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Inequities in access to health care in South Africa
Bronwyn Harris a, * , Jane Goudge a , John E. Ataguba b , Diane McIntyre b , Nonhlanhla Nxumalo a , Siyabonga Jikwana c , and Matthew Chersich a,d
Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Private Bag X3, Wits, 2050, Johannesburg, South Africa. E-mail: firstname.lastname@example.org
Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. National Department of Health, Pretoria, South Africa.
Department of Obstetrics and Gynecology, International Centre for Reproductive Health, Faculty of Medicine, Ghent University, Ghent, Belgium.
Abstract Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population without imposing an unaffordable burden on individuals or households. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n ¼ 4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries. Journal of Public Health Policy (2011) 32, S102–S123. doi:10.1057/jphp.2011.35
Keywords: out-of-pocket payments; access; health-care utilization; inequities; household survey; South Africa
More than a billion people, mainly in low- and middle-income countries (LMICs), are unable to access needed health services as these are unaffordable.1 In South Africa, health-care access for all is
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S102–S123 www.palgrave-journals.com/jphp/
Inequities in access to health care in South Africa
constitutionally enshrined; yet, considerable inequities remain, largely due to distortions in resource allocation.2–4 Access barriers also include vast distances and high travel costs, especially in rural areas; high outof-pocket (OOP) payments for care;5 long queues;6 and disempowered patients.7 These barriers, created by uneven social-power relationships, resonate with access hurdles experienced elsewhere in LMICs.1,8 Globally policy attention has turned to universal health coverage (UHC) as a remedy for inaccessible, unaffordable health services. Achieving equitable UHC requires the provision of accessible, necessary services (‘depth’) for the entire population (‘breadth’), and accommodating the ‘differential needs’ and financial constraints of disadvantaged groups (‘height’).8 Access is therefore the opportunity and freedom to use services,9 and encompasses the circumstances that allow for appropriate service utilization, plus a sufficiently informed individual or household (demand-side) empowered to exercise choice within the health system (supply-side).9,10 The ‘degree of fit’ between demand- and supply-sides, rather than each in isolation, determines the degree of access achieved.9 South Africa’s apartheid past still shapes health, service, and resource inequities.2 Racial, socio-economic, and rural-urban differentials in health outcomes, and between the public and private health sectors remain challenging.2,3,11 In 2005, spending per private medical scheme member was ninefold higher than public sector expenditure, and one specialist doctor served fewer than 500 people in the private sector but around 11 000 in the public sector.11 Large information gaps remain about health access in the general population in South Africa, especially around utilization rates and OOP payments for health care.12 Documenting demand-side perspectives of users, too-long neglected, could inform future policies.8,9 We conducted a national household survey to fill these gaps and to examine access barriers.
In 2008, we conducted a household survey in South Africa, with households selected using multi-stage sampling, detailed elsewhere and in this edition.13,14 The team selected five randomly-chosen households within 960 enumerator areas. Within each household, we administered the questionnaire to an adult responsible for household health decisions. If the health-head declined or was ineligible, the household
r 2011 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 32, S1, S102–S123 S103
32. The team assessed equity by considering whether access was equal among those with equal need for health care. 0197-5897 Journal of Public Health Policy Vol.12 and. and affordability. by contrasting levels of need with service use in different population groups. and reasons for delaying care when someone was ill and then the illness worsened in the previous year. To detect differences among categorical variables we used the Rao–Scott F statistic to determine P-values. 5–9 per cent high.Harris et al was substituted by the one to the immediate left. which are strongly related to socio-economic status in South Africa. and age and gender of household heads. We used two indicators of need: self-assessed health status as poor or very poor in main respondents. and above 10 per cent catastrophic). S102–S123 . Data analysis We analyzed the data using STATAs 11 and weighted it for differential probability of participant inclusion. among the total population. health-insurance status.16 We then categorized S104 r 2011 Macmillan Publishers Ltd. The Universities of Cape Town and the Witwatersrand provided ethics approval for the study and all respondents provided informed consent. virtually all associations were significant. we developed a composite index of socio-economic status based on variables including access to water and sanitation. Using principal component analysis. and inpatient (number of admissions per 1000 people/year) services. We examined the access dimensions9 of availability (distances and travel mode to facilities). we calculated household ‘burdens’ of OOP payments (0–4 per cent of total household expenditure is lowmoderate. For affordability. S1. utilization of outpatient (annualized number of visits/person in the last month). any household member experiencing recent illness or injury. including reasons for delayed care). Measurement of access and need We collected information on: health status.15 Given the large sample size. user satisfaction and health system perceptions. acceptability (reasons for provider choice. We verified 20 per cent of questionnaires telephonically and double entered the data.5 We calculated the transportation burden by dividing transportation costs for outpatient visits by total household monthly expenditure. housing characteristics. such as socioeconomic quintiles.
