STUDY INTRODUCTION AND BACKGROUND
Health care reform is essential for countries aiming to improve their health systems, necessitating collaboration with successful global partners Effective healthcare delivery relies on the optimal use of material, human, and financial resources, with human resources playing a critical role across various government levels Engaging healthcare workers and the community in decision-making enhances service ownership and efficiency Public participation is a vital component, allowing communities to influence healthcare policies and reforms In South Africa, the constitution mandates civil society involvement in policymaking, particularly in initiatives like the National Health Insurance (NHI), ensuring accountability, transparency, and representation in legislative processes.
When developing or amending policies like Health Reforms or the National Health Insurance (NHI), it is crucial to consult all stakeholders, including healthcare workers, to gather their insights Community engagement in health is essential for several reasons: it helps identify local needs and aspirations, promotes health equity, enhances service design and quality of care, and fosters local accountability Effective community engagement can take various forms, such as public hearings, opinion surveys, and participation in advisory committees Additionally, direct actions, both peaceful and violent protests, serve as significant methods for civil society to engage in governance and influence policy processes throughout different stages of policy development.
Studies on community engagement in the National Health Insurance (NHI) implementation in South Africa reveal significant disparities in consultation processes between affluent and impoverished communities (Setswe and Monash, 2012) Wealthier neighborhoods have access to various engagement methods, such as community meetings, petitions to local officials, and leveraging technology through emails and social media platforms like Facebook and Twitter In contrast, underprivileged rural and squatter areas lack the necessary resources and organizational cohesion, leading to their views being underrepresented in the consultation process Organizations like Black Sash and Oxfam-Monash play a crucial role in voicing the concerns of these marginalized communities regarding the NHI Additionally, the perspectives of healthcare workers, who are integral to society, may also vary based on their community affiliations, affecting the representation of their views.
Despite the need for a transparent process of consultation regarding health system reforms such as the NHI, it is important also to determine whether the systems in operation are
Addressing the health needs of society requires a comprehensive evaluation of existing policies, such as through SWOT analysis, to identify the necessity for new reforms Shisana (2011) highlights that past health reforms in South Africa have failed to meet the needs of the entire population, evidenced by numerous documented initiatives that were influenced by colonialism and Apartheid These historical systems were marked by fragmentation within the public health sector and a divide between public and private healthcare.
1 At an early stage, health facilities were racially segregated and curative and preventive services were separated when Public Health Amendment Act of 1897 was implemented
2 The 1919 Health Act gave responsibility for hospital curative care to four provinces and preventive and promotive health care to the local authorities
3 The Gluckman Commission (1942–44) was an attempt to redirect the health system At the heart of this vision was a chain of community health centres, which were forerunners of community-based primary health care Gluckman became Minister of Health in 1945, but the Nationalist Party assumed power in 1948, before the Gluckman recommendations had been implemented, and they were subsequently rejected
4 The apartheid system further entrenched fragmentation of health care when the
During the apartheid era in South Africa, Bantustans were established, each with its own health department, functioning as quasi-independent entities under the careful manipulation of Pretoria By the end of this period, there were 14 distinct health departments, with a significant focus on hospital services, while primary healthcare remained severely underdeveloped.
5 Post 1994 attempts to transform the healthcare system and introduce healthcare financing reforms were thwarted This has entrenched a two-tiered health system, public and private, based on socioeconomic status and it continues to perpetuate inequalities in the current health system
With regard to the NHI, perceptions were sought from the society at large These included health care workers at operational level who usually advocate for such reforms with the
Research in South Africa, including studies by Shisana et al (2006), McIntyre (2010), and Evans and Shisana (2012), reveals a generally positive perception of the National Health Insurance (NHI) among various societal groups However, there are concerns regarding the need for comprehensive discussions among stakeholders before the NHI's implementation, particularly in light of past reform failures.
