Browsing Doctoral Degrees (Economics) by browse.metadata.advisor "Burger, Ronelle"
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- ItemAccess to healthcare services in resource-constrained environments : evidence from Zimbabwe(Stellenbosch : Stellenbosch University, 2023-12) Chari, Abigail; Burger, Ronelle; von Fintel, Dieter; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.ENGLISH SUMMARY: Access to healthcare services is fundamental to health and well-being, yet approximately half of the world’s population is unable to access healthcare services in times of need, which derails attainment of the Sustainable Development Goals. Weak access to healthcare services is a global health challenge, and is prevalent in Zimbabwe. This weak access is attributed to a fragile and fragmented health system, characterised by weak and ineffective service delivery. The fragmented health system affects particularly the already disadvantaged population through healthcare services that are either unaffordable or unavailable. As part of achieving the global Sustainable Development Goals, Zimbabwe aims to address inequality in and weak access to its healthcare services. This thesis examined fiscal incidence and inequality in access to healthcare services in Zimbabwe, using 2017 administrative health expenditure data from the Ministry of Health and Child Care and the Prices, Income, Consumption and Expenditure Survey of the Zimbabwe National Statistics Agency. Fiscal incidence was found to be, on average, pro-poor for Zimbabwe’s low-level facilities, and pro-rich for high-level facilities. It was further found that availability and affordability are, on average, pro-rich. Thus, differential access to health services between rural and urban areas was contributing to pro-rich inequality. Despite government healthcare expenditure, inequality in availability and affordability of healthcare services remains a challenge. Pockets of inequality persist in the healthcare sector, as the more affluent continue to benefit from well-resourced facilities. The government should, therefore, focus on poor and rural populations, who bear the brunt of weak access to healthcare services. While the effects and causes of drug stockouts are well articulated, there is a dearth of literature on the link between district-level drug stockouts and poverty. This thesis investigated the spatial inequality of drug stockouts and the relationship between drug stockouts and district poverty in Zimbabwe using data on district-level drug stockouts and poverty. The results showed that spatial inequality in drug stockouts and district poverty exists, while the relationship between drug stockouts and district poverty was weak and insignificant. Spatial interdependence in drug stockouts between districts also exists, indicating hot spots in drug stockouts. In times of drug stockouts, individuals tend to use alternatives to healthcare, some of which pose health dangers, and it is therefore important to improve drug availability in underserved districts by reducing spatial inequality and hot spots in drug stockouts. Given the negative effects of malaria on the vulnerable population, this thesis examined the association between malaria prophylaxis stockouts and birth- and maternal outcomes in Zimbabwe. Preventive efforts against malaria are crucial, given that pregnant women and neonates bear the greatest malaria burden. Therefore, it was hypothesised that women who do not receive malaria prophylaxis during pregnancy are at risk of malaria infections, which compromise birth weight and cause maternal anaemia. Combining the administrative data on malaria prophylaxis stockouts and 2015 nationally representative Demographic Health Survey data, the results showed that malaria prophylaxis stockouts occur frequently over time, and have a significant association with birth weight, especially for neonates with an average birth weight. Stockouts are associated with neonates tending towards the lower end of a normal birth weight, compromising their development. Thus, there is a need to invest in pharmaceutical information- and stock-ordering systems to improve drug availability at the point of care. In conclusion, there is inequality in healthcare services in Zimbabwe, which causes a heavy burden on poor and rural populations. These vulnerable populations have weak access to healthcare services, despite the government's efforts to improve service provision. This thesis sheds more light on access to healthcare services, to enhance relevant stakeholders’ understanding of this subject. To achieve an equitable society, policymakers should address the inequalities in access to healthcare services, together with the socio-demographic determinants of health. Policymakers should improve resource management, follow a needs-based approach, invest in pharmaceutical information systems and stock-ordering systems, and foster multi-stakeholder collaboration to ensure improved access to healthcare services.
