Health care access is complex and multi-faceted and, as a basic right, equitable access and services should be available to all user groups.
The aim of this article is to explore how service delivery impacts on access to healthcare for vulnerable groups in an urban primary health care setting in South Africa.
A descriptive qualitative study design was used. Data were collected through semi-structured interviews with purposively sampled participants and analysed through thematic content analysis.
Service delivery factors are presented against five dimensions of access according to the ACCESS Framework. From a supplier perspective, the organisation of care in the study setting resulted in available, accessible, affordable and adequate services as measured against the District Health System policies and guidelines. However, service providers experienced significant barriers in provision of services, which impacted on the quality of care, resulting in poor client and provider satisfaction and ultimately compromising acceptability of service delivery. Although users found services to be accessible, the organisation of services presented them with challenges in the domains of availability, affordability and adequacy, resulting in unmet needs, low levels of satisfaction and loss of trust. These challenges fuelled perceptions of unacceptable services.
Well developed systems and organisation of services can create accessible, affordable and available primary healthcare services, but do not automatically translate into adequate and acceptable services. Focussing attention on how services are delivered might restore the balance between supply (services) and demand (user needs) and promote universal and equitable access.
L'accès aux soins est complexe et polyvalent, et étant un droit fondamental, tous les groupes d'utilisateurs devraient avoir également accès à ses services.
Le but de cet article est d'examiner l'impact de la prestation de services sur l'accès aux soins pour les groupes vulnérables dans un cadre urbain de soins primaires en Afrique du Sud.
On a utilisé un modèle d'étude qualitative. On a recueilli les données au moyen d'entrevue semi-structurées avec des participants préalablement sélectionnés, puis on les a analysées au moyen d'une analyse thématique du contenu.
Les facteurs de prestation de services sont présentés par rapport à cinq aspects d'accès selon le Cadre ACCESS. Du point de vue du fournisseur, l'organisation des soins dans le cadre de l'étude a eu pour résultat des services disponibles, accessibles, raisonnables et adéquats par rapport aux politiques et directives du Système de santé de district. Cependant, les prestataires de service se sont heurtés à des obstacles considérables dans la prestation de services qui ont eu un effet sur la qualité des soins, et ont mal répondu aux besoins des clients et des prestataires, et ont fini par compromettre l'admissibilité des prestations de service. Bien que les utilisateurs aient trouvé que les services étaient accessible, l'organisation des services présentait des défis dans les domaines de la disponibilité, de la rentabilité et du caractère adéquat, ce qui a eu pour effet des besoins non satisfaits, peu de satisfaction et une perte de confiance. Ces défis ont nourri des sentiments de rejet des services.
Les systèmes et l'organisation de services bien développés peuvent créer des services sanitaires primaires accessibles, abordables et disponibles, mais ne se traduisent pas automatiquement en services adéquats et acceptables. L'attention accordée à la façon dont sont fournis les services pourrait rétablir l'équilibre entre la fourniture (services) et la demande (besoins de l'utilisateur) et promouvoir un accès universel et équitable.
Access to healthcare is a basic human right,
A number of authors have tried to capture the complexity and multi-faceted nature of health care access through different frameworks.
In this article, ACCESS
The dimensions of access to healthcare services according to the ACCESS Framework.
Dimension | Defintion2p1586 | Aspects to consider |
---|---|---|
Availability | ‘The existing health services and goods meet clients` needs.’ | Adequate supply of services, goods and facilities, including types of services, sufficient skilled human resources |
Accessibility | ‘The location of supply is in line with the location of clients.’ | Proximity, means of transportation and travel time |
Affordability | ‘The prices of services fit the clients’ income and ability to pay.’ | Direct and indirect costs of accessing health care |
Adequacy | ‘The organization of health care meets the clients’ expectations.’ | Organisation of services, including the standard of the facilities and meeting user expectations |
Acceptability | ‘The characteristics of providers match with those of the clients.’ | Ethical standards and the appropriateness of services, goods and facilities to address cultural and gender differences and life-cycle requirements; to improve outcomes; and to ensure confidentiality, effective communication and facilitating attitudes |
As set out by Flaskeru and Winslwow
The focus of this article is on the impact of these five dimensions on the health care access of a group of vulnerable users, including people living in poverty, people living with HIV and/or AIDS or chronic conditions such as diabetes mellitus, people with disabilities (PWD), women, all members of women-headed households, youths, elderly people, members of minority cultures and persons with low levels of education and literacy.