Health care workers play a crucial role in health care reforms and are integral to their communities Research highlights that community perceptions significantly influence the implementation of these reforms, particularly regarding communication of objectives and the rationale behind them For instance, Franco et al (2002) found that when health workers' goals align with reform objectives, their motivation increases, especially in terms of training and performance outcomes Additionally, barriers to utilizing health services, such as resource availability and access to public health services, must be addressed The effects of health care reform on specific groups, like nurses and doctors, reveal limited career advancement opportunities and inadequate recognition of achievements Furthermore, factors affecting employment decisions and retention of health personnel, including financial incentives and workplace conditions, are critical to the success of health reforms (Franco et al., 2002; Lipinge et al., 2006; Bakeera et al., 2009; Rupert, 2010; George et al., 2013).
From these studies it seems there are health services systemic issues that impact negatively or positively on universal access to health care e.g availability of staff and material resources
The South African health sector, similar to reforms seen in Brazil's Unified Health System and the United States' Affordable Care Act, has implemented changes aimed at enhancing access to healthcare services.
Health reforms in South Africa have a historical context that dates back to 1928, when the Commission on Old Age Pensions and National Insurance made initial recommendations This was succeeded by the 1935 Committee of Enquiry into National Health Insurance and later by the National Health Services Commission from 1942 to 1944 The evolution of these reforms culminated in the tax-funded national health system of the 1980s, as noted by McIntyre (2010).
By 1994, South Africa established a two-tiered health system that has struggled to uphold principles of equity and access, leading to the introduction of the National Health Insurance (NHI) This system has resulted in significant disparities in the quality of healthcare services between the private and public sectors Discussions on health system reform and mandatory health insurance have been ongoing since the 1930s, with renewed interest from progressive academics in the early 1990s This concept was formally integrated into the African National Congress's National Health Plan in 1994.
The Taylor Committee of Inquiry (2002) advocated for a comprehensive social security system in South Africa, emphasizing the need for a National Health Insurance (NHI) that unifies public and private medical services under a universal contributory framework Currently, the private sector offers superior quality care, while the public sector, which serves 84% of the population, struggles with significant shortages in healthcare personnel, supplies, and facilities This disparity affects all South Africans, including healthcare workers A study by George et al (2013) revealed that public sector health workers experience the worst working conditions, characterized by high stress, heavy workloads, inadequate remuneration, substandard work environments, insufficient human resources, and limited in-service training opportunities.
The aim and objective of the study
This study aimed to evaluate the perspectives of healthcare workers on the National Health Insurance (NHI) within the South African health system, specifically at the Pietersburg-Mankweng tertiary hospital complex in Limpopo Province, in light of the current challenges facing the sector.
The objective of the study was to explore the perspectives of healthcare workers on the implementation of the National Health Insurance (NHI) at Pietersburg-Mankweng Tertiary Hospital in Limpopo Province.
Summary
This chapter provides an overview of the study's introduction and background, highlighting the problem statement that guided the formulation of the study's aims and objectives.
LITERATURE REVIEW
This chapter aims to establish a foundation for the study by reviewing existing research related to the National Health Insurance (NHI) and its significance It is organized into six key sections: the necessity for the NHI, community perceptions about the NHI, the impact of healthcare workers on the NHI, the implications of the NHI, and the factors affecting enrollment in the NHI.
2.2 The need for the NHI
The World Health Organisation (WHO) strives to safeguard global health through initiatives like Universal Health Coverage (UHC), which aims to provide essential health services to all individuals without financial hardship Achieving UHC necessitates a robust health system, effective financing, access to essential medicines, and a well-trained workforce WHO collaborates with organizations such as the World Bank, which views UHC as a smart investment and a fundamental human right, drawing insights from successful health coverage models in advanced economies like Europe, Canada, and Japan Countries such as Brazil, Russia, India, China, and South Africa, representing nearly half of the global population, are adopting similar approaches, with Rwanda in Africa making significant investments in universal health coverage.
