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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.
Introduction
More than a billion people, mainly in low- and middle-income countries (LMICs), are unable to access needed health services as these are unaffordable.1 In South Africa, health-care access for all is constitutionally enshrined; yet, considerable inequities remain, largely due to distortions in resource allocation.2, 3, 4 Access barriers also include vast distances and high travel costs, especially in rural areas; high out-of-pocket (OOP) payments for care;5 long queues;6 and disempowered patients.7 These barriers, created by uneven social-power relationships, resonate with access hurdles experienced elsewhere in LMICs.1, 8 Globally policy attention has turned to universal health coverage (UHC) as a remedy for inaccessible, unaffordable health services.
Achieving equitable UHC requires the provision of accessible, necessary services ('depth') for the entire population ('breadth'), and accommodating the 'differential needs' and financial constraints of disadvantaged groups ('height').8 Access is therefore the opportunity and freedom to use services,9 and encompasses the circumstances that allow for appropriate service utilization, plus a sufficiently informed individual or household (demand-side) empowered to exercise choice within the health system (supply-side).9, 10 The 'degree of fit' between demand- and supply-sides, rather than each in isolation, determines the degree of access achieved.9
South Africa's apartheid past still shapes health, service, and resource inequities.2 Racial, socio-economic, and rural-urban differentials in health outcomes, and between the public and private health sectors remain challenging.2, 3, 11 In 2005, spending per private medical scheme member was ninefold higher than public sector expenditure, and one specialist doctor served fewer than 500 people in the private sector but around 11 000 in the public sector.11 Large information gaps remain about health access in the general population in South Africa, especially around utilization rates and OOP payments for health care.12 Documenting demand-side perspectives of users, too-long neglected, could inform future policies.8, 9 We conducted a national household survey to fill these gaps and to examine access barriers.
Methods
In 2008, we conducted a...