Healthcare reform priorities for South Africa : four essays on the financing, delivery and user acceptability of healthcare

Smith, Anna Maria (2016-03)

Thesis (PhD)--Stellenbosch University, 2016.

Thesis

ENGLISH ABSTRACT: peers, South Africa is achieving health outcomes that are comparable to those of low-income countries. This dissertation contains four essays on the financing, user acceptability and delivery of healthcare in South Africa. The main contribution of the dissertation is to determine how the user acceptability of healthcare services influences not only health seeking behaviour in South Africa, but also influences the ability of healthcare services to impact health outcomes. Without sufficient focus on user acceptability, the success of the health system will be undermined by creating missed opportunities for the prevention, detection and treatment of disease. The first essay considers the potential role of private health insurance (medical schemes) in reducing inequality to healthcare access and alleviating the burden from a constrained public healthcare system by providing access to healthcare services of higher user acceptability levels. The analysis indicates that, in the absence of a number of regulatory changes in the market primarily aimed at increasing the affordability of medical schemes, the size of the formal skilled labour market will continue to set the limits of the private health insurance market. The second essay examines the causal impact of access to private health insurance (medical schemes) on healthcare utilisation and healthcare provider choice by using the exogenous variation in private health insurance coverage induced by the roll-out of the Government Employees Medical Scheme (GEMS). Contrary to most of the findings in the literature, the analysis finds that providing access to healthcare perceived to be of greater user acceptability in South Africa’s polarised healthcare market has a large positive effect on total healthcare utilisation. It also increases the likelihood of using private providers and, in particular, private doctors. In the third essay, the dissertation considers the health seeking behaviour of adults with potential tuberculosis (TB) symptoms (coughed ≥2 weeks) in the Western Cape. Only one third of adults indicated they sought help for TB symptoms and only one fourth of those who coughed ≥2 weeks reported these symptoms at primary healthcare facilities. Women were less likely than men to be asked for a sputum sample at these facilities, indicating poor adherence by healthcare staff to the well-defined TB testing protocol. Lastly, the fourth essay explores the causes of late antenatal care access amongst a sample of women in metropolitan Cape Town. More than a quarter of women attended antenatal care late (≥20 weeks) and, of those who attended late, 48.2% indicated late recognition of pregnancy as the major reason for delayed attendance. While late access was predominantly associated with demandside factors, late recognition of pregnancy, together with high levels of unplanned pregnancies, point towards issues related to effective access to contraception. The analysis in the first two essays indicate that there is a demand for healthcare of greater user acceptability, and the last two essays show that this would need to include improved preventative care, enhanced health system effectiveness and better clinical quality monitoring.

AFRIKAANSE OPSOMMING: Ten spyte van gesondheidsbestedingsvlakke wat vergelykbaar is met dié van ander hoër-middelinkomste lande, bereik Suid-Afrika gesondheidsuitkomste vergelykbaar met dié van lae-inkomste lande. Hierdie proefskrif bevat vier opstelle oor die finansiering, gebruikersaanvaarbaarheid en voorsiening van gesondheidsorg in Suid-Afrika. Die hoofbydrae van die proefskrif is om te bepaal hoe die gebruikersaanvaarbaarheid van gesondheidsorg beide gesondheidsoekende gedrag en die vermoë van die stelsel om ‘n impak op gesondheidsuitkomste te hê, beïnvloed. Sonder genoegsame fokus op gebruikersaanvaarbaarheid sal die sukses van die gesondheidstelsel ondermyn word deur die verbeuring van geleenthede vir die voorkoming, identifikasie en behandeling van siektes. Die eerste opstel oorweeg die moontlike rol van privaat mediese versekering (mediese fondse) in die vermindering van ongelyke toegang tot gesondheidsorg, sowel as die verligting van die las op die publieke gesondheidstelsel, deur toegang te verskaf tot gesondheidsdienste van hoër gebruikersaanvaarbaarheidsvlakke. Die analise dui daarop dat, in die afwesigheid van ‘n aantal regulatoriese veranderinge in die mark hoofsaaklik daarop gemik om die bekostigbaarheid van mediese fondse te verbeter, die grootte van die formele, geskoolde arbeidsmark sal aanhou om die grense van die privaat mediese versekeringsmark te bepaal. Die tweede opstel ondersoek die kousale impak van toegang tot privaat mediese versekering (mediese fondse) op die gebruik van gesondheidsorg, asook gesondheidsverskafferkeuse deur die benutting van die eksogene variasie in privaat mediese versekeringsdekking wat teweeggebring is deur die uitbreiding van die Regeringswerknemers Mediese Skema (GEMS). In teenstelling met meeste bevindinge in die literatuur, toon die analise dat toegang tot gesondheidsorg van oënskynlik hoër gebruikersaanvaarbaarheid in die konteks van Suid-Afrika se gepolariseerde gesondheidsmark, ‘n groot positiewe impak op die benutting van gesondheidsorg het. Dit verhoog ook die waarskynlikheid van die gebruik van privaat gesondheidsverskaffers en, meer spesifiek, privaat dokters. In die derde opstel stel die proefskrif ondersoek in na die gesondheidsoekende gedrag van volwassenes met moontlike tuberkulose (TB)-simptome (hoes ≥2 weke) in die Wes-Kaap. Slegs een derde van volwassenes het aangedui dat hul hulp gesoek het vir moontlike TB-simptome en slegs ‘n kwart van dié wat ≥2 weke gehoes het, het hierdie simptome aangemeld by ‘n primêre gesondheidsorgfasiliteit. Voorts was die neiging dat minder vroue as mans by hierdie fasiliteite vir ‘n sputummonster gevra is, wat dui op op gesondheidspersoneel se swak nakoming van die goed gedefineerde TB-toetsingsprotokol. Laastens ondersoek die vierde opstel die oorsake van laat toegang tot voorgeboortesorg in ‘n steekproef van vroue in metropolitaanse Kaapstad. Meer as n kwart van die vroue het voorgeboortesorg laat in hul swangerskappe bygewoon (≥20 weke) en, van dié wat dit laat bygewoon het, het 48.2% laat bewuswording van swangerskap as die hoofrede vir die vertraging van hul bywoning aangevoer. Terwyl laat bywoning hoofsaaklik geassosieer was met vraagkant-faktore, dui die laat bewuswording van swangerskap, tesame met hoë vlakke van onbeplande swangerskappe in die steekproef, op kwessies rondom effektiewe toegang tot voorbehoedmiddels. Die analises in die eerste twee opstelle dui op ‘n vraag na gesondheidsorg van hoër gebruikersaanvaarbaarheid en die laaste twee opstelle toon hoe hierdie sorg verbeterde voorkomende gesondheidsorg, hoër stelseleffektiwiteit en beter kliniese gehaltekontrolering sal moet insluit.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/98711
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