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International Journal for Equity in Health
Published in: International Journal for Equity in Health 1/2018

Open Access 01-12-2018 | Research

Assessing changes in social determinants of health inequalities in South Africa : a decomposition analysis

Authors: Kehinde O. Omotoso, Steven F. Koch

Published in: International Journal for Equity in Health | Issue 1/2018

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Abstract

Background

Despite various policy interventions that have targeted reductions in socio-economic inequalities in health and health care in post-Apartheid South Africa, evidence suggests that not much has really changed. In particular, health inequalities, which are strongly linked to social determinants of health (SDH), persist. This study, thus, examines how changes in the SDH have impacted health inequalities over the last decade, the second since the end of Apartheid.

Methods

Data come from information collected on social determinants of health (SDH) and on health status in the 2004, 2010 and 2014 questionnaires of the South African General Household Surveys (GHSs). The health indicators considered include ill-health status and disability. Concentration indices and Oaxaca-Blinder decomposition of change in a concentration index methods were employed to unravel changes in socio-economic health inequalities and their key social drivers over the studied time period.

Results

The results show that inequalities in ill-health are consistently explained by socio-economic inequalities relating to employment status and provincial differences, which narrowed considerably over the studied periods. Relatedly, disability inequalities are largely explained by shrinking socio-economic inequalities relating to racial groups, educational attainment and provincial differences.

Conclusion

The extent of employment, location and education inequalities suggests the need for improved health care management and further delivery of education and job opportunities; greater effort in this regard is likely to be more beneficial in some way.
Footnotes
1
Several articles have validated the use of wealth indices against external criteria. They conclude that they are good proxies for income differences [95‐98]. A detailed description of the construction of the wealth index is contained in “Appendix A” section.
 
2
Factor analysis (FA) is a multivariate statistical technique used to reduce the number of variables in a data set into a smaller number of ’dimensions’ [99, 100].
 
