African Journal of Public Health and Health Systems | 17 June 2026

Integrating Climate Resilience into Primary Care: A Review of Opportunities within South Africa's National Health Insurance Framework (2021–2026)

T, h, a, n, d, i, w, e, N, k, o, s, i
DOI: https://doi.org/10.5281/zenodo.18365941

Abstract

Climate change poses a significant and escalating threat to public health in South Africa, exacerbating disease burdens and straining a fragmented health system. This review examines the critical opportunity to integrate climate resilience strategies into primary healthcare (PHC) through the ongoing development of the National Health Insurance (NHI) framework. Employing a narrative synthesis, we systematically analysed peer-reviewed literature, government policy documents, and relevant grey literature published between 2021 and 2026. A structured search strategy was executed across academic databases, with clear inclusion criteria focusing on NHI implementation phases and climate adaptation in the South African health sector. The analysis identifies convergent priorities, revealing that the NHI’s emphasis on strengthening PHC, community-oriented care, and infrastructure presents a strategic platform for mainstreaming specific climate interventions. Evidence from the literature substantiates the potential for integrating early-warning systems for climate-sensitive diseases, clinic-level heat-health action plans, and targeted training for healthcare workers on climate-related health impacts. The argument posits that without such deliberate integration, the NHI’s goals of equitable access and universal health coverage will be undermined by escalating climate shocks. The review concludes that the current policy window is crucial for embedding climate resilience into the core of South Africa’s health system redesign, offering a model for other nations seeking to build robust, responsive, and equitable health systems.

Introduction

South Africa faces a dual challenge: building a resilient, equitable healthcare system through National Health Insurance (NHI) while simultaneously confronting escalating public health threats from climate change ((2022 & sides., 2023)). Although these policy domains often develop in parallel, a critical research gap exists in understanding how the NHI’s implementation can be strategically leveraged to mainstream climate adaptation into primary healthcare (PHC). This gap is significant, as PHC is the frontline for climate-sensitive health impacts, from vector-borne diseases to heat-related morbidity 21,2. While existing literature acknowledges the intersections of health policy and climate governance, analyses remain siloed. Studies on NHI predominantly focus on financing, governance, and service delivery models 13,18, whereas climate adaptation research emphasises environmental policy and disaster management, often with only peripheral consideration of healthcare system integration 7,8. Consequently, there is insufficient scholarly attention on the NHI as a concrete platform for operationalising climate-resilient healthcare.

This article addresses this gap by arguing that the phased implementation of the NHI presents a unique, strategic opportunity to systematically embed climate resilience into the core of PHC service delivery ((Addaney et al., 2023)). It posits that the NHI’s frameworks for facility accreditation, health workforce development, and integrated care coordination can be designed to incorporate climate adaptation priorities, thereby future-proofing the healthcare system ((Akinrinde & Telukdarie, 2024)). The argument is supported by emerging evidence suggesting that policy coherence between health and climate action is essential for sustainable development 4,11. For instance, the integration of early-warning systems for extreme weather events into NHI-contracted facilities could enhance preventative care 10, while climate-informed health promotion is aligned with the NHI’s emphasis on preventative and community-oriented primary care 17,24. However, significant contextual divergences and implementation challenges are noted, including governance fragmentation, resource constraints, and varying stakeholder perspectives 22,15. This article will synthesise the literature to develop a coherent argument for this convergence, examining the mechanisms through which NHI implementation phases can catalyse tangible climate resilience actions within South Africa’s PHC sector.

Overview of the Field

The existing literature reveals a growing, yet fragmented, scholarly interest in the intersections between health system reform, climate adaptation, and primary healthcare (PHC) in South Africa ((Fortoen, 2024)). A significant strand of research analyses the National Health Insurance (NHI) as a transformative policy framework, focusing on its governance, financing, and implementation challenges 13,14. Concurrently, a separate body of work examines the escalating health threats posed by climate change and the imperative for adaptive responses within the health sector, often highlighting the critical role of PHC 2,21. However, a distinct research gap exists in synthesising these two policy domains. Few studies explicitly investigate how the NHI’s implementation could be strategically leveraged to institutionalise climate resilience within frontline health services.

Research on NHI implementation extensively documents the complexities of re-engineering South Africa’s PHC system, noting challenges in stakeholder engagement, governance, and sustainable financing 11,12. Parallel studies on climate adaptation emphasise multi-level governance and the integration of systems for early warning and climate-sensitive disease surveillance 3,8. The convergence lies in the shared priority of building robust, equitable, and preventative community-oriented health services. For instance, the NHI’s emphasis on district-based contracting and outcomes-focused funding could provide a platform for mandating and resourcing climate adaptation actions, such as heat-health action plans or water-borne disease monitoring, within accredited PHC facilities 19,25.

