Distance as a barrier to health care access in South Africa

Access to health care is a particular concern given the centrality of poor access in perpetuating poverty and inequality. South Africa's apartheid history leaves large racial disparities in access despite post-apartheid health policy to increase the number of health facilities, even in remote rural areas. However, even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health. Using new data from the first nationally representative panel survey in South Africa together with administrative geographic data from the Department of Health, we investigate the role of distance to the nearest facility on patterns of health care utilization. We find that many apartheid legacies remain in place. Ninety percent of South Africans live within 7km of the nearest public clinic, and two-thirds live less than 2km away. However, 15% of Black African adults live more than 5km from the nearest facility, in contrast to only 7% of coloureds and 4% of whites. There is a clear income gradient in proximity to public clinics. Also, we find distance decay in the uptake of important health services such as having a skilled birth attendant, an immunization record and a growth chart for children. The poorest tend to reside furthest from the nearest clinic and an inability to bear travel costs constrains them to lower quality health care facilities. Within this general picture, men and women have different patterns of health care utilization, with the reduction in utilization of health care associated with distance being larger for men than it is for women. Much has been done to redress disparities in South Africa since the end of apartheid but progress is still needed to achieve equity in health care access.