8 health coverage system after the 1994 genocide and recently close to 80 percent of Rwandans are insured and life expectancy has more than doubled (World Bank Group,
The National Health Insurance (NHI) aims to safeguard the human right to healthcare by providing universal access to healthcare services, impacting both the population and healthcare workers To achieve universal health coverage, the World Bank, through the International Development Association (IDA), has implemented various strategies that affect healthcare workers in developing countries Notably, between 2003 and 2013, the IDA has successfully executed several initiatives to enhance healthcare systems globally.
The World Bank Group has made significant contributions to global health by training over 2.6 million health personnel and ensuring skilled attendance at more than 29 million births They have constructed, renovated, and equipped over 10,000 health facilities, while also immunizing nearly 600 million children Additionally, the organization has provided antenatal care to more than 194 million pregnant women and reached over 210 million individuals, including pregnant and lactating women, adolescent girls, and children under five, with essential nutrition services Furthermore, they have purchased and distributed over 149 million long-lasting insecticide-treated malaria bed nets and 386 million condoms, enhancing public health outcomes worldwide.
The National Health Insurance (NHI) aims to reduce health disparities by eliminating financial barriers and is supported by benefits such as resource pooling, risk protection against medical costs, and guaranteed coverage availability Health insurance is increasingly viewed as a pathway to achieving universal health coverage (UHC) in many African nations However, the concept remains relatively new and poorly understood, particularly in countries where most of the population is employed outside the formal sector.
The World Bank Group has made significant contributions to health systems in various countries, notably in Brazil, where it strengthened health surveillance and improved access to essential services for vulnerable groups, resulting in 74% of the indigenous population being immunized by 2010 and a 60% reduction in malaria-related deaths In Rwanda, support from the World Bank Group increased health insurance enrollment from 7% to over 70%, led to a 50% rise in health service utilization among poor children, and decreased malaria incidence by 62%, alongside a 30% reduction in child mortality Additionally, by 2013 in Vietnam, 68% of the population had fully subsidized health insurance, with coverage for the "near-poor" in the central north region reaching 64% due to the Bank's efforts.
2.3 Community perceptions regarding the NHI
Health sector reforms elicit diverse perspectives from both recipients and providers of health services, reflecting individual and group differences in experiences Some community members advocate for universal health coverage, with opinions divided on whether this should be achieved through tax increases or reductions Notably, disadvantaged groups tend to favor raising taxes to support this initiative (Shisana et al).
Active public participation is crucial in health reforms, as demonstrated by studies from South Africa and Western Pennsylvania Effective governance and debate involvement are essential for policy formulation, particularly regarding the National Health Insurance (NHI) initiative The inclusion of all stakeholders—such as healthcare workers, NGOs, and the private sector—is vital for identifying and pursuing reforms that ensure universal access to healthcare However, inadequate communication of the NHI's principles and implementation could lead to public backlash, similar to the controversy surrounding e-tolling, as noted in recent research.
The acceptability of the National Health Insurance (NHI) in Kenya is closely tied to community knowledge and understanding of the reform As Kenya progresses towards Universal Health Coverage (UHC), it is crucial to educate and engage communities to enhance the acceptability of the National Health Insurance Scheme (NHIS) Despite a high level of awareness about health insurance schemes, many individuals lack a clear understanding of how these systems operate, particularly regarding income and risk cross-subsidization A study revealed that 77% of individuals without any health insurance were aware of at least one community-based health insurance (CBHI) in their area, with 55.7% knowing the procedures to join However, focus group discussions indicated mixed awareness levels, with many participants citing limited promotional efforts for CBHIs and a lack of access to information due to rural settings Additionally, those in formal employment tended to have a better understanding of health insurance, as membership in the National Hospital Insurance Fund (NHIF) or CBHIs is mandatory for them.