but education was not associated with recent illness or injury. 0197-5897 Journal of Public Health Policy Vol. Need was unevenly distributed. including.3–1. S102–S123 S105 . 5.3 per cent). were recently ill or injured among the total population.3–$53. For main respondents. need was higher among main respondents with only primary education or less (31. Results The health decision-maker declined participation or was ineligible in 238 households (5 per cent). yet. 6.7/month (IQR ¼ $13. S1.Inequities in access to health care in South Africa respondents into five socio-economic quintiles. While almost 20 per cent of the uninsured in both groups needed care.9 per cent spending below $15/month.3. although patterns varied between these measures (Table 2). In contrast. and the remainder either pensioners (8. more black Africans (20. almost half had only primary schooling or less.7 per cent) than those with tertiary qualifications (3. with 28.2 per cent) reported poor health. 223 of which were substituted. $1 ¼ R7. and 39.2 per cent of insured main respondents reported poor health. from poorest (quintile 1) to wealthiest (quintile 5).3 per cent).4 per cent spent $250/month or more. Conversely. r 2011 Macmillan Publishers Ltd.6 per cent of the total insured were recently ill or injured.9 per cent inhabited rural areas (Table 1).5). Most did not have health insurance (88. or children and students (44. The 4668 households sampled contained 21 159 individuals. a similar proportion unemployed. a third of Indians or Asians. the socio-economic status of those ill or injured was fairly evenly distributed. Almost 20 per cent of women in both groups needed care: 1.6 per cent of black Africans. Similarly. Median per capita expenditure (for everything. A quarter were employed.6 per cent of the richest. health services) was US$26. Four-fifths were black Africans. decreasing to 16. and 23. Within both groups a third of those above 65 years needed care.6-fold more than males. but not restricted to.5 per cent).8 per cent of main respondents who reported poor health and the similar proportion of the total population who experienced illness or injury in the preceding month were in need of care. over 20 per cent of those in the poorest three quintiles needed care compared to just 5.4 per cent). Relative to other groups. Need and utilization We assumed that the 17. 32.
5 1.2) Colored (9.0 8.4 76.0 3.6 1.5) Indian or Asian (2.8 20.7 2.4 0.4) Sex Female (55.5 84.8 1.0 4.9) 2.7 4.3 97.1 51.2 1.7 1.1 0.6 9.7 8.9 4.4 59.2 0.7 4.9 1.2 3.9 50.1 1. 0197-5897 Journal of Public Health Policy Vol.0 0.Harris et al Table 1: Population characteristics and health service utilization in the general population in South Africa Outpatient visits (per person/year) Public hospital 0.9) Informal-urban (17.3 101.8 2.9) 18–24 (15.6 20.2 1.6 1.2 28. 32.9 2.2 4.7 30.1 5.1 0.4 0.2 Private Public Total outpatient Inpatient admissions (per 1000 people/year) Private 5. S1.2 2.7) Male (44.1) 25–49 (31.3 2.5 1.5 27.2 4.5 4.5 Variable (% of study population) Clinic/CHC 1.6 1.8 0.2) Formal-urban (42.6 .2) White (6.9 1.7 1.4 2.1 93.1 1.5 2.1 58.1 4.4) 65 þ (5.4 113.5 33.2 0.7 0.8 8.1 3.6 53.6 Age o18 (37. S102–S123 Race Black African (82.9 0.1) 50–64 (10.7 84.6 176.0 S106 r 2011 Macmillan Publishers Ltd.1 109.1 4.3) 2.0 6.7 1.7 Area type Rural (39.6 4.8 13.3 100.8 3.0 2.0 0.1) 2.7 0.3 116.
5 5.4 406.9 1.1 5.3 61.5 2.3) 1.7 1.9 105.7 1.0 14.7 4.4) Insured (11.2 291.0 4. S1.9 1.1 5.7 3.8 0.1) Some secondary (31. .8 10.6 Health statusa Excellent (22.5 0.4 0.1 5.9 136. 0197-5897 Journal of Public Health Policy Vol.4 0.2 190.1 0.3 3.5) Pensioner (8.8 0.8 1.2 1.3 3.9) Average (26.7 4.1 1.6) 2.8 0.7) Very poor (3.6) 2.0 0.0 1.5 2.3 118.7) Tertiary (4.7 44. S102–S123 S107 a Restricted to main respondent (n=4668).9) Unemployed (23.2 4.4 7.1 112.5 2.3 2.2 101.7 153.5 7.4 2.5 9. 32.7 0.7 5.9 71.1) 1.4 1.0 2.5) Poor (14.3 11.7 1.5 3.6 2.9 34.5 5.3 121.7 41.9 14.7 1.o 5.2 84.4 4.2 25.6 4.7 4.1 23.7 36.5 163.3) Student/child (44.0 20.6 6.8 Inequities in access to health care in South Africa r 2011 Macmillan Publishers Ltd.5 88.8 35.0 Employment Employed (23.8 5.0 1.0 5.4 14.5 21.8 32.4 0.6 Health insurance None (88.Education Non-primary (47.7) Good (32.7 2.4 0.6 0.7) Complete secondary (16.
