When the present study was conducted at the Department of Internal Medicine of CMJAH, the NHI policy process had already reached three steps; the NHI Green Paper, NHI White Paper and the NHI Policy, which preceded the tabling of the NHI Bill at the South African Parliament5–7. At each step of the policy process, the South African National and Provincial Health Department had the responsibility to ensure that awareness and involvement in the NHI policy processes were initiated and promoted.
The finding that majority of the participants of the present study were not aware of the NHI was unanticipated, because that the NHI policy process commenced in 2011 and this study was conducted 6 years later. The finding that the awareness levels of the NHI were low in the present study was also inconsistent with a similar paper by by Setswe, et al. found a much higher proportion, of 80.3%, of their participants were aware of the NHI18. This awareness percentage is virtually the inverse of what the present study found. The study by Setswe, et al. 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 the study by Setswe et al., 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 when compared to the present study. This research focused on patients only and was conducted in a central hospital department, which is situated in an urban area only, which is not a NHI pilot site.
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-making20.
Although the patients in the present study were aware of their right to be involved in the policy making process of the NHI, 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. Pateman (2012) found that even though citizens may not be au fait with the technicalities of health policies they are still interested in being involved21. This is important since health policies affect their lives directly21. Pateman’s findings are consistent with the findings of this study because a majority of participants were interested in being involved in the policy making process.
The patients in the present study were aware of their right to be involved in the policy making process of the NHI and they were interested in being involved in this process, however, only a minority (2.87%) had received an opportunity to be involved NHI policy 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 entailed. Further research needs to be done to investigate the procedures followed during health policy engagement in the South African setting and similar settings to establish if the processes are representative and whether these procedures result in meaningful and effective engagement.
The sex variable was a significant predictor, with the odds of awareness were higher for males participants. Females are considered to be more active users of the health system compared to males22. 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 the male participants, 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 public health system7.
Education is identified as a domain of public health action and promotes health equity23. 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 discussions23–25. 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 NHI26. 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.
This study is not generalizable to all patients, because of the potential bias of the sampling methodology of convenience sampling. 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. In addition, language was a limitation because the researcher who conducted the interviews was only fluent in English, isiXhosa and isiZulu and the questionnaire was not officially translated into isiZulu and isiXhosa. .