South Africa’s evolving health landscape, driven by the National Health Insurance (NHI) initiative, demands a radical rethinking of professional roles within primary health care (PHC). Implementing the NHI scheme promises universal health coverage (UHC), aiming to dismantle historical inequities and ensure equitable access to care. As the country grapples with a quadruple burden of disease, human immunodeficiency virus or acquired immune deficiency syndrome (HIV/AIDS), non-communicable diseases, maternal and child mortality and violence-related injuries, the need for accessible, community-based care has never been more urgent (Myezwa & Van Niekerk
The
However, rehabilitation services, particularly physiotherapy, remain underrepresented in NHI pilot programmes and strategic documents (Myezwa & Van Niekerk
Physiotherapists can play a vital role in the early detection and management of various medical conditions, which are among the leading contributors to disability-adjusted life years (DALYs) in South Africa (Narain & Mathye
The NHI Bill presents both a challenge and an opportunity. Section 7(2)(b) of the bill mandates that access to all health services, including physiotherapy, should occur at the PHC level. However, without deliberate planning, physiotherapy risks being excluded from implementation. Physiotherapy must be part of this vision, not as an afterthought, but as a cornerstone of preventive and rehabilitative care.
As of March 2025, South Africa had 9235 registered physiotherapists for ~ 64 million people (≈1:6930), with the vast majority working in the private sector (Health Professions Council of South Africa [HPCSA]
Despite their potential, physiotherapists are unevenly distributed across the health system. Only 3% work in primary care settings, while 80% are concentrated in secondary and tertiary hospitals (Conradie et al.
Workforce development is further hampered by limited postgraduate training and a lack of incentives for rural deployment (Narain & Mathye
Physiotherapy’s exclusion from PHC disproportionately affects marginalised populations. The Constitution of South Africa guarantees the right to access health care services. Realising this right requires a health system that includes rehabilitation as a core component, not a luxury.
Physiotherapists possess a unique blend of diagnostic acumen, rehabilitative expertise and preventive insight. Their ability to manage musculoskeletal conditions, chronic diseases of lifestyle, cardiorespiratory conditions and promote functional independence makes them ideal candidates for PHC integration. In rural and underserved communities, where access to physicians may be limited, physiotherapists can offer timely interventions that reduce the burden on hospitals and improve patient outcomes (Narain & Mathye
Despite their potential, several systemic challenges hinder physiotherapists from assuming a first-contact role:
Physiotherapy is often omitted from key health policy documents, limiting its visibility and strategic inclusion in PHC frameworks. The
The profession suffers from an urban-centric workforce, with rural areas facing acute shortages. The public sector suffers from a severe shortage of physiotherapists, especially in rural areas. Most physiotherapists are in the private sector, leaving PHC clinics understaffed (Rule et al.
A rigid medical hierarchy often relegates physiotherapists to subordinate roles, undermining their autonomy and scope of practice. Doctors and nurses usually dominate PHC decision-making, marginalising rehabilitation professionals (Mlenzana et al.
Current training models emphasise curative care over health promotion and disease prevention, misaligning with PHC principles. Curricula remain hospital- and impairment-focused, underpreparing graduates for PHC and preventive care roles (M’kumbuzi & Myezwa
Many South Africans are unaware of what physiotherapists do, leading to underutilisation of their services. Many patients are unaware that they can consult physiotherapists directly, and some medical aids still require a general practitioner (GP) referral (Hanass-Hancock et al.
Physiotherapists in South Africa have held autonomous (first-line) practitioner status since 1985, formally recognised by the HPCSA in 1997 (South African Society of Physiotherapy [SASP]
Diagnose and treat patients autonomously
Refer for imaging or specialist care
Issue medical certificates and manage chronic conditions
Physiotherapists do not require a referral to see a patient. Yet, despite this legal recognition, physiotherapists are often perceived as secondary providers, consulted only after physician referral (Narain, Mathye & Mtshali
To reposition physiotherapists as first-contact providers playing a prominent PHC-level role under the NHI, South Africa must focus on the following aspects:
Physiotherapists must be actively involved in health policy development. Narain et al. (
The government must invest in expanding the physiotherapy workforce, particularly in rural and underserved areas. Incentives such as scholarships, housing allowances and career development opportunities can attract professionals to these regions (Conradie et al.
In integrated teams, physiotherapists should work alongside nurses, doctors and community health workers. This requires dismantling professional hierarchies and fostering mutual respect across disciplines.
Robust research is needed to demonstrate physiotherapy’s cost-effectiveness and health impact in PHC. Studies should evaluate outcomes such as reduced hospital admissions, improved functional status and enhanced quality of life.
Universities should revise physiotherapy curricula to include modules on PHC, public health and health systems management if not in place or strengthened where they are in place. Exposure to community-based practice during training can prepare graduates for frontline roles. Curricula must emphasise community health, prevention and interdisciplinary collaboration (Myezwa & Van Niekerk
Running campaigns promoting physiotherapy as a first-contact option is important. Improving societal knowledge of physiotherapy is essential. Campaigns should highlight the profession’s role in managing chronic conditions, promoting mobility and function and preventing disability. Strengthening professional advocacy through bodies such as the SASP is also important.
Imagine a South African clinic where a patient with early signs of arthritis walks in and is immediately assessed by a physiotherapist, and no referral is needed. The therapist not only provides targeted interventions but also educates the patient on lifestyle modifications, preventing disease progression. This is not a distant dream but a tangible future, contingent on systemic reform and visionary leadership.
Physiotherapists in South Africa have the scope, competencies and legal authority to serve as first-contact practitioners. The underutilisation of this workforce represents a missed opportunity within the national reform agenda. For NHI to achieve equitable access, physiotherapists must be integrated into PHC as first-contact providers, supported by workforce redistribution, education reform and policy recognition. As South Africa rolls out NHI, embracing physiotherapy as a cornerstone of PHC will be vital to achieving health equity, system sustainability, efficiency and excellence in health care.