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Affordability: an exploration of the missing criterion in health system decision making

Project Description

We are looking to recruit an enthusiastic and talented PhD student to work with Susan Cleary and John Ataguba at the University of Cape Town and Joanna Coast and Will Hollingworth at the University of Bristol. This 4-year studentship is based across the two Universities, with the student expected to spend approximately equal time in each location. The PhD will focus on theoretical development of the concept of 'affordability' in health care decision making and empirical exploration of this concept across the two very different settings of South Africa & UK, with the ultimate aim of informing policy development in the South African context.

Research Aims

Affordability is an important consideration at the health system level, although the issue has often been fudged or ignored. The emphasis within health economics has typically been on the criterion of cost-effectiveness, but cost-effectiveness thresholds have often been developed without explicit consideration of affordability either within the health system or broader society. There is increasing disquiet about both the theoretical and empirical bases of the cost-effectiveness thresholds typically used in decision making, with international organisations such as WHO starting to focus on this issue.

These issues are particularly pertinent for South Africa, where a policy commitment to universal health coverage (UHC) under a proposed system of National Health Insurance (NHI) seeks substantive health system organisational and financing reforms. As part of these reforms, the NHI legislation will be developed during the period 2017-2022 and the resulting institutions will need to grapple directly with the challenges associated with affordability. These challenges are particularly stark for countries such as South Africa where, compared to other upper-middle income countries, health spending per capita is high but access to care is highly variable and health outcomes are poor. The aim of this research will therefore be to theoretically develop the concept of 'affordability' in priority setting and to explore this concept empirically across the two very different settings of South Africa & UK.

Research Approach

The student will initially explore concepts of affordability within health care decision making, drawing on the broad priority setting literature from across a number of disciplines, including economics, philosophy, politics/policy and psychology. The empirical research will involve the use of in-depth interviews with local and national decision makers and the application of quantitative techniques to explicitly account for affordability in decision making.

Candidate requirements

This programme is open only to citizens of South Africa and other African countries that are included on the OECD Development Assistance Committee (DAC) list.

Academically, candidates for the PhD may qualify for admission if they have: a Master’s degree; an Honours degree, or a 4-year Bachelor’s degree, plus at least 1 year of registration for the Master’s degree; a 3-year Bachelor’s degree plus at least 2 years of registration for a Master’s degree. The PhD candidate will ideally have a background in economics/health economics or another relevant (social science or medical) discipline.

For further details please see . Interested and suitably qualified candidates should make informal contact with Joanna Coast (), Susan Cleary (), Will Hollingworth () or John Ataguba () before 14th May 2019. The project is available for immediate start.

How to apply

Please make an online application for this project at Please select Faculty of Health Sciences and Population Health Science PhD on the Programme Choice page. You will be prompted to enter details of the studentship in the Funding and Research Details sections of the form. For general enquiries linked to the online application process, please email

Funding Notes

This is a fully-funded PhD Scholarship which includes all tuition fees. When the student is physically present in Bristol, they will receive the standard UK stipend for PhD students, scaled to the amount of time spent in Bristol (currently £14.8 k per annum). Similarly, when the student is resident in Cape Town they will receive a PhD Fellowship award of ZAR 200 000 per year or part thereof (which includes the PhD tuition fee of between ZAR 20 – and ZAR 30 000). A sum of £3k per year is available to cover project expenses, directly incurred as a part of the research. Three return air flights are also included in the Scholarship package, and funds to attend one international conference during the PhD will be provided.

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