7 74.8 54.0 10.6 3.4 17.6 3.5 3.7 13.8 1.7 3.5 21.0 16.4 64.1 18.6 44.7 48.2 2.8 17.9 76.5 3.4 9.1 3.3 5.1 31.5 227.4 0.4 80.7 S108 r 2011 Macmillan Publishers Ltd.2 2.3 5.1 10.3 6.1 17.9 105.7 15.1 13.9 16.6 70.5 34.3 5.2 224. 32.6 19.1 61.7 25.5 4.1 33.5 19.4 2.5 32.6 8.8 15.8 28.7 16.6 0.2 16.9 8. 0197-5897 Journal of Public Health Policy Vol.6 17.9 0.1 51.1 9.7 7.4 3.2 12.2 74. S102–S123 Inpatient total population District hospital Regional hospital Tertiary hospital Private hospital Public sector visits (mean)d Public sector visits if ill/injured (mean)d Private sector visits (mean)d Private sector visits if ill/injured (mean)d .8 17.9 5.7 5.9 8.5 3.3 19.9 5. utilization.8 248.4 8.5 18.8 9.4 9.6 Variable Category %a Need Poor or very poor healthb Ill or injured Utilization Outpatient total population Public clinic/CHC District hospital Regional hospital Tertiary hospital Private non-hospital facility Private hospital Public sector visits (mean/year) Public sector visits if ill/injured (mean/year)c Private sector visits (mean/year) Private sector visits if ill/injured (mean/year)c 68. S1.3 11.7 11.2 20.5 2.4 31.2 2.2 4.8 28.8 12.7 264.9 51.0 29.7 15.2 200.7 15.3 15.Harris et al Table 2: Differentials in need.8 1.7 3.5 16.6 60.6 31.4 0.2 0.2 74.3 21.7 35.0 5. and health system access between socio-economic quintiles Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Total 21.8 4.1 1.2 30.8 9.7 33.2 192.3 206.1 61.7 7.2 1.7 2.9 1.3 4.2 22.5 12.4 2.
6 34.6 38.2 48.2 21.6 3.9 62.7 23.9 0.9 29.9 5.6 26.2 30.5 0.2 1.2 7.2 3.2 4.5 9.8 0.2 1.6 40.0 2.8 31.4 1.1 2.5 2.0 3.Availability Transport to facility 41.2 12.2 15.2 21.2 1.9 7.3 0.5 Walked Public transport Private vehicle Other Travel time Mean minutes Chose facility as it’s closest Outpatient Inpatient Affordability Chose facility as don’t have to pay 37.0 47.4 6.0 15. S1.1 15.4 14.8 42.4 7.2 10.0 39.7 1.8 1.6 2.6 38.7 8.1 13.7 6.0 50.8 2.9 22.6 54.3 8.0 45.0 30.4 12.7 9.1 15.3 2. S102–S123 S109 OOP household burdenf Transport 5–9% X10% Outpatient public service 5–9% X10% Outpatient private service 5–9% X10% Inpatient public services 5–9% X10% Inpatient private services 5–9% X10% .8 5.5 26.7 9.1 54.7 55.3 7.0 41.2 41.6 41.2 34.3 1.9 8.5 10.6 55.4 2.7 1. 32.1 11.7 5.3 59.0 17.2 57.4 4.0 42.5 20.2 23.6 6.1 7.5 17.4 38.4 Outpatient Inpatient 35.1 1.3 13.2 63.9 2.7 4.2 5.2 0.2 2.0 1.7 54.3 1.2 7.3 45.6 46.5 7.6 0.0 51.2 0.9 2.0 34.5 10.3 37.2 21.9 10.2 5.2 19.7 13. 0197-5897 Journal of Public Health Policy Vol.4 Delayed care as Transport unaffordablee Unable to get time off worke Inequities in access to health care in South Africa r 2011 Macmillan Publishers Ltd.7 6.7 26.0 5.4 18.5 45.8 11.4 59.
