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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

Former top politician talks at UFS School of Management

2007-04-25

Dr Matthews Phosa, the non-executive chairman of EOH and former politician, presented a guest lecture to a group of MBA students at the University of the Free State's (UFS) School of Management. At the lecture were from the left: Mr Tate Makgoe (Free State MEC for Finance), Ms Nontobeko Scheppers (MBA student), Dr Phosa, Prof. Helena van Zyl (Director: UFS School of Management) and Mr Setjhaba Tlhatlogi (MBA student).
Photo: Stephen Collett

Exploring some of the myths and opportunities cyber space offers

Mathews Phosa

Introduction

It is no longer business as usual. Globalisation poses new challenges as well as opportunities to business, education and society in general. Many of these new opportunities are alive with paradoxes and tensions between local sustainability and global market opportunities. The growth in new communication technologies challenges us to critically explore some popular myths, opportunities and define possible responses.

Cyberspace is often described as the new frontier – not only in the race for newer and faster technologies, but also in education. Any user or provider of services who does not explore this new frontier will soon be considered using “outdated” and will be accused of using obsolete methodologies. Cyberspace, like the spaces embodied in continents, is something that should be claimed and conquered.

Cyberspace and specifically access to information, including online education is hailed as the great equaliser. It is now claimed that everyone will have equal access to “Knowledge”. Cyber education for example is celebrated as “education-without-borders”, but as Bauman states, while it does change borders and access, it creates new “haves” and “have-nots”.

To put it in a nutshell: rather than homogenizing the human condition, the technological annulment of temporal/spatial distance tends to polarize it. It emancipates certain humans from territorial constraints and renders certain community-generating meanings exterritorial – while denuding the territory, to which other people go on being confined, of its meaning and its identity-endowing capacity.
(Bauman 1989:18; emphasis mine).

Virtual environments and the possibilities offered by the World Wide Web are new spaces that are being colonised and occupied by those who have capital (whether economic or academic) and who are looking for new labour or markets. While the new mediums include and conquer new spaces, it also excludes and “otherises” communities and segments of society (Prinsloo 2005). Cyberspace provides institutions and corporations with a space to operate without the responsibilities and obligations of locality – as long as you can afford the privilege of operating in cyberspace.

Cyberspace is therefore not neutral. Spaces are occupied, reoccupied, abandoned, claimed, fortified, secured – contested. Those with mobility define and map spaces continuously according to their claims. Those without capital and the mobility it brings, contest these claims, contest the spaces and hack into the space. Reclaim it. Recolonise it.

Re-Appropriating Cyberspace

A number of authors explores such a re-appropriation of cyberspace. Instead of seeing the Internet and related functions like online teaching as just accessing and transferring information, cyberspace is explored as political, social, personal and economic space. Institutions across the spectrum including higher education institutions venturing into cyberspace often think that it offers them a space without the usual socio-cultural complexities. Gunn, McSporran, Macleod and French (2003:14) however indicate that online “interactions that take place through electronic channels lose none of the socio-cultural complexity or gender imbalance that exists within society”.

Instead of cyberspace being a new space where the differences and disparities of non-virtual life on earth cease to exist, “cyberspace is an imagined network layer sitting on top of the physical infrastructure of cities. Cyberspace is an imagined, continuous, worldwide, networked city; the global city that never sleeps, always experienced in real time” (Irvine 1999, Online). Cyberspace therefore not only sits on top of the physical infrastructure, but is also a mirror image of the power structures and disparities of non-virtual life on earth.

Cyberspace is also much more than just a replication of non-virtual reality. New subcultures and new self-defined communities are coming into existence (Irvine 1999, Online). These new communities in cyberspace resemble communities in non-virtual format, but they are also vastly different. For example, Grierson (Online) explores the similarities between cemeteries and the communities in cyberspace. She finds that, although both “communities” are constituted in space, it is a “placeless place” which “links and mirrors society, with all its alter-egos and hidden desires … a virtual site holding up a mirror to physical reality where subjective presence is delineated in imaginary absence”.

