In 2003, prior to the government scheme, insurance coverage among South African civil servants was 56% (35
). Our analysis shows that two years after the government scheme was initiated in 2006, 74.3% of civil servants were insured, and 41.9% of these belonged to the government scheme. Although evidence suggests that membership has increased, with 53.8% of civil servants enrolled in the government scheme in 2012 (27
), other studies on enrolment in health insurance schemes in Ecuador, Ghana, Mali, Senegal and Uganda, have found similar low levels of enrolment (36
The newly-insured group included those from population groups who commonly experience financial and other access barriers, such as younger employees, women, unmarried single people, black Africans, and those living in informal housing or with lower-incomes. Therefore, in contrast to private health insurance in the general population, where 71% of members are located in the richest 20% of the population (41
), the government scheme is comparatively pro-poor. Nevertheless, a considerable portion of socio-economically vulnerable groups remained uninsured (more than half of the lowest salary category for example), including men, black African or coloured race groups,7
less educated and lower-income employees, and those living in informal housing. This is despite membership for the lowest salary tier being fully subsidised.
Factors discouraging or deterring enrolment included affordability, the perceived administrative complexity of joining the scheme, and difficulties in obtaining information about the benefit options. Moreover, the comparatively poorer uptake of the government scheme in the more rural North West and KwaZulu-Natal provinces, may reflect underlying variations in geographical access to services (). Proximity of a primary care provider contracted with the scheme is likely an important factor influencing a potential member's decision to join the scheme. Transport costs have been shown to be an important barrier to accessing care in the South African setting (42
), and the distance to a scheme-contracted provider may increase problems of affordability. This was likely an important issue in some provinces at the time of the survey. As argued in a recent review of UC in Thailand, ‘Financing reform must go hand in hand with ensuring physical access to services.’ (7
, p. 17). In 2009, to improve access to primary health care services, the government scheme in South Africa expanded the network of primary healthcare service providers and geo-mapped members’ homes and workplaces against the provider in order to improve availability (43
). In 2010, the scheme reported reaching a target of having at least 90% of members within 10 km from the nearest network provider (43
). At a provincial level, this target was achieved in four of the country's nine provinces (Free State, Gauteng, KwaZulu-Natal and the Western Cape); in the rural North West province 84.8% of members were within 10 km of a registered provider. It will be important to document whether these changes have diminished the differentials between membership across provinces.
Affordability (or lack thereof) of member contributions was an important factor encouraging (or discouraging) enrolment in the government scheme. As Carrin et al. observe (44
, p. 803), ‘Affordability of premiums or contributions is often mentioned as one of the main determinants of membership.’ The South African Ministerial Task Team commissioned investigation of low-income medical schemes found that ‘… the fundamental obstacle to expanding coverage to low-income households in South Africa remains affordability’ (24
, p. 124). Several other studies have pointed to premiums being unaffordable as a factor discouraging demand for insurance in West Africa (45
), Kenya (46
) and India (47
). Of note, a similar scheme to that studied here was implemented in Botswana in 1990, with all government employees entitled to a 50% subsidy from the government for health insurance. Nearly 70,000 members had enrolled by 2010 (48
Preferences and expectations of the range of services and approved providers within benefit options can encourage (or deter) enrolment. Earlier research among households in South Africa indicated dissatisfaction and poor perceptions of public health services (10
), creating a preference for private health care, including primary and inpatient care. This might explain the relatively poor uptake of low-cost option 1, despite a full subsidy for those in the lower-salary categories. The ‘free’ low-cost option only provides members with access to basic outpatient services at pre-specified facilities and public hospitals, which may conflict with their strong preference for private primary and inpatient care. This might also explain the popularity across all salary categories of comprehensive option 4, which provides access to any private hospital.
The study identified perceptions and understandings of insurance, particularly among low-income employees, as a barrier to enrolment in the government scheme. These point to peoples’ underlying understandings of the potential role that insurance might play in either reducing or averting health care costs. This suggests a need for effective communication strategies to enhance knowledge about concepts of insurance to encourage enrolment in a health insurance scheme. The findings also suggest that older people (i.e. 60 years and older), whites, those in higher salary categories and tertiary education who probably have been with their current scheme for a long time may have ‘brand loyalty’ and consumer inertia, even if the new scheme offers better value for money due to the subsidy. Further research could more clearly define reasons and preferences for this.
Previous research exploring low enrolment in a community health insurance (CHI) scheme in Uganda identified ‘a mixed understanding on the basic principles of CHI and on the routine functioning of the schemes’, lack of information, affordability, poor quality of care, enrolment complexities and issues of trust as barriers to enrolment (38
, p. 172). Similarly, in Ghana, a household study of the National Health Insurance Scheme identified premiums, registration fees and administrative arrangements as key factors influencing enrolment and retention (49
). In Uganda (38
) and Tanzania (50
), lack of familiarity with community insurance schemes, particularly insurance principles of pooling and prepayments, contributed to low levels of enrolment. However, as Basaza et al. (38
, p. 182) caution, ‘… a good understanding of CHI principles, per se, will not directly translate into increased enrolment.’ Qualitative research can improve understanding of the ways in which quality of care, benefit options, contributions and information shape peoples’ knowledge and views of health insurance and their decision to enrol.
Being a cross-sectional survey of existing civil servants, the study was unable to examine the period prior to the government scheme (i.e. pre 1993 when enrolment in one of a few pre-determined schemes was mandatory for some employees, or the period 1993 to 2005, where employees were free to choose which scheme they joined). The cross-sectional design cannot examine the institutional context within which insurance for civil servants has operated, changes that occurred in the scheme and how these may impact on participation. The ability to draw conclusions is also limited by the timing of the survey, which was only about three years after introduction of the scheme. The frequent changes made to the scheme in the period preceding this study and thereafter, restrict our ability to compare the study findings with outcomes of schemes in other countries or contexts. Also, it is possible that factors influencing enrolment in the long-run vary from those described here in the relatively early stages of the scheme. Moreover, data on the influence of perceptions and experiences of public health services on the decision to join the government medical scheme was not collected.