e Did not seek care when ill.2 75. f 0–4% burden is low to moderate.Table 2 continued Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Total 6.3 56.0 13.9 10.5 6.0 8.0 3.7 11. above 10% catastrophic.7 7.9 Harris et al Variable Category %a Acceptability Chose facility as respectful service Outpatient Inpatient Delayed care as Queues too longe Care likely to be ineffectivee Won’t be treated respectfullye Illness not seriouse a S110 r 2011 Macmillan Publishers Ltd.0 7.0 3.8 3.1 6.1 79.6 6.2 71.7 6.1 9. Main respondent only.4 62.4 15.7 8.6 19.1 0.4 8.1 2. 5–9% high.6 5.7 7. then illness worsened (in past year). c Those ill or injured in the last month (of whole population). 32.4 9.4 9.2 4.9 68. 0197-5897 Journal of Public Health Policy Vol. S1.8 8. d Mean admissions/1000 people/year.2 6. S102–S123 b Among whole population unless stated otherwise. .2 11.5 3.
rather than private facilities for all but the richest. Outpatient visits in the private sector were concentrated in the richer quintiles. made 3. 68.7 private admissions for the ill or injured. S1.7 visits).5 visits). Main respondents in very poor health experienced threefold as many public admission-days as those reporting excellent health (406. r 2011 Macmillan Publishers Ltd.3) – almost double that of those who were ill or injured.7 visits/year). rising to 227. Patients with only primary education or less. and 17.3–3. the mean days admitted per 1.8 per cent of the wealthiest. and pharmacies). private dentists. with only 13. Insurance status was associated with differential utilization of inpatient care.3 for those without insurance.6 in the private sector. Most inpatient care took place in public. For rural-dwellers and those living in informal-urban areas. Inpatient care For the total population.9 per cent admitted privately compared to just 5. academic.8 per cent).7 per cent in quintile 2 (Table 2).2 visits). In addition.3 per cent) hospitals.9 per cent district hospitals).000 people/year was 80. and specialist hospitals) (Table 2).2 per cent in quintile 1. use of private-outpatient services was high among those with tertiary education (4.6 versus 136. especially in the private sector.7 per cent of the poorest to 60. S102–S123 S111 . For public sector admissions. and the insured (4. 32. Whites (3. Indians or Asians (3.Inequities in access to health care in South Africa Utilization Outpatient care While total utilization was similar across socio-economic groups (2.8 per cent) or regional (40. while the richest were thrice as likely to use tertiary hospitals (including national central. Conversely.8 per cent attended clinics. a group that also used private-hospital outpatients four times more than those in quintile 1 (Table 2). 0197-5897 Journal of Public Health Policy Vol. people in the lowest quintile mostly used district facilities (53.0 per cent admitted to a tertiary facility.4 times as many visits to public clinics as those with tertiary qualifications (Table 1). For ambulatory private care (including general practitioners. with 61.8 visits). with a mean 118.6 admission-days for the insured versus only 3.7 public and 44.5 in the public sector and 16. and 0. utilization rose steadily from 15. public sector admissions among the richest quintile were predominantly at tertiary (44. the poorest mainly visited primary health care (PHC) facilities (in quintile 1.
5 min). compared to 28. Average travel time to a facility was 30. travel times in rural areas were long (38. Affordability In the public sector. and only 6.4 min).8 admissions). followed by Indians or Asians (22.0 per cent). While women’s total inpatient utilization was higher than men (115. ‘not having to pay’ informed the choice of over half using primary care. ‘Closest service’ was also important for half (49. Travel was shortest for whites (17.4 per cent using hospitals as outpatients. Similarly large differentials occurred in private admissions between those in the poorer.3 per cent in the private.2 per cent) or walked to outpatient health services (37. more rural provinces of Limpopo (2.7 admissions).4 per cent). and S112 r 2011 Macmillan Publishers Ltd.5 min). People in formal-urban areas were sevenfold more likely to use private transport than rural residents.8). while this influenced just a quarter of private inpatients. Referral was the commonest reason for selecting private hospitals (38.2 min). and black Africans (32. The wealthiest quintile appeared more willing to travel. but almost twice as long for the poorest (38.5 admissions).7 min. better-resourced provinces of Gauteng (32. were taken there in an emergency. 0197-5897 Journal of Public Health Policy Vol. Availability The majority used public transport (45. S1. S102–S123 .5 per cent in the public sector. with only 30.2 min) (Table 2).6 per cent of whites used public means. 30.3 admissions).4 versus 73.2 minutes) than the richest (20. 28.6 admissions). and the Western Cape (32. Of inpatients. men were 1.8 min).Harris et al total utilization of inpatient private facilities was just a tenth of urbanformal residents (33.4 per cent of users selecting private-outpatient services for their proximity. Mpumalanga (6. coloreds (25.9 admissions) versus the urban. 32. and Eastern Cape (6.9 per cent in the public sector and 14. although two-thirds (63.6 per cent) of the richest used private means.5 per cent using public sector hospital outpatients chose the facility because it was close. Similarly. Two-thirds using public sector outpatient primary care and 53.8 per cent) of those using public-inpatient facilities.5-fold more likely to be admitted to private hospitals.
