Health shocks, medical insurance and household vulnerability: Evidence from South Africa

Background
South Africa has a dual system of healthcare model differentiated across socio-economic lines. While on the one hand there exists high quality private facilities that is expensive and accessible to the minority, on the other is the free but stretched and over-crowded public healthcare that the rest of the population relies on. Accessing private facilities requires private medical insurance or requires coping strategies that can lead to household vulnerability.
Objective
The objective of this study is to analyse the relationship between health shocks and household vulnerability in the South African context of high poverty and low medical insurance penetration rate.
Data
The study employs data from waves three to five of South Africa’s nationally representative National Income Dynamics Study (NIDS) conducted between the period 2012–2017 in approximately two-year intervals.
Methods
Using food expenditure shock as an indicator for vulnerability, the study utilises a range of econometric techniques from panel logit regression to quasi-experimental design based difference in difference regressions to assess the association between health shocks, medical insurance and household vulnerability.
Findings
The main finding of the study is that a significant proportion of households in the upper income quintile utilise private healthcare even when not covered by private medical insurance. This preference for private over public health facilities make them vulnerable to health shocks as they cope by sacrificing food consumption to incur additional health expenditure. In contrast, lower income households that are unable to access the high-cost private healthcare tend to rely on the strained public healthcare system. They are not able to use their constrained food expenditure as a coping strategy for private or out-of-pocket medical expenses because their food consumption is already at a bare minimum.
Conclusion
The results confirm that access to quality healthcare is a privilege in South Africa, available only to the minority of the population. The study paints a grim picture of household vulnerability in South Africa and underlines the need for a National Health Insurance that would enable universal access to quality healthcare in the country.

背景：南非实行按社会经济分层的二元医疗体系。一方面，存在面向少数群体的高价优质私立医疗机构；另一方面，则是面向其余多数民众的免费却资源紧张、人满为患的公立医疗体系。若要使用私立医疗机构，要么需持有私人医疗保险，要么就得采取可能加剧家庭经济脆弱性的应对策略。
研究目标：本研究旨在以南非高贫困率、私人医疗保险普及率偏低的现实背景为依托，剖析健康冲击与家庭经济脆弱性之间的内在关联。
数据来源：本研究采用南非全国代表性追踪调查——全国收入动态研究（National Income Dynamics Study, NIDS）2012至2017年间的第3至5轮调查数据，该调查以约两年为一个周期开展。
研究方法：本研究以食品支出冲击作为家庭经济脆弱性的衡量指标，运用多种计量经济学分析工具，涵盖面板logit回归、基于准实验设计的双重差分回归等方法，以评估健康冲击、私人医疗保险与家庭经济脆弱性三者间的关联关系。
研究结果：本研究的核心发现显示，高收入五分位组中有相当比例的家庭，即便未持有私人医疗保险，仍会选择私立医疗机构。这类群体相较于公立医疗机构，更倾向于选择私立医疗服务，这使得他们在遭遇健康冲击时，不得不削减食品消费以承担额外的医疗开支，进而陷入家庭经济脆弱性的困境。与之形成鲜明对比的是，低收入家庭无力承担高昂的私立医疗费用，往往只能依赖本就资源紧张的公立医疗体系。由于食品消费已处于最低温饱线，他们无法通过缩减食品开支的方式，来应对私立医疗或自付医疗费用带来的经济压力。
研究结论：研究结果证实，在南非，获取优质医疗服务属于一项特权，仅为少数群体所享有。本研究勾勒出南非家庭经济脆弱性的严峻图景，并强调了推行全民健康保险（National Health Insurance）的必要性——该制度可助力该国实现全民公平享有优质医疗服务的目标。