A study in Kenya mirrors findings from South Africa, highlighting disparities in community consultation between affluent and impoverished neighborhoods Wealthier residents have access to various engagement methods, including community meetings, petitions to local officials, and the use of technology like emails and social media platforms such as Facebook and Twitter to express their views on the National Health Insurance (NHI) In contrast, underprivileged rural and squatter communities lack the necessary resources, coordination, and cohesion that their more affluent counterparts possess (Setswe and Monash, 2012).
A study conducted in Kenya revealed that 93% of surveyed households supported the implementation of a compulsory national health insurance scheme, with the government being the preferred revenue-collecting organization at 51.8% In contrast, only 11.7% favored private purchasing institutions Similarly, perceptions among General Practitioners (GPs) in South Africa regarding the National Health Insurance (NHI) were mixed; 47% remained neutral, while 21.5% supported it and 32.5% opposed it, primarily due to concerns over clarity and risk management Notably, 24.2% of GPs rated their understanding of the NHI capitation proposal as poor, highlighting a significant gap in comprehension among healthcare providers.
In a study by Komape (2013) on community perceptions of healthcare delivery, focus groups revealed a stark contrast between views on private and public hospitals, with participants predominantly viewing private facilities as "good" and public ones as "bad." Approximately 95% of respondents recognized health insurance as a reliable alternative to the cash and carry system, emphasizing its role in enhancing access and cost-effectiveness of health services One participant noted that health care became more accessible for those with insurance, simplifying financing Additionally, the benefits of national health insurance schemes were highlighted, particularly in terms of long-term health sector developments, such as infrastructure improvements, equipment procurement, and a greater emphasis on preventive healthcare.
2.4 The influence of Health Care Workers on the NHI
Health care workers significantly influence patients' decisions to access health services, with their attitudes, language, and working conditions playing crucial roles A study by the WHO revealed that 2.8% of participants preferred private health care over public services, primarily due to negative experiences with health care workers in the public sector (Juma and Manongi, 2009; WHO, 2012) This highlights the importance of improving health care worker behavior and facility conditions to enhance patient engagement.
In 2010, it was found that health care workers in reformed Primary Health Care (PHC) units exhibit a more satisfactory attitude towards work-related issues compared to their counterparts in non-reformed units, a trend closely linked to the National Health Insurance (NHI) initiative A study conducted among PHC nurses in Johannesburg's Metropolitan district D2 revealed that these nurses are generally positive and willing to support the NHI's implementation However, for successful execution of the project, it is essential to ensure proper stakeholder engagement, buy-in, and thorough planning.
In South Africa, various studies among healthcare workers, particularly general practitioners, reveal mixed opinions regarding the implementation of the National Health Insurance (NHI) While some practitioners oppose the NHI, viewing it as potentially harmful, others express support due to anticipated personal benefits and the overarching goal of achieving universal healthcare coverage This reflects a broader commitment to open dialogue and engagement on the topic (Amandla, 2009; Ramjee and McLeod, 2010; Surrender et al., 2015).
RESEARCH METHOD
This chapter aims to outline the quantitative method employed to address the research objective, covering key aspects such as research design, study setting, sample selection, data collection techniques, data analysis procedures, and ethical considerations.
A cross-sectional descriptive quantitative research design was utilized to draw conclusions from a broad population This approach systematically investigates data and their relationships, emphasizing the importance of measurement to reveal connections between observations Rooted in the scientific method, quantitative research employs deductive reasoning, where researchers formulate hypotheses, collect data, analyze findings, and ultimately validate or refute the hypotheses The fundamental steps in a quantitative design include hypothesis formation, data collection, analysis, and conclusion sharing.
1 Make your observations about something that is unknown, unexplained, or new and
Investigate current theory surrounding your problem or issue
2 Hypothesize an explanation for those observations
3 Make a prediction of outcomes based on your hypotheses and formulate a plan to test your prediction
4 Collect and process your data
5 If your prediction was correct, go to step
6 If not, the hypothesis has been proven false
7 Return to step 2 to form a new hypothesis based on your new knowledge
10 Present your findings in an appropriate form for your audience.
PRESENTATION AND INTERPRETATION OF THE FINDINGS
This chapter presents and interprets the response rate, demographic characteristics, and detailed results that align with the study's objectives, following the previous chapter's outline of the study design, settings, population, sample size, sampling technique, data collection, and analysis methods.