falling to 2. for private inpatients.3 per cent for Indians/ Asians). In contrast.7 per cent of the poorest. declining step-wise across quintiles to 1. Transport costs were similarly a problem for 42.3 per cent in Limpopo Province).1 per cent of the richest said this was due to unaffordable transport costs (Table 2).2 per cent for the wealthiest. and 35.7 per cent for informal urban to 14.0 per cent of insured.1 per cent of the poorest versus 1. Table 2). Inability to leave work prevented immediate care-seeking for 10.7 per cent for households that sought private-outpatient care.7 per cent of the unemployed. varying markedly by race (from 36. S102–S123 S113 . these levels were 23.5 per cent living in Eastern Cape and 19.3 per cent of those living in rural areas.9 per cent of the richest.8 per cent of the uninsured. OOP payments for outpatient care in the public sector were lowto-moderate (0–4 per cent) for most households across the different variables. Unsurprisingly. This also affected more black Africans (11. area type (54.Inequities in access to health care in South Africa 29. compared to 5. Unaffordable transport also obstructed immediate care for 18. Financially catastrophic transport costs occurred in 15.0 per cent of the poorest. Of household members who delayed seeking care. OOP payments were also catastrophic for 14. 14. transport costs were catastrophic (X10 per cent of household expenditure) for 19.2 per cent of those aged above 65. 32. through 30.0 per cent of inpatients.1 per cent of pensioners faced financially catastrophic costs following privateoutpatient visits. and 13.4 per cent for formal urban). Less than 5 per cent gave this reason for using private services. but only 1. as well as 15. and only few whites (1. compared to r 2011 Macmillan Publishers Ltd. Similarly.1 per cent for rural. 0197-5897 Journal of Public Health Policy Vol. 21.2 per cent of children under 6.5 per cent for the poorest.6 per cent).5 per cent in Limpopo.0 per cent of the uninsured versus just 4. insurance status was strongly linked with financial catastrophe.6 per cent of the insured.0 per cent of those uninsured (Table 3). Over two-fifths of those above 65.3 per cent for black Africans to 3. and 12. and socio-economic status (59. S1. experienced by 43. For those who sought outpatient care. catastrophic only in a very small minority (except 5.2 per cent of pensioner private inpatients and 16. five times as many uninsured respondents faced catastrophic costs than those with insurance.8 per cent) than other groups.5 per cent of the wealthiest (Table 2).0 per cent of the insured utilizing private-outpatient care (Table 3).
0 8.1 4.0 22.9 2.8 6.9 25.3 8.8 4.6 7.8 7.7 0.0 2.7 10.6 9.0 5.6 12.3 6.7 43.7 5.2 11.2 13.3 6.1 2.8 9.3 9.Harris et al Table 3: Factors associated with high and catastrophic out-of-pocket payments for health care as a percentage of household expenditure Variable OOP transport to outpatient care OOP outpatienta OOP inpatientb Public Burden on household Age o18 18–24 25–49 50–64 65 þ Sex Female Male Race Black African Colored Indian or Asian White Area type Rural Informal-urban Formal-urban Education Non-primary Some secondary Complete secondary Tertiary Employment Employed Unemployed Pensioner Student/child Health insurance None Insured Health status Excellent Good Average Poor Very poor a b c Private 5–9 9.5 41.5 10.6 6.0 2.1 14.6 7.3 Public 5–9 10.7 11.7 6.6 15.1 11.7 1.7 9.4 1.6 14.6 7.6 3.6 5.7 10. X10% catastrophic.9 19. c 0–4% burden is low to moderate.7 3.2 1.4 33.2 6.2 19.0 10.8 8.3 5.7 15.4 54.4 12.1 1.2 4.6 1.3 16. excludes transportation.5 27.6 13.9 10.6 6.6 11.8 14.5 1.0 13.5 0.7 