Over the past three decades there has been a significant increase in adiposity - prevalence of accumulation of excess fat around some human organs - globally. This has been characterised by an increase of body mass index (BMI) among men and women. In Sub-Sahara Africa, South Africa has one of the highest prevalence of obesity and the country currently experiences some epidemiological transitions. Excess adiposity is a major risk factor for a number of non-communicable diseases creating a burden for individuals, families, the health care system and society at large (Colditz, 1999). Therefore, there are both direct and indirect costs that can be averted by effectively controlling the obesity epidemic. Still this can only be achieved when there is a good understanding of its determinants. This study sought to investigate association between neighbourhood deprivation and adult adiposity (a combination of body mass index and waist circumference), the association of neighbourhood deprivation and body mass index and waist circumference individually and to examine individual and household level determinants impacting adult adiposity. The study utilised the South African National Income Dynamic Survey (NIDS) 2012 (wave 3) and the ward level South African Index of Multiple Deprivation 2011 (SAIMD 2011) produced by Southern Africa Labour and Development Research Unit (SALDRU) and the Southern African Social Policy Research Institute/Insights (SASPRI) respectively. Individuals with high body mass index (BMI ≥ 25kg/m²) and an expanded waist circumference (WC ≥ 102cm for men and WC ≥ 88cm for women) were considered as having high adiposity. Multilevel logistic regression was used for data analysis due to hierarchical nature of the data to allow simultaneous examination of the impact of some socio-economic factors influencing adiposity. The results showed that individuals that were living in districts that are in quintile 3 (OR= 0.659; 95% CI 0.461, 0.942) of the multiple deprivation score had significantly lower odds of having high adiposity as compared to those living in the least deprived districts. Those living in districts that are in quintiles 3 (OR= 0.652; 95% 0.449, 0.945) and 4 (OR= 0.621; 95% 0.393, 0.983) of the multiple deprivation score were at significantly lower odds of having high BMI as compared to those living in the least deprived districts. When the analysis was stratified by gender the results showed that women living in districts in that are in quintiles 3 (OR= 0.654; 95% 0.450, 0.951) and 4 (OR= 0.624; 95% 0.394, 0.986) of the multiple deprivation score were at lower odds of having high adiposity as compared to women living in the least deprived district. The results for men on the other hand showed no association between adiposity and district level deprivation. Our results show that individual level characteristics and neighbourhood level deprivation regardless of how far distal has an impact on adiposity. Neighbourhood affluence seems to be a buffer that promotes weight gain. The impact of neighbourhood deprivation on adiposity is stronger among women as compared to men. However, further studies that employ a smaller area metric of analysis (preferably ward level) are required to better inform policy prescriptions of neighbourhood deprivation and adiposity.

