Abstract
Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population without imposing an unaffordable burden on individuals or households. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n=4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.
Similar content being viewed by others
References
World Health Organization. (2010) The World Health Report – Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organisation.
Coovadia, H., Jewkes, R., Barron, P., Sanders, D. and McIntyre, D. (2009) The health and health system of South Africa: Historical roots of current public health challenges. Lancet 374 (9692): 817.
Gilson, L. and McIntyre, D. (2007) Post-apartheid challenges: Household access and use of health care in South Africa. International Journal of Health Services 37 (4): 673–691.
Constitution of the Republic of South Africa. (No. 108 of 1996). Statutes of the Republic of South Africa – Constitutional Law 38: 1241–1331, http://www.info.gov.za/documents/constitution/1996/a108-96.pdf, accessed 4 May 2011.
Goudge, J., Russell, S., Gilson, L., Gumede, T., Tollman, S. and Mills, A. (2009) Illness-related impoverishment in rural South Africa: Why does social protection work for some households but not others? Journal of International Development 21: 231–251.
Nteta, T.P., Mokgatle-Nthabu, M. and Oguntibeju, O.O. (2010) Utilization of the primary health care services in the Tshwane region of Gauteng province, South Africa. PLoS ONE 5 (11): e13909.
Schneider, H., le Marcis, F., Grard, J., Penn-Kekana, L., Blaauw, D. and Fassin, D. (2010) Negotiating care: Patient tactics at an urban South African hospital. Journal of Health Services Research & Policy 15 (3): 137–142.
Frenz, P. and Vega, J. (2010) Universal Health Coverage with Equity: What We Know, Don’t Know and Need to Know. Background paper for the global symposium on health systems research. Montreux, Switzerland: First Global Symposium on Health Systems Research, http://www.hsr-symposium.org/images/stories/9coverage_with_equity.pdf, accessed 4 May 2011.
Thiede, M., Akweongo, P. and McIntyre, D. (2007) Exploring the dimensions of access. In: D. McIntyre and G. Mooney (eds.) The Economics of Health Equity. Cambridge: Cambridge University Press, pp. 103–123.
Penchansky, R. (1977) The Concept of Access: A Definition. Hyattsville, MD: National Health Planning Information Centre.
McIntyre, D. et al (2007) A Critical Analysis of the Current South African Health System. Cape Town, South Africa: Health Economics Unit, University of Cape Town and Centre for Health Policy, University of the Witwatersrand.
Ataguba, J. and McIntyre, D. (2009) Financing and Benefit Incidence in the South African Health System: Preliminary Results. Cape Town: Health Economics Unit. Report No. 09-1.
McIntyre, D., Goudge, J., Harris, B., Nxumalo, N. and Nkosi, M. (2009) Prerequisites for national health insurance in South Africa: Results of a national household survey. South African Medical Journal 99 (10): 725–729.
Nxumalo, N., Alaba, O., Harris, B., Chersich, M. and Goudge, J. (2011) Utilization of traditional healers in South Africa and costs to patients: Findings from a national household survey. Journal of Public Health Policy 32 (Supp 1): S124–S136.
Rao, J.N.K. and Scott, A.J. (1984) On chi-squared tests for multi-way contingency tables with cell proportions estimated from survey data. Annals of Statistics 12: 46–60.
McIntyre, D., Muirhead, D. and Gilson, L. (2002) Geographic patterns of deprivation in South Africa: Informing health equity analyses and public resource allocation strategies. Health Policy and Planning 17 (1): 30–39.
McIntyre, D. and Gilson, L. (2002) Putting equity in health back on the social policy agenda: Experience from South Africa. Social Science and Medicine 54 (11): 1637–1656.
Tudor Hart, J. (1971) The inverse care law. Lancet 297 (7696): 405–412.
McIntyre, D., Gilson, L., Valentine, N. and Soderlund, N. (1998) Equity of Health Sector Revenue Generation and Allocation: A South African Case Study. Washington DC: Partnerships for Health Reform.
Sauerborn, R., Adams, A. and Hien, M. (1996) Household strategies to cope with the economic costs of illness. Social Science and Medicine 43 (3): 291–301.
Xu, K., Evans, D.B., Kawabata, K., Riadh, Z., Klavus, J. and Murray, C.J. (2003) Household catastrophic health expenditure: A multi-country analysis. Lancet 362 (9378): 111–117.
Saksena, P., Xu, K., Elovaino, R. and Perrot, J. (2010) Health Services Utilization and Out-of-Pocket Expenditure at Public and Private Facilities in Low-income Countries. Geneva: World Health Organisation. Background paper no. 20.
African National Congress. National Health Insurance. (2010) ANC National General Council, Additional Discussion Documents. 24–28 September; Durban, South Africa: African National Congress. pp. 1–48.
Nkosi, M., Govender, V., Erasmus, E. and Gilson, L. (2008) Investigation the Role of Power and Institutions in Hospital-level Implementation of Equity-oriented Policies. Johannesburg, South Africa: Centre for Health Policy, University of the Witwatersrand; Health Economics Unit, University of Cape Town and London School of Hygiene and Tropical Medicine.
Gilson, L. (2007) Acceptability, trust and equity. In: D. McIntyre and G. Mooney (eds.) The Economics of Health Equity. Cambridge: Cambridge University Press, pp. 124–147.
Gilson, L. and Erasmus, E. (2005) Supporting the Retention of HRH: SADC Policy Context. Johannesburg: Centre for Health Policy. Equinet Discussion Paper No. 26.
Mann, C.J. (2003) Observational research methods. Research design II: Cohort, cross sectional, and case-control studies. Emergency Medicine Journal 20 (1): 54–60.
Hunt, P. (2006) The human right to the highest attainable standard of health: New opportunities and challenges. Transactions of the Royal Society of Tropical Medicine and Hygiene 100 (7): 603–607.
Acknowledgements
For their highly valued contribution to the data collection, management and analysis, we would like to thank our colleagues, including Vanessa Daries, Veloshnee Govender, Okore Okorafor, Robert Moeti, Adelaide Maja, Natasha Palmer, Anne Mills, and Olufunke Alaba. For conceptual guidance, we would like to thank Duane Blaauw and Laetitia Rispel. SACBIA survey was a collaborative initiative between Health Economics Unit, University of Cape Town; Centre for Health Policy, University of the Witwatersrand; South African National Department of Health (NDoH); and the London School of Hygiene and Tropical Medicine. NDoH funded the survey through a European Union grant. The Community Agency for Social Enquiry collected the data. Diane McIntyre is supported by the South African Research Chairs Initiative of the Department of Science and Technology and National Research Foundation.
Author information
Authors and Affiliations
Corresponding author
Additional information
Drawing on a national household survey, the authors found barriers to equitable access to health care in South Africa. They highlight the importance of understanding access barriers from the user-perspective in order to achieve universal health care coverage.
Rights and permissions
About this article
Cite this article
Harris, B., Goudge, J., Ataguba, J. et al. Inequities in access to health care in South Africa. J Public Health Pol 32 (Suppl 1), S102–S123 (2011). https://doi.org/10.1057/jphp.2011.35
Published:
Issue Date:
DOI: https://doi.org/10.1057/jphp.2011.35