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05 July 2023 | Story Dr Larisse Prinsen | Photo Supplied
Dr Larisse Prinsen
Dr Larisse Prinsen is a Senior Lecturer in the Department of Public Law, University of the Free State.


Opinion Article by Dr Larisse Prinsen, Senior Lecturer in the Department of Public Law, University of the Free State


Earlier this month, the National Health Insurance (NHI) Bill was passed by the South African National Assembly. From there, the Bill will be sent to the National Council of Provinces and if also passed there, it will be signed into law by the President. This process may, however, still take years to complete.

The provision of universal access to healthcare has long been envisioned by not only the Constitution of the Republic of South Africa which states in section 27 that everyone has the right to access to healthcare, but also by the National Health Act of 2003 which in its Preamble declare an aim of the Act as providing for a framework for a structured uniform health system within the Republic. The NHI Bill is the manifestation of this statement.

The Bill aims to ensure that all South Africans have access to quality health-care services and to provide for the establishment of a fund which will be utilised to pay for almost all medical treatments from accredited provides, with rates to be determined by the State. Private health insurers will thus only be able to pay for treatments, health products and services which are not covered by the fund.

This Bill, however, has from the inception been contentious and has been fought against from the start. This is seen in the fact that a mere two weeks before the passing thereof in the National Assembly, the South African Medical Association rejected the Bill in its current form. There have also been multiple court cases launched against the Bill and various different voices have been raised against it.

In spite of this, the Bill will most probably become law in some shape or form, at some point in time and it is thus pertinent to perhaps examine that which it espouses, National Health Insurance, as this concept is a noble one at its core – the achievement of a more equitable society in context of access to healthcare.

Advantages of national health insurance

Some of the proposed and hoped-for advantages of a system of NHI include:

  • Lower overall health-care costs by having the government determine and control the price of healthcare and by decreasing administrative costs;
  • Finite determination of costs related to health-care procedures with no unexpected costs or depletion of medical aid benefits;
  • Potential improvements in healthcare due to higher standards being set for hospitals and clinics;
  • Possible improvement in available services, hygiene and safety in public hospitals;
  • The removal of health-related barriers to education for children with undiagnosed or untreated health issues;
  • Stimulation of the economy by allowing for a healthier workforce where the NHI provides for preventive care;
  • Better salaries for medical practitioners in the public sector;
  • Improvement of social security by for example, preventing future social issues such as crime and welfare dependency;
  • The promotion of equality by removing barriers to health care based on the ability to pay; and
  • A real attempt being made at the progressive realisation of socio-economic rights and an addressing of the inequities and scarcity of health-care resources in South Africa.

Disadvantages of national health insurance

Some of the disadvantages of a system of NHI include:

  • A blow to autonomy as all South Africans will be forced to make use of NHI, regardless of whether they want to or not;
  • The healthy paying for the sick and increased burdens on taxpayers;
  • Uncertainty and vagueness surrounding the financial aspects of the NHI;
  • A decrease in financial incentives to be and to remain healthy;
  • Unemployment could rise as those previously employed by medical aid schemes may be retrenched due to whole departments of these enterprises becoming redundant;
  • Medical practitioners will seek greener pastures and more financially lucrative employment overseas leaving South Africa with a human resource deficit in context of healthcare;
  • Long waiting times for elective procedures as the primary focus of the NHI will be directed towards basic and emergency healthcare;
  • There may be fewer health-care facilities and providers due to an uncertain system of accreditation;
  • A decrease in the quality of care provided;
  • Uncertainty regarding what will in fact be covered by the NHI and what will not;
  • The NHI may be seen to be political pandering rather than a real-life workable and practical system;
  • NHI necessitates confidence by the people in a system under governmental control; and
  • The (very real) potential for corruption and misappropriation of funds.

What national health insurance means to South Africans?

The current two-tier system of health-care provision has not sufficiently catered for good quality healthcare for all. This system has precluded the poor or those without medical aid from accessing a large number of health professionals, services and facilities. NHI will establish a single pool of health-care funding for private and public health-care providers and will pay both these providers on exactly the same basis while expecting the same standard of care from them.