This article is based on the results from a large international study entitled ‘Enabling universal and equitable access to healthcare for vulnerable people in resource poor settings in Africa’.
Gugulethu, a small township (less than 10 km2) in the Klipfontein subdistrict of the Klipfontein and Mitchells Plain substructure of the City of Cape Town Metro health district, has a population density of 15 161.7 persons per km
The study population comprised the community and service providers in the public, traditional and private health care services in Gugulethu. Purposive and snowball sampling techniques were employed to identify a participant group with a wide diversity of experience and views.
Eight public health care users, and four persons who stopped using public health care (non-users) were selected from various vulnerable groups in consultation with community leaders and non-governmental organisations.
Vulnerability profile of health care users and non-users.
Vulnerability factor present | Non-users | Users |
---|---|---|
Poverty | 4 | 8 |
HIV and AIDS | 0 | 3 |
Chronic conditions, excluding HIV and AIDS | 2 | 4 |
Physical disability | 3 | 5 |
Women | 3 | 4 |
Women-headed household | 1 | 3 |
Aged | 1 | 0 |
Youth | 0 | 1 |
Minority groups (subculture) | 0 | 1 |
Low level of education (Illiterate or education level of less than grade 7) | 1 | 2 |
Health care providers were purposively sampled from the Community Health Centre (CHC) and two clinics. The first author used her knowledge of the health care system to identify the clinics, one east and the other west of the more centrally located CHC. One clinic was near an informal housing area, whilst the other in a slightly more resourced area with formal housing close to a shopping centre. The public healthcare providers interviewed included professional service providers, community health care workers, support staff (e.g. administrative, cleaning, security) and a community liaison officer.
Occupational profile of providers interviewed at the Primary Health Care facilities.
Post/category of provider | Number |
---|---|
Security staff | 1 |
Cleaning staff | 1 |
HIV and/or AIDS Counsellor | 1 |
Health promoter | 1 |
Administrative clerk | 2 |
Enrolled nurse | 2 |
Orthopaedic aftercare professional nurse | 1 |
Community liaison officer | 1 |
Clinical nurse care practitioner | 1 |
Professional nurse | 3 |
Physiotherapist | 1 |
Family physician | 1 |
Operation manager (professional nurse) | 1 |
Orthotist-prosthetist | 1 |
Social worker | 1 |
Data were collected through 44 semi-structured interviews between April and November, 2010. Fourteen interviews (private general practitioner and traditional healers) were excluded in the results presented in this article since the data did not add any insights to the PHC service delivery process, which is the focus of this study. As an adjunct to the interviews, direct observation
The interviews were divided between research team members according to language proficiency and were conducted by the primary author (14 interviews), a co-researcher (2 interviews) and three research assistants (28 interviews). This might have added bias, since the primary author and co-researcher, unlike the research assistants, are graduates with experience in the fields of research and health care service delivery. The team was trained by the core research group. Additional training sessions for the research assistants were held by the primary author.
Interviews were conducted at venues determined by the participants and included the participants’ homes, places of work and public places such as community centres. The study was explained to each participant, and informed consent and permission to digitally record the interviews was obtained. Interviews lasted between 45 and 90 minutes.