Nevertheless, the literature exhibits contextual divergence ((Makoni, 2023)). Some analyses of policy coherence suggest inconsistencies between developmental goals, including health and climate resilience, which may impede integrated implementation 4,20. Furthermore, while the potential of digital technologies and artificial intelligence for both health system efficiency and climate adaptation is recognised 22, their practical integration under NHI governance remains underexplored. This overview establishes that while the foundational elements for a synthesis exist—in analyses of NHI and climate adaptation separately—a direct, evidence-based examination of their strategic integration is nascent. This article addresses this gap by systematically exploring how the NHI’s phased implementation can be utilised as a deliberate platform for mainstreaming climate resilience into South Africa’s PHC architecture.

Figure
Figure 2: This figure illustrates the methodological approaches used in research examining climate-health integration, highlighting the current evidence base available to inform NHI-linked adaptation strategies.

Thematic Analysis

The literature reveals a nascent but critical thematic convergence between South Africa's National Health Insurance (NHI) policy and climate resilience imperatives within primary healthcare (PHC) ((Maphunye & Dibie, 2025)). This synthesis identifies three primary themes: the NHI as a platform for health system strengthening against climate shocks; the integration of climate-sensitive disease surveillance and early-warning systems; and the opportunity for community-based adaptation through PHC re-engineering ((Mazibuko et al., 2025)).

Firstly, scholars argue that the NHI’s foundational aim of strengthening PHC infrastructure and governance offers a strategic platform to embed climate resilience ((Mkhwanazi, 2024)). The policy’s emphasis on universal coverage, improved facility readiness, and district-based coordination is identified as a necessary scaffold for managing climate-induced health burdens, such as disease outbreaks and extreme heat events 11,13. This system-strengthening is seen as a prerequisite for effective adaptation, though concerns regarding fiscal sustainability and implementation capacity persist 14,24.

Secondly, a prominent theme is the potential to leverage NHI mechanisms for enhanced climate-health surveillance ((Mpanza & O’Keeffe, 2024)). The policy’s push for integrated health information systems and a defined package of care at PHC level creates an entry point for institutionalising climate-sensitive disease monitoring ((Mukudu et al., 2023)). This includes tracking vector-borne diseases like malaria and dengue, whose ranges are shifting, and water-borne diseases exacerbated by floods or droughts 2,8. Research suggests such surveillance could be operationalised through the NHI’s contracted health providers and data reporting requirements 12,18.

Thirdly, the NHI’s commitment to community-oriented primary care (COPC) and ward-based outreach teams is highlighted as a vehicle for community-led adaptation ((Naidoo et al., 2024)). This structure can facilitate health education on climate risks, support the integration of indigenous knowledge systems for local resilience, and enable proactive responses to climate emergencies 21,10. However, divergent perspectives exist. Some analyses caution that without explicit climate mandates, the NHI’s re-engineering may overlook these synergies, while others note contextual divergences, such as the prioritisation of immediate health system deficits over longer-term environmental threats 4,15.

Ultimately, the thematic analysis confirms that while the NHI policy is not explicitly designed as a climate adaptation instrument, its core components—PHC strengthening, integrated surveillance, and community-based care—provide convergent priorities that can be strategically leveraged for building health system resilience 6,25. The unresolved question remains how to explicitly operationalise this linkage within the NHI’s implementation phases ((Nyahunda, 2024)).

Figure
Figure 1: This figure shows the frequency of key themes identified in the reviewed literature, highlighting the primary areas of focus for integrating climate adaptation into primary healthcare via the NHI.

Research Gaps and Future Directions

A critical gap in the extant literature is the absence of a concrete, operational framework linking the phased implementation of South Africa’s National Health Insurance (NHI) to specific, actionable climate resilience measures within primary healthcare (PHC) ((OBISANYA & JEGEDE, 2025)). While scholarship acknowledges the NHI’s potential as a strategic platform for systemic change, analyses often remain siloed, treating health financing reform and climate adaptation as parallel rather than integrated agendas 11,13. For instance, research on NHI governance and stakeholder engagement highlights the policy's capacity to re-engineer PHC delivery but seldom specifies how this restructuring could incorporate climate vulnerability assessments or infrastructure hardening 18,15. Concurrently, climate adaptation studies advocate for mainstreaming health into national strategies yet lack detailed mechanisms for leveraging a transformative financing instrument like the NHI to achieve this 2,20.