1.2 0.1 0.5 25.0 5.1 22.8 28.4 0.7 9.0 1. S102–S123 .1 15.5 3.8 5.2 3.9 2.8 10.7 14.1 7.4 1.5 16.2 7.1 15.9 2.4 6.8 3.8 6.6 8.1 23.9 2.2 5.6 Most recent visit.5 31.5 0.1 16.4 0.9 14.6 1.3 3.5 8.6 7.7 14.9 6.6 2.7 1.6 2.0 10.0 X10 0.4 9.3 7.1 2.6 0.8 5.2 20.7 13.6 2.2 6.2 11.7 9.0 0. Most recent admission.0 2.0 3.4 2.0 7.4 15.0 1.1 6.7 11. OOP: Out-of-pocket payments.1 X10 3. S1.1 0.7 5.7 8.5 0.7 0.5 7.6 8.0 Private 5–9 0.2 5.6 5–9 1.3 6.3 2.4 34.9 0.4 8.5 3.8 1.4 5.7 0.5 14.7 6.5 6.3 14.4 17.5 15.9 23.2 7.4 11.9 16.7 36.0 2.0 2.2 0.7 6.3 3.2 9.9 2.9 X10 20.5 0.0 12.0 2.1 4.0 1.0 14.4 8.9 22. S114 r 2011 Macmillan Publishers Ltd.6 6.6 1.1 1.2 0.8 1. 0197-5897 Journal of Public Health Policy Vol.8 7.2 6.9 1.7 16.0 5–9 13.4 6.3 6.5 4.6 8.7 1.7 5.7 4.6 2.6 X10 8.8 0.4 1.9 17.0 2.0 2.4 9.1 46.1 4.0 16.2 1.2 5.7 0.2 12.0 5.9 10.7 1.9 6.5 5.0 4.4 3.5 6.2 7.9 10.1 30.9 13.0 2.7 18.1 5.0 4.7 13.0 0.0 0.0 12.4 1.2 3.9 1.8 13.7 35.5 1.4 1.4 1.2 0.5 17.5 3.8 1.3 10.5 X10 6.3 22. 32.2 7.6 12.7 13.9 2.9 7.7 1.3 5.7 11.0 0.5 1.1 9.1 12.7 2. 5–9% high.2 8.8 7.9 9.6 2.7 4.7 9.3 0.3 11.4 10.4 0.1 4.1 9.4 11.9 1. excludes transportation.6 10.6 6.4 8.5 25.4 8.3 2.0 0.0 5.9 12.9 1.6 7.8 4.5 3.
2 per cent of rural-dwellers. delays were due to a belief that the illness was not serious enough to warrant immediate care (68. Over half of all respondents (54.8 per cent). Perceptions. compared to 54.2. 32.5 per cent). as did rural (10. A fifth of the poorest. S1.4 per cent of those living in the largely rural Limpopo Province.1 per cent) than public patients (7.7 per cent of uninsured patients attending a PHC facility. and 5.7 per cent of Whites. S102–S123 S115 . Despite free PHC services and hospital user fee exemptions for uninsured children under 6.8 per cent) than women (5. 10. Desire for respectful treatment influenced the health-seeking behavior of almost a quarter (22. with 46. Around fourfifths of main respondents who used public-inpatient services in the past year reported being treated respectfully by health providers.8 per cent). and half in quintile 2.17 OOP were made by 17. however.1 per cent of Indians or Asians. Most commonly. r 2011 Macmillan Publishers Ltd.3 per cent) experienced catastrophic costs. highest among the richest and insured (Table 2).0 per cent of the employed.7 per cent using public hospitals.5 per cent). experienced catastrophic costs as private inpatients. falling to 4.1 per cent).7 per cent who had never been admitted. varied by source.9 per cent below 18. and anticipated disrespectful treatment (2.1 per cent accessing public PHC services. but only 4.Inequities in access to health care in South Africa 3. For inpatients.9 per cent of private inpatients (Table 4). perceived ineffective care (6.1 per cent) relative to urban-formal dwellers (4. and 8.0 per cent of children under 6 as public sector inpatients and 7. Catastrophic payments for public inpatients were also borne by 9. while for the upper three quintiles this burden was low-to-moderate.2 per cent) encountered low-to-moderate OOP burdens as public sector inpatients. as well as 12.7 per cent) felt that patients at public hospitals are ‘rarely treated with respect and dignity’. However. anticipation of respectful treatment was twofold as important for private (17.3 per cent of those actually admitted to a public hospital in the past year holding this view. Acceptability Long queues (8. almost twice as many men (9. compared to 92.2 per cent basing their views on media reports. Most (88.3 per cent) attending privateoutpatient services.9 per cent) partly accounted for delayed care-seeking. 0197-5897 Journal of Public Health Policy Vol. and 54.