Background: The total number of people living with non-communicable diseases in South Africa currently is unknown even though non-communicable diseases (NCDs) was accountable for 60% of the top ten causes of death in South Africa for the year 2015. In 2016, according to Stats SA, noncommunicable diseases were accountable for 57.4% of all deaths in South Africa. In 2011 they were accountable for 23% of years of life lost and 33% of disability adjusted life years. Government total expenditure is also unknown but it is estimated at more than one billion rands per annum for low to middle income countries such as South Africa. NCDs negatively impact the labour market by decreasing labour productivity, increasing employee turnover and early retraction from the labour market. This further decreases individual and household income especially for the urban poor who carry the heaviest non-communicable disease burden in South Africa and contributes to the medical poverty trap as well as, worsening income inequality in South Africa. Objective: This dissertation investigates the association between non-communicable diseases and labour market participation (LFP) and the effect it has on household income (HHI). Methods: Using the longitudinal data from the National Income Dynamics Study (NIDS) with information on labour force participation, household income and diseases such as high blood pressure, diabetes, cancer, chronic lung disease, heart problems, stroke, arthritis; were used for analysis. The analysis used the 2008 (wave1), 2012 (wave 3) and 2016 (wave 5) data sets from the NIDS. The analysis is restricted to the population aged 18 years to 65years. The Study examines these associations using logistic and linear regression models for NCDs exposed households and non NCDs exposed households, comparing the two for differences and the effect observed on labour force participation and household Income. The control variables include location, age, race, gender, marital status and level of education. The NCDs are treated as exposure variables with labour Force Participation (LFP) and House Hold Income (HHI) being outcome variables. The study is guided by a conceptual framework that views the household as a unitary function. Lastly, the Policy Brief summarises the issues at hand, the findings and concludes with policy recommendations. Results: LFP: Based on the regression results, as a group NCDs show a negative relationship with labour force participation as a non-significant decrease but individually it depends on the type of NCD an individual is exposed to. Cancer, stroke and heart attacks are negatively associated with labour force participation. Asthma, diabetes and hypertension are positively associated with labour force participation. When an individual suffers from one NCD the relationship/association depends on the type of NCD, If and when an individual is burdened by a second or third NCD (Co-morbidities) the relationship with LFP tends to be positive (an increase in LFP). HHI: Counterintuitively as a group NCDs is associated positively with household income; a significant increase of 15% at 5 % level of significance. However, individually, hypertension, cancer, asthma, heart problems and stroke have a negative relationship (a decrease) with household income except Diabetes. Objectively there is insufficient evidence to conclude that NCDs decrease household income via decreasing labour force participation indirectly contributing to poverty in South Africa, as majority of household income comes from wages and remittances. Individually almost all NCDs (with Cancer and Hypertension having significant results) decrease household income but as a group increase household income. This requires further investigation into the NCD burdened household dynamics in South Africa. Conclusion: Therefore, as recommended by the WHO; individual specific interventions will be more effective than population-based interventions to alleviate the ripple effects of the non-communicable disease burden in low to middle income countries (LMIC). Universal Health Care and up scaled prioritisation at Primary Health Care level is needed as NCDs accounted for half the global burden of disease but only received 2% of international donations compared to human immune-deficiency virus (HIV/AIDS) that accounted for 4% of the global burden of disease receiving 29% of international donations and grants.

Includes bibliographical references. / In South Africa, health care is financed through different mechanisms - allocations from general taxes, private health insurance contributions and direct out-of-pocket payments. These mechanisms impact differently on different households. While there are empirical evidence in developed countries, the distributional impact of such payments and methodological challenges in such assessments in the context of Africa are scarce. Borrowing from the tax literature, the thesis aims to assess the relative impact of health care financing on households' welfare and standards of living. Methodological issues around the assessment of income redistributive impact of health care payments in the context of South Africa are also explored.

Includes bibliographical references (leaves 204-214). / Universal coverage is built around financial protection and access to needed care for all members of the society. The main focus in many countries, including Ghana, has been on financial protection. However removing financial barriers does not necessarily remove other access barriers to the use of health care services. The extent to which a population gains access to health care depends on a multiplicity of factors. The study investigated the distribution of health care benefits across socioeconomic groups, assessed if these benefits are distributed according to need and identified health system and community access factors that influence the distribution of benefits from using health care services in Ghana, in order to identify policy options for promoting equitable access to and use of health services in Ghana.

Includes bibliographical references (leaves 253-282). / The policy motivation for this research is primarily to investigate how in the direct absence of significant third-party financing mechanisms and government subsidies, direct purchase of healthcare affects the relative abilities of households to meet their other financial obligations after paying for the cost of health services. In other words, this study aims to analyze the redistributive effect of the direct healthcare financing in Nigeria.

Hospitals consume a significant proportion of healthcare budgets and are a key avenue for the delivery of key interventions. Understanding how hospitals use resources is therefore an important question. Priority setting research has however focused on the macro (national) and micro (patient) level, and neglected the meso (organizational, hospital) level practices. There is also a dearth of literature on priority setting in developing country hospitals, although they are recognized to suffer severe resource scarcity. This thesis describes and evaluates priority setting practices in Kenyan hospitals and identifies strategies for improvement. METHODOLOGY: A case study approach was used, where two public hospitals in coastal Kenya were selected as cases and three priority setting processes examined as nested cases. Data were collected over a seven month fieldwork period using in - depth interviews, document reviews, and non - participant observations. A modified thematic approach was used for data analysis. FINDINGS: Hospitals exhibit properties of complex adaptive systems (CASs) that exist in a dynamic state with multiple interacting agents. Weaknesses in the system hardware (resource scarcity) and software (tangible - guidelines and procedure s and intangible - leadership and actor relationships) led to the emergence of undesired properties. Both hospitals had comparable system hardware and tangible software, but differences in intangible software contributed to variations in priority setting practices. For example, good leadership and actor relations in one hospital lead to better inclusion of stakeholders and perceptions of fairness while weak leadership, heightened tensions among actors and less inclusive processes in the other hospital lead to distrust and perceptions of unfairness. RECOMMENDATIONS: The capacity of hospitals to set priorities should be improved across the interacting aspects of organizational hardware, and tangible and intangible software. Interventions should however recognize that hospitals are CASs. Rather than rectifying isolated aspects of the system, they should endeavor to create conditions for productive emergence.

