Only about one-third of South Africans have confidence in the overall health system, including primary public services such as mental health, maternity and paediatrics, a wide-ranging 15-country survey has found, MedicalBrief reports.
The first step in improving a health system is to understand how it is performing, with governments often focusing evaluations on metrics like numbers of providers or health facilities. However, this approach is limited, said the team of health policy researchers from Harvard TH Chan School of Public Health in the US.
Drawing on data from a 15-country survey, they aimed to fill in what they see as a crucial gap in many health system assessments: the opinions of healthcare consumers.
In a series of six papers published online in The Lancet Global Health, the researchers compared various aspects of health system performance globally, including people’s confidence in their health system and views on the quality of care they’ve received, and inequities in coverage and quality, among other issues.
The studies used data captured in 2022 and 2023 from more than 25 000 adults across 15 countries: South Africa, Argentina, Colombia, Ethiopia, Greece, India, Italy, Kenya, Laos, Mexico, Peru, South Korea, United Kingdom, United States and Uruguay.
Participants were contacted through the People’s Voice Survey, a new instrument designed by the Quality Evidence for Health System Transformation (QuEST) Network, a multi-country research consortium based at Harvard Chan School.
The overarching message from the survey is that people worldwide are not confident their health systems can meet their needs.
Only one-quarter said their system worked well, and fewer than half were confident they could get and afford good quality care if they got sick – even in countries with universal insurance systems.
Within global regions, people in Kenya and Ethiopia, for instance, had lower confidence in affording care than people in South Africa.
Regarding quality of a country’s national health system, 54.4% of South Africans rated the private health system as very good or excellent while public scored a dismal 28.1%.
On quality of public primary key services, maternity scored 33.7%, paediatric 36.2%, care for chronic illness 35.1%, and mental healthcare just 30%.
If it’s any consolation to the SA National Department of Health, those appalling figures outperform Mexico, for instance, which scored 15% for mental illness and 26% for maternity.
By the same token, Mexico soared past SA in governmental response to public input, chalking up a “very good” 73.7% while SA managed 51%. Ethiopia scored higher than SA, with 79.6%
The researchers said across all countries, study participants rated mental healthcare at or near the bottom of all services, with fewer than one in five giving a high rating. This low rating is in stark contrast to the size of the epidemiological burden presenting to primary care in most countries, led by chronic conditions (e.g, hypertension and diabetes) and common mental health disorders (e.g, depression and anxiety).
Mental health care is a highly neglected service in health systems in low-income and middle-income countries and is under growing strain in high-income countries, they noted.
Stigma among the population and health workers also contributes to low access and quality.
Overall, a minority of respondents in the study countries (11.1%–41.1%) endorsed their current health system as is or with only minor changes. The highest endorsement was in South Korea, and the lowest was in Greece, where negative sentiment could be linked to past austerity measures.
Compared with past results from countries of similar income levels, overall endorsement appears to have decreased.
For study countries with available past data, endorsement was similar in South Africa, Mexico, Kenya and India to what it was in 2017, and declined in Argentina from 29% to 17%.
Most respondents in the lowest income countries (i.e, Ethiopia, Laos and Kenya) reported that systems had been improving in the past two years, while only about a third agreed in middle-income countries (South Africa, Argentina, Peru, Colombia and Uruguay).
Just 21.3% of South African respondents believe the current health system works well or only needs minor changes, with only 41% saying the system has improved over the past two years.
Endorsement dropped dramatically in the UK from 63% in 2013 to 15% in 2023.
“The level of unhappiness in the health systems of high-income countries was surprising,” said Margaret Kruk, professor of health systems and director of the QuEST Network. For example, 70% of Ethiopians think their health system has been improving over the past two years while just 6% of Britons and 15% of Americans do.
Other key findings from the series:
• Women and people with post-secondary education, and, in some countries, young people, were more pessimistic about their health systems than respondents with lower education levels, men and people older than 30 years.
• In countries with a public primary care system, only four in 10 people use public primary care as their usual provider. Others rely on private providers and secondary care facilities such as hospitals.
• The availability of public health insurance in Africa and Asia isn’t necessarily leading to more people receiving important preventive services. For example, people with public insurance aren’t much more likely to receive blood pressure checks than people without insurance and are less likely to receive them than people with private insurance.
Kruk said that the pessimism expressed across countries by people with higher incomes and more education, and by young people, “bodes poorly for future support for publicly financed insurance, including efforts for universal health coverage, as these groups are essential contributors to any such scheme”.
She and her colleagues suggest that governments will need to gain trust from their populations before moving ahead with health system reforms.
Study details
Population confidence in the health system in 15 countries: results from the first round of the People's Voice Survey (introduction)
Margaret Kruk, Neena Kapoor, João Breda, et al.
Published in The Lancet on 11 December 2023
Abstract
Summary
Population confidence is essential to a well functioning health system. Using data from the People's Voice Survey – a novel population survey conducted in 15 low-income, middle-income, and high-income countries – we report health system confidence among the general population and analyse its associated factors. Across the 15 countries, fewer than half of respondents were health secure and reported being somewhat or very confident that they could get and afford good-quality care if very sick. Only a quarter of respondents endorsed their current health system, deeming it to work well with no need for major reform. The lowest support was in Peru, the UK, and Greece, countries experiencing substantial health system challenges. Wealthy, more educated, young, and female respondents were less likely to endorse the health system in many countries, portending future challenges for maintaining social solidarity for publicly financed health systems. In pooled analyses, the perceived quality of the public health system and government responsiveness to public input were strongly associated with all confidence measures. These results provide a post-Covid-19 pandemic baseline of public confidence in the health system. The survey should be repeated regularly to inform policy and improve health system accountability.
The Lancet The People’s Voice series (Open access)
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