but only 9.5 4. 0197-5897 Journal of Public Health Policy Vol.4 Private 6.5 37.2 13. because the availability of good medical care varied inversely with population health needs. S102–S123 .8 Delineating access barriers is a first-step towards reversing inequities and is a prerequisite for achieving UHC.8 This study is strengthened by the use of two need measures: selfreported health status among main respondents.7 9.7 9. Other acceptability factors that evoked dissatisfaction included cleanliness. and 25.5 per cent of public outpatients. When gauged by health status. confidence in the effectiveness of care received influenced outpatient facility choice for almost half (43.9 15.18 Forty years on.0 13.5 22. while fewer were dissatisfied with overall quality of private care (9. Among public sector patients.5 19.9 21. Discussion In 1971. despite their greater need.9 5. Finally.1 17.3 15. between a third and a quarter were dissatisfied with the overall quality of care received.6 17.7 per cent of private outpatients.1.0 Inpatient service Public 10.1 Dissatisfaction levels were high regarding the time taken to receive services: 37. although slightly higher in public inpatients (18.5 per cent) of those in the private sector. many poor or disadvantaged social groups are denied equal access to good-quality services.3 7.3 19.2 6.8 10.3 25. gender. and recent illness or injury within all household members.1.5 3. the ‘inverse-care law’ was coined. privacy. and S116 r 2011 Macmillan Publishers Ltd. and confidentiality. need varied predictably by socio-economic status. S1.0 per cent outpatients.3 Private 4.2 8.6 per cent using PHC.8 9.5 per cent of public inpatients (Table 4). and 13. 5.8 per cent). 32.1 5.Harris et al Table 4: Service dissatisfaction among main respondents Variable (% dissatisfied with service used in past month) Outpatient service Public Clean facility Consultation in private Health problems kept confidential Treated with respect and dignity Drugs received improved their health Timely medical attention Overall quality of care 10.1 3.1 per cent inpatients).7 per cent using public hospitals. 17.
and insured. Unaffordable transport. total utilization was similar across socio-demographic groups. Because tertiary hospitals are concentrated in the largely urban. For care seekers. remembering recent illness in other household members may incur recall bias. and therefore under-report or ‘ignore’ illness. and are better resourced and specialized than district facilities. The finding also raises questions around referral systems that may unfairly privilege certain groups. and a belief that care would be ineffective were more prominent access barriers for these latter groups. doctor-led curative services within the public sector illustrates the inverse-care law. a perception that illness was not serious enough to warrant medical attention was the commonest reason for delayed treatment. urban. Need for health care is difficult to measure as it is embedded within social norms and constructions of illness and perceptions of health. It is well documented that low-income groups cannot ‘afford’ to be ill. around a fifth of quintiles 1 and 2 also used private-outpatient care. wealthier provinces of Gauteng and Western Cape. 0197-5897 Journal of Public Health Policy Vol. in South Africa this r 2011 Macmillan Publishers Ltd. OOP burdens of outpatient care also fall on uninsured members. and within the public sector itself. 32. noted between the type of care accessed. access to specialized. Utilization of higher-level public facilities was greatest among richer. S102–S123 S117 . Marked disparities were. both between private and public sectors.19. largely from their use of private providers.22 However. suggesting that they might have had less serious illnesses than the poor and uninsured.8 This emphasizes the need for considering ‘depth’ dimensions of UHC (type of services offered) alongside the ‘breadth’ (coverage for all).2 this finding raises equity concerns.20 In our results.21 Our results suggest that the poorest bear disproportionate cost burdens. and accounted for over 20 per cent of outpatient visits for the poorest groups in 39 LMICs. however. or recent illnesses of other members may be conflated with service utilization.12. However. and why some groups of people appear to ‘by-pass’ the district health system – a cornerstone of efforts to address access inequities. S1.2 Costs of accessing services can be crippling for poor households. As elsewhere. Considerable private sector use across all socio-economic quintiles is not unique to South Africa. Although the poorest quintiles make more use of public PHC services.Inequities in access to health care in South Africa residence.20 Further. need assessed by the second measure was less clearly differentiated across such variables. anticipation of disrespectful providers. This perception was especially prominent among the rich and insured.
