This was an explorative-descriptive qualitative study, as the authors aimed to understand the expressed reactions of social media users regarding the implementation of the NHI in South Africa.

This study relied on secondary data, as there was no physical setting. The study was conducted on various social media platforms, including X (formerly known as Twitter), Facebook, Instagram and TikTok. Twenty-seven South African media rooms were utilised to access the secondary data based on the availability of the post regarding NHI.

The population of this study comprised all individuals with access to social media, irrespective of age, as age is not verifiable. Convenience sampling was used based on what a news media company posted, and the authors selected the first 10 reactions from each news media company. All South African media rooms that posted matters about NHI implementation in May 2024 were included. All other non-South African media rooms talking about NHI were excluded, as the reactions and comments were mainly focused on the views of South African media rooms. All South African media rooms that neither posted nor had any comments about the NHI implementation or signing were also excluded from the study. Lastly, all the information from the South African media room in the form of print was excluded as the study was mainly focused on online content.

Authors reviewed different social media platforms. These social media platforms included X (formerly known as Twitter), Facebook, Instagram and TikTok. Within these platforms, 27 South African media houses were searched and included in this study based on the post each media house posted. The authors backdated the search from 13 May 2024 to 15 May 2024, which was mainly the date of the announcement for NHI signing by the President of the Republic of South Africa. On finding the post, the authors systematically selected the first 10 reactions and comments from social media users regarding the announcement. Some of the questions posted by the South African media rooms were:

Data collection was stopped when there were no available posts regarding NHI from the selected South African media rooms.

Data were analysed using thematic content analysis. The authors viewed all the raw data, which were social media users’ reactions and comments as ‘transcripts’. Raw data included screenshots of the different users’ reactions. The authors collected the information verbatim from the screenshots and created two main transcripts with the first 10 reactions from each news media account. All transcripts were imported into the NVivo 14 software and continued with coding and creating themes. Authors created codes based on the similarities. Lastly, the authors identified and interpreted meaningful themes, which were presented as the qualitative findings (refer to Table 1).

All the principles of trustworthiness were followed and applied. For transferability, authors collected enough data from different social media platforms to reflect the broader population of social media users in South Africa. Additionally, the authors outlined all the processes followed in detail so that other researchers can apply them in their studies. A team of five authors worked together during data collection to ensure credibility, quality and rich data. Conformability was achieved by following the stipulated process of data analysis logically. Lastly, to ensure dependability, the authors used an independent coder to serve as a reviewer after data collection and analysis.

Ethical clearance to conduct this study was obtained from the University of the Free State, Health Sciences Research Ethics Committee (No. UFS-HSD2024/1503/2708). No consent form was required as the study applied secondary data from the various social media platforms. To ensure confidentiality, social media users’ real names or handles were not used. To ensure confidentiality and anonymity, the authors used pseudo-names such as X (947), which represent a social media platform and the news media company where users reacted, along with the number of users, thereby upholding the Protection of Personal Information Act (POPIA).

Many social media users have serious concerns about the NHI’s ability to remain financially viable. Many believe that raising taxes is the only option to finance such a huge financing system for health because the government lacks the resources to carry it out successfully. With numerous references to growing living expenses, inflation and the unemployment rate, users express concern about the growing financial strain on the middle class. It is believed that funding the NHI will make already severe economic challenges worse and that the government is overly dependent on tax income:

One of the most common issues raised by social media users was corruption by government officials. Many felt that, similar to other state-owned entities’ failures (e.g. Eskom, South African Airways [SAA]), the NHI fund would turn into another ‘cash cow’ for government officials. It is believed that even with the best of intentions, a policy will be unsuccessful because of inadequate administration, bad governance and a lack of accountability. The government’s capacity to manage such a large responsibility without significant financial leaks is also questioned:

The discourse was dominated by users’ concerns about the current status of public healthcare facilities, with many saying that government-run clinics and hospitals are already experiencing a crisis as a result of staff shortages, long waiting times and lack of funding. With the public system currently in turmoil, there is uncertainty on whether the government can provide good-quality healthcare under the NHI. Many people are concerned that healthcare standard would drop and that this might compromise the private healthcare system:

A large number of users fear that because of possible salary cuts, greater workloads and inadequate incentives, NHI would cause a mass exodus of South African healthcare professionals. Some predict that the nation’s healthcare system will have trouble keeping qualified professionals, which will cause healthcare services to continue to deteriorate:

Some social media users are in support of NHI, pointing out that it will give everyone in South Africa, especially the underprivileged and those without medical aid, equal access to healthcare. They believe that the NHI can lessen the disparities that now exist between the public and private healthcare sectors and that healthcare is an essential human right. There are, however, disagreements that maintain that those who currently receive private healthcare benefits may suffer if healthcare resources are redistributed:

