The majority of the participants of the present study were not aware of the NHI. However, after a brief description of the NHI was provided, most of the participants responded that they were aware that they have a right to be involved in the policy making process of a policy of the NHI. This study also showed that sex race and employment status were significant predictors of the participants’ awareness of the NHI were sex, race and employment status. There were higher odds of awareness for males compared to females; for White and Indian participants compared to Black participants; and for retired participants compared to those who were unemployed.
The percentage participants’ awareness percentage of the NHI was low in this study, however a similar study by Setswe, et al. (2015) found that 80.3% of their participants were aware of the NHI18. This awareness percentage is virtually the inverse of what the present study found. This study was conducted in three provinces in South Africa, with a combination of participants from rural, peri-urban and urban areas. Some of the participants in this study were from a NHI pilot site (Edendale Hospital in Umgungundlovu district). Even though awareness on the NHI was high in this study, the majority of participants had limited understanding of important concepts of health insurance.18 The difference in the awareness levels can be attributed to the difference in the sample population involved in this study. This research focused on patients only and was conducted in an urban area only, which is not a NHI pilot site.
The interviews for the present study were conducted after the release of the NHI Policy in June 2017, which is the policy document that preceded the NHI Bill1,5. At this point, the knowledge levels on the policy may have been limited generally, however the public, including patients should have at least been aware of the NHI. Without awareness and information about the NHI, patients are not equipped to be involved in the policy making process15 .
Raboshakga (2015) indicated that awareness of rights and stimulating public interest is are both essential in ensuring that the public is involved in the policy making process15. In the present study, most of the participants knew that they have a right to be involved in the policy making process of the NHI. This finding is contrary to what was found in study conducted in a Tanzanian district, wherein the community members did not participate in the policy discussions because they were not aware that they had a right to be involved in policy decision-making21. In order for the right to be involved in policy making to be realised, there ought to be fair opportunity for patients to be involved in the policy making process, which the majority of the participants in the present study were not provided. Pateman (2012) found that even though citizens may not be au fait with the technicalities of health policies they are still interested in being involved22. This is important since health policies affect their lives directly22. Pateman’s findings are consistent with the findings of this study because, majority of all participants were interested in being involved in the policy making process.
Even though most of the participants were interested in being involved, they had not been provided with an opportunity to be involved in the policy making process. The questionnaire did not have a follow-up question to establish what the involvement of those who had received an opportunity to be involved (2.87%) entailed. Further research needs to be done to investigate the procedures followed during health policy engagement in the South African and similar settings to establish if the processes are representative and whether these procedures result in meaningful and effective engagement.
Sex was a significant predictor, with the odds of awareness were higher for males than females participants. Females are considered to be more active users of the health system compared to males23. Even though females are more active users of the health system, they have lower odds of awareness than males, who use the health system less than females. The study did not include a follow-up question to determine the sources of information on the NHI. It can be presumed that the hospital setting is not where the patients received information about the NHI, if that were the case, females may have been more aware of the NHI.
Race was also a significant predictor of awareness of the NHI, with White and Indian participants having higher odds of awareness on the NHI than Black participants, even though most users of the public health system and population in South Africa are Black citizens7. Much like males, this indicates that White and Indian participants had access to information about the NHI, the sources of information that has influenced this result, are not known since the study did not have a follow-up question on sources of information.
It is an interesting finding that unemployed participants were 3 times less likely to be aware of the NHI than retired participants. The NHI would benefit and be of interest to both categories. The retired participants may need to use the system more than unemployed participants of working age because of their age and chronic illness. However, unemployed participants would need to access the public health system as well because they do not have an alternative for health care. Unemployed and black participants should be aware of the NHI, given their reliance of the system7.
Education is identified as a domain of public health action and promotes health equity24. Education plays an important role in the levels of awareness of the NHI, with the odds of awareness of those who had tertiary education being more than those who had primary education only. The odds of awareness of those with tertiary education compared to primary education were the highest in the multivariate analysis, even though not statistically significant. Literature has shown that there is a directly proportional relationship between education level and awareness. The higher the education level, the more likely citizens are to have access to information and therefore have the ability to be involved in policy discussions24–26. A similar study on the awareness, knowledge and perceptions on the NHI found that the levels of support of the NHI were associated with the level of education, with higher education levels being associated with increased levels of awareness and support for the NHI27. The education level results in the present study are limited by the sample size, and further research could be pursued to study the relationship education level of patients and the awareness on the NHI.
Language was a limitation because the researcher is only fluent in English, isiXhosa and isiZulu. This limited patients who do not speak these languages from participating in the study, however, the questionnaire was not officially translated into isiZulu and isiXhosa. This study is not generalizable to all patients, because of the sampling methodology of the study. The study was part of a Masters research28 and due to the time limitations the participants were limited to the Internal Medicine Department at CMJAH. The follow-up clinics were chosen specifically because patients who continuously use the health facility’s follow-up clinics ought be aware of any developments in the health system over time. Three clinics were chosen instead of one, to allow spread of the participant pool, given the sampling methodology.