All interviews were transcribed verbatim and the isiXhosa and Afrikaans interviews translated into English. The one Afrikaans translation was verified by the primary author, an Afrikaans first language speaker; the isiXhosa translations were verified by an independent person employed in the public health care service, whose duties included interpreting, and who was not part of the EquitAble research team. Data were analysed using thematic content analysis to identify emerging and recurring themes. Individual experiences and factors relating to health care access were identified and coded from each transcript. Codes were then grouped together into themes. Some themes were predetermined based on the interview schedule, whilst new themes were identified as experiences were explored. Recurring themes were grouped together to eventually form three main themes, as set out in the results section.
Data coding was developed and verified, through discussion in the research team, to allow for comparative coding for the four SA sites.
Triangulation of data was done by comparing experiences of participant groups with one another and was augmented by direct observations and perusal of policy and procedure documents. Presentation of the results to the wider community provided a further opportunity to verify and triangulate the findings.
The study was registered and approved by the Committee for Human Research of Stellenbosch University (reference number N09/10/270), and permission to perform the study was granted by the Western Cape Department of Health for the CHC and the City of Cape Town for the two clinics.
Identifiable information was depersonalised by means of coding along the guidelines developed for the EquitAble framework. All digital data were stored and backed up electronically using password protected entry to both the folders and files. Paper records were archived with Stellenbosch University.
Three main themes, namely service factors, personal factors and environmental considerations were identified. This article presents the findings on the service factors according to the five dimensions of access as defined by the ACCESS Framework:
availability
accessibility
affordability
adequacy
acceptability.
Quotes from the interviews are provided as examples of common themes.
Availability refers to the type of services offered, whether human and other resources are sufficient to meet the demand, and to the knowledge and skills of service providers.
Public healthcare services in Gugulethu are provided by a CHC and four clinics.
Summary of the public health care services in Gugulethu.
Summary | Community health Centre ( |
Clinics ( |
---|---|---|
Hours | 7.30 am until 4.30 pm weekdays | 7.30 am until 4.30 pm weekdays |
24 hours emergency and maternity services | ||
Extended hours (Saturday and after hours clinics) for services such as women's health clinics, children and baby clinics to accommodate people who work. | ||
Health care staff | Medical officer | Professional nurse |
Family physician | Clinical nurse care practitioners | |
Professional nurses | Other levels of nursing staff | |
Clinical nurse care practitioners | Weekly consultant visits by clinical specialists | |
Other levels of nursing staff | Community health workers | |
Social workers | Counsellors | |
Physiotherapists | Health care promoters | |
Community health workers | ||
Counsellors | ||
Health care promoters | ||
Outreach visits by the sub district occupational therapist and prosthetist from the provincial orthotic and prosthetic workshop | ||
Services offered | Full primary health care package | Health promotion |
Various preventative and curative care services |
Although the services offered at the CHC and clinics are in line with District Health System (DHS) requirements (as noted in the process and policy documents perused), users expressed dissatisfaction as services were not always what they expected. For instance, the CHC had both emergency and rehabilitation services, but the clinics did not (see
‘And they [
‘It's not right because I must see the physiotherapist every now and then. I sometimes don't have money but I'm forced to get it [
Observation showed that rehabilitation services were offered at the CHC only and was facility-based with a focus on treating acute conditions through individual sessions weekly, twice monthly, or monthly. Frequency of sessions is often determined by time constraints rather than the norm for specific conditions.