- ItemThe assessment and improvement of the health status of vulnerable and low income individuals in South Africa: an analysis using quantitative and experimental methods(Stellenbosch : Stellenbosch University, 2016-12) Rossouw, Laura; Burger, Ronelle; Van der Berg, Servaas; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.ENGLISH SUMMARY : More than two decades after the end of apartheid, inequalities in health across socioeconomic subgroups are still a pervasive and persistent trend. South Africa also faces a high burden of disease which is disproportionate to its level of economic development. This dissertation contains three chapters on the contribution of demand-side factors to South Africa’s health burden, focusing on the health perceptions and eventual health choices of vulnerable individuals. Vulnerable individuals assessed in this dissertation include the income and wealth poor and, in particular, women living in low-resource areas with limited access to sexual and reproductive health services. Evidence is provided on innovative interventions aimed at improving the health-seeking behaviour and health outcomes of these individuals. Chapter two of the dissertation calculates the impact of reporting differences on the accurate measurement of health inequalities by wealth status. The analysis is performed by benchmarking the reporting behaviour of individuals using anchoring vignettes. A statistically significant difference in the reporting behaviour by wealth status is found, which will lead to an underestimation of health inequalities to the disadvantage of the poor. Chapter three explains how a package intervention to improve the health-seeking behaviour of pregnant women living in a low-resource area in the Western Cape was designed, implemented and tested. The results from a randomized controlled trial show that a community health worker programme and an incentive jointly led to a statistically significant improvement in the timing and frequency of antenatal care-seeking behaviour. The impact of the intervention on behaviour change is explored by measuring differences in the preferences for care. This heterogeneity in preferences for antenatal care is measured by looking at differences in time preferences and prioritization. The intervention also led to a statistically significant reduction in maternal depressive symptoms and a statistically significant improvement in the intention to exclusively breastfeed for six months. Lastly, the fourth chapter considers the cost-efficiency of two alternative approaches to providing women with better access to urine pregnancy tests. Even though having access to these tests have been linked to improved timing of healthcare-seeking behaviour, the availability and acceptability of test distribution at public health facilities is of poor quality. Two approaches, namely distribution at a mobile health facility and door-to-door distribution, are compared. Door-to-door distribution is found to be a more cost-effective approach. The dissertation is aimed at establishing a better understanding of the demand-side of health, the factors driving health-seeking behaviour and the factors affecting health reporting.
- ItemAn assessment of malaria prevention, diagnosis and treatment services in Uganda(Stellenbosch : Stellenbosch University, 2022-04) Kimbugwe, Hassan; Burger, Ronelle; Matovu, Fred; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.ENGLISH SUMMARY: Government, donor partners, and the private sector invest large amounts of financial resources annually in malaria prevention and care. Despite substantial spending on malaria prevention programmes by 2019/2020, the disease still accounted for 13.3% Uganda's mortality, as well as 29.8% of outpatient visits and 34.9% of inpatient admissions. To combat malaria more effectively, it is critical to understand whether these substantial investments in malaria prevention and care reach those who are most vulnerable to malaria, and whether approved malaria diagnosis and treatment protocols are followed diligently. This PhD was thus structured to consider three distinct but related issues: (i) the equity of bed net use and ownership in 2009 and 2014, (ii) the uptake of malaria prophylaxis amongst pregnant women, and (iii) the relationship between financial incentives and appropriate malaria diagnosis and case management. The first essay examines the equity in access to and utilisation of bed nets in 2009 and 2014. It was found that the availability of bed nets increased over time. Access to and use of bed nets became more equitable, with higher levels of access and use amongst poorer households. Households with access to at least one bed net rose from 59.2% to 94.1%. The percentage of households who slept under bed nets increased from 51.8% to 72.6%. The percentage of children under five years who slept under bed nets increased from 45.8% to 81.5%. The percentage of pregnant women who slept under bed nets increased from 78.6% to 83.8%. Through recentered influence functions (RIF) decomposition method, the study examined whether the demographic factors were associated with the relationship between the wealth index and bed net utilisation in 2009 and 2014. Results suggest that in 2009, place of residence, number of nets in a household, mother’s education level, region and household size were associated with the relationship between wealth index and bed net utilisation. In 2014, age of household members, and mother’s education level were associated with the relationship between the wealth index and bed net utilisation. In both years having a mother with at least primary level of education was vital in promoting bed net utilisation. The results further indicate that younger household members, women, household members from the northern region, household members from the poorest wealth quintile, mothers with a post-secondary education, and households with more bed nets and few members were more likely to sleep under bed nets in 2014. The second essay reviews factors associated with uptake of intermittent preventive treatment (IPT) of three doses of Sulfadoxine-pyrimethamine (SP) (IPT-SP3) during pregnancy. The analysis indicated a double and notable improvement in uptake over time, from 9.91% in 2011 to 17.89% in 2016. However, the uptake was still far below the 79% target of Uganda’s Health Sector Strategic Plan (Uganda Ministry of Health (MoH) 2014). Results showed that uptake was higher amongst younger women (under the age of 25 years) than older women (above the age of 34 years), higher amongst women who attended their first antenatal care (ANC) visit early (during the first trimester) than those who attended later (during the third trimester), higher amongst women from the upper wealth quintile than women from the poorest quintile, and higher amongst women from the northern region of Uganda than among women from the central region. Results also indicated that uptake of IPT-SP3 was lower amongst women from the western region than women from the central region. Findings from the pooled model (unrestricted) indicate that the relationship between IPT-SP3 and the covariates in the two different time period (2011 and 2016) have not changed. The third and final essay focuses on the relationship between financial incentives and the likelihood of private providers adhering to national guidelines on malaria diagnosis and dispensing practices. The specific concern is that volume or revenue-based staff remuneration may provide a strong incentive for provision of malaria drugs to patients who have not yet tested for malaria. This tension is observed in a subsample where facilities do not have malaria testing capabilities and only sell malaria treatment and staff are paid based on the volume of drugs sold or the revenue. The results suggest that the private healthcare providers who receive salaries are more likely to adhere to malaria treatment protocols. Descriptive findings indicate significant variations between drug-shop attendants and other private healthcare providers with regard to malaria diagnosis, antimalarial dispensing practices, and adhering to malaria treatment procedure.
