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.

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BackgroundLow-income and middle-income countries (LMICs) have difficulties achieving universal financial protection, which is primordial for universal health coverage. A promising avenue to provide universal financial protection for the informal sector and the rural populace is community-based health insurance (CBHI). We systematically assessed and synthesised factors associated with CBHI enrolment in LMICs.MethodsWe searched PubMed, Scopus, ERIC, PsychInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL, Cochrane Library, conference proceedings, and reference lists for eligible studies available by 31 October 2013; regardless of publication status. We included both quantitative and qualitative studies in the review.ResultsBoth quantitative and qualitative studies demonstrated low levels of income and lack of financial resources as major factors affecting enrolment. Also, poor healthcare quality (including stock-outs of drugs and medical supplies, poor healthcare worker attitudes, and long waiting times) was found to be associated with low CBHI coverage. Trust in both the CBHI scheme and healthcare providers were also found to affect enrolment. Educational attainment (less educated are willing to pay less than highly educated), sex (men are willing to pay more than women), age (younger are willing to pay more than older individuals), and household size (larger households are willing to pay more than households with fewer members) also influenced CBHI enrolment.ConclusionIn LMICs, while CBHI schemes may be helpful in the short term to address the issue of improving the rural population and informal workers’ access to health services, they still face challenges. Lack of funds, poor quality of care, and lack of trust are major reasons for low CBHI coverage in LMICs. If CBHI schemes are to serve as a means to providing access to health services, at least in the short term, then attention should be paid to the issues that militate against their success.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1179-3) contains supplementary material, which is available to authorized users.