Moving towards universal coverage in South Africa? Lessons from a voluntary government insurance scheme

Abstract

Background : In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues.

Objectives : This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment.

Methods : Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression.

Results : Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs.

Conclusion : Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.

• health insurance
• civil servants
• health-finance reforms
• universal coverage
• South Africa

Acknowledgements

We would like to thank Diane McIntyre for reviewing earlier drafts of this paper, in addition to two anonymous reviewers. We thank our SHIELD colleagues whose work contributed to this paper.

Notes

¹The lowest cost benefit option is fully subsidised for those in the two lowest salary categories; for the other four benefit options, the government pays 75% of the employee's total monthly contribution, subject to an upper-limit.

²Employees appointed prior to 2006 still received a subsidy for membership of any insurance scheme.

³Retired civil servants were not included in the study sample. This population was initially excluded from participation in the government scheme, but later included.

⁴As brokers could not make any financial gains from enrolling civil servants in the government scheme, we considered them unlikely to have any role or influence on the decision to enrol. Hence they were not considered in this study.

⁵1US$=7.5 South African Rand.

⁶Networks refer to designated health-care providers contracted through the government scheme to provide services to members.

⁷In this paper, racial categories structured through apartheid are used in recognition that race remains an important social and economic fault line in the post-apartheid context.