The majority of the social media users perceived the signing of the NHI bill into law as a method of the South African ruling party to win votes as a campaigning tool during Election Day. Additionally, some social media users showed some disappointed reactions that politicians use real life-changing experiences just to capture and distract voters into believing the ruling party cared for them:

There were various suggestions from the comments of the social media users that the government should instead focus on refining and strengthening the existing healthcare system rather than introducing something new that might fail as the current healthcare system has. Most of the social media users felt that the South African government could use the existing resources to enhance existing hospitals, clinics and staff levels before introducing the NHI:

Almost all the social media users in this study had doubts about NHI implementation in South Africa, some related to how corruption has messed up many great bills and emphasised that if South Africa could not provide basic services like employment to its doctors and nurses, then the NHI is a dream. Lastly, some social media users were sceptical about the government’s ability to deliver on its promises, and some compared it with other failed existing governmental entities and initiatives:

The study found that the most prominent theme emerging from social media commentary is the financial concerns and tax burden the NHI may place on taxpayers, underscoring the public’s anxiety about the NHI’s sustainability. This aligns with findings in other contexts where healthcare reforms are met with skepticism regarding funding sources and economic impact.^{20,21,22,23,24}

Many users expressed skepticism about the government’s ability to fund the system without disproportionately increasing taxes – a concern echoed in the broader literature on UHC.^24,25 The fear of increased taxes, particularly among the middle class, is consistent with research showing that tax-funded healthcare systems can face significant public resistance because of perceived economic burdens.^26,27,28

The social media commentary in South Africa demonstrates a pervasive distrust in the government’s fiscal management, a sentiment exacerbated by the current economic climate in South Africa, characterised by high unemployment and inflation.^29,30,31 Furthermore, apprehensions concerning corruption and administrative deficiencies additionally compound these financial concerns.

Contrary to this public sentiment, the South African healthcare leadership expresses confidence in its political leadership, enduring commitment, and proactive, adaptable strategies to facilitate a shift towards the NHI, thereby promoting UHC.^17,32 This discrepancy highlights a fundamental disparity in perspectives between those in leadership and governance roles and deep-seated concerns and expectations among the populace, specifically concerning the level and efficacy of stakeholder engagement.

Corruption is a well-documented obstacle to effective policy implementation and public sector reform in developing countries, and this pervasive concern significantly undermines public trust in South Africa’s proposed NHI. Similar challenges have been observed in countries like Nigeria and Kenya, where NHI schemes faced allegations of fund mismanagement, reducing public trust and limiting effective implementation.^{33,34,35,36,37}

While governance scandals have plagued South African public institutions, the skepticism surrounding the government’s capacity to manage the NHI fund efficiently is particularly salient. This skepticism mirrors broader critiques of large-scale government programmes, notably the failures of state-owned enterprises like Eskom and SAA.^38,39 The social media discourse reveals a deep-seated fear that the NHI will become another vehicle for state capture and financial malfeasance, echoing observations made by Transparency International and other anti-corruption organisations.^{36,40,41,42,43,44}

Public concerns regarding the quality of healthcare services under the proposed NHI were also prevalent. Many social media users emphasised the existing deficiencies within the public healthcare system, arguing that the government should prioritise improving the current infrastructure before implementing an ambitious national insurance plan. This skepticism about the NHI’s ability to enhance healthcare quality is deeply rooted in the current state of public healthcare facilities.

The current state of public healthcare facilities is characterised by widespread dissatisfaction with long wait times, staff shortages and inadequate resources in state-owned hospitals, reflecting findings from numerous studies on healthcare access and quality in South Africa. For instance, reports by South Africa’s Department of Health and academic research by the Global Burden of Disease 2019 Study and the Health Systems Trust’s South African Health Review 2023 (SAHR) consistently document these challenges.^45,46,47 This sentiment aligns with research from Thailand’s universal healthcare system, which faced initial challenges in service delivery because of inadequate facilities and workforce shortages.^19,48 Critically, the fear that the NHI will lead to a decline in healthcare standards, even in the private sector, reflects a lack of confidence in the government’s ability to integrate and manage a unified healthcare system effectively.

This fear extends to the potential exodus of medical professionals, a critical issue that could further undermine the NHI’s success. Many fear salary reductions, increased workload and poor working conditions under NHI. Similar challenges have been reported in Ghana’s NHI Scheme, where healthcare professionals migrated to better-paying private and international opportunities, undermining service delivery in public hospitals.^49,50,51 This aligns with healthcare worker migration and retention research, which shows that inadequate compensation, poor working conditions and a lack of professional development opportunities can drive healthcare professionals to seek employment elsewhere.^52,53

Overall, the social media commentary reflects a concern that the NHI’s implementation will exacerbate existing challenges in retaining skilled healthcare staff and the current state of public healthcare facilities, thus potentially leading to further deterioration of healthcare services. If not adequately addressed, this could lead to declining healthcare standards and exacerbate workforce shortages in South Africa.

