Elsevier

Health Policy

Volume 109, Issue 3, March 2013, Pages 321-331
Health Policy

South African health financing reform 2000–2010: Understanding the agenda-setting process

https://doi.org/10.1016/j.healthpol.2012.12.012Get rights and content

Abstract

Governments around the world are struggling to address persistent disparities in health care access. However, this priority competes with many others for support in moving onto and up the political agenda. In this paper, a novel method of agenda-setting analysis is developed by merging and modifying the Hall and Kingdon models. As a case study, this method is used to explore how health financing reform reached the policy agenda in South Africa between the years 2000 and 2010. Certain factors are identified that could have determined the agenda-setting process: a change in government, increase in the cost of private medical schemes, and increase in support for reform from various stakeholders. Further analysis, using a conceptual framework of interacting trends and shocks, identifies the growing middle class, the private sector, and workers unions as powerful actors and outlines further factors that may have contributed to the process: a broad political shift in the second half of the decade and the changing prioritisation of HIV/AIDS. Study findings have relevance to academics and policy makers in South Africa and beyond.

Introduction

As the deepening financial crisis and persistent economic recession continues to shape public policy globally [26], within-country health inequities are growing [49]. However, there appears to be little literature exploring how health finance agendas are shaped, and priorities emerge, especially outside the US [9]. This article uses health finance reform in South Africa as a case study to test a novel method that explores the agenda-setting process.

South Africa is an upper-middle income country (MIC) at the tip of Sub-Saharan Africa. Home to an ethnically diverse population, the country has eleven official languages and an equally diverse portfolio of economic activity – ranging from agriculture to mining, manufacturing and tourism among others. The ruling African National Congress party has been in power since 1994, however challenges remain, especially in health and health care. South Africa is currently facing a quadruple burden of disease [50]: high HIV/AIDS prevalence; rising non-communicable disease; diseases of poverty and the highest global rates of violence and injuries [17], [69], [70], [76]. Health inequality in South Africa is among the worst in the world [5], the country has a gini coefficient of 63.1 (2009) [86]. 17 Years after the end of apartheid, there are still very significant differences in health between black and white communities, as well as substantial inequalities between the populations of richer and poorer provinces, urban and rural populations and urban middle class and informal settlement dwellers [17].

South Africa currently has a two-tiered healthcare system, with personnel and financing disproportionately concentrated in a private sector that serves a wealthy urban minority, whilst the public sector serving the majority is under-resourced. 16% Of the population has private medical insurance coverage, with a further 16% using private primary health care on an out-of-pocket basis while depending on public hospitals for tertiary care. Within the private insurance sector, fragmentation reduces risk-pooling and income cross-subsidisation [4]. 68% Of the population is fully dependent on public sector healthcare. In 2008, out of a total of 8.5% of gross domestic product (GDP) spent on health [89], ZAR 10,000 (approximately $1253) per capita was spent in the private sector while ZAR 1,900 (approximately $238) was spent in the public sector [4]. Human resources in the healthcare system are also biased towards the wealthy; 79% of doctors work in the private sector [17]. This is not a significant improvement from the healthcare inequalities the apartheid regime left behind, more than 18 years ago [69]. Though the public sector is theoretically open to all, perceived lack of quality means that many of those who can afford private insurance do not use the public system [54].

While there is broad academic consensus in South Africa that comprehensive reform of the health care sector must take place to address persistent health inequalities, comprehensive health financing reform has only recently reached the government's agenda. This paper aims to explore the agenda-setting process, in order to understand why it has recently become a priority.

Section snippets

Methodology

For the purposes of this paper the policy agenda is defined as “[a] list of issues to which an organisation is giving serious attention at any one time with a view to taking some sort of action” ([16]: p. 63). The analysis is split into three parts. The first identifies the time period to be analysed and shows that reform has reached the government's agenda. The second describes the agenda-setting process using a modified form of the Hall model that adopts the temporal dimension of the Kingdon

Findings

This section first identifies when health finance reform reached the political agenda in South Africa using findings from the literature search described above. The time period for subsequent analysis is thus defined. Second, using the modified Hall model, a primary analysis of the factors that contributed to the agenda-setting process is conducted. Finally, a deeper analysis is performed using a model of trends and shocks interacting in a causal web.

Discussion

The above three-part analysis has revealed a complex agenda-setting process involving various factors and multiple stakeholders. Results of this multifaceted approach are best summarised in Fig. 2. They suggest that an appreciation of the position of certain powerful actors – the growing middle class, the private sector and unions – as well as broader changes in public discourse are of importance in understanding this agenda-setting process.

South Africa is an interesting case study as it shares

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