Could the NHI fuel anti-immigrant sentiment?

There is no government deadline. In fact, nothing exists outside of a fake flyer circulating on social media warning foreigners they will be arrested, detained or deported unless they leave the country. The kind of nothing that blocked clinic doors for months, demanding papers from suspected non-nationals without any legal right. Which is to say this fake deadline of 30 June is very real indeed.

As is the anti-immigrant sentiment unfolding on the streets that has the very real potential for the kind of violence which took 62 lives in 2008, including 27 South Africans, and has hardened since the COVID-19 pandemic. 

President Cyril Ramaphosa addressed the issue directly on 7 June, announcing a plan that included increased immigration enforcement, border security, ending the green ID book, capping foreign worker quotas, and regional diplomacy.

The Human Sciences Research Council, which has been tracking sentiment towards immigrants since 2003, had already noted a hostile upswing since COVID-19. In 2021, 30% of South Africans said they would “welcome no immigrants” to the country. By 2025, that climbed to 42%, mostly driven by the poor and lowest socioeconomic classes. In KwaZulu-Natal alone, those numbers blistered furiously from a quarter of those surveyed in 2021 to 60% in 2025. 

Anti-immigration politics, researchers say, gives leaders a way to address what people are angry about — immigrants — while not addressing what's actually broken. In the health sector, you don’t have to look far for examples of what’s broken: take the 2021 Tembisa Hospital “skinny jeans” scandal where R2-billion was stolen and the corruption linked to communications company Digital Vibes, uncovered in the same year, during Zweli Mkhize’s reign as health minister. 

But fixing endemic corruption and maladministration is more difficult than shouting down presumed non-nationals and blocking their access to clinics and hospitals, even when the Constitution says no one — no matter their nationality — may be refused emergency medical treatment. On healthcare, the National Health Act is explicit: anyone not on medical aid, regardless of citizenship or immigration status, is entitled to free primary healthcare services at public facilities, generally meaning those services provided at clinics. 

That didn’t stop Health Minister Aaron Motsoaledi from, in 2018, saying migrants were overloading the healthcare system, even while admitting it was more anecdotal than based on any hard documentation. 

In interviews since 2024, he told Bhekisisa’s TV programme, Health Beat, he knows very well that foreigners are coming to South African clinics to get HIV treatment. And he’s doing nothing to stop it because, he says, “we believe it will work in reverse for us to fight the disease if you deny people treatment”. 

Antiretrovirals (ARVs) don’t just keep people with HIV healthy, they lower the levels of the virus in a person’s body so they aren’t able to infect others; not treating everyone who tests positive for HIV, or not allowing them to take medications that can stop them from contracting the virus in the first place, means the virus will spread.

The NHI roll-out is “on pause”, while the Constitutional Court is considering if fair processes were followed for it to become law; a judgment is not expected until December or early 2027. But regardless of the ruling, scientists and activists will fight hard to have the clause about access to HIV treatment for foreigners adjusted. 

The current version of the Act says refugees, undocumented migrants and asylum seekers will only qualify for free health treatment for emergencies and “notifiable diseases” — diseases like tuberculosis or cholera — that can lead to an outbreak with a major impact on public health. But that list doesn’t include HIV, which is normally treated in primary healthcare clinics.

Mia Malan asked Motsoaledi why HIV didn’t make the list of notifiable diseases (in interviews in 2024, and again in 2025), and if he would consider starting a process to change the Act, should the Constitutional Court rule the Act could go ahead. The health minister's answer in short: yes, he believes everyone in South Africa should have access to ARVs, regardless of where they’re from, or if they can pay for it. 

Mia Malan (MM): Is there a possible amendment for the part of the NHI that says asylum seekers and undocumented migrants cannot access ARVs because HIV is not considered a “notifiable disease”? How will we get around that?

Aaron Motsoaledi (AM): That’s very tricky in terms of definition. The only reason that HIV and Aids is not a notifiable disease is because people refused it politically. But clearly it meets all the characterisation of notifiability by the World Health Organisation. With all infectious diseases, you can't exclude people because you'll be working in reverse. They will just spread it. If the Act clearly says we are excluding these people on ARVs, we will need to revisit that. It's not going to work. 

MM: So will the solution then be to make HIV notifiable?

AM: I personally would like that because if HIV and Aids was notifiable long ago, I don't think we'd be here where we are. But it was found to be totally out of line with the politics of that time, for the simple reason that it is a very sensitive issue. There will be people on treatment for HIV, but they don't want to come out into the open, and we still appreciate that. But if you were to ask me, personally, yes, I would like it to be a notifiable disease. But the choice cannot be made by me only. 

MM: If that doesn't happen, the other solution is to make an amendment to the Act, right?

AM: I don't think there was an intention for exclusion. If it is excluding people, it was just an element of technicalities. I don't know what practically it will mean. 

We know that there are people from other countries who are coming to get ARVs. We know they are not South Africans. There are people who jump the border and come here to our clinics. We're not trying to stop it because … we believe it will work in reverse for us to fight the disease if you deny people treatment. 

MM: So if you can't make HIV a notifiable disease, would you consider an amendment to the Act if that is what it takes? 

AM: I don't think I'll have the power to make it notifiable. It's just a desire. The problem with HIV and Aids is that it is extremely sensitive. And I would not like to venture in that area and start a new battle. 

If in the Act it clearly says we are excluding these people on ARVs, we will need to revisit that. It’s not going to work. It’s like vaccination. It’s like during COVID. Imagine if we didn’t treat some people during COVID, how much it would have spread. 

MM: So you’re willing to look at processes to change the Act? 

AM: The NHI Act is not written in stone or in concrete. No Act is. All Acts get amended [when] you realise they’re not serving their purpose. Even the Constitution has been amended.

MM: If you can reach some sort of compromise on the issues that some of these parties are very concerned with?

AM: Obviously, it all depends if Parliament wants to change anything.

MM: Absolutely, but we also know that the ANC is the main party in Parliament. So if you as a party decide you vote for certain compromises, then it will be passed.

AM: You know the state of Parliament now, the ANC no longer has the majority, like previously. If the Act needs 51%, it needs other parties. There’ll have to be an agreement with other parties.

MM: And it will be, you know, within your negotiating power [to get some of the parties on your side]?

AM: Yes, I will say so/that’s true. All I'm saying is that no one party can pass anything alone in Parliament now.