Table 1 Overview of the policies of focus

Uniform Patient Fee Schedule

After national-level approval, the UPFS was implemented across provinces in 2001/2. It sought to ensure the uniform billing of public hospital patients and stipulated that certain services, for example primary care and services to pregnant women and children younger than 6 years, were free of charge to all or almost all (members of health insurance schemes were, for example, excluded from certain free services). Other services were charged according to the patient’s income sources and levels and, where applicable, other factors such as health insurance membership and non-South African citizenship. Patients were classified as H0 (fully subsidised), H1 (highly subsidised), H2 (moderately subsidised), and H3 (full public sector rate) [46].

For exemptions and patient classification, H1 was the default category for a patient without sufficient proof of income. Providing documents from other government agencies, for example a card to prove receipt of a social grant or income from the Unemployment Insurance Fund (formal unemployment), would result in a move to H0.

For other patients, especially the self-employed and those not regarded as formally unemployed, classification or exemption could involve making sworn statements at police stations to “prove” their unemployment (although this was not accepted by all facilities), completing an income and expenditure form, and providing proof of bills such as utility accounts that might shed light on their financial position.

Patients Rights Charter

The PRC, launched in the late 1990s, outlined to patients and health workers the common standards of service and behaviour expected. It was partly intended to rebalance the patient-health system relationship and to bring healthcare provision in line with South Africa’s new constitution, given that during the apartheid era “the vast majority of the South African population has experienced either a denial or violation of fundamental human rights, including rights to health care services” [47]. The PRC contained rights such as refusal of treatment, confidentiality and privacy, and a healthy and safe environment, which were balanced by responsibilities such as complying with prescribed treatment, taking care of health records, and respecting the rights of other patients and health workers.