extent to which efficiencies will be realised.”

Despite this, the R940bn figure is routinely presented in public debate as a definitive and unavoidable annual bill, an interpretation the authors themselves explicitly caution against.

Costing ‘comprehensive care’ not the NHI as legislated

Crucially, Genesis does not cost the NHI as set out in legislation or policy documents. Instead, the report is explicit about the system it models:

“For the purposes of analysis, we assume savings of 4.5% of scheme expenditure – the cost of providing comprehensive healthcare similar to the average scheme beneficiary.”

Later, the report draws a clear conclusion from this assumption: “The cost of providing comprehensive healthcare (similar to the average scheme beneficiary) will be unaffordable.”

In effect, Genesis asks a specific and narrow question: What would it cost if every South African consumed healthcare at private medical scheme levels?

The R940bn figure is the answer to that question, not a costed estimate of NHI as designed.

An explicitly high-cost benchmark

Genesis is transparent about the scale of expansion implied by this modelling choice. It states that providing such comprehensive care would require:

“Increasing the number of GPs by 113%, the number of specialists by 80%, and hospital beds by 113%.”

These figures are not incidental. They are the mechanical result of extending private-sector utilisation patterns to a population of roughly 60 million people.

Yet this intentionally high-cost benchmark is increasingly treated in public debate as the unavoidable price of NHI itself.

Demand treated as inevitable, efficiencies as uncertain

Where cost pressures are concerned, Genesis adopts firm assumptions. The report states: “As Government seeks to extend access to care, demand for healthcare facilities, practitioners and medicines will increase.”

By contrast, when it comes to potential savings, the report repeatedly highlights uncertainty. Genesis notes that:

“The NDoH has not provided quantification of the efficiencies on which this analysis is based.”

And while acknowledging possible price reductions through central purchasing, the authors add:

“The buying power of NHI as a single purchaser may reduce prices, but the extent of this is uncertain.”

The modelling choice is explicit in the text: uncertain savings are treated cautiously, while increased demand is assumed.

No phasing, no lower-cost alternatives

The R940bn estimate assumes a fully implemented, mature system funded immediately at scale. Genesis illustrates the fiscal magnitude of this scenario starkly:

“If this were to be funded by a payroll tax, that tax would need to be of the order of 26% of salaries.”

And: “Health expenditure would need to increase from approximately 8% to between 12% and 13% of GDP.”

What the report does not do is model phased implementation, narrower benefit packages, or alternative system designs. This is notable given the authors’ own warning that:

“Any change of this magnitude creates a number of significant additional risks.”

A conditional analysis, not a policy verdict

Genesis is careful throughout to define the scope of its work. The report states plainly that: “This report does not assess the desirability of NHI, but its economic implications under a set of assumptions.”

Those assumptions, private-sector utilisation, comprehensive benefits, and limited efficiency gains, are precisely what generate the R940bn figure.

Once removed from those assumptions and caveats, however, the number has taken on a life of its own.

What the report actually shows

Read honestly, the Genesis report does not conclude that NHI is unaffordable. It concludes something far narrower: “The cost of providing comprehensive healthcare (similar to the average scheme beneficiary) will be unaffordable.”

That is a warning against replicating South Africa’s private healthcare model at scale, not an argument against universal healthcare itself.

How a scenario became a scare figure

The controversy, then, is not the analysis. It is how selectively it has been used.

A hypothetical stress test has been repackaged as fiscal certainty. A conditional scenario has been sold as inevitability. And a report dense with qualifications has been reduced to a single, alarming number.

Genesis issued the warnings, repeatedly and explicitly. Many simply chose not to read them.

Dr Sanele Ngcobo is a lecturer in the Department of Family Medicine in the Faculty of Health Sciences at the University of Pretoria