Literature
1.
2.
Arcaya MC, Arcaya AL, Subramanian S. Inequalities in health: Definitions, concepts, and theories. Glob Health Action. 2015; 8(1):27106.PubMedCrossRef
3.
Graham H, Kelly MP. Health inequalities: concepts, frameworks and policy. In: Health Development Agency (HDA) Briefing Paper: 2004.
4.
Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: A conceptual framework. Am J Public Health. 2006; 96(12):2113–21.PubMedPubMedCentralCrossRef
5.
Balaj M, McNamara CL, Eikemo TA, Bambra C. The social determinants of inequalities in self-reported health in Europe: Findings from the European social survey (2014) special module on the social determinants of health. Eur J Public Health. 2017; 27(1):107–14.PubMedCrossRef
6.
Devaux M. Income-related inequalities and inequities in health care services utilisation in 18 selected OECD countries. Eur J Health Econ. 2015; 16(1):21–33.PubMedCrossRef
7.
Hu Y, van Lenthe FJ, Borsboom GJ, Looman CW, Bopp M, Burström B, Dzúrová D, Ekholm O, Klumbiene J, Lahelma E, et al. Trends in socioeconomic inequalities in self-assessed health in 17 European countries between 1990 and 2010. J Epidemiol Community Health. 2016; 70(7):644–52.PubMedCrossRef
8.
Owusu-Addo E, Renzaho AM, Smith BJ. The impact of cash transfers on social determinants of health and health inequalities in sub-Saharan Africa: A systematic review. Health Policy Plan. 2018; 33(5):675–96.PubMedPubMedCentralCrossRef
9.
Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Technical report. Geneva: Geneva: World Health Organization; 2008.
10.
11.
Commission on Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008.
12.
Marmot M, on Social Determinants of Health C, et al. Achieving health equity: From root causes to fair outcomes. Lancet. 2007; 370(9593):1153–63.PubMedCrossRef
13.
Wagstaff A. Research on equity, poverty and health outcomes: Lessons for the developing World. Washington, DC: World Bank; 2000.
14.
Hakura MDS, Hussain MM, Newiak MM, Thakoor V, Yang MF. Inequality, Gender Gaps and Economic Growth: Comparative Evidence for Sub-Saharan Africa. In: International Monetary Fund Working Paper, No 16/111: 2016.
15.
Orach D, Garimoi C. Health equity: Challenges in low income countries. Afr Health Sci. 2009; 9(2):49–51.
16.
Braveman P, Tarimo E. Social inequalities in health within countries: Not only an issue for affluent nations. Soc Sci Med. 2002; 54(11):1621–35.PubMedCrossRef
17.
18.
Kabudula CW, Houle B, Collinson MA, Kahn K, Gómez-Olivé FX, Tollman S, Clark SJ. Socioeconomic differences in mortality in the antiretroviral therapy era in Agincourt, rural South Africa, 2001–13: A population surveillance analysis. Lancet Glob Health. 2017; 5(9):924–35.CrossRef
19.
Adeyanju O, Tubeuf S, Ensor T. Socio-economic inequalities in access to maternal and child healthcare in Nigeria: Changes over time and decomposition analysis. Health Policy Plan. 2017; 32(8):1111–8.PubMedCrossRef
20.
Republic of South Africa Department of Health. National health insurance in South Africa: Policy paper. Pretoria: Republic of South Africa Department of Health; 2011.
21.
Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The health and health system of South Africa: Historical roots of current public health challenges. Lancet. 2009; 374(9692):817–34.PubMedCrossRef
22.
African National Congress. A national health plan for South Africa. Johannesburg South Africa: Government Printer; 1994.
23.
Chopra M, Lawn JE, Sanders D, Barron P, Karim SSA, Bradshaw D, Jewkes R, Karim QA, Flisher AJ, Mayosi BM, et al. Achieving the health Millennium Development Goals for South Africa: Challenges and priorities. Lancet. 2009; 374(9694):1023–31.PubMedCrossRef
24.
Dhai A. Healthcare reform in South Africa: A step in the direction of social justice: editorial. S Afr J Bioeth Law. 2011; 4(2):48–9.
25.
Ruff B, Mzimba M, Hendrie S, Broomberg J. Reflections on health-care reforms in South Africa. J Public Health Policy. 2011; 32(1):184–92.CrossRef
26.
Govender V, Penn-Kekana L. Gender biases and discrimination: A review of health care interpersonal interactions. Glob Public Health. 2008; 3(1):90–103.PubMedCrossRef
27.
Harrison D. An overview of health and health care in South Africa 1994–2010: Priorities, progress and prospects for new gains; 2009. Washington, DC: Henry J Kaiser Family Foundation; 2012.
28.
Van den Heever AM. South Africa’s universal health coverage reforms in the post-apartheid period. Health Policy. 2016; 120(12):1420–8.PubMedCrossRef
29.
Mayosi BM, Lawn JE, Van Niekerk A, Bradshaw D, Karim SSA, Coovadia HM, team LSA, et al. Health in South Africa: changes and challenges since 2009. Lancet. 2012; 380(9858):2029–43.PubMedCrossRef
30.
Kleinert S, Horton R. South Africa’s health: Departing for a better future?Lancet. 2009; 374(9692):759–60.PubMedCrossRef
31.
Motsoaledi A. Progress and changes in the South African health sector. Lancet. 2012; 380(9858):1969–70.PubMedCrossRef
32.
Young M.Private vs. Public Healthcare in South Africa. Kalamazoo: Western Michigan University, ScholarWorks at Western Michigan University (WMU); 2016.
33.
Booysen F. Urban–rural inequalities in health care delivery in South Africa. Dev South Afr. 2003; 20(5):659–73.CrossRef
34.
South Africa Constitution. Constitution of the Republic of South Africa Act, No. 108 of 1996. South Africa, Pretoria: Government printer; 1996.
35.
36.
Republic of South Africa Department of Health. National health insurance for South Africa: Towards universal health coverage. Pretoria, South Africa: Republic of South Africa Department of Health; 2015.
37.
Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. Lancet. 2009; 374(9693):934–47.PubMedCrossRef
38.
Bhorat H, Van der Westhuizen C. Poverty, inequality and the nature of economic growth in South Africa. Testing democracy: Which way is South Africa going. 2010.
39.
Meiring T, Kannemeyer C, Potgieter E. The gap between rich and poor: South African society’s biggest divide depends on where you think you fit in. Southern Africa Labour and Development Research Unit (SALDRU) Working Paper Series 220(1) 1-31, University of Cape Town. 2018.
40.
World Bank. Overcoming Poverty and Inequality in South Africa: An Assessment of Drivers, Constraints and Opportunities. Washington DC: World Bank Publications, The World Bank Group; 2018.CrossRef
41.
Naledi T, Barron P, Schneider H. Primary health care in South Africa since 1994 and implications of the new vision for PHC re-engineering. South Africa: Health Systems Trust (HST); 2011.
42.
Mayosi BM, Benatar SR. Health and health care in South Africa—20 years after mandela. N Engl J Med. 2014; 371(14):1344–53.PubMedCrossRef
43.
Harrison D. An overview of health and health care in South Africa 1994–2010: Priorities, progress and prospects for new gains. Discussion Document Commissioned by the Henry J. Kaiser Family Foundation to help inform the National Health Leaders’ Retreat Muldersdrift, January 24-26 2010. Washington, DC: Henry J Kaiser Family Foundation; 2009.
44.
45.
Booysen S. Twenty years of South African democracy: Citizen views of human rights, governance and the political system. Washington DC; 2014.
46.
Gilson L, McIntyre D. Post-Apartheid challenges: Household access and use of health care in South Africa. Int J Health Serv. 2007; 37(4):673–91.PubMedCrossRef
47.
Honda A, Ryan M, van Niekerk R, McIntyre D. Improving the public health sector in South Africa: Eliciting public preferences using a discrete choice experiment. Health Policy Plan. 2015; 30(5):600–11.PubMedCrossRef
48.
49.
Christian CS. Access in the South African public health system: Factors that influenced access to health care in the South African public sector during the last decade. South Africa: Master dissertation, Department of Economics, University of Western Cape; 2014.
50.
Ataguba JE, Akazili J, McIntyre D. Socioeconomic-related health inequality in South Africa: Evidence from General Household Surveys. Int J Equity Health. 2011; 10(48):1–10.
51.
52.
Bradshaw D, Masiteng K, Nannan N. Health status and determinants. S Afr Health Rev. 2000; 2000(1):89–124.
53.
Bradshaw D. Determinants of health and their trends: Primary health care: in context. S Afr Health Rev. 2008; 2008(1):51–69.
54.
Harris B, Goudge J, Ataguba JE, McIntyre D, Nxumalo N, Jikwana S, Chersich M. Inequities in access to health care in South Africa. J Public Health Policy. 2011; 32(1):102–23.CrossRef