- ItemAn economic examination of non-profit accountability to client-communities in South Africa(Stellenbosch : Stellenbosch University, 2019-12) Dineo, Shirley Seabe; Burger, Ronelle; Jegers, Marc; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.ENGLISH SUMMARY : The target of non-profit organisation (NPO) accountability is efficacy in achieving the mission, the efficiency with resource use, risk-minimising and guarding against corruption (Mook, 2012). However, for a long time, the focus has been on efficient use of money and policing maleficence. The emphasis on functional accountability has created a narrow view off accountability as answering to donors at the expense of being accountable to the people they serve (Gent, Crescenzi, Menning & Reid, 2013; Mook, 2010: Murtaza, 2012). There has however been a shift inspired by normative ideas about the NPOs’ responsibility to their clients beyond “a moral responsibility to provide services that reflect their true needs” (Guo, 2007, p. 459). Despite this shift and the arguments for greater accountability to NPO clients, we still know very little about the role of client-communities as principals of NPOs. These principals have even received limited treatment in the theoretical economics literature (Jegers, 2015). This study, therefore, provides an economic investigation of the NPOs’ accountability to client-communities using South Africa as a case study. Its first applies spatial econometric techniques to test the hypothesis that if NPOs are responsive to the needs of the people, a correlation between NPO density and need should be evident. The study then draws from principal-agent theory and the rights-based approach to formulate a framework and construct propositions that can guide research on NPO accountability to client-communities. This research test three of the propositions: two related to the leadership characteristics correlated with greater accountability to these stakeholders and the other to the implications of greater NPO accountability for community satisfaction with the NPO’s operations. The findings showed that NPOs are geographically concentrated due to agglomeration benefits from knowledge and skills, as well as the availability of private philanthropic resources, but have broad geographic reach in terms of meeting the needs of communities. The organisations are also accountable to communities, which translated to favourable evaluations by community members. However, the findings showed that NPOs are more likely to be responsive if altruistic leaders with more education and experience control the organisations. Furthermore, revenue, location and organisational type are significant conditions for community accountability and the mediators of its relationship with community satisfaction. Overall, the findings lead to the conclusion that NPOs in South Africa, especially small community-based organisations are accountable to client-communities. Nonetheless, we identified several limitations which could be addressed by future research.
