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Healthcare Reform Priorities for South Africa: Four Essays on the Financing, Delivery and User Acceptability of Healthcare by Anna Maria Smith

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Healthcare Reform Priorities for South Africa: Four Essays on the Financing, Delivery and User Acceptability of Healthcare by Anna Maria Smith Healthcare reform priorities for South Africa: four essays on the financing, delivery and user acceptability of healthcare by Anna Maria Smith Dissertation presented for the degree of Doctor of Philosophy in Economics in the Faculty of Economic and Management Sciences at Stellenbosch University Department of Economics Stellenbosch University Private Bag X1, Matieland 7602 South Africa Supervisor: Professor Ronelle Burger Co-supervisor: Professor Servaas van der Berg March 2016 Declaration By submitting this dissertation electronically, I declare that the entirety of the work contained therein is my own, original work, that I am the sole author thereof (save to the extent explicitly otherwise stated), that reproduction and publication thereof by Stellenbosch University will not infringe any third party rights and that I have not previously in its entirety or in part submitted it for obtaining any qualification. This dissertation includes one publication (Chapter 4). The development and writing of this paper was the principal responsibility of myself and a declaration is included in the dissertation indicating the nature and extent of the contributions of co-authors. The publication of the paper will not infringe upon my right to use the paper in this dissertation or to publish the completed dissertation via Stellenbosch University’s SunScholar portal. The article has been reprinted in the dissertation with the permission of the International Union Against Tuberculosis and Lung Disease (Copyright © The Union). The publication is listed in full below: Chapter 4: Smith, A., Burger, R., Claassens, M., Ayles, H., Godfrey-Fausset, P. and Beyers, N. 2016. Health care workers’ gender bias in testing could contribute to missed tuberculosis cases in South Africa. International Journal of Tuberculosis and Lung Disease. 20(3):350–356. http://dx.doi.org/10.5588/ijtld.15.0312http://dx.doi.org/10.5588/ijtld.15.0312 Copyright ©2016 University of Stellenbosch All rights reserved i Declarations with respect to co-authoring: With regard to Chapter 3, the nature and scope of my contribution were as follows: Nature of contribution Extent of contribution Helped formulate research question, literature 35% review, positioning and description of industry context, first attempt at data estimation The following co-author(s) have contributed to Chapter 3: Name Email address Nature of contribution Extent of contribution Rulof Burger [email protected] Data estimation and 65% empirical analysis, drafting of data and results sections Signature of candidate: Date: 24 September 2015 Declaration by co-authors: The undersigned hereby confirm that: 1. the declaration above accurately reflects the nature and extent of the contributions of the candidate and the co-authors to Chapter 3, 2. no other authors contributed to Chapter 3 besides those specified above, and 3. potential conflicts of interest have been revealed to all interested parties and that the necessary arrangements have been made to use the material in Chapter 3 of this dissertation. Signature of co-author(s): ______________________ Date: 24 September 2015 ii With regard to Chapter 4, the nature and scope of my contribution were as follows: Nature of contribution Extent of contribution Detailed data analysis, wrote first draft, 65% incorporated all comments received on first and later drafts, expanded version of paper submitted for publication into PhD chapter through a more detailed literature review The following co-author(s) have contributed to Chapter 4: Name Email address Nature of contribution Extent of contribution Ronelle Burger [email protected] First attempt at identifying 10% gender patterns in health seeking cascade using dataset, edited and commented on drafts Mareli Mischa [email protected] Edited and commented on 7.5% Claassens drafts Helen Ayles [email protected] Edited and commented on 5% drafts Peter Godfrey- [email protected] Edited and commented on 5% Fausset drafts Nulda Beyers [email protected] Edited and commented on 7.5% drafts, provided guidance on data analysis and larger TB context Signature of candidate: Date: 24 September 2015 Declaration by co-authors: The undersigned hereby confirm that: 1. the declaration above accurately reflects the nature and extent of the contributions of the candidate and the co-authors to Chapter 4, iii above, and 2. no other authors contributed to Chapter 4 besides those specified parties and that the necessary 3. potentialconflicts of interest have been revealed to all interested arrangements have been made to use the material in Chapter 4 of this dissertation. Signature of co-author(s) : Date:24 SePtember 2015 IV With regard to Chapter 5, the nature and scope of my contribution were as follows: Nature of contribution Extent of contribution Amended questionnaire/instrument used for 90% data collection, managed data collection process, quality control of collected data, data analysis, wrote first draft of chapter, incorporated all edits and comments on various drafts of chapter The following co-author(s) have contributed to Chapter 5: Name Email address Nature of contribution Extent of contribution Vivian Black [email protected] Developed first version 10% of questionnaire used for data collection for chapter, provided edits and comments on drafts Signature of candidate: Date: 24 September 2015 Declaration by co-authors: The undersigned hereby confirm that: 1. the declaration above accurately reflects the nature and extent of the contributions of the candidate and the co-authors to Chapter 5, 2. no other authors contributed to Chapter 5 besides those specified above, and 3. potential conflicts of interest have been revealed to all interested parties and that the necessary arrangements have been made to use the material in Chapter 5 of this dissertation. v Signature of co-author(s): ______________________ Date: 24 September 2015 vi Abstract Despite expenditure levels on healthcare comparable to those of its upper-middle-income country 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 vii (≥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 demand- side 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. viii Opsomming Ten spyte van gesondheidsbestedingsvlakke wat vergelykbaar is met dié van ander hoër-middel- inkomste 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.
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