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The pros and cons of the National Health Insurance (NHI) Bill

05 July 2023 | Story Dr Larisse Prinsen | Photo Supplied

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:

Access to healthcare could be improved for those who previously faced barriers due to financial constraints or geographical location;
Healthcare could become more affordable as the NHI aims to pool funds to provide affordable health-care services;
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;
Equity in healthcare will be promoted;
Healthcare quality will change due to the emphasis on “quality” care which will necessitate increased scrutiny on the quality of health-care services;
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
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

Official opening ceremony of the UFS Qwaqwa Campus

2006-02-15

Official opening ceremony of the UFS Qwaqwa Campus
11th February 2006 – Multipurpose Hall

Opening Speech:
Prof. Peter A. Mbati
Campus Principal

Successfully rising to the challenges of incorporations and mergers – developing a vibrant and academically stimulating satellite campus of the University of the Free State.

Thank you Mr. Program Director and good morning ladies and gentlemen.

I wish to once again welcome all of you to the official opening ceremony of the University of the Free State QQ campus. Thank you for taking time to share with us an important date in our campus academic calendar. I bring you greetings from our Rector and Vice Chancellor Prof. Frederick Fourie.

During such occasions we try and reflect on important matters that have affected us as an institution in the preceding year, commit ourselves to specific objectives for the current year, while planning for the proceeding year.

Today I shall be talking on Successfully rising to the challenges of incorporations and mergers – developing a vibrant and academically stimulating satellite campus of the University of the Free State’.

SRC inauguration
I would like to congratulate the SRC President and the entire SRC leadership for being elected into important positions of student leadership and authority.

As a university we are proud of the quality of our student leadership on the Qwaqwa campus. I am confident that you young leaders will rise to the challenges of your office and discharge your duties with diligence and without fear or favour. That you will rise above your party affiliations and provide effective leadership to the entire student body on campus.

Leadership is complex and requires you to be objective, just and fair in your approach to the many challenges that you will encounter. You will be judged not by the populist decision that you take when confronted with difficult choices, but rather, on the wisdom that you exercise in reaching consensus in decision making processes.

The era when management and student leadership viewed each other with suspicion and as adversaries is long gone. Management, academic and administrative staff, parents and students must have common agendas in as far the quality growth and development of our university is concerned and to strive towards academic excellence. I leave the challenge to you students, and more so to the inaugurated student leaders to define your agenda in achieving this noble objective. I trust that you will make the right choices.

Brief history of incorporation
On the recommendations of the National Working Group of Higher Education, the Qwaqwa Campus of the then University of the North was incorporated into the University of the Free State on 1st January 2003. We suddenly had to move from a campus that was originally semi-autonomous and with its own culture developed over almost 20 years, into a campus that had to operate as a fully integrated campus of the UFS, a 100 year old institution with its distinct culture.

Following incorporation, we not only had to continue with our core business of teaching, learning, research and community service, but we also had to engage in other important aspects such as exploring the most appropriate models of governance for the campus, encouraging dialogue and interactions at all levels between personnel at the different campuses with a view to developing trust between colleagues. And with the added dimensions such as participation in the transformation task team we in effect are at the fore front of developing a new institutional culture at the UFS and a truly South African University.

UFS Strategic objectives
The strategic and transformation priorities of the University of the Free State for 2006 – 2008 as approved by the Executive Management at its retreat in January 2006 are:

Quality and Excellence
Equity, diversity and redress
Financial sustainability
Regional co-operation and engagement

Central to this priority is the integration of the Qwaqwa campus as a valuable constituent part of the UFS, and the strategic reconfiguration of the campus in order that the UFS can play a meaningful role in regional engagement and development.

National leadership

The five strategic objectives cannot be viewed in isolation and run simultaneously and in concert with each other.

The Question must therefore be what we on the QQ campus, staff and students, parents and our broader community are willing to do to achieve these strategic objectives. The reconfiguration and strategic planning of this campus, and therefore its success, must be a collaborative effort between colleagues at QQ and on the main campus. We must all be ready to work together, to plan together, to shoulder responsibilities together and sometimes, to share the pain and disappointments together.

The second question must therefore be: are we prepared to go that extra mile for our campus to ensure that we claim our rightful stake within the ranks of well respected academic institutions of higher learning in this country? At this point in its history this campus requires committed men and women from across the cultural spectrum who appreciate the challenges ahead of us and who are ready to give of their best and to constructively engage at all levels to make this dream a reality. Because this dream is possible and this dream will be realized!

Quality and Excellence (1st strategic objective)

As mentioned by the Rector in his speech at the official opening ceremony of the university on the main campus on Friday 3rd February, the university will in 2006 pay extra attention to Quality and Excellence. This is informed by the Higher Education Quality Committee’s (HEQC) institutional audit which is scheduled to take place this year. Our university as well as several other HEI’s will be subjected to this audit. This will call for a lot of hard work on your part in preparation for a successful audit and in this regard therefore I request for your cooperation.

As a further step in confirming our commitment to quality and excellence, we have simultaneously introduced on the QQ campus and the main campus workshops on performance management systems to a cohort group. This will be expanded in 2006 to a wider group of managers on the QQ campus to include among others all Program Heads and Subject Heads. PMS is an invaluable tool for fair, effective and efficient management of a very important resource on campus – the human resource. Benefits of PMS include among others:

Instilling and enriching a culture of performance management (quality assurance) as an integral part of the day to day functioning of staff at the campus
Improving staff performance through mentoring, development and training

Tri campus project
One of the more important projects that we as a university undertook in 2005 was the Tri Campus Project which was coordinated by the Free State Higher Education Consortium (FSHEC) through Niel Butcher and Associates consultants.

The Tri-Campus project focused on the strategic planning for higher education campuses in the Free State that have been incorporated with UFS and CUT during the reshaping of the South African higher education landscape. The Bloemfontein Vista campus and the Qwaqwa campus of the University of the North were incorporated with the UFS, and the Welkom Vista campus with the CUT.

The planning process involved a range of research and consultation activities during the course of 2005. This included:

Conducting situational analyses of the Qwaqwa campus during which staff and students were widely consulted;
Consulting with the campus and with a range of stakeholders in the sub-region
Review of the Free State Provincial Growth and Development Strategy and Integrated Development Plans (IDPs) of the regions and other research of relevance to the sub-regions, province and country.

An operational framework for the reconfiguration of the campus with a range of possible Program Qualification Mixes has been produced. In December 2005, the Rector, the Vice Rector Academic Planning Prof. Magda Fourie and I discussed this document with senior members of the DoE in Pretoria, and we will soon be meeting with the National Minister of Education Me Naledi Pandor for her guidance and to seek support in the further refinement of the document and subsequent implementation.

Recapitalization
This year a further R 6 M has been budgeted for recapitalization. In about two weeks time the third of phase of renovations on campus will commence and attention will be given to the administration building, the humanities and the outstanding work in the lecture hall complex. There- after the library, sciences and education buildings will follow. As you will recall a substantial portion of the R 8.4 million in 2005 was used to upgrade the student residences and the lecture hall complex.

I am certain that the renovations and upgrading of our infrastructure and physical facilities including landscaping will create an enabling environment for you to enjoy your work and studies on this campus.

Renovations come with some measure of inconveniences and I therefore wish to request for your patience and support during this period.

Closing remarks
There is a heightened spirit of optimism on what the future holds for this campus. This is evident when I talk to a large cross section of staff and students of this campus – and I therefore invite all of you to come and be partners with us on this journey of optimism and hope of what the future holds for the UFS – QQ campus.

Thank you and God bless!

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