- ItemExamining child health and nutrition inequalities in Tanzania(Stellenbosch : Stellenbosch University, 2022-04) Mkupete, Mkupete Jaah; Von Fintel, Dieter; Burger, Ronelle; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.ENGLISH SUMMARY: More than one-third of stunted children under the age of five reside in sub-Saharan Africa. Due to the multifaceted underlying causes of malnutrition, this has become a challenging situation to address. Tanzania is among the top five countries in Eastern and Southern Africa with unacceptably high prevalence and spatial inequality in malnutrition, making it an interesting case study for generating evidence to inform policies in sub-Saharan Africa. Over three chapters, this thesis attempted to explain the persistent malnutrition and inequality in malnutrition and highlight potential pathways to tackle it using data from Tanzania. Chapter 2 examines the impact of the maize price fluctuation on the growth of the children from households that produce foods and those which do not. Chapter 3 explored the impact of meat and milk consumption on child growth and how the effects are mediated by keeping homestead livestock. Chapter 4 estimates the inequality of opportunity in malnutrition and considers the contribution made by access to water and sanitation. Three major findings emerged from this thesis. The first relates to the heterogeneity impact of high maize prices on the growth of children from food-producing and food non-producing households. While a large body of research advocates for low food prices to protect children's nutrition, this thesis found that children from households that produce food could benefit from high prices. The negative impact of high maize price on growth is significantly more stronger on children from households that do not produce food than from food producing households. The results also show that girls from food non-producing households suffered more than boys from high maize prices. Across children of different ages, the study found that children aged 24-35 months who were no longer breastfeeding and began to eat from the same plate as older household members are more vulnerable to shock than other age groups. The mechanism through which the maize price affects child growth is by reducing micronutrient and diet diversity in food non-producing households and increasing consumption in the food producers. Second, the results show that the effects of milk are revealed after transitioning from breastfeeding, while the effects of meat is insignificant in all age groups. Specifically, milk significantly led to higher growth in children aged 24-35 months and 36-60 months living in households which own mixed but. Third, the findings reveal that 20 per cent of inequality of opportunity in Tanzania needs to be compensated in order for equality of opportunity to prevail. Strikingly, the results show that the circumstances affecting children in urban and rural areas are different. Water and sanitation contribute 42 per cent of the inequality of opportunity in rural areas. Intergenerational aspects, early life feeding practices and market volatility were found to be more important in urban areas than rural areas. Overall, the results suggest that for the effective reduction of malnutrition, public health interventions should consider the different underlying levels and causes of child malnutrition between subgroups and the impact that a range of interventions could have on children from rural and urban areas. Policies that address the needs of specific groups could effectively reduce malnutrition in Tanzania. A combination of nutrition and water and sanitation interventions has the potential to reduce both the prevalence of malnutrition and inequality of opportunity in Tanzania.
- ItemExploring demand and supply constraints on early TB detection in South Africa(Stellenbosch : Stellenbosch University, 2019-12) Christian, Carmen; Burger, Ronelle; Van der Berg, Servaas; Burger, Cobus; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.ENGLISH SUMMARY : The infectious nature of tuberculosis (TB) makes early TB detection an important public health objective. In the South African context, where the high TB burden remains concentrated among the poor and is exacerbated by the human immunodeficiency virus epidemic, TB control is a high priority for the National Department of Health. However, without an adequate grasp of the supply and demand issues underlying delays in TB detection, policies intended to improve detection, and ultimately TB outcomes, are unlikely to succeed. The overarching aim of the three chapters in this thesis is to consider the role of crucial demand-and supply-side constraints on early TB detection in South Africa. In this regard, three key factors are considered: The health-seeking behaviour of TB-symptomatic persons, the quality of TB care at the primary healthcare level and the role of nurse workloads in TB-detection protocol compliance. Early TB detection advances access to treatment, thereby preventing further transmission, in other words, demand prevention. Of great importance in determining whether a TB-symptomatic person seeks healthcare or not are the individual’s social and economic circumstances, as well as other generally unobservable factors such as TB stigma. Findings from Chapter 2 indicate that most persons with a chronic cough did not seek care for it. This is a perturbing finding considering that data were collected in high TB burden communities. Findings also provide evidence that in these communities, TB-control interventions may benefit from focusing on youth, those with lower levels of education, smokers and higher socioeconomic status sub-groups. Although no role for stigma in health-seeking behaviour was found, this finding underscores the need to improve methods to measure stigma. On the supply side, access to affordable, quality healthcare services with adequate capacity and the willingness to identify presumptive TB patients are essential prerequisites for the timely detection of TB. Chapters 3 and 4 explore supply-side weaknesses that place critical constraints on the effectiveness of TB detection at the primary healthcare level. Chapter 3 uses the unannounced Standardised Patient (SP) method to measure the quality of TB screening at primary healthcare facilities in urban South Africa. Findings from this chapter highlight the disconnect between the prescribed TB protocols and its implementation. Even though gaps and missed opportunities for early TB detection are identified (i.e. there is room for improvement), some findings are positive. These positive findings imply that there is a stronger than expected responsiveness to TB detection in South Africa than the current literature would suggest, although it is clear that weaknesses remain. Chapter 4 uses an SP fixed effects model to estimate primary healthcare facility correlates of TB-detection protocol compliance. The chapter provides evidence that human resource constraints at primary healthcare facilities are associated with suboptimal quality of TB detection. This chapter also recommends further investigation regarding the role of management in quality of care. The findings of this thesis contribute to the small but growing literature on the economics of infectious diseases and are intended to inform, guide and further enhance TB policies in South Africa. It also provides quantitative evidence for future quality-improvement research in this area.
