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

[摘要] ENGLISH ABSTRACT: peers, South Africa is achieving health outcomes that are comparable to those of low-incomecountries.This dissertation contains four essays on the financing, user acceptability and delivery of healthcarein South Africa. The main contribution of the dissertation is to determine how the user acceptabilityof healthcare services influences not only health seeking behaviour in South Africa, but alsoinfluences the ability of healthcare services to impact health outcomes. Without sufficient focus onuser acceptability, the success of the health system will be undermined by creating missedopportunities for the prevention, detection and treatment of disease.The first essay considers the potential role of private health insurance (medical schemes) in reducinginequality to healthcare access and alleviating the burden from a constrained public healthcaresystem by providing access to healthcare services of higher user acceptability levels. The analysisindicates that, in the absence of a number of regulatory changes in the market primarily aimed atincreasing the affordability of medical schemes, the size of the formal skilled labour market willcontinue to set the limits of the private health insurance market.The second essay examines the causal impact of access to private health insurance (medicalschemes) on healthcare utilisation and healthcare provider choice by using the exogenous variationin private health insurance coverage induced by the roll-out of the Government Employees MedicalScheme (GEMS). Contrary to most of the findings in the literature, the analysis finds that providingaccess to healthcare perceived to be of greater user acceptability in South Africa's polarisedhealthcare market has a large positive effect on total healthcare utilisation. It also increases thelikelihood of using private providers and, in particular, private doctors.In the third essay, the dissertation considers the health seeking behaviour of adults with potentialtuberculosis (TB) symptoms (coughed ≥2 weeks) in the Western Cape. Only one third of adultsindicated they sought help for TB symptoms and only one fourth of those who coughed ≥2 weeksreported these symptoms at primary healthcare facilities. Women were less likely than men to beasked for a sputum sample at these facilities, indicating poor adherence by healthcare staff to thewell-defined TB testing protocol.Lastly, the fourth essay explores the causes of late antenatal care access amongst a sample ofwomen 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 themajor reason for delayed attendance. While late access was predominantly associated with demandsidefactors, 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 useracceptability, and the last two essays show that this would need to include improved preventativecare, enhanced health system effectiveness and better clinical quality monitoring.

[发布机构] Stellenbosch University