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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

Volksblad: Moshoeshoe Memorial Lecture
2006-05-27

27 Mei 2006

Moshoeshoe het mense saamgebind
KONING MOSHOESHOE kon bewys dat verskeidenheid ’n bindende eienskap kan wees. Dit blyk ’n sleutelbeginsel van sy leierskap te wees – en dit is nie ’n maklike een om te begryp nie.

Jy bereik die grootste eenheid tussen onderskeidende entiteite waar jy relatief vrye ruimte aan hulle gee om hul eiesoortige kenmerke na vore te bring.

Dít blyk uit prof. Njabulo Ndebele se gedenklesing oor koning Moshoeshoe.
Lesotho; het; onder Moshoeshoe se leierskap mense van verskeie dele van die subkontinent gelok.
Dié mense het hierheen gevlug van die verwoesting wat as lifaqane bekend geword het toe Shaka sy koninkryk met militêre onderwerping verstewig het.

Ndebele het gesê daar is algemene ooreenkoms dat die oorloë wat hieruit gespruit het, die maatskaplike grondslae van talle samelewings in Suider-Afrika geskud het.

“Dit was in dié konteks dat Moshoeshoe leierskap getoon het.”
Prof. Frederick Fourie, rektor en visekanselier van die Universiteit van die Vrystaat (UV), het gesê die lesing vorm deel van ’n groter debat oor leierskapmodelle, veral die konsep van Afrika-leierskap, en die voortgesette diskoers oor nasiebou en versoening.

Die Moshoeshoe-projek is in 2004 aan die UV begin om met Suid-Afrika se eerste dekade van demokrasie saam te val.
Die projek was deel van die UV se eeufeesvieringe in 2004.
Met dié projek word geprobeer om ’n groot Afrika-leier te vereer en die UV se verbintenis tot transformasie te toon sodat ’n ware inklusiewe en nie-rassige universiteit geskep kan word.

“As die stigter van die Basoeto-nasie, word daar wyd erkenning aan koning Moshoeshoe vir sy buitengewone leierskapstyl gegee.

“Diplomasie, versoening en vreedsame naasbestaan is van die kenmerke van sy leierskap, soos getoon in sy pogings om verskillende groepe in een nasie te verenig,” sê Fourie.

KONING MOSHOESHOE, een van Afrika se eertydse groot leiers. Hy is meer as 130 jaar gelede dood. Foto: verskaf

Waarde van openbare spraak ‘nou bedreig’
AANDUIDINGS bestaan dat die waarde van openbare spraak wat hoog deur koning Moshoeshoe van Lesotho op prys gestel is, nou onder ernstige bedreiging kan wees.

Om dié rede dra hy die koning Moshoeshoe-gedenklesing op aan al dié mense in Suid-Afrika en elders wat die moed het om hul oorwoë mening uit te druk oor belangrike sake wat die samelewing in die gesig staar, het prof. Njabulo Ndebele, visekanselier van die Universiteit van Kaapstad, gesê.

Ndebele, wêreldbekende skrywer, het gesê dié lesing kom op ’n kritieke punt in Suid-Afrika se nuwe demokrasie.
Dié lesing, om die buitengewone nalatenskap van een van Afrika se groot leiers te eer, is eergisteraand op die kampus van die Universiteit van die Vrystaat (UV) gelewer en het ’n staande toejuiging deur ’n groot gehoor uitgelok.

Ndebele het gesê die mense wat hul menings uitdruk oor belangrike sake, kan rubriekskrywers, redakteurs, kommentators, alle soorte kunstenaars, akademici, koerantbriefskrywers, nie-gewelddadige optoggangers met plakkate en strokiesprentkunstenaars wees “wat ’n spieël voor ons oë sit”.

“Selfs wanneer hulle dit waag op heilige gebied, soos sommige strokiesprentkunstenaars onlangs gedoen het, herinner hulle ons net dat selfs die heilige misbruik kan word vir doeleindes wat min met heiligheid te doen het.

“Dit is hul manier om ons te help, dalk meer diepsinnig as wat ons besef, om daardie einste ruimte van heiligheid in ons lewe te bewaar.

“Hulle verdiep ons insigte deur ons begrip te verdiep.
“Dit is gepas om hul dapperheid te vier,” het Ndebele gesê.
“Hulle herinner ons dat leierskap nie al is wat ons doen wanneer ons in ’n sekere magsposisie geplaas is om ’n organisasie of ’n sekere instelling te stuur nie.”

Hy het gesê onder die mense wat gevier moet word, sluit hy nie dié in wat deur haatspraak ander aanhits om geweld te pleeg; teen; mense; wat hul andersdenkende menings lug nie.

“Dit is nie met dapperheid dat hulle aanhits nie, maar weens hul toevlug tot die narkotiese beskerming van die skare.”

Mense voel glo ál kwesbaarder
Vise-kanselier lewer Moshoeshoe-gedenklesing
’n TOENEMENDE aantal hoogs intelligente, sensitiewe en toegewyde Suid-Afrikaners oor die klas-, ras- en kulturele spektrum heen bely dat hulle – soos nog nooit tevore nie – onseker en kwesbaar voel sedert 1994.

Só het prof. Njabulo Ndebele, vise-kanselier van die Universiteit van Kaapstad, gesê in die Universiteit van die Vrystaat (UV) se eerste koning Moshoeshoe-gedenklesing.