- ItemHealthcare reform priorities for South Africa : four essays on the financing, delivery and user acceptability of healthcare(Stellenbosch : Stellenbosch University, 2016-03) Smith, Anna Maria; Burger, Ronelle; Van der Berg, Servaas; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of EconomicsENGLISH 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.
- ItemMaking under-resourced health systems work for vulnerable women and children : antenatal care in Malawi(Stellenbosch : Stellenbosch University, 2020-03) Mchenga, Martina; Burger, Ronelle; Von Fintel, Dieter; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.ENGLISH ABSTRACT : This thesis investigates the implementation barriers and adoption of maternal health care interventions in Malawi, a sub-Saharan African country with one of the highest maternal mortality rates and most poorly resourced health systems in the region. Although antenatal care has universal components that apply to all pregnant women, the guidelines are designed to be adaptable so that countries with different health system structures and burdens of disease can implement them according to their context and the needs of their population (Benova et al., 2018). However, a lack of empirical evidence, means it is difficult to know and assess whether the existing models of care are being successfully implemented and, furthermore, whether they achieve the intended – or even unintended – objectives and provide solutions for the future, especially in settings where resources are limited. This thesis attempts to address this gap. I focused on two major aspects of antenatal care (ANC): the supply aspect (quality of care) and the demand aspect (utilisation of care), to analyse three broad objectives. In the first objective, I examine the impact of the 2001 Focused Antenatal Care (FANC) model on quality of care and utilisation of ANC services in Malawi. In the second objective, I estimate the optimal number of visits that are effective in improving birth outcomes in low-resourced settings. In the third objective, I compare women’s self-reports on the quality of ANC received to the direct observation of facilities to understand how to counter biases and mismeasurements that can impede accurate local tracking of the quality of services provided. An examination of the impact of the 2001 World Health Organization FANC model on the utilisation, early access and quality of care in Malawi, using three comparable demographic and health datasets, and the interrupted time series analysis, confirms that, when it comes to policy, one size does not always fit all. The findings reveal that, although FANC only recommends a minimum number of four visits and is therefore potentially cost effective, in Malawi the model did not translate into improved quality of care and was found to be associated with the unintended consequence of increased underutilisation of ANC. It is therefore questionable whether revising the minimum number of visits from four to eight, as recommended by the 2016 WHO guidelines would be effective in low-resourced settings. Villar et al. (2002) noted that most ANC policies in low and medium-income countries (LMICs) are adopted without thorough scientific evaluation and that there is a lack of empirical evidence on the average number of visits likely to produce the most benefit in improving maternal and child health outcomes. Therefore, this thesis extends the analysis from objective one and estimates the number of visits that would be effective to improve birthweight in Malawi. Using nationally representative Malawi Demographic and Health Survey data, I apply instrumental variable models together with highly flexible non-linear spline specifications and Wald tests to estimate breaks in the relationship between the number of ANC visits and the probability of low birthweight. Results suggest that only three visits are required to reduce the probability of low birthweight to the same extent as more visits would. This implies that low-income health systems are likely to perform just as well if fewer routine visits are conducted with more attention to quality, and reserving additional ANC visits to women who critically need them. The analysis in the first two objectives takes advantage of the publicly available nationally representative household Malawi Demographic and Health Surveys, which are based on women’s self-reports on the services provided. However, the reliability of this data depends on a number of factors: the client’s ability to recall with accuracy; the client’s access to information and knowledge of the content of care; an understanding of the questions being asked and the ability to link them to what the provider was doing, among others. These highlighted limitations may lead to an upward or downward bias in the quality of care measurement, limiting the utility of survey results for programme improvement. Given that most LMICs rely on household and client exit surveys to obtain estimates of healthcare quality, accurate information on ANC quality is important. In this part of the thesis, therefore, I assess the extent to which women’s self-reports on the quality of ANC is congruent with facility-observed estimates by testing the sensitivity, specificity and receiver-operating curves (ROCs) of ANC quality components. The results suggest that women overestimate the quality of care, mainly due to a lack of knowledge about complicated items of ANC and an overall understanding of the questions beings asked in the surveys. For example, complicated quality components asking whether the provider had counselled the client on the side effects of iron and pregnancy-related complications had lower reporting accuracy than objective indicators asking whether the provider had prescribed medication for malaria prevention, and iron/folic tablets. The main recommendations in this regard are that, in measuring the quality of care, it is important to compare women’s self-reports to facility data to get accurate quality estimates; and that the emphasis needs to be on women to place them at the forefront of policy change by educating them on what to expect during healthcare consultations. The overall findings suggest that public policy has an important role to play when it comes to maternal preventive healthcare. Demand-side policy tools such as increased access to basic information on the importance of accessing ANC services and specific components to expect during a consultation can only be successful if the supply side is adequate and effective.