24 are important for addressing the differential acceptability needs of disadvantaged groups (the ‘height’ of UHC). Fewer public service users felt they were treated with respect and dignity. which sustain access.23 As in many other LMIC contexts. grants. particularly for socially disadvantaged groups who generally bear the brunt of unacceptable care. It emphasizes the need for reforming the private health sector in South Africa.Harris et al burden on the poor bears vivid testimony to the country’s distinctive private-public sector split.25 and ensuring compliance with the Patients Rights Charter. particularly in largely rural and poorly resourced provinces. Policy-makers therefore need to challenge negative perceptions and stereotypes.5 It also illustrates the ‘discretionary power’ of providers and bureaucrats who determine who ultimately qualifies for exemptions. especially in the private sector with financial incentives to influence user choice. within the same geographical setting. poor.1. Although the Clinic Upgrading and Building Programme has improved service availability. and experiences of family and friends.5 We found that a considerable portion of the groups exempted from user fees still pay for services. This undermines the equity-objectives of the government’s exemption policies2. 0197-5897 Journal of Public Health Policy Vol. our results show that perceptions about health care vary according to whether respondents had recently used public sector services (more positive) or not (more negative). which severely limits cross-subsidization from wealthy to poor. and from healthy to sick.22 transportation costs and travel distance emerged as key access barriers.3 we found that access barriers relate to the geographic inaccessibility of health facilities. and user fee exemptions.25 and shaped by the media. stimulating a shift from S118 r 2011 Macmillan Publishers Ltd.5 This suggests a need for holistic and inter-sectoral approaches to support worse-off households. a reminder that the acceptability of health care is socially ingrained.17 and risks undoing this important financial protection for poor households and vulnerable groups.24 Understanding how frontline staff shape acceptability of health care is crucial. S1. different households cope differently with illness.13 Improved acceptability. especially for black Africans. including mobile services.25 Respectful treatment. However.12.8 Finally.25. while simultaneously addressing legitimate concerns about the quality of care on offer.1. and rural residents. 32. Provider respect engenders trusting patient-provider interactions. S102–S123 .26 Strengthening interventions to change organizational culture and management practices. attracts users to certain facilities.
1. for example. many prefer using the private sector.8 and resonating strongly with studies in other LMICs. Treasury and National Health Accounts. yet these pose substantial cost burdens. methodologically. S1.21. signaling the limited power of vulnerable social groups to ‘claim and use entitlements and opportunities’. This results in greater resources flowing to private facilities. triangulated from the Medical Schemes Council. efforts to revitalize PHC and district systems – which might enhance affordability and availability – need to consider acceptability.5. responses were restricted largely to curative care.11 Monthly premiums paid to medical schemes were not considered in our OOP calculations.8. thus worsening the public sector.1.27 where.1. but will not deal with other access barriers found in this survey.8 A financing-centered approach to National Health Insurance may reduce some of the affordability barriers. Future cohort and qualitative analyses might define the order of such events. Similarly. uninsured. the right to access health must be realized across society so that those who need care are able to access it regardless of who or where they are. S102–S123 S119 . and ‘height’ of access.28 Our findings concur with previous South African studies. or their ability to pay. rather than financing reform alone. temporal relationships cannot be established between variables within cross-sectional surveys.22 Undoing this status quo requires a comprehensive approach to UHC. confirming that poor. Limitations Poor recall might account for the total OOP payments in this survey being approximately $66 million below other recent estimates. whether intended users will actually r 2011 Macmillan Publishers Ltd.2.3. ‘depth’. black Africans. 0197-5897 Journal of Public Health Policy Vol. which considers the ‘breadth’. Indeed. Further. high OOP payments might account for present socio-economic status. Conclusion To achieve equitable UHC.Inequities in access to health care in South Africa private to public services. Although we enquired about preventative and related non-curative services. 32.7 These inequities mirror the South African context. given the choice. even if it incurs catastrophic payments. would diminish the adverse financial burdens incurred through private providers. and rural groups have inequitable access.
Centre for Health Policy. Acknowledgements For their highly valued contribution to the data collection. including Vanessa Daries. University of the Witwatersrand. The Community Agency for Social Enquiry collected the data. About the Authors Bronwyn Harris. and the London School of Hygiene and Tropical Medicine. Okore Okorafor. and patient–provider relationships in health systems. S102–S123 . 32. Johannesburg. Improving public sector service quality and perceptions thereof. Veloshnee Govender.Harris et al access these services. unhealthy realities that many continue to face. University of the Witwatersrand. Robert Moeti. Jane Goudge. School of Public Health. Natasha Palmer. For conceptual guidance. management and analysis. could reduce use of private providers and thus minimize financially catastrophic charges. equity. is Director of the Centre for Health Policy. She conducts research on access. These steps would create a closer ‘fit’ between the equity-seeking objectives of present policies and the inequitable. we would like to thank Duane Blaauw and Laetitia Rispel. Anne Mills. 0197-5897 Journal of Public Health Policy Vol. and comprehensive primary health care. S120 r 2011 Macmillan Publishers Ltd. and Olufunke Alaba. Adelaide Maja. S1. NDoH funded the survey through a European Union grant. we would like to thank our colleagues. is a researcher at the Centre for Health Policy. MA. Johannesburg researching access to health care. School of Public Health. PhD. Diane McIntyre is supported by the South African Research Chairs Initiative of the Department of Science and Technology and National Research Foundation. and creating equitable access to different levels of public care. University of Cape Town. South African National Department of Health (NDoH). University of the Witwatersrand. equitable financing. SACBIA survey was a collaborative initiative between Health Economics Unit.
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