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
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(=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.