Socio-economic inequalities in the multiple dimensions of access to healthcare: the case of South Africa.

BACKGROUND: The National Development Plan (NDP) strives that South Africa, by 2030, in pursuit of Universal Health Coverage (UHC) achieve a significant shift in the equity of health services provision. This paper provides a diagnosis of the extent of socio-economic inequalities in health and healthcare using an integrated conceptual framework. METHOD: The 2012 South African National Health and Nutrition Examination Survey (SANHANES-1), a nationally representative study, collected data on a variety of questions related to health and healthcare. A range of concentration indices were calculated for health and healthcare outcomes that fit the various dimensions on the pathway of access. A decomposition analysis was employed to determine how downstream need and access barriers contribute to upstream inequality in healthcare utilisation. RESULTS: In terms of healthcare need, good and ill health are concentrated among the socio-economically advantaged and disadvantaged, respectively. The relatively wealthy perceived a greater desire for care than the relatively poor. However, postponement of care seeking and unmet need is concentrated among the socio-economically disadvantaged, as are difficulties with the affordability of healthcare. The socio-economic divide in the utilisation of public and private healthcare services remains stark. Those who are economically disadvantaged are less satisfied with healthcare services. Affordability and ability to pay are the main drivers of inequalities in healthcare utilisation. CONCLUSION: In the South African health system, the socio-economically disadvantaged are discriminated against across the continuum of access. NHI offers a means to enhance ability to pay and to address affordability, while disparities between actual and perceived need warrants investment in health literacy outreach programmes.

Trends and socio-economic inequality in public perceptions of healthcare delivery in South Africa.

OBJECTIVE: To assess trends and inequality in public perceptions of healthcare delivery as reported by South African households. DESIGN: Secondary data analysis of the South African Social Attitudes Survey (SASAS). SETTING: Nationally representative weighted sample of South African households. PARTICIPANTS: 28 326 household representatives interviewed during the annual SASAS survey (2007-16). MAIN OUTCOME MEASURES: Adequacy of healthcare services and satisfaction with healthcare delivery. RESULTS: On aggregate, 68.2% only of households reported their healthcare needs as being adequately met, while only 54.3% were satisfied with healthcare delivery. In total, only 41.5% of households was both satisfied with healthcare delivery and adequately provided for in terms of the household's healthcare needs. Adequacy of healthcare provision and satisfaction therewith has however improved rapidly since 2009-10, but overall satisfaction with healthcare delivery has not changed considerably. Public perceptions of healthcare delivery improved with household wealth. Socio-economic inequality in adequacy and satisfaction is pronounced and pro-rich, but inequality in satisfaction has declined significantly since 2009-10. CONCLUSIONS: Although public perceptions of healthcare delivery improved, many poor South Africans' healthcare needs are still not adequately met. In addition, many South Africans are not satisfied with government's efforts at healthcare delivery, especially the poor. Further research is required to pinpoint how expectations impact on public perceptions of healthcare delivery and to identify the specific factors that underlie the public opinions expressed in surveys of this nature.