Journal of Public Health Policy

, Volume 32, Supplement 1, pp S102–S123 | Cite as

Inequities in access to health care in South Africa

  • Bronwyn HarrisEmail author
  • Jane Goudge
  • John E Ataguba
  • Diane McIntyre
  • Nonhlanhla Nxumalo
  • Siyabonga Jikwana
  • Matthew Chersich
Original Article


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.


out-of-pocket payments access health-care utilization inequities household survey South Africa 



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.


  1. World Health Organization. (2010) The World Health Report – Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organisation.Google Scholar
  2. 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.CrossRefGoogle Scholar
  3. 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.CrossRefGoogle Scholar
  4. Constitution of the Republic of South Africa. (No. 108 of 1996). Statutes of the Republic of South Africa – Constitutional Law 38: 1241–1331,, accessed 4 May 2011.
  5. 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.CrossRefGoogle Scholar
  6. 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.CrossRefGoogle Scholar
  7. 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.CrossRefGoogle Scholar
  8. 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,, accessed 4 May 2011.Google Scholar
  9. 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.CrossRefGoogle Scholar
  10. Penchansky, R. (1977) The Concept of Access: A Definition. Hyattsville, MD: National Health Planning Information Centre.Google Scholar
  11. 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.Google Scholar
  12. 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.Google Scholar
  13. 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.Google Scholar
  14. 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.CrossRefGoogle Scholar
  15. 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.CrossRefGoogle Scholar
  16. 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.CrossRefGoogle Scholar
  17. 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.CrossRefGoogle Scholar
  18. Tudor Hart, J. (1971) The inverse care law. Lancet 297 (7696): 405–412.CrossRefGoogle Scholar
  19. 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.Google Scholar
  20. 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.CrossRefGoogle Scholar
  21. 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.CrossRefGoogle Scholar
  22. 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.Google Scholar
  23. 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.Google Scholar
  24. 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.Google Scholar
  25. 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.CrossRefGoogle Scholar
  26. Gilson, L. and Erasmus, E. (2005) Supporting the Retention of HRH: SADC Policy Context. Johannesburg: Centre for Health Policy. Equinet Discussion Paper No. 26.Google Scholar
  27. Mann, C.J. (2003) Observational research methods. Research design II: Cohort, cross sectional, and case-control studies. Emergency Medicine Journal 20 (1): 54–60.CrossRefGoogle Scholar
  28. 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.CrossRefGoogle Scholar

Copyright information

© Palgrave Macmillan, a division of Macmillan Publishers Ltd 2011

Authors and Affiliations

  • Bronwyn Harris
    • 1
    Email author
  • Jane Goudge
    • 1
  • John E Ataguba
    • 2
  • Diane McIntyre
    • 2
  • Nonhlanhla Nxumalo
    • 1
  • Siyabonga Jikwana
    • 3
  • Matthew Chersich
    • 1
    • 4
  1. 1.Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Private Bag X3, WitsJohannesburgSouth Africa
  2. 2.Health Economics Unit, School of Public Health and Family Medicine, University of Cape TownCape TownSouth Africa
  3. 3.National Department of HealthPretoriaSouth Africa
  4. 4.Department of Obstetrics and GynecologyInternational Centre for Reproductive Health, Faculty of Medicine, Ghent UniversityGhentBelgium

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