Die onderwerp was Reflections on the leadership challenges in South Africa.
Wanneer ontembare optimiste beken hulle voel dinge is van stryk, versprei die naarheid van angs. “Dit moet iets te doen hê met ’n ophoping van gebeure wat die gevoel van dreigende inploffing oordra.”

’n Gevoel heers dat Suid-Afrika ’n baie komplekse samelewing het wat liewer eenvoudige, gesentraliseerde beheer voortbring in die hoop dat dienslewering dan beter en vinniger gedryf kan word. Die kompleksiteit van beheer word dan in ’n enkele struktuur van gesag gevestig, eerder as in die afgewentelde strukture soos wat in die Grondwet beoog word.

Dat die afgewentelde strukture nie hul grondwetlik-gedefinieerde rolle verwerklik nie, moenie toegeskryf word aan die mislukking van die beheermeganisme nie.

“Dit is te vroeg om te sê dat wat ons sedert 1994 bereik het, nie gewerk het nie,” het Ndebele gesê.
Dit lyk of ’n kombinasie van omstandighede tot die “gevoel van ontknoping” lei.
“Ek wil dit vermy om te sê: ‘Kyk na Khutsong’, asof u sal verstaan wat ek bedoel wanneer ek sê u moet na Khutsong kyk.”
Sulke kennis lei tot wanhoop, want dit roep ’n werklikheid op wat só oorweldigend is dat dit fatalisties kan wees.
Ndebele het gesê niks kon meer vreesaanjaend wees as toe ’n komplot van die Boeremag oopgevlek en sekere Boeremaglede aangekeer is nie.

Sekere Boeremaglede het van ’n maksimum-sekuriteit-tronk ontsnap. “Sover ek weet, is hulle nie weer gevang nie.
“Wat is gedoen om die gaping te oorbrug?” was een van sy vrae hieroor.
“Van só ’n belangrike saak weet die publiek nie baie nie. Die karige kommunikasie kan die gevaarlike boodskap uitdra dat óf niks gedoen word nie, óf die staat in dié saak misluk.”

Hy het gevra: “Hoekom het die kwessie van munisipale afbakening tot die situasie in Khutsong gelei? Dit lyk of die probleem voortgaan, sonder ’n oplossing in sig.”

’n Aantal soortgelyke, oënskynlik plaaslike rebellies het oor die land heen plaasgevind. “Is hier ’n patroon?”
Ndebele het na die onlangse verhoor van oud-adj.pres. Jacob Zuma, wat van verkragting aangekla was, verwys.
Dié drama blyk ver van oor te wees. Dit beloof “om ons almal sonder verligting te hou, in ’n toestand van angs”.
Die gemene draad van dié gebeure is die gevoel van ’n oneindige spiraal van probleme wat vertroue tap. Daar kan ’n sterk suggestie in al dié gebeure wees “dat ons dalk nooit sosiale samehang in Suid-Afrika gehad het nie...”

“Wat ons sekerlik oor dekades gehad het, is ’n mobiliserende visie. Kan dit wees dat die mobiliserende visie onder die gewig van die werklikheid en omvang van maatskaplike heropbouing kraak en dat die legitieme raamwerk om oor dié probleme te debatteer ineenstort?”

‘Swart mense staar hulself in die gesig’
DIE swart meerderheid staar homself nou in die gesig: dalk werklik vir die eerste keer sedert 1994.
Só het prof. Njabulo Ndebele gesê toe hy die koning Moshoeshoe-gedenklesing by die Universiteit van die Vrystaat in Bloemfontein gelewer het.

Hy het gesê dit lyk of Suid-Afrika ’n meganisme nodig het om selfvertroue te bou.
Deur dié meganisme “kan ons die situasie waarin ons is, erken, wat dit ook al is”.
“Ons het ’n meganisme nodig wat die verskillende posisies van die mededingers sal bevestig en hul eerlikheid sal bekragtig op ’n manier wat die publiek vertroue sal gee dat werklike oplossings moontlik is.”

Dit is dié soort “openheid wat nooit maklik kom nie”, wat lei tot deurbraak-oplossings.
Ndebele het gesê ’n komplekse demokrasie soos Suid-Afrika s’n kan nie oorleef met ’n enkele gesag nie.
Net veelvuldige owerhede binne ’n grondwetlike raamwerk “het ’n ware kans”.
“Kan ’n deel van die probleem wees dat ons nie in staat is om die idee van ‘opposisie’ te hanteer nie?
“Ons is verskrik dat enige van ons ‘die opposisie’ kan word.
“Dit is tyd dat ons die koms voorsien van ’n oomblik wanneer daar nie meer ’n enkele, oorweldigende, dominante politieke mag is soos wat nou die geval is nie.”

Ndebele het gesê: “Ek glo ons het dalk ’n oomblik bereik wat nie fundamenteel verskillend is nie van die ontnugterende, tóg hartversterkende nasiebourealiteite wat gelei het tot Kemptonpark in die vroeë jare negentig.”

“Die verskil tussen toe en nou is dat die swart meerderheid nie nou na wit landgenote oor die onderhandelingstafel kyk nie.

“Die swart meerderheid staar homself in die gesig: dalk werklik vir die eerste keer sedert 1994.”
Dit is weer “tyd vir visie”, het Ndebele gesê.

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