While concerns about potential decline in healthcare quality and the exodus of healthcare professionals dominated social media discussions, some users supported the NHI, emphasising its potential to equalise access and reduce disparities between public and private healthcare.

Universal healthcare, often framed as a fundamental human right, has demonstrated its ability to reduce health inequalities in countries like Thailand and Costa Rica (Knaul et al., 2012).^54,55,56 However, opposition to the NHI revealed a fear that resource redistribution might compromise care quality for those accustomed to private services. This tension between equitable access and maintaining existing private healthcare standards emerged as a central challenge. Simultaneously, strong support for the NHI’s goal of universal access to quality healthcare, aligning with established principles of UHC,⁵⁷ was also evident. Ultimately, the debate underscored the necessity of balancing competing interests, ensuring quality and workforce retention while expanding access to underserved populations for successful NHI implementation.

Adding to the scepticism surrounding the NHI, many users perceived its implementation as an electioneering tactic, questioning the timing of the bill’s enactment. This perception, prevalent in other countries where healthcare reforms are introduced to gain political mileage,^58,59 highlights the politicisation of healthcare reform in South Africa. Research on the political economy of healthcare reinforces this, demonstrating how political considerations and electoral cycles often influence healthcare policies.^60,61,62 The social media commentary reflected a widespread cynicism about the government’s intentions, with many viewing the NHI as a vote-buying strategy rather than a genuine effort to improve healthcare. This scepticism could further weaken public trust in the policy’s intentions if left unaddressed.

Widespread doubts regarding the NHI’s feasibility centred on the government’s perceived incapacity to manage such a large-scale reform. Many users advocated prioritising the strengthening of the existing healthcare system, a strategy aligned with international best practices. A gradual enhancement of healthcare infrastructure and governance often precedes successful universal healthcare reforms.^30,56,63 This suggests that a phased approach, ensuring system readiness before comprehensive rollout, may be more prudent for South Africa. The social media commentary revealed a strong sentiment that addressing current systemic weaknesses should precede any ambitious new national healthcare initiative.

This advocacy for improving the existing public healthcare system reflects a pragmatic approach, emphasising addressing current challenges before embarking on significant reform. Such a perspective is supported by research on health system strengthening, highlighting the importance of leveraging existing infrastructure and resources.^47,56 The prevalent lack of confidence in the government’s delivery capacity, fuelled by perceived failures in other state-led initiatives and ongoing public service delivery issues, further underscores the need for a phased NHI implementation. This phased approach was detailed by South Africa’s President during the State of the Nation Address in 2025, which includes, among other recommendations, the establishment of a Ministerial Advisory Committee on health technologies and healthcare benefits.⁶⁴ Building trust through tangible improvements in current healthcare services is crucial to mitigating scepticism and ensuring public buy-in for future reforms.

This study offers valuable insights into public perceptions of the NHI by analysing social media discourse, a platform of growing influence for policy debate. Thus, capturing real-time public sentiments contributes to the expanding body of research on digital health policy discussions.

However, while social media provides a dynamic window into public opinion, several limitations necessitate a cautious interpretation of the findings. Specifically, this study’s reliance on South African online media platforms excludes print media and international perspectives, potentially overlooking crucial contextual elements.

Furthermore, the variability of NHI-related reactions across online platforms suggests that certain public viewpoints may have been missed. Beyond these limitations in scope, the inherent nature of social media data introduces further considerations. Social media users tend to be younger and more digitally literate, potentially skewing the sample away from marginalised or less digitally connected communities. Additionally, while effective, the thematic analysis employed carries the potential for subjective interpretation.

To address these limitations and achieve a more comprehensive understanding of public sentiment, future research could adopt a mixed-methods approach, integrating traditional media analysis and survey-based data to ensure a more representative and robust assessment. Furthermore, future research should expand its scope to explore the perspectives of diverse stakeholders, including healthcare professionals, patients and policymakers. Employing both qualitative and quantitative methods will be crucial in capturing the nuances of their experiences and opinions.

Beyond simply assessing sentiment, it is imperative to examine the real-world impact of the NHI’s implementation. Studies should investigate the long-term effects on healthcare access, quality and equity, providing empirical evidence of the policy’s effectiveness. Finally, research should delve into the critical role of public engagement and communication in fostering trust and support for healthcare reform. Understanding how to effectively communicate policy changes and engage with the public is essential for successful implementation and long-term sustainability.

The findings have significant implications for policymakers and healthcare stakeholders: