Assessing changes in the social determinants of health and health inequality

Abstract

This thesis broadly investigates the relative changes in socio-economic related health inequalities over the second decade of post-apartheid South Africa. This period is characterised by di erent policies and reforms, aimed at reducing socio-economic inequalities that pervaded all aspects of life before 1994. By extension, these policies and reforms have also been applied to the health care system. Speci cally, policy interventions such as scal redistribution directed at key sectors, abolition of user fees for primary health care, and the ongoing discussions related to universal health coverage through yet-to-be-implemented national health insurance have targeted reductions in socio-economic related health inequality. However, evidence from the academic and policy-oriented literature suggests that not much has changed. Health inequality which is strongly linked to inequalities in its social determinants, persist, despite notable policies targeting socio-economic factors. Moreover, existing literature has not identi ed drivers of change, and, therefore, presents a narrow perspective of health inequality. Hence, it is important to analyse changes in social determinants of health and health inequality over the current post-apartheid period. This thesis uses data from the nationally representative General Household Surveys (GHS), which started in 2002. After scrutinising the data for consistency and comparability across the years, the thesis pro les trends in health outcomes across a spectrum of socio-demographic factors, using the GHS data covering the years 2004 - 2014. The health variables considered are ill-health status, medical aid coverage, and preference for public or private health care. As there are few obvious patterns in the raw health variables' time series, the analysis, which is descriptive in nature, relies upon both parametric and non-parametric techniques to smooth the time series in order to outline a few general trends. It is found that medical aid coverage and the general population's preference for public health care decreased by 0.2% and 0.1%, per year, respectively, while reports of ill-health status increased by 0.4%, annually. Moreover, the probability that an individual, who is covered by a medical aid scheme, would utilize public health care decreased by about 44%. Having established changes in the health indicators, the thesis further explores some key socio-economic drivers of these changes. Speci cally, the thesis uses information collected on social determinants of health (SDH), and a variety of health indicators in the 2004 and 2014 GHS data, to explain how changes in the SDH have impacted health inequalities over that decade. Using the Oaxaca-Blinder decomposition of change in a concentration index, the thesis nds that rising inequalities in ill-health are largely explained by changes in the composition of those residing in urban areas and in relatively richer provinces. Meanwhile, rising inequality in medical aid coverage and the utilisation of private health care are attributable to changes in educational attainment and racial composition. On the other hand, changing elasticities in SDH, rather than increasing inequalities, are found to explain a widening preference for private health care in the event of illness. Finally, the thesis investigates socio-economic factors driving health inequality at a fairly disaggregated level, by examining the relative contributions of SDH to changes in gendered health di erentials between 2005 and 2014. Using di erences-in-decompositions, the thesis nds that the gender gap in health narrowed by approximately 2% between 2005 and 2014, and the narrowing of that gap can be attributed to changes in educational attainment and social grant receipt. Speci cally, the relative increase in social grant receipt by females explains approximately 28% of the reduction, while the relative increase in the receipt of formal education by females explains about 1.11%.