South Africa’s President Cyril Ramaphosa signed a measure into law on Wednesday that promises to offer universal health coverage, hailing it as a significant step towards a more equitable society, two weeks before a fiercely competitive election.

The National Health Insurance (NHI) Act aspires to create a two-tier health system, with a publicly financed sector serving 84% of the population and private insurance providing access to better treatment.

Opponents have pledged to challenge it in court and labelled it as a ploy for votes, which the presidency disputed, ahead of an election in which the ruling African National Congress (ANC) is trying to keep its legislative majority after 30 years.

The legislation will gradually reduce the role of private insurance, establish a new public fund to give free access to South African people, and regulate the fees and prices that private doctors and healthcare providers can charge for NHI-funded benefits.

“The provision of healthcare in this country is fragmented, unsustainable and unacceptable,” said Ramaphosa, framing the legislation as a solution to inequalities that date back to the apartheid era.

“For those who would like to see (their) privileges continuing, sorry, you are on the wrong boat. The boat we are on is about equality,” he said at a signing ceremony at the Union Buildings, the seat of government in Pretoria.

Opponents argue that the plan will deplete already-strained public funds, limit patient choice, lower care quality, and drive talented doctors out of the nation.

According to industry and political commentators, the legislation is expected to be mired in litigation for years, with the funding model being the most contentious issue. The government has stated that the National Treasury will select the NHI’s funding sources, which will include an obligatory pre-payment system and other forms of levies.

Big local health insurers, such as Discovery Momentum Metropolitan Health and AfroCentric, say they support universal health coverage but disagree with the proposed funding approach.

“There is no funding plan yet and given the country’s constrained fiscal position, low economic growth and narrow tax base, this can only be solved in the longer term,” said Adrian Gore, group CEO of Discovery.

“We see no scenario in which there is sufficient funding for a workable and comprehensive NHI in its current form.”

South African President, Cyril Ramaphosa, denied on Monday that a recent halt in the country’s long-running energy disruptions was due to the May 29 election.

Rolling power outages enforced by state utility Eskom reached record levels in 2023 and continued into the first quarter of this year, but there has now been no load-shedding, as South Africans refer to the cuts, for 48 straight days, the longest period in more than two years.

According to statistics collected by The Outlier, an independent South African publication specializing in public service data visualisations, power outages occurred every day over the same 48-day period last year.

The rapid improvement in power supply has become a talking point in South African media, prompting opposition charges that the timing was intended to boost voter contentment with the ruling African National Congress.

The ANC is expected to lose its legislative majority for the first time in 30 years, facing its most challenging election ever. According to Ramaphosa’s weekly communication, Eskom’s increased performance demonstrates the success of the government’s 2022 energy plan.

“Yet, against all the available evidence, some people have claimed that the reduced load-shedding is a political ploy ahead of the elections,” he said. “This is not borne out by the facts.”

Ramaphosa credited the improvement to Eskom’s renewed focus on maintenance, additional generation capacity from renewable energy projects, and increasing demand for rooftop solar panels, aided by tax breaks.

Last Monday, the Democratic Alliance, the largest opposition party, ascribed the improved power supply to “political interference” by the ANC, accusing it of exerting pressure on Eskom to keep the lights on.

“South Africans should not be fooled by this brazen abuse of power and they must act to decisively vote out the manipulators on the 29th of May,” it said in a statement on its website.

A key point of contention was whether Eskom was burning more diesel to enhance supplies, as claimed last week by the utility’s former CEO, Andre de Ruyter, who is openly hostile to the ANC.

“If the lights are on, well done, but they’re on because we are pouring money into diesel at a rate of knots,” de Ruyter, who stepped down in February 2023, told a conference in South Africa, in comments widely reported by local media.