55.
Alaba O, Chola L. Socioeconomic inequalities in adult obesity prevalence in South Africa: A decomposition analysis. Int J Environ Res Public Health. 2014; 11(3):3387–406.PubMedPubMedCentralCrossRef
56.
Silal SP, Penn-Kekana L, Bärnighausen T, Schneider H. Local level inequalities in the use of hospital-based maternal delivery in rural South Africa. Glob Health. 2014; 1(10):1–7.
57.
Charasse-Pouélé C, Fournier M. Health disparities between racial groups in South Africa: A decomposition analysis. Soc Sci Med. 2006; 62(11):2897–914.PubMedCrossRef
58.
Obuaku-Igwe CC. Health inequality in South Africa: A systematic review. Afr Sociol Rev / Revue Africaine de Sociologie. 2015; 19(2):96–131.
59.
Oaxaca R. Male-female wage differentials in urban labor markets. Int Econ Rev. 1973; 14(3):693–709.CrossRef
60.
Wagstaff A, Van Doorslaer E, Watanabe N. On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam. J Econ. 2003; 112(1):207–23.CrossRef
61.
Statistics South Africa. General Household Survey 2004 [Statistical Release P0318 2005]. Pretoria: Statistics South Africa [producer], 2005. Pretoria: South African Data Archive, National Research Foundation [distributor], 2005. 2004.
62.
Statistics South Africa. General Household Survey 2010 [Statistical Release P0318 2011]. Pretoria: Statistics South Africa [producer], 2011. Pretoria: South African Data Archive, National Research Foundation [distributor], 2011. 2010.
63.
Statistics South Africa. General Household Survey 2014 [Statistical Release P0318 2015]. Pretoria: Statistics South Africa [producer], 2015. Pretoria: South African Data Archive, National Research Foundation [distributor], 2015. 2014.
64.
Pillay-van Wyk V, Bradshaw D. Mortality and socioeconomic status: The vicious cycle between poverty and ill health. Lancet Glob Health. 2017; 5(9):851–2.CrossRef
65.
Burgard SA, Treiman DJ. Trends and racial differences in infant mortality in South Africa. Soc Sci Med. 2006; 62(5):1126–37.PubMedCrossRef
66.
Schiel R, Leibbrandt M, Lam D. Assessing the impact of social grants on inequality: A South African case study In: Besley T, editor. Contemporary Issues in Development Economics. Chap. 8. Palgrave Macmillan, London: Springer: 2016. p. 112–35.
67.
Patel L. Poverty, gender and social protection: Child support grants in Soweto, South Africa. J Policy Pract. 2012; 11(1–2):106–20.CrossRef
68.
Wittenberg M, Leibbrandt M. Measuring inequality by asset indices: A general approach with application to South Africa. Rev Income Wealth. 2017; 63(4):706–30.CrossRef
69.
Wagstaff A, Paci P, Van Doorslaer E. On the measurement of inequalities in health. Soc Sci Med. 1991; 33(5):545–57.PubMedCrossRef
70.
Kakwani N, Wagstaff A, Van Doorslaer E. Socioeconomic inequalities in health: Measurement, computation, and statistical inference. J Econ. 1997; 77(1):87–103.CrossRef
71.
72.
Mackenbach JP, Kunst AE. Measuring the magnitude of socio-economic inequalities in health: An overview of available measures illustrated with two examples from Europe. Soc Sci Med. 1997; 44(6):757–71.PubMedCrossRef
73.
Mackenbach JP, Stirbu I, Roskam A-JR, Schaap MM, Menvielle G, Leinsalu M, Kunst AE. Socioeconomic inequalities in health in 22 European countries. N Engl J Med. 2008; 358(23):2468–81.CrossRef
74.
O’Donnell OA, Wagstaff A, et al. Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation. Washington DC: World Bank Publications; 2008.
75.
Solmi F, Von Wagner C, Kobayashi LC, Raine R, Wardle J, Morris S. Decomposing socio-economic inequality in colorectal cancer screening uptake in England. Soc Sci Med. 2015; 134(7):76–86.PubMedCrossRef
76.
Wagstaff A. The bounds of the concentration index when the variable of interest is binary, with an application to immunization inequality. Health Econ. 2005; 14(4):429–32.PubMedCrossRef
77.
StataCorp. Stata Statistical Software: Release 14. Texas: College Station, TX StataCorp LP; 2015.
78.
Marmot M, Friel S, Bell R, Houweling T, Taylor S. Closing the gap in a generation: Health equity through action on the social determinants of health. Lancet. 2008; 372(9650):1661–9.PubMedCrossRef
79.
