The assessment and improvement of the health status of vulnerable and low income individuals in South Africa: an analysis using quantitative and experimental methods

[摘要] 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 testdistributionatpublichealthfacilitiesisofpoorquality.Twoapproaches,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.

[发布机构] Stellenbosch University