A total of 363 questionnaires were distributed among nurses, doctors, allied health professionals, and EMS personnel, achieving a response rate of 70% with 255 completed forms returned The analysis focused on the demographics and objectives of the study based on all 255 responses received.
4.3 Demographic characteristics of the respondents
A study involving 255 healthcare workers revealed that 29% of respondents were aged 30-39 years, while 20% fell within the 40-49 year age group Additionally, 22% of participants chose not to disclose their age.
DISCUSSIONS AND CONCLUSION
This chapter presents the results and interpretations aligned with the study's objectives, comparing the findings with previous research on respondents' demographic characteristics, knowledge of the National Health Insurance (NHI), and perceptions of the NHI Additionally, the chapter outlines the study's limitations, concludes the findings, and offers recommendations for future research.
In our study, the age distribution of participants revealed that 29% were aged 30-39 years, followed by 20% in the 40-49 age group, while 22% did not disclose their age This contrasts with a South African study where 34% of participants were aged 50-59 years, and only 11% were in the 25-29 and 40-49 age categories (Khuzwayo, 2015) Gender distribution showed that 79% of our participants were female, differing from findings in South Africa and Bangladesh, where most healthcare workers were male (Bezuidenhout and Matlala, 2014) Additionally, a study in Bangladesh indicated that 50% of healthcare workers were male (Cockcroft, 2011) Notably, some participants in our study also chose not to indicate their age, mirroring findings from Bezuidenhout and Matlala (2014) Regarding educational qualifications, 95% of participants held tertiary education, with only 5% having secondary education, aligning with Bezuidenhout and Matlala's study, where 34.6% of participants had tertiary qualifications.
In the current study, 40% of respondents had a tertiary level of education, while 32.5% achieved a secondary level More than half of the participants were nurses (57%), followed by allied health professionals (19%) and doctors (18%), with emergency medical services (EMS) making up the remainder This contrasts with a study on health reforms in Bangladesh, which found that 73% of healthcare workers were paramedical staff, 17% were nurses, and only 10% were doctors.
In the current study, a significant majority of healthcare workers from nursing, clinical, allied, and EMS categories (64%) demonstrated an understanding of the National Health Insurance (NHI) Their knowledge was assessed based on their familiarity with the facility's role in NHI implementation, the sources of their information regarding NHI, and the specifics of NHI policy content.
Research conducted at George Mukhari Hospital in South Africa revealed that 54.58% of healthcare workers were knowledgeable about the National Health Insurance (NHI) (Bezuidenhout and Matlala, 2014) Similarly, a study involving civil servants from the health and education sectors across four provinces—Gauteng, Western Cape, KwaZulu-Natal, and North West—found that 23.7% of participants identified a lack of information as a significant barrier to enrolling in the scheme (Govender et al., 2013) Consistent findings were reported in Kenya, where a study on community perceptions of the National Hospital Insurance Fund indicated that 91.2% of household survey respondents were aware of the NHIF's existence (Mulupi et al., 2013).
The success of health reforms largely hinges on the involvement of healthcare workers, who are essential service providers To ensure positive outcomes, it is crucial to include these professionals in the strategic planning and implementation phases of the reform process Keeping them informed about the changes can significantly influence their reactions, which may lead to either beneficial or detrimental effects on the reform efforts (Rigoli and Dussault, 2003).
In our study, we found that 48% of participants were unaware of the National Health Insurance (NHI) policy contents Notably, a higher percentage of allied health professionals (62%) and doctors (63%) also lacked knowledge about the NHI policy.
41 about the policy contents of NHI compared to emergency services (40%) and nurses (40%), (p