There is a global emphasis to move towards universal health coverage (UHC) with the goal of making health services more equitable and accessible for all, without the risk of financial catastrophe when paying for the services. A key element of UHC reforms is to move away from out-of-pocket payments for health services towards a greater emphasis on mandatory prepayment health financing. The main challenge for low- and middle-income countries is how to extend coverage for informal sector populations, which in most cases are disproportionately exposed to catastrophic and impoverishing healthcare costs. This study explored the nature of the informal sector in Kenya, the experience of members of the informal sector with the health system, their views on different prepayment mechanisms for health services and compares the resource requirements for UHC through a system that requires contributions from the informal sector and a system that is non-contributory.

Valid and reliable data on household health expenditure and other household consumption expenditure are important for monitoring the progress towards Universal Health Coverage (UHC). However, the difficulty in obtaining reliable estimates of private expenditure on health often undermine the credibility of health accounts, limit the tracking of financial resources, and make international comparisons extremely difficult. This study assessed the sensitivity of estimates of out-of-pocket health payments and catastrophic health expenditure to the choice of survey instruments. The study used a household budget survey dataset collected in Ghana, in 2017/2018 by the Navrongo Health Research Center. The health expenditure questions were disaggregated into three different levels: Versions I, II and III containing 11, 44 and 56 health expenditure items, respectively. The number of non-health items and recall periods, however, were held constant across versions. Catastrophic health expenditure was measured as out-of-pocket health expenditure that exceeded a certain fraction of household non-food expenditure, depending on the socioeconomic group. Concentration indices were also used to determine the concentration of catastrophic health expenditure. The mean and median household out-of-pocket health expenditure per annum ranged from US$74.11 to USD$106.49, and US$13.69 to US$20.33, respectively depending on the type of survey instrument used. Also, between 7.98% and 12.68% of households incurred catastrophic out-of-pocket health payments, depending on the survey instrument used. The findings show that estimates of out-of-pocket health spending and financial catastrophe are sensitive to the level of disaggregation of out-of-pocket health spending questions in survey instruments. The concentration indices for catastrophic headcount and overshoot were all negative across all catastrophic threshold levels and data versions implying that catastrophic health payments are concentrated among poor households. Further research is needed, preferably validation studies, to enhance the reliability and comparability of estimates of OOP health expenditure and catastrophic health expenditure.

The North West Department of Health requested that research be conducted on ways of addressing the inequity in district Primary Healthcare (PHC) spending. Literature has shown that using a needs- based approach to allocate resources may have a positive effect on equity across geographic areas. This study aimed to examine inequity in current district PHC expenditure, to examine the effect of using a needs-based methodology on equity in resource allocation (by examining different needs-based formulae) and finally to make recommendations on how to promote equity in PHC spending in the province. Mid-to-senior level district and provincial management were interviewed to gain insights into their views on equity, needs-based resource allocation and the indicators of need to be included in the study. The suggested indicators of need were examined and appropriate data sources for each indicator were identified. Two sets of financial data were interrogated: 2013/2014 district PHC expenditure and the total provincial PHC budget from 2009/10 to 2013/14. Finally four needs-based resource allocation formulae were created and the possible effects on equity investigated.

Includes bibliographical references. / The study explores the cost and quality of malaria care in public and private heatlh facilties at the primary health level in an urban community in south western Nigeria. A pre-tested questionnaire is adminstered to patients attending either public or private health facilities to estimate the direct and indirect cost of accessing healthcare services. Costs was estimated from the providers's perspective by using interviews and review of financial records to assess the total and unit cost of such services. Structural quality (adequacy of equipment and staff mix) and process quality (interpersonal relationship, use of treatment guidelines and algorithms) are assessed using structured checklist, observation and proxies such as patients' satisfaction.