Introduction: Multimorbidity is a growing concern worldwide, with approximately 1 in 4 adults affected. Most of the evidence on multimorbidity, its prevalence and effects, comes from high income countries. Not much is known about multimorbidity in low income countries, particularly in sub-Saharan Africa. The aim of this study was to determine the prevalence of multimorbidity and examine its association with various social determinants of health in South Africa.

In recent years, there has been a dramatic increase in obesity in low and middle income countries. However, there is limited research in these countries showing the prevalence and determinants of obesity. In this study, we examine the socioeconomic inequalities in obesity among South African adults. We use nationally representative data from the South Africa National Income Dynamic Survey of 2008 to: (1) construct an asset index using multiple correspondence analyses (MCA) as a proxy for socioeconomic status; (2) estimate concentration indices (CI) to measure socioeconomic inequalities in obesity; and (3) perform a decomposition analysis to determine the factors that contribute to socioeconomic related inequalities. Consistent with other studies, we find that women are more obese than men. The findings show that obesity inequalities exist in South Africa. Rich men are more likely to be obese than their poorer counterparts with a concentration index of 0.27. Women on the other hand have similar obesity patterns, regardless of socioeconomic status with CI of 0.07. The results of the decomposition analysis suggest that asset index contributes positively and highly to socio-economic inequality in obesity among females; physical exercise contributes negatively to the socio-economic inequality. In the case of males, educational attainment and asset index contributed more to socio-economic inequalities in obesity. Our findings suggest that focusing on economically well-off men and all women across socioeconomic status is one way to address the obesity problem in South Africa.

BackgroundMany low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC.MethodsUsing a cross-sectional survey across four of South Africa’s nine provinces, we interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. Multivariate logistic regression was used to determine if service utilisation was associated with insurance status.ResultsA quarter of respondents remained uninsured, even higher among 20–29 year olds (46%) and lower-skilled employees (58%). In multivariate analysis, the odds of an outpatient visit and hospital admission for the uninsured was 0.3 fold that of the insured. Cross-subsidisation within the scheme has provided lower-paid civil servants with improved access to outpatient care at private facilities and chronic medication, where their outpatient (0.54 visits/month) and inpatient utilisation (10.1%/year) approximates that of the overall population (29.4/month and 12.2% respectively). The scheme, however, generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having 1.0 outpatient visits/month compared to 0.6/month with lowest benefits.ConclusionsBy introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The inequities generated by the scheme have thus been institutionalised within the country’s financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.

The use of traditional medicine is widespread in developing countries. We report on the utilization of traditional healers, using data obtained in a 2008 national survey of 4762 households in South Africa. Only 1.2 per cent of survey participants reported utilization of traditional healers. Respondents' reasons for visiting traditional healers included continuity of care and a belief in their effectiveness. Traditional healer utilization rates (0.02 visits per month) were considerably lower compared to utilization rates of public sector clinics (0.18 visits per month) or hospitals (0.09 visits per month). Almost three-quarters of the poorest quintile spent more than 10 per cent of their household expenditure in the previous month on traditional healers. Given the use of two parallel health-care systems, policy-makers should develop strategies to protect poor South Africans from out-of-pocket payments for health care. Simultaneous utilization of these systems evidently absorbs expenditure from low-income households significantly.

IntroductionSocial capital is said to influence health, mostly in research undertaken in high income countries' settings. Because social capital may differ from one setting to another, it is suggested that its measurement be context specific. We examine the association of individual and neighbourhood level social capital, and neighbourhood deprivation to self-rated health using a multi-level analysis.MethodsData are taken from the 2008 South Africa National Income Dynamic Survey. Health was self-reported on a scale from 1 (excellent) to 5 (poor). Two measures of social capital were used: individual, measured by two variables denoting trust and civic participation; and neighbourhood social capital, denoting support, association, behaviour and safety in a community.ResultsCompared to males, females were less likely to report good health (Odds Ratio 0.82: Confidence Interval 0.73, 0.91). There were variations in association of individual social capital and self-rated health among the provinces. In Western Cape (1.37: 0.98, 1.91) and North West (1.39: 1.13, 1.71), trust was positively associated with reporting good health, while the reverse was true in Limpopo (0.56: 0.38, 0.84) and Free State (0.70: 0.48, 1.02). In Western Cape (0.60: 0.44, 0.82) and Mpumalanga (0.72: 0.55, 0.94), neighbourhood social capital was negatively associated with reporting good health. In North West (1.59: 1.27, 1.99) and Gauteng (1.90: 1.21, 2.97), increased neighbourhood social capital was positively associated with reporting good health.ConclusionOur study demonstrated the importance of considering contextual factors when analysing the relationship between social capital and health. Analysis by province showed variations in the way in which social capital affected health in different contexts. Further studies should be undertaken to understand the mechanisms through which social capital impacts on health in South Africa.