The Internet as “sites for power and knowledge” is further explored by a number of authors, amongst othersNewman and Johnson (1999), Usher (2002), Walmsley (2000) and Borer (Online). Jordan (1999, Online) investigates culture and politics in cyberspace. He explores three “intertwined levels”, namely cyberspace as “playground of the individual”, as “social space, a place where communities exist” and as “being a society or even a digital nation”. In each of these three levels, power is played out and claimed in a “sociological, cultural, economic and political battle between the individual and a technopower elite”.

The so-called impact of the Internet on society is discounted by Bennet (2001:197). He suggests rather that the Internet “should be regarded as a “form of life – whose evolving structure becomes embedded in human consciousness and social practice, and whose architecture embodies an inherent valence that is gradually shifting away from the assumptions of anonymity upon which the Internet was originally designed” (2001:197).

We started by stating that it is no longer business as usual. We can no longer afford epistemologies of ignorance and politeness. Cyberspace and the opportunities it offers for business, society and education in particular need to be interrogated using a hermeneutics of suspicion, confronting certain myths, exploring opportunities and defining appropriate responses.

It is evident that the impact of the cyberspace stretches across the total spectrum of the human experience and condition. Due to the complexity of discussing the total spectrum of options this discussion focuses on Higher Education as one entity to demonstrate the implications and level of reflection required.
To come to terms with some of theses realities it is necessary to address some of the typical myths. The following aspects provide an indication of some of the myths:

Myth 1 - Access. The Internet and online education is not the great equaliser. Access to the Internet on a sustainable and affordable basis is still for the rich and the privileged. There is good reason to celebrate the widening access citizens have to the Internet. In the last number of years the so-called “digital-divide” has indeed decreased. It is however still disputable that having access to the World Wide Web changes lives for the better. For the World Wide Web to deliver on its promise of changing society into more just and compassionate communities, the other divides in society have to be addressed as well.
Myth 2 - Quality of information available. Even when/if sustainable and affordable access to the Internet would be available to all; the overwhelming quantity of information on the Internet would require participants to have critical information literacies. Such literacies will be crucial in allowing the “having access to more information” to really allow participants to live differently. Bauman (1989) and others warn of the increasing commodification and consumerisation of knowledge; the immense amounts of information available on the Web, results in information and knowledge becoming “cheap”, and un-validated.
Myth 3 – The role of race and gender. Current research indicates that the unequal socio-economic gender relations are perpetuated in cyberspace. Females have less access and often less frequent access due to prescribed and patriarchally perpetuated life-roles. Research also indicates that males frequently dominate online discussions, often relegating female participants to roles of quiet observer. In this “neutrality” of cyberspace the assumption often is that gender should not matter in a space where identity is often just a name and a short introduction. There is however enough research to validate the role identity and specifically race and gender play in online learning environments.
Myth 4 – Guaranteed success as learning platform. International research indicates that very few students opt for fully online learning. Even in countries where access to online environments are either state-sponsored or very cheap, learners do not prefer online learning to more face-to-face learning environments. Students seem to prefer a range of blended learning experiences, rather than fully online. This has impacted on several world-class universities forcing them to cancel fully online offerings. Fully online learning and interaction require specific literacies and personality traits of participants. Online learning is not a “one size fits all”.

Research in South Africa indicates that many learners use computers at work to access their learning environments. Not only does this impact on productivity, but learners therefore do not have access to their online learning environments over weekends and when they prepare for the examination. Employers also increasingly block mass-generated electronic correspondence from universities and limit learners’ access to the Internet. This results in learners experiencing growing frustrations with “fire-walls” that do not allow an effective learning environment.

Very few learners are sufficiently prepared to engage and sustain their own learning in a fully online environment. Institutions offering online learning are often inundated with requests for more support, often face-to-face.