Ogura S, Jakovljevic M. Health Financing Constrained by Population Aging- An Opportunity to Learn from Japanese Experience/Finansiranje Zdravstvene Zaštite U Uslovima Starenja Popualcije-Prilika Da Učimo Na Japanskom Iskustvu. Serbian J Exp Clin Res. 2014; 15(4):175–81.CrossRef
80.
Jakovljevic M, Getzen TE. Growth of global health spending share in low and middle income countries. Front Pharmacol. 2016;7(21).
81.
Reading CL, Wien F. Health inequalities and the social determinants of Aboriginal peoples’ health. Prince George, BC: National Collaborating Centre for Aboriginal Health; 2009.
82.
Van Doorslaer Ev, Koolman X. Explaining the differences in income-related health inequalities across European countries. Health Econ. 2004; 13(7):609–28.PubMedCrossRef
83.
Reus-Pons M, Kibele EU, Janssen F. Differences in healthy life expectancy between older migrants and non-migrants in three European countries over time. Int J Public Health. 2017; 62(5):531–40.PubMedPubMedCentralCrossRef
84.
Hajizadeh M, Mitnitski A, Rockwood K. Socioeconomic gradient in health in Canada: Is the gap widening or narrowing?. Health Policy. 2016; 120(9):1040–50.PubMedCrossRef
85.
Großschädl F, Stronegger WJ. Long-term trends in obesity among Austrian adults and its relation with the social gradient: 1973–2007. Eur J Public Health. 2013; 23(2):306–12.PubMedCrossRef
86.
Cockerham W, Hamby B, Oates G. The social determinants of chronic disease. Am J Prev Med. 2017; 52(1):5–12.CrossRef
87.
Adler NE, Glymour MM, Fielding J. Addressing social determinants of health and health inequalities. J Am Med Assoc. 2016; 316(16):1641–2.CrossRef
88.
Novaković R, Cavelaars A, Geelen A, Nikolić M, Altaba II, Vinas BR, Ngo J, Golsorkhi M, Medina MW, Brzozowska A, et al. Socio-economic determinants of micronutrient intake and status in Europe: A systematic review. Public Health Nutr. 2014; 17(5):1031–45.PubMedCrossRef
89.
Chapman K. Using social transfers to scale up equitable access to education and health services. London; 2006.
90.
Goldblatt B. Gender and social assistance in the first decade of democracy: A case study of South Africa’s Child Support Grant. Politikon: S Afr J Political Stud. 2005; 32(2):239–57.CrossRef
91.
Taylor Commission, et al.Report of the Committee of Inquiry into a Comprehensive System of Social Security for South Africa. Pretoria: Department of Social Development; 2002.
92.
Guglielmin M, Muntaner C, O’Campo P, Shankardass K. A Scoping Review of the Implementation of Health in All Policies at the Local Level: Elsevier; 2018.
93.
Shankardass K, Solar O, Murphy K, Greaves L, O’Campo P. A scoping review of intersectoral action for health equity involving governments. Int J Public Health. 2012; 57(1):25–33.PubMedCrossRef
94.
Braveman P, Egerter S, Williams DR. The social determinants of health: Coming of age. Annu Rev Public Health. 2011; 32:381–98.PubMedCrossRef
95.
Filmer D, Pritchett L. Estimating Wealth Effects without Expenditure Data–or Tears: An Application to Educational Enrollments in States of India. In: Policy Research Working Papers No. 1994: 1998.
96.
97.
Wittenberg M. Weighing the value of asset proxies: The case of the Body Mass Index in South Africa. Southern Africa Labour and Development Research Unit (SALDRU) Working paper 39, University of Cape Town. 2009.
98.
Wittenberg M. Estimating expenditure impacts without expenditure data using asset proxies. Econ Lett. 2011; 110(2):122–5.CrossRef
99.
Vyas S, Kumaranayake L. Constructing socio-economic status indices: How to use principal components analysis. Health Policy Plan. 2006; 21(6):459–68.PubMedCrossRef
100.
Wittenberg M, Leibbrandt M. Measuring inequality by asset indices: A general approach with application to South Africa. Rev Income Wealth. 2017; 63(4):706–30.CrossRef
Metadata
Title
Assessing changes in social determinants of health inequalities in South Africa : a decomposition analysis
Authors
Kehinde O. Omotoso
Steven F. Koch
Publication date
01-12-2018
Publisher
BioMed Central
Published in
International Journal for Equity in Health / Issue 1/2018
Electronic ISSN: 1475-9276
DOI
https://doi.org/10.1186/s12939-018-0885-y

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