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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

Questions about racial integration in residences answered
2007-07-31

Answers to frequently asked questions about the racial integration of student residences at the UFS

1. Why does the UFS want to change the current situation in the student residences?

There are many reasons why a new approach to placement in the student residences is necessary. However, the main reason is of an educational nature. As a university, the UFS should create an environment in its residences where students can learn to appreciate and respect the rich diversity that is on offer at the university. A university accommodates students from many different backgrounds in terms of race, language, religion, economic status, culture and other aspects. If a student can learn to appreciate the value in this rich diversity at university, he or she will also be able to appreciate the value of this diversity in the workplace and broader society.

The current situation of predominantly white and predominantly black residences has not been able to cultivate such an appreciation for diversity and respect for one another as human beings, and will not equip students with the knowledge and skills required to manage diversity.

Besides this, there are many other areas of life in the residences that need attention. For one, we need to urgently establish a human rights culture in the residences so that the rights of all students can be respected. We need to address the abuse of alcohol, provide disabled students with their rightful place, and last but not least, really entrench a culture of learning in student residences.

Let us make the residences places we can be proud of – places of learning, of diversity, of respect; places of growth and development. This is the ideal we should all strive to achieve.  

2. Why does the management want to force us to integrate?

It is a false argument to debate the issue in terms of “force”. Any decision by a University, or any other organisation, regarding matters of policy, rules and regulations implies a restriction on the choice of an individual and an obligation to comply.  What we should focus on is whether this decision of the Council is in the best interests of our students.

The management of the university believes that it has a responsibility to give students the best education possible, not only in terms of what you learn in the lecture rooms, but especially in the residences as well. The residences can be very powerful places of learning about matters of great importance, both academic and non-academic.

The parallel-medium language policy separates students into largely white/Afrikaans and black/English classes. Efforts are being made to bridge this divide in the classroom, but we can also try to eliminate it in the residences.

The university is committed to building a new culture for the entire institution that is based on values and principles – such as an academic culture, non-racialism, respect for human rights and diversity – among staff and students.

In the context of student residences, the application of these values and principles still allows substantial room for the voluntary exercising of choice by individuals as well as by Residence Committees, notably with regard to the placement of students (they can still place 50 percent of first-year students), as well as the determination of the future character and traditions of a diverse residence.

Furthermore, students can still choose their residences (subject to availability of places), can choose a roommate, and so forth.

3. What about freedom of association?

The rights we enjoy in a democracy must be balanced against other rights, as well as the laws of the country. This means that the right to freedom of association must be balanced against laws that make it illegal to discriminate against other people on the basis of race, language or religion, for instance.

Freedom of association pertains to the right of individuals to form voluntary organisations such as clubs or private boarding houses, or their right to join or not join existing organisations.  You exercise that right when you decide to become a student of the UFS, and again when you choose to live in one of its residences.

However, once you have decided to join an organisation voluntarily, you cannot subsequently demand that that organisation should provide a “club” or residence to your liking where, for instance, you only associate with your choice of co-members. You must accept the policies of that organisation.

In any case, how would that right of yours be balanced against the right of another individual who wishes to associate with a different set of co-members? (For instance – what about the freedom of a student to associate with students NOT from his own background, but indeed from another language, cultural, racial or economic background?) 

The constitutional right to freedom of association can, in any case, not be used to exclude or discriminate on the basis of race or religion (Section 18 of the Bill of Rights).

Besides, the new policy guidelines will still make provision for freedom of association. This right can be exercised freely within a diverse residence with regard to friendships, joint academic work, socialising, sport, etc.

4. Will residences not lose their traditions?

The University appreciates that there are many valuable elements of tradition in residences. However, we must bear in mind that the traditions and character of student residences have evolved and changed over time, and they will continue to evolve and to change. In addition, we do not need to accept all aspects of residence life purely on the basis of tradition, including the unacceptably high level of alcohol abuse and unsavoury, humiliating and discriminatory orientation practices. The new approach to integrated residences provides the opportunity to retain the positive aspects of the current traditions and character, but also to develop new traditions and give residences a new character.

We can now establish a tradition and a character for each residence that are reconcilable with the values of the University as a place of scholarship and are aligned with the human rights approach of our country’s Constitution, the laws of our country and the strengths and diversity of the students in a particular residence.

5. Have students been involved in this process? Is there a role for them to play after the decision has been taken by the Council of the UFS?

In the first semester of 2007, during two rounds of consultations, the primes, SRC and student organisations were consulted about the proposed new placement policy to increase diversity in residences. Some residences also made written submissions on the matter (such as Madelief, Soetdoring, Wag-'n-bietjie, Vergeet-my-nie, Emily Hobhouse). Other residences requested and were granted more time, but did not make any submissions in the end (such as Reitz and Armentum).

Management also had several meetings with the above-mentioned structures to hear first-hand from students their concerns and solutions regarding possible challenges presented by integration in residences.

During these interactions, several excellent ideas and proposals were put forward by students. These views had a definite impact on the eventual proposal that was taken to the University Council, in particular regarding the minimum level of diversity (30%) in junior residences and the fact that residences still want to have a say in the placement of students, rather than the placement decision being left in the hands of Management alone (hence the 50% placement portion of residences). Management values the effort that was put into the process by the primes and residence committees, and thanks them for their contributions.

However, it should be stressed that consultation should not be understood as a process of negotiation, nor does it imply that consensus must be reached. What it means is that Management must take a considered decision after hearing the views of stakeholders.

Management would like students to continue to provide input and ideas regarding the implementation details of the policy guidelines. Task teams have been established and students will be informed about how they can interact with the task teams on an ongoing basis.

6. But integration in the residences was tried in the past (in the late 1990s), and then it failed. Why will it work now?

Yes, the University of the Free State did integrate its residences as far back as 1993, and for a few years it worked. The UFS did it at that time and is now doing so again, because it is the right thing to do. Yet it is important to understand why the previous attempt at racial integration in residences was not successful.

Firstly, both black and white students were much polarised because of the apartheid past. Secondly, there was insufficient management support for students in the residences, the student leaders generally as well as residence heads, in terms of dealing with diversity and related issues. Thirdly, the institutional culture of the UFS and the residences in particular was not addressed as part of broader transformation and integration in residences, whereas it is now being addressed.

In addition, the current decision to integrate residences has the benefit of being implemented after several more years of integration in schooling, sport, workplaces and other aspects of life.

This decision is also based on Management’s commitment to give all the possible support it can to this process.

This is a very important initiative that the UFS is undertaking. Management, in co-operation with students, must ensure that it succeeds. Integrated residences that produce high-quality graduates equipped to deal with the challenges of the workplace and our society is a worthwhile ideal we should all strive to achieve.

If you would like to make a proposal regarding the implementation and practical aspects of the new policy, please send it to the following email address: rector@ufs.ac.za

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