Myth 5 - Quality in an online learning environment. At present there are no quality indicators specifically focused on online learning environments in higher education. The quality of the current offerings range from “drop-off and go” experiences where students carry the cost of printing materials with very little continued support and interaction from the side of the institution, to very intensive online teaching which overestimates the time and resources that students have for such learning.
Myth 6 - Accountability. Many overseas institutions offer online qualifications in other countries without any guarantee that the qualifications will be accredited by local institutions of learning or employers. Many students wrongfully belief that because it is offered by an international provider using online, that the learning experience will be of a high quality and that it will be accredited by local education institutions and employers.
Myth 7 - Global is better. Though there is a legitimate trend to ensure internationalisation in education, the need for contextual, local and authentic learning remains equally important. The challenges learners face are often context-specific and international tutors in online environments often have very little understanding for the cultural and socio-economic specificities of local contexts. Some metaphors and examples often used in online environments exclude participants from non –western cultures to fully comprehend and apply the learning to their own contexts.
Myth 8 - Online teaching and learning is ideologically neutral. All curricula arise from context specific ideological and socio-economic relations and epistemologies. Very few institutions foreground their specific beliefs and assumptions about knowledge and learning. This is even more so applicable in online learning environments where the “designers” of the learning are often even more hidden than in face-to-face contexts.

Opportunities

The Internet does however offer scores of opportunities for institutions of higher learning to seriously consider. The following is but a few of the opportunities that await careful and critical consideration.

Opportunity 1 - Reaching the un-reached. Yes, online teaching and learning bring opportunities to many learners who have been previously excluded from training, development and higher education. The reach of higher education does not only entail those who were previously excluded, but also brings into reach qualifications at internationally renowned institutions.
Opportunity 2 - Access to information. With the Internet, students have access to the most recent, cutting-edge information. Students will increasingly be able to compile their own curricula and have it validated by institutions of higher learning. Students now have access to the international discourses in the different disciplines at the click of a mouse. While there is a real danger that not all students have (yet) the critical literacies required by the Information age and secondly that they may be overwhelmed and become lost in cyberspace.
Opportunity 3 - Communication. With the Internet and other mobile communication technologies, learners can increasingly be in touch with institutions of learning and educators and peers. Learning experiences can be enriched by synchronous and asynchronous communication, between the institution and tutors, tutors among themselves, between tutors and learners and among learners themselves. Online learning really open up a Habermasian “public sphere” for “communicative action”.
Opportunity 4 - Mode 3 knowledge-production. Traditionally knowledge production in higher education focused on discipline specific transfer of knowledge, called mode 1 knowledge production. Paulo Freire called this “banking education” (1989). Recent years saw the development of Mode 2 knowledge production where knowledge was applied and arose from practical application to appropriate problem-spaces. Online learning environments make it increasingly possible to move to Mode 3 knowledge production where learners address problem-space from the foundations of a specific discipline but then continue to explore contributions from a range of other disciplines Knowledge production has moved form “knowing-how” to “knowing-in-the-world”. Barnett refers to this change as an “ontological turn” (2005).

The changing role of higher education

It will be naïve and irresponsible for higher education not to interrogate popular notions and epistemologies of online education and the role of the Internet. We have explored a number of myths and (hopefully) created sufficient suspicion to invite further discourse. We have also explored a number of opportunities an online environment offers to business, higher education and society in general.

