Explaining the role of the social determinants of health on health inequality in South Africa

Abstract

Background: Action on the social determinants of health (SDH) is relevant for reducing health inequalities. This is particularly the case for South Africa (SA) with its very high level of income inequality and inequalities in health and health outcomes. This paper provides evidence on the key SDH for reducing health inequalities in the country using a framework initially developed by the World Health Organization.

Objective: This paper assesses health inequalities in SA and explains the factors (i.e. SDH and other individual level factors) that account for large disparities in health. The relative contribution of different SDH to health inequality is also assessed.

Design: A cross-sectional design is used. Data come from the third wave of the nationally representative National Income Dynamics Study. A subsample of adults (18 years and older) is used. The main variable of interest is dichotomised good versus bad self-assessed health (SAH). Income-related health inequality is assessed using the standard concentration index (CI). A positive CI means that the rich report better health than the poor. A negative value signifies the opposite. The paper also decomposes the CI to assess its contributing factors.

Results: Good SAH is significantly concentrated among the rich rather than the poor (CI=0.008; p<0.01). Decomposition of this result shows that social protection and employment (contribution=0.012; p<0.01), knowledge and education (0.005; p<0.01), and housing and infrastructure (-0.003; p<0.01) contribute significantly to the disparities in good SAH in SA. After accounting for these other variables, the contribution of income and poverty is negligible.

Conclusions: Addressing health inequalities inter alia requires an increased government commitment in terms of budgetary allocations to key sectors (i.e. employment, social protection, education, housing, and other appropriate infrastructure). Attention should also be paid to equity in benefits from government expenditure. In addition, the health sector needs to play its role in providing a broad range of health services to reduce the burden of disease.

Keywords: South Africa; health inequality; inequality decomposition; inter-sectoral action; self-assessed health; social determinants of health.

Fig. 1

The contribution of social determinants of health to health inequality in South Africa, 2012/13. The error bars represent 95% confidence intervals based on bootstrapped standard errors using 1,000 replications.

Fig. 2

Selected public expenditure categories as a share of total public expenditure, South Africa 1994–2012. From ref. (51).