- ItemSocioeconomic status and chronic diseases in South Africa(Stellenbosch : Stellenbosch University, 2022-12) Gangaidzo, Trust; Burger, Ronelle; Von Fintel, Marisa; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.ENGLISH SUMMARY: The global burden of non-communicable diseases (NCDs) is on the rise, and is expected to increase. The United Nations, through the 2030 Agenda for Sustainable Development Goals, acknowledged the public health importance of addressing NCDs, and set a goal to reduce premature mortality from NCDs by one-third by 2030. Key to achieving targets for prevention and control of NCDs is a holistic approach to understanding the underlying contextual causes. This thesis examines the role of inequality in socioeconomic status in the development of chronic diseases in South Africa, a highly unequal middle-income country battling communicable diseases and maternal and child mortality. To achieve this, the study had three objectives: (1) To examine how exposure to negative household events and neighbourhood characteristics relates to systolic blood pressure in South Africa; (2) To determine socioeconomic factors that explain depressive symptoms in South Africa; and (3) To ascertain the influence of the COVID-19 pandemic on income-related inequality in depressive symptoms in South Africa. The study is presented in three essays. In the first essay, I estimate the relationship between systolic blood pressure and exposure to stressful (negative) household events and neighbourhood characteristics. Using the correlated random effects model, I found that systolic blood pressure is significantly higher among respondents from households that had registered the death of a household member and those that reported a reduction in grant income and remittances. The direct effects of neighbourhoods were related to neighbourhood income level, whereby moving from a low-income neighbourhood to a middle-income neighbourhood was negatively associated with systolic blood pressure. With regard to the heterogenous effects of neighbourhoods, I found a negative and significant mean-level “job loss” effect. The implications of the study results are vast in a country like South Africa, which is already burdened with high mortality due to causes such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and tuberculosis (TB), injury and homicide, and NCDs such as cardiovascular diseases and diabetes. In the second essay, I examine the relationship between depressive symptoms and socioeconomic factors using the ordinary least squares model and the fixed effects model. Results from both models suggest significant socioeconomic gradients in depressive symptoms, whereby depressive symptoms are negatively associated with per capita household income, education, and social capital. However, I found a positive and significant association between depressive symptoms and unemployment only in men. The significant differences in the effects of variables by gender and by residence are a unique contribution to understanding the differences in health in South Africa, and may inform policies. Firstly, there are significant gender- and residence profiles in depression. Secondly, men who self-report good health may overestimate their health, most likely by excluding their state of mental health. Lastly, whilst the goal is to reduce the prevalence of mental disorders by targeting socioeconomic factors, differences by gender and residence underscore the need for mental health policies that promote equity. As reported in the third essay, I used a recentred influence function regression decomposition method developed by Heckley et al. (2016) to ascertain the influence of the COVID-19 pandemic on inequality in depressive symptoms related to income in South Africa. I found that the COVID-19 pandemic negatively and significantly influenced income-related inequality in good mental health in South Africa. This means that the COVID-19 pandemic disproportionately increased mental health problems amongst the affluent. I did not find an education profile in the joint distribution of income and mental health. Self-reported health-, age-, population group-, and gender profiles were present in the covariance between Income and good mental health. I used publicly available longitudinal data from the South African National Income Dynamics Survey in the study. Overall, the findings of this study suggest that socioeconomic factors contribute to the rising burden of chronic diseases in South Africa. Notwithstanding the study’s limitations, this thesis makes a significant contribution to understanding the typical mechanisms and pathways through which poverty and chronic conditions interact and reinforce each other in South Africa, and other low- to middle-income countries. This, in turn, provides useful inputs for policy and programmes to address the burden of chronic conditions in poor societies. Whilst pharmacological and medical technology advancements are important in extending life expectancy, socioeconomic interventions are equally important in curbing both rising morbidity and mortality from chronic diseases, and in addressing poverty and inequalities in low- to middle-income countries. Unlike physiological causes, socioeconomic determinants of health can be influenced through health- and government policy interventions, which could also be justifiable in terms of efficiency and equity.