Higher education has to indeed decrease the “digital divide” not only in the form of broadening access, but also by seriously interrogating the accompanying epistemologies. From the above it would seem as if a responsible and robust response would entail the following:

Response 1 - Empower learners with critical literacies for the information age. having access to the information the Internet offers will challenge higher education institutions and learners alike to be able to critically evaluate information and its sources. While addressing access may in fact decrease the digital divide but it is worthless if the decrease in the digital divide does not and cannot result in students’ critical engagement with information and with one-another.
Response 2 - Increase access to the Internet through collaborative agreements. Higher education institutions have much more bargaining power than individual learners. It is almost unbelievable that with the “captive audiences” higher education institutions have, that they have not been successful to negotiate more affordable and sustainable access to online environments.
Response 3 – Develop quality online learning. Higher education should be very clear about the minimum standards for learning platforms, opportunities for peer and tutor interaction and the sustaining of a teacher presence in Virtual Learning Environments (VLEs).
Response 4 – Maintain scholarly online teaching. Higher education should encourage research, individual and collaborative projects to determine the indicators of success of online learning in specific contexts for specific audiences.
Response 5 – Higher education as critical praxis. Higher education traditionally has validated all claims to knowledge and expertise. As Barnett (2000, 2005) has indicated, higher education is no longer the only “producers of knowledge”. However, higher education still has the mandate to validate knowledge, whether claimed or made available in cyberspace. Higher education has the unique opportunity to rise to the occasion and to interrogate knowledge claims. The opportunities should be considered in the context of the realities of cyberspace as discussed. Fundamental to this is the fact that it requires higher education to increase the capacity of students for critical and compassionate action to assist in the formation and utilisation of the challenges and new opportunities. Essentially the challenge is to create opportunities and empower students and the broader society to utilise the potential cyberspace towards a more just and equitable society.

In Conclusion

There are a number of myths surrounding online education and the impact of the Internet on business, education and development. Only once cyber space has been demythologised, it is then that our eyes open to the opportunities that it offers. Higher education is therefore called upon to reflexively exploit the opportunities online learning and the Internet offer to engaging one another in learning experiences. Higher education will do well to take both the myths and the opportunities seriously and courageously.

Cyberspace is a new frontier. As previously done with colonial frontiers, this frontier can be exploited ruthlessly. There is however also an opportunity for business and higher education to engage with cyberspace – and use cyberspace to create hospitable, nourishing environments for active learning and a more just and equitable society for all.

References

Barnett, R. 2000. University knowledge in an age of supercomplexity. Higher Education 40:409-422.
Barnett, R. 2005. Recapturing the universal in the university. Educational Philosophy and Theory, 37(6):785-797.
Bauman, Z.1998. Globalization. The human consequences. Cambridge: Polity Press.
Bennet, CJ. 2001. Cookies, web bugs, webcams and cue cats: patterns of surveillance on the World Wide Web. Ethics and Information Technology 3:197-210.
Borer, MI. The Cyborgian self: toward a critical social theory of cyberspace. Available URL:
http://reconstruction.eserver.org/023/borer.htm (accessed on 10/04/2007).
Freire, P. 1989. Learning to question: a pedagogy of liberation. Geneva: World Council of Churches.
Gunn, C, McSporran, M, Macleod, H & French, S. 2003. Dominant or different? Gender issues in computer support learning. JALN 7(1):14-30.
Grierson, EM. From cemeteries to cyberspace: identity and a globally technologised age. Available URL: Click here!
(accessed on 10/04/2007).
Irvine, M. 1999. Global cyber culture reconsidered: cyberspace, identity and the global informational city. Available URL: http://www.georgetown.edu/faculty/irvinem/articles/globalculture.html
(accessed on 10/04/2007).
Jordan, T. 1999. Cyberpower: the culture and politics of cyberspace. Available URL:
http://www.isoc.org/inet99/proceedings/3i/3i_1.htm (accessed on 10/04/2007).
Newman, R & Johnson, F. 1999. Sites of power and knowledge? Towards a critique of the virtual university. British Journal of Sociology of Education 20(1):79-88.
Prinsloo, P. 2005. Don Quixote in cyberspace – charging at the invisible. Open and Distance learning in Africa Number 1, 2006: 78-94.
Usher, R. 2002. Putting space back on the map: globalisation, place and identity. Educational Philosophy and Theory 43(1):2002.
Walmsley, DJ. 2000. Community, place and cyberspace. Australian Geographer 31(1):5-19.

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