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


OBJECTIVE
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.


CONCLUSIONS
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 Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa. veloshnee.govender@uct.ac.za
Veloshnee
V
Govender
Matthew F
MF
Chersich
Bronwyn
B
Harris
Olufunke
O
Alaba
John E
JE
Ataguba
Nonhlanhla
N
Nxumalo
Jane
J
Goudge
D000328:Adult; D000367:Age Factors; D003625:Data Collection; D004522:Educational Status; D005260:Female; D006078:Government Programs / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D007182:Income; D007348:Insurance, Health / Q000458:organization & administration* / Q000706:statistics & numerical data; D007407:Interviews as Topic; D016015:Logistic Models; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D012737:Sex Factors; D013019:South Africa; D019472:Universal Health Insurance / Q000458:organization & administration* / Q000706:statistics & numerical data; D035141:Voluntary Programs
South Africa; civil servants; health insurance; health-finance reforms; universal coverage