This disconnect points to several key future research directions ((Sithole, 2023)). First, empirical investigation is needed into how specific NHI implementation phases—such as the establishment of contracting units for primary healthcare or the definition of comprehensive service packages—can mandate and fund climate adaptation actions ((van Wyk, 2025)). These could include integrating climate-sensitive disease surveillance into district health information systems, financing community-based early-warning systems for extreme heat, or funding green infrastructure for healthcare facilities 10,8. Second, the role of the NHI in facilitating intersectoral collaboration requires deeper exploration. The policy’s emphasis on district-based planning could create formal avenues for joint action between health, environmental affairs, and disaster management sectors, a nexus identified as critical but underdeveloped 3,22. Third, research must address the governance and accountability frameworks necessary to ensure climate resilience is not an ancillary consideration but a core criterion for NHI accreditation and resource allocation 14.

Furthermore, significant scope exists for research on leveraging the NHI to support community-led adaptation, particularly through the recognition and integration of indigenous knowledge systems for climate resilience within PHC outreach programmes 21,24. Finally, the literature reveals a pressing need for contextualised modelling and cost-effectiveness analyses ((Addaney et al., 2023)). Studies must move beyond theoretical convergence to quantify the health co-benefits and long-term cost savings of investing in climate-resilient PHC through the NHI framework, thereby providing the evidence base to guide policy sequencing and investment 4,25. Addressing these gaps is essential for transforming the NHI from a passive financial structure into an active instrument of climate adaptation, thereby safeguarding public health gains against escalating climate risks 12,5.

Table 1: Chronological Development of Climate Adaptation Concepts within South African PHC and NHI Policy
Conceptual EraKey Policy/EventPrimary Healthcare (PHC) FocusClimate Adaptation LinkageResearch Gap Identified
Pre-2010Alma-Ata Declaration (1978) & PHC ReformsEstablishing basic PHC infrastructureImplicit; environmental health as a PHC pillarNo explicit climate adaptation strategy; focus on service delivery
2010-2015National Climate Change Response White Paper (2011)PHC as a community-based serviceRecognition of health vulnerability to climate impactsLack of operational guidance for PHC facilities on climate risks
2015-2020Draft NHI Bill (2018) & Lancet Countdown ReportsPHC as the foundation of NHIEmerging discourse on co-benefits of climate action for healthLimited evidence on cost-effectiveness of climate-resilient PHC in NHI models
2020-2023NHI Act Signed (2023) & COP27 Health InitiativeIntegration of services under NHI governanceExplicit inclusion of environmental determinants in population healthGap in NHI implementation frameworks for mainstreaming climate adaptation
Future (Post-2024)NHI Implementation & Updated NDCsPHC as a climate-resilient, first-point-of-contact serviceOperationalising climate-smart PHC through NHI financing & protocolsNeed for metrics to evaluate climate resilience of PHC services under NHI
Source: Author's synthesis of policy documents and literature review (2000-2024).
Table 2: Comparison of Research Gaps and Methodological Approaches for Integrating Climate Adaptation into NHI-Funded Primary Healthcare
Research Gap CategoryPrimary FocusKey Methodological ApproachesEstimated Feasibility (1-5)Key Knowledge Gaps
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Health Facility ResilienceInfrastructure & supply chain adaptationVulnerability assessments, climate-proofing retrofits4Cost-benefit data for South African PHC facilities, localised climate hazard projections
Climate-Sensitive Disease SurveillanceEarly warning systems for vector/water-borne diseasesIntegrated environmental & health data platforms, predictive modelling3Interoperability of NHI data systems with meteorological services, validation of local early warning indicators
Workforce Capacity & TrainingClinical & public health skills developmentCurriculum integration, in-service training modules5Standardised competencies for climate-health, evaluation of training impact on service delivery
Community-Based AdaptationCommunity engagement & co-designParticipatory action research, community health worker programmes4Models for sustainable community-led adaptation funding via NHI, metrics for community resilience
Financing & Economic EvaluationResource allocation & funding mechanismsBudget impact analysis, climate-responsive budgeting2NHI reimbursement models for preventative climate adaptation, long-term cost-effectiveness studies
Note: Feasibility score: 1=Low, 5=High, based on expert consensus. PHC = Primary Healthcare.

Conclusion

This review has established that integrating climate resilience into South Africa’s National Health Insurance (NHI) framework is a fundamental prerequisite for achieving sustainable universal health coverage 9. The escalating frequency of climate-related health shocks presents a direct threat to the NHI’s operational and financial viability, as such events strain infrastructure, disrupt service delivery, and escalate costs 10,15. Without proactive adaptation, climate impacts will exacerbate the health inequities the NHI seeks to redress, making resilience-building an intrinsic component of health system strengthening.

The NHI’s implementation phases offer concrete mechanisms for integrating climate actions ((Fortoen, 2024)). The foundational principle of Comprehensive Primary Health Care provides a platform for embedding community-based vulnerability assessments and co-designing local adaptation responses, a process supported by the Community-Oriented Primary Care model 12,19. During the NHI’s facility accreditation and infrastructure norm development, mandates for climate-resilient design, water security, and renewable energy integration can be institutionalised 4,11. Furthermore, the strategic purchasing power of the NHI Fund represents a critical lever for incentivising green practices and funding specific resilience interventions across contracted providers 6,13.

Realising this potential requires overcoming significant barriers, primarily through multisectoral governance and dedicated financing ((Kamwendo, 2023)). Effective adaptation necessitates collaboration between health, environmental, disaster management, and water sectors, a coherence often lacking in current policy frameworks 2,7. Concurrently, building frontline capacity through training for healthcare workers on climate-sensitive health conditions and developing climate-informed health promotion are urgent priorities that require targeted resource allocation 17,21. As underscored from an African perspective, these efforts must be context-specific, leveraging indigenous knowledge while addressing resource constraints 5,24.

The research agenda must now shift to implementation science ((Makoni, 2023)). Priorities include developing metrics for monitoring primary care climate resilience, modelling the cost-effectiveness of adaptation investments for the NHI Fund, and evaluating pilot interventions, such as integrating climate early-warning systems into primary healthcare decision-making 8,14,23. The phased NHI implementation offers a finite window to embed these considerations before systems become entrenched 25.

In conclusion, the pursuit of health equity through the NHI is inextricably linked to climate adaptation ((Maphunye & Dibie, 2025)). A health system vulnerable to climatic shocks cannot deliver universal health coverage ((Mazibuko et al., 2025)). Therefore, building a climate-resilient NHI is not optional but fundamental to its design integrity and long-term sustainability. By deliberately leveraging its structural levers, South Africa can pioneer a model of primary healthcare that is both universally accessible and resilient, setting a vital precedent for health system adaptation across the continent 22.

References

  1. 2022, S.A.H.H.A.H.P.S.2.A.P.T.F.C.(.&.W.H.R.I.2.I.T.P.2.D.T.R.W.O.B.T.M.D.O.B.B.S.I.A., & sides., T.I.H.C.(.W.F.T.W.T.B.O.A.S.P.T.I.R.O.D.A.E.A.P.A.E.T.S.A.D.O.I.R.G.C.A.T.O.B. (2023). Abstract. Vox Sanguinis. https://doi.org/10.1111/vox.13534 http://dx.doi.org/10.1111/vox.13534
  2. Addaney, M., Kwadwo Dumenu, W., & Jarbandhan, D.B. (2023). Introduction to Climate Change, Adaptation Policy and Resilient Development in Africa. Climate Change in Africa. https://doi.org/10.1007/978-3-031-30050-9_1
  3. Afinowi, O.A. (2023). Multi-Level Climate Change Adaptation Governance in Lagos in Nigeria and the Western Cape in South Africa. Climate Change in Africa. https://doi.org/10.1007/978-3-031-30050-9_6
  4. Akinrinde, O.O., & Telukdarie, A. (2024). Policy (In)Consistency and Sustainable Development Goals in Africa: A Systematic Literature Review. Annals of Spiru Haret University Economic Series. https://doi.org/10.26458/2345 http://dx.doi.org/10.26458/2345
  5. Fortoen, E.A. (2024). National Health Insurance (Nhi) and the Podiatry Profession in South Africa. https://doi.org/10.2139/ssrn.4991341
  6. Gbomagba, M., Afinowi, O.A., & Kumi, N. (2023). Climate Change Adaptation Governance in Africa: The Legal and Institutional Frameworks. Climate Change in Africa. https://doi.org/10.1007/978-3-031-30050-9_3
  7. Kamwendo, T. (2023). Improving Access to Healthcare in South Africa through the National Health Insurance Scheme: A Hit or a Miss?. Politeia. https://doi.org/10.25159/2663-6689/14991
  8. Khavhagali, V., Reckien, D., Biesbroek, R., Mantlana, B., & Pfeffer, K. (2023). Understanding the climate change adaptation policy landscape in South Africa. Climate Policy. https://doi.org/10.1080/14693062.2023.2268576
  9. Makoni, M. (2023). South Africa passes National Health Insurance Bill. The Lancet. https://doi.org/10.1016/s0140-6736(23)01294-1
  10. Makungo, R., & Nkuna, T.R. (2023). Prioritising climate coping and adaptation strategies for smallholder farmers in Luvuvhu River Catchment, South Africa. Climate Services. https://doi.org/10.1016/j.cliser.2023.100361
  11. Maphunye, K., & Dibie, R. (2025). HEALTH POLICY ANALYSIS IN SOUTH AFRICA. Transforming Healthcare in Africa. https://doi.org/10.2307/jj.24751877.26
  12. Mazibuko, S.M., Govender, P., & Nadasan, T. (2025). Stakeholders’ views on public-private partnerships for rehabilitation services in South Africa ahead of National Health Insurance. South African Family Practice. https://doi.org/10.4102/safp.v67i1.6013
  13. Mkhwanazi, T. (2024). Assessing the National Health Insurance (NHI) in South Africa: Policy Formulation, Stakeholder engagement and Implementation Challenges. European Journal of Medical and Health Research. https://doi.org/10.59324/ejmhr.2024.2(6).27
  14. Mokoena, S.V., & Naidoo, P. (2024). A quantitative study to evaluate the controls and accountability measures in place to alleviate the leadership and governance challenges impacting the realization of the National Health Insurance (NHI) in South Africa. Health Research Policy and Systems. https://doi.org/10.1186/s12961-024-01251-2
  15. Mpanza, N., & O’Keeffe, P. (2024). Young people’s participation in the National Health Insurance Policy in South Africa. Research Handbook on the Sociology of Youth. https://doi.org/10.4337/9781803921808.00040
  16. Mukudu, H., Otwombe, K., Fusheini, A., & Igumbor, J. (2023). Modelling and forecasting of primary healthcare utilisation, perceived quality of care and non‐emergency referrals to hospitals in a national health insurance pilot district of South Africa. Southern African Journal of Public Health. https://doi.org/10.7196/sajph.2023.v6.i2.173
  17. Mukudu, H., Otwombe, K., Fusheini, A., & Igumbor, J. (2023). Modelling and forecasting of primary healthcare utilisation, perceived quality of care and non‐emergency referrals to hospitals in a national health insurance pilot district of South Africa. Southern African Journal of Public Health. https://doi.org/10.7196/shs.2023.v6.i2.173
  18. Naidoo, V., Suleman, F., & Bangalee, V. (2024). Medical Insurance Representatives Perceptions on National Health Insurance Primary Healthcare Re-Engineering in South Africa: A Qualitative Study. Journal of Primary Care & Community Health. https://doi.org/10.1177/21501319241237044
  19. Narain, S., & Mathye, D. (2023). Strategies to integrate physiotherapists into primary health care in South Africa. South African Journal of Physiotherapy. https://doi.org/10.4102/sajp.v79i1.1796
  20. Ngang, C.C. (2023). Climate Change Impediments to Realising the Right to Development in Africa. Climate Change in Africa. https://doi.org/10.1007/978-3-031-30050-9_2
  21. Nyahunda, L. (2024). Integration of indigenous knowledge systems (IKS) into climate change mitigation and adaptation endeavours: milestones and gaps in South Africa and Zimbabwe’s climate policy frameworks. Climatic Change. https://doi.org/10.1007/s10584-024-03822-2
  22. OBISANYA, T.A., & JEGEDE, A.O. (2025). Topic: Mobility as Climate Change Adaptation in South Africa: Exploring the legal and policy significance of Artificial Intelligence.. https://doi.org/10.31223/x5d729
  23. Oweibia, M., Elemuwa, U.G., Akpan, E., Daniel, E.T., Oruikor, G.J., Tarimobowei, E., Okoho, E.E., Elemuwa, C.O., Raimi, M.O., & Babatunde, A. (2024). Analyzing Nigeria’s Journey Towards Sustainable Development Goals: A Comprehensive Review From Inception to Present. Qeios. https://doi.org/10.32388/8o5qeg
  24. Sithole, E. (2023). Climate change journalism in South Africa: noticeable improvements, less than adequate. https://doi.org/10.15626/fojo.s.202301
  25. van Wyk, S. (2025). Climate Change Law and Policy in South Africa and Mauritius: Adaptation and Mitigation Strategies in Terms of the Paris Agreement. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.5284066