Providers complained that, although they had full staff complements in accordance with the approved post lists (APL), they were not sufficient for the number of patients. Service delivery was further compromised by absenteeism, leave and compulsory training:
‘We do have a high absenteeism rate – that's part of the problem. So you've got … 15 nurses on the staff but there's only seven of them on duty because two of them are on a course, two are on leave and three are off sick, you know. So actually on paper our staff is enough, but maybe on the floor we don't have enough because of absenteeism.’ (Healthcare professional, female, 34–49 years)
Rehabilitation services were provided by one specialised professional nurse and one physiotherapist who also served the larger district. The physiotherapist was based at the CHC whilst the professional nurse was based outside the study area:
‘… sometimes I only get to see a patient every two weeks which is not ideal but that is the best that I can come up with … some patients they require it [
Providers felt that they lacked the necessary knowledge and skills to manage health care for PWD and that the support systems were inadequate:
‘We're just loaded with everything. I would say that the Department of Health is just loading us because it wants us to do everything yet we don't have the skills or the facilities to refer to.’ (Health care professional, female, 50–64 years)
Users with disabilities concurred with this view:
‘They [
‘I thought if they communicate with people or patients, for instance in my case they should have approached my special doctor [
Users in need of comprehensive rehabilitation or medical management of impairments underlying their disabilities are referred to services outside of the area but service providers did not appear well informed of these referral pathways:
‘I think it is more difficult now for the people to get what they need, because there are just so few people who really know what is going on. It takes a long time before the patients are being directed in the proper channels.’ (Healthcare professional, disability-specific services, female, 34–49)
According to the providers many referral services had backlogs, with waiting periods as long as two years.
Periodic shortages of equipment and resources were experienced, particularly in the trauma unit of the CHC:
‘This month it could be gloves. Next month it could be oxygen masks …’ (Health care professional, female, 50–64 years)
In addition, administrative delays were reported with the purchasing of consumables and the replacement of condemned equipment. Equipment was reportedly shared between departments and consultation rooms in the CHC and clinics, leading to time wasted searching for it:
‘… your practitioners are spending most of their time running around to borrow this or to find that. That is not a system that can work, you know.’ (Health care professional, female, 50–64 years)
Whilst some providers found creative solutions, others were unable to deliver services without all available equipment:
‘I mean, we sometimes run out of a certain size of bandages; I just saw [
There was an ample supply of assistive devices, such as basic folding frame wheelchairs, walking sticks and crutches at the CHC. However, periodic shortages of consumables like catheters and stoma bags were reported, and although users are notified and supplied immediately when consumables are again available, they may be without these necessary health supplies for short periods.
In summary, providers and users agreed that service availability was challenged by a lack of equipment and consumables and too few service providers. Services to PWD specifically were further hampered by a lack of disability-specific knowledge, not enough human resources and the way in which services were delivered.
In the context of accessibility within the ACCESS Framework,
Affordability refers to the direct costs of care as well as indirect costs such as travel costs, lost time and loss of income.
According to the liaison officer, long waiting times was the most common complaint received from users. Waiting times varied between two hours for those with scheduled appointments and four hours or longer for those without appointments.
Users employed strategies to decrease waiting times such as asking staff or other users to take their registration cards to the facility ahead of their arrival:
‘Some of them in the neighbourhood ask us, which makes things difficult for us. An old person knocking at your door in the morning – “please can you take my card in there”. You can't say no to an older person …’ (Health care services staff, non-professional services, female, 50–64 years)
In accordance with DHS guidelines users had to access the facility (CHC or clinic) that provided services to the geographic service area (GSA) in which they live. However, some users preferred to access the CHC instead of the clinic in their GSA. They accessed the CHC after normal clinic hours knowing that, in accordance with policy, they would not be turned away:
‘I think they're [
In addition, according to set referral pathways, users are not allowed to access secondary or tertiary level services without a referral from primary level:
‘I don't have a problem to go to hospital. But the road to hospital is via the clinic … I can't go there.’ (Non-user, female, 35–49 years, single parent)
As reported by providers and documents reviewed, in excess of 1500 patients are seen daily at the CHC and at the two clinics investigated. Systems such as appointments and 6-monthly prescriptions for chronic medications were introduced to reduce overcrowding, improve patient management and flow and to contribute to patient-focussed care. Extended service hours and outreach services further improve both access and patient flow. Triage systems at all entry points screen and prioritise unscheduled users. The elderly and PWD receive preferential services. Service delivery is divided into dedicated service streams such as diabetes, hypertension, psychiatric and HIV clinics. These clinics are open on specific days and at specific times (see
‘