Overall, a system of NHI may impact South Africans in the following manner:

  1. Access to healthcare could be improved for those who previously faced barriers due to financial constraints or geographical location;
  2. Healthcare could become more affordable as the NHI aims to pool funds to provide affordable health-care services;
  3. Health-care service delivery will be impacted as the NHI Fund will be responsible for purchasing services which may result in changes to how services are delivered, organised, and managed;
  4. Equity in healthcare will be promoted;
  5. Healthcare quality will change due to the emphasis on “quality” care which will necessitate increased scrutiny on the quality of health-care services;
  6. The NHI may require changes to the health-care workforce which may include changes in the demand for these practitioners, their roles, and responsibilities as well as their training, retention and distribution across the country; and
  7. Health-care governance will be restructured with the NHI Fund having set powers and functions while policy-making, regulation and accountability will also be impacted.

For South Africans without medical aid or in lower income groups, the NHI will be beneficial in that it will offer more equitable access to health-care services and will allow for these persons to consult private health-care practitioners and make use of private health-care facilities and practices with the NHI footing the bill. Not only will it provide health insurance to those not currently a member of a medical aid, but the NHI purports to improve the resourcing of public hospitals and health-care services as the burden of care will be more evenly distributed.

For South Africans who do have medical aid, the NHI may be a shock to the system. Those who are accustomed to private care may have to settle for lower standards while still paying a similar or higher fee. South Africans within a certain income bracket will still have to make mandatory monthly payments towards healthcare in addition to carrying a higher tax burden.

Implications for medical aid schemes

Once the NHI is implemented, medical aid schemes will not be able to offer any services offered by the NHI and will only be able to provide for “complementary or top-up cover” which does not overlap with that which is provided for by the NHI. South Africans will be able to use their free NHI cover for various health-care needs and no co-payments will be charged. The Bill does provide for gap cover but the relevant section of the Bill is greatly understood and interpreted as meaning that medical aid schemes will cease to operate since current members will be obligated to make use of their NHI. Arguments have been made that negating and destroying the role of medical aid schemes is counterproductive to universal healthcare as there simply are not enough resources to meet the needs of all South Africans and that limiting the right to choose to purchase health insurance is unprecedented, inappropriate and might even constitute a limitation of rights similar to making use of private education or private security.

The private sector, for now, will not be nationalised and as such private practices, pharmacies and hospitals will still be available and South Africans will still be able to register with their preferred health-care provider.

In closing

Universal access to healthcare and the ideal of a national system of health insurance are important concepts which relate directly to core human rights and as such are noble and necessary. However, as is often the case, an ideal may be fine in theory but falls short when it must be put into practice. The NHI Bill is no exception and many concerns and critiques have been lobbied at the Bill and its implementation ranging from the migration of hospitals to semi-autonomous entities, the structure of the contracting unit for primary health-care needs, establishment of the fund, the Health Patient Registration System, accreditation issues, purchasing of services, the amendment of other pieces of legislation to make room for the NHI and payment concerns. Thus far, satisfactory solutions have not been offered to all these problems. The NHI cannot be avoided but perhaps, but for it to be beneficial to all and truly live up to its potential for betterment, it should not be rushed.

News Archive

Centenary medals awarded
2004-10-15

Speech, Rector and Vice-Chancellor: Prof. Frederick Fourie

Op 28 Januarie 2004 het ons die honderdste herdenking van die geboorte van hier­die hoër onderwys instelling gevier met ‘n groot partytjie voor die Hoofgebou. Dit was ‘n wonderlike en vreugdevolle aand.

Die historiese prosessie tydens die amptelike opening van 6 Februarie 2004, in kleurvolle akademiese togas, vanaf ons wortels in Grey-Kollege tot by die Hoof­gebou, het die reistog vanaf die verlede na die hede treffend ge­simbo­liseer.

Talle ander eeufeesgeleenthede het gedurende hierdie jaar plaasgevind. Woensdagaand het ons die premiêre van ‘n dokumentêre film oor koning Moshoeshoe beleef – ‘n belangrike eeufeesprojek van die UV wat onder meer gemik is op die ontwikkeling van ‘ n gedeede geskiedenisbesef – a shared sense of history – and the celebration of a very special leadership, of a spirit of nation-building and reconciliation, in somebody like king Moshoeshoe (also MT Steyn and others…)

Last night we experienced a wonderful and moving honorary doctorary ceremony, with a wonderful group of South Africans like Khotso Mokhele, Antjie Krog, Jakes Gerwel, Van Zyl Slabbert, Jaap Steyn, Saleem Badat, and others - giving so much food for thought.

This evening, where we honour outstanding contributors to the development of this University, is a suitable moment to reflect on the course of the first 100 years of the University of the Free State.

1. ‘n Voëlvlug oor die geskiedenis: die vyf fases

1.1 Eerste fase: 1904 – 1927 (Eerste kwarteeu)

Eerste wankelende treë in die totstandkoming van die
Grey Universiteitskollege

Gedurende 1904 – 1920 word die eerste en mees basiese vakke in geestes- en natuurweten­skappe ingestel, eerste Senaat en eerste Raad saamgestel, en eerste geboue opgerig (hoofgebou en manskoshuis). Teen 1920 was daar egter slegs ongeveer 100 studente, die instelling was finansieel in die knyp, met geen vooruitgang en groei, en ook nie ‘n vaste rektor nie – klaar­blyk­lik was die GUK nog geen lewensvatbare instelling nie. Vrystaatse kinders word steeds eerder na ander universiteite gestuur.

Hierna maak ds JD Kestell, rektor 1920 – 1927, ‘n reuse bydrae om ‘n versukkelde, arm, klein universiteitskollege lewensvatbaat te kry. Hy slaag met fonds­insameling en oortuig Afrikaanse én Engelse ouers om hulle kinders na die GUK te stuur. Teen 1927, met 420 studente, word die eerste nederige mylpale van kritiese massa bereik te midde van ‘n steeds armoedige Vrystaat­se gemeenskap en ‘n studentekorps met gelapte klere. [Maar ook die tyd waarin die Reitz-saal, waarin hierdie plegtigheid plaasvind, gebou is.]

1.2 Second phase: 1927 – 1950 (Tweede kwarteeu)

The Grey University College becomes a fully fledged university

By 1950 the establishment of main basic and career-oriented faculties were completed – Faculty of Commerce in 1937; Faculty of Law as wel as the Faculty of Education in 1945. Student numbers reached 1000 in 1950.

Die UKOVS beleef en oorleef die Groot Depressie, die armblankevraagstuk, die Tweede Wêreldoorlog, taal- en politieke stryd onder Afrikaners, en die stryd van Nat vs Sap, ook op die kampus. Die tydperk word veral gestempel deur die taalstryd met DF Malherbe (rektor 1929 – 1934) as sterk kampvegter vir Afrikaans. Veral na 1948 volg rektor Van der Merwe Scholtz ‘n doelbewuste enkel­talige Afrikaanse rigting (Christelik-nasionaal).

1.3 Derde fase: 1950 – 1976 (Derde kwarteeu)

Ongekompliseerde groei ná onafhanklikheid

Hierdie periode word gestempel deur verkryging van onafhanklikheid as universiteit op 18 Maart 1950. Daarna beleef die UOVS onder rektore Scholtz, Flippie Groene­woud en Benedictus Kok stelselmatige groei sonder beduidende finansiële kommer. Die UV is duidelik ‘n Afrikaanse ‘volksuniversiteit’ op Christelik-nasionale grondslag, onlosmaaklik in­gebed in die dominante politieke bedeling van apartheid en afsonder­like ontwikke­ling. Dit is die hooggety van Afrikaner (en blanke) self­vertroue en heerskappy. Vir personeel sowel as studente is dit ‘n relatief onge­kom­­pliseerde tyd getipeer deur groeiende voor­spoed in die blanke en Afrikaanse gemeenskap, goeie werksvooruitsigte vir studente, kommer­lose studentepret, en min spanning op die kampus.

The academic focus is on teaching, especially to provide staff for the growing public service and education sectors. Research has a low profile. More career-oriented or professional faculties are established: agriculture in 1958 and the medical faculty in 1970. Student numbers reach 2000 in 1960, 4000 in 1970 en 7000 in 1975. Many new residences and academic buildings are erected, especially in the Kok-era.

Teen 1976 was die vernaamste boustene van ‘n medium-grootte universiteit in posisie: onafhanklikheid, genoeg fakulteite, genoeg koshuise en akademiese geboue, goeie sport en kultuur. Op die oog af is die ideaal van volwaardige, onaf­hanklike universiteit verwesenlik.

1.4 Vierde fase: 1976 – 1989

Op koers na die jaar 2000: van die statiese na vernuwing

Politieke onstabiliteit en oorgang in die land begin met die Soweto-onluste, die drie-kamer parlement, PW Botha se Rubicon-toespraak, noodtoestande, die ‘struggle’ en opkoms van UDF, en so meer. Die UOVS is swaar onder die indruk van die ‘totale aanslag’ en die regering se totale teen-strategie. Die Universiteit word polities en akade­mies geïsoleer en intellektueel gemarginaliseer. Ekonomies is dit moeiliker tye na die oliekrisis en die begin van hoë inflasie, en die Staat se finansies wat begin knyp.

Academically this period is distinguished by the strong stimulation and support of the research capacity and orientation by rector Wynand Mouton, which leads to a significant growth in research, especially in the natural sciences. The faculty of Theology is establishyed, the Sasol-UFS library erected. Student numbers continue to grow, but at a much slower rate then before.

Twee ander fasette kenmerk hierdie tydperk: eerstens die toelating van die eerste swart studente (nagraadse 1978, voorgraads 1988) en die begin van die era van multikulturaliteit; tweedens, die begin van subsidie- en finansiële probleme en die eerste rasionalisasie van personeel. Albei hierdie is voortekens van ingewikkelde jare wat sou volg vanaf 1990.

1.5 Fifth phase: 1990 – 2004: The turn of the century brings winds of change

(a) 1990 – 1996:

Die Francois Retief era word gedomineer deur die gevolge van die politieke verande­ringe deur president FW de Klerk en die vrylating van Nelson Mandela. Die UV ontwaak tot die realiteit van die oorgang na ‘n post-apartheid samelewing en komende ANC regering. Die eerste versigtige trans­for­ma­sie­stappe word ingestel, multikulturaliteit word die groot uitdaging, en die eerste fasiliterende strukture (bv. die Multikulturele Komitee) word gevestig. Die eerste senior swart personeel word aangestel.

The dramatic decision about the introduction of parallel-medium teaching in 1993 signals the start of multilingualism as well as a significant growth in the admission of black students. Total student numbers are stable at approximately 9000, but black student numbers grow to 36% in 1995. Initially the change to parallel-medium impact negatively on staff teaching load and hence onresearch outputs.

Die inkrimping in staatsubsidie lei tot ernstige finansiële probleme, besparings­pogings, grootskaalse rasionalisasie van personeel in veral die fakulteit Lettere en Wysbegeerte, spanning tussen Senaat en rektoraat oor finansies – en mismoedig­heid onder personeel.

(b) 1997 – 2004:

The time of rector Stef Coetzee and his successor is the era of the new democracy and transformation. At the beginning of this phase Afrikaans parents start sending their children to other Afrikaans universities; residence become half full. Tensions arise between student groups. This is followed by the large breakthroughs in student transformation in 1997, which normalises the situation. The University becomes a leader in transformation. This leads to the acceptance of the multicultural and multilingual character, on a Christian foundation, of the University. The name changes to the University of the Free State (UFS).

Met ‘n finansiële krisis en verdere rasionalisasie van personeel op hande word die akade­miese en finansiële ‘draaistrategie’ in Januarie 2000 geloods. ‘n Drama­tiese finansiële ommekeer lei tot herinvestering in kampus­fasiliteite en toerusting, ‘n toename in personeel en beduidende verhoging in vergoeding bokant inflasie. Terselfdertyd is daar ‘n opbloei in die akademie: innoverende onderrig­programme, e-leer, ‘n fokus op programgehalte. Konsolidering van fakulteite vind plaas, die Bestuurskool word gestig, daar is sterk internasio­na­lisering en groei in navorsing. Profes­sionele bemarking en strategiese kommunikasie verander die beeld van die UV.

Studentegetalle groei dramaties van 10 000 in 2000 na meer as
23 000 in 2003/4; groei moet nou beperk word. Afrikaanse studente keer terug; koshuise kry lang waglyste. Die verhou­ding tussen wit en swart studente op die hoofkampus is rondom 50:50.

The period ends with the incorporation of the Qwaqwa en Vista Bloemfontein campuses, the approval of a new language policy which also established multilingualism in management and administration, and purposeful efforts to consolidate the foundations of an institutional culture of multiculturalism, multilingualism, non-racialism and non-sexism – a culture of tolerance, embracement and justice in diversity. The Centenary is celebrated with harmony and prosperity on the campus in 2004 (although always with a good sprinkling of unexpected challenges and problems).

2. Vanaand bring ons hulde, en sê ons dankie aan, die bouers van die UV

Oor ‘n honderd jaar het honderde, duisende mense ‘n bydrae gelewer tot die UV se ontwikkeling.

Kom ons eer en dank diegene wat, 100 jaar gelede in a baie arm gemeen­skap wat bykans verwoes is deur die Anglo-Boere oorlog, nooit opgehou droom het oor ‘n eie universiteit om die jongmense te dien, om die mense te dien – die arm Vrystaatse mense van daardie tyd.

Let us honour and thank all those who painstaking built this university from very humble beginnings, from the first fragments and embrio of a university – through a hundred years of various wars, of the struggle, of poverty, of bad times but also good times.

In elke dekade, in elke een van die honderd jaar, is hierdie instelling gebou deur die harde werk, idealisme en verbintenis (“commitment”) van leiers, akademiese personeel, steundiens­personeel, dienswerkers. Laat ons hulle eer en dank.

Let us honour the spirit of commitment and ‘vasbyt’, of ‘never let go’, the determination to overcome obstacles, of timely and pre-emptive adjustment to new challenges and new needs, which made that possible.

Kom ons vier en eer die duisende studente wat in die 100 jaar hier was, wat die spesiale tradisies en spesiale gees geskep het van Kovsiekampus, van Kovsie studentelewe – en wat gedurig nuwe tradisies en gebruike geskep (en gepleeg) het, soos net studente dit kan doen.

Let us celebrate the way this University has, in the last 20 years, once again taken up the challenge of transformation and adjusting to new needs, serving all the people, especially those most in need at this time of our history – thereby closing the circle, going fully “from post Anglo-Boer War to Post-Apartheid”.

Kom ons vier, en wees innig dankbaar vir, die wyse waarop hierdie Universiteit in die laaste 5 jaar gedraai het, finansieel sowel as akademies, en die wonderlike periode van akademiese groei en ontwikkeling en verdieping waarin ons nou staan – tesame met die geleenthede wat QwaQwa en Vista Bfn vir ons bied. Hierdie voorspoed sien ons in die nuwe fisiese aangesig van die kampus, insluitend hierdie wonderlike Eeufeeskompleks.

Let us thank God, the Almighty, who has guided this university through a tumultuous century, for always being there for us, for blessing us in so many ways. In Deo Sapientiae Lux

* * *

So: vanaand is ons hier om erkenning te gee en dankie te sê…

Soveel mense het veel vroeër hul fondament-leggende bydraes gelewer, en alles wat ons vandag hier sien, moontlik gemaak. Selfs mense uit meer onlangse jare is reeds oorlede – enkeles terwyl hulle nog in diens van die UV was, ander na hul aftrede.

‘n Bepaalde groep was bevoorreg en geseend om in die laaste ongeveer 30 jaar by die UV betrokke te kon wees, én om vandag nog in die lewe te wees. Dit is van hulle wat vanaand hier is, en wat vanaand Eeufeesmedaljes ontvang.

Geweldige moeite is gedoen om hierdie proses van seleksie en keuring so billik en deeglik as moontlik te doen. Uiteraard is so ‘n proses nie volmaak nie en sal almal nie saamstem met die uitkomste van die proses nie. Groot moeite is egter gedoen in hierdie fase om mense nie verkeerdelik uit te laat uit of in te sluit in die toekenningslys nie, in volle bewustheid dat daar waarskynlik steeds foute gemaak sal word. Onvermydelik sal daar foute wees, of mense wat uitgelaat is. Ons vra daarvoor nederig om verskoning en begrip.

Billikheid, so ‘n belangrike rigsnoer vir hierdie Universiteit, veral in hierdie tye, lei ons ook dat ons oë oop is vir die bydraes vir mense uit alle afdelings van die Universiteit, wat lei tot ‘n bepaalde balans tussen fakulteite, tussen fakulteite en steundienste, tussen poskategorieë, tussen geslag en ras, en individue soveel as mense in spanverband.

In Deo Sapientiae Lux

God bless this university / Modimo o thlonolofatse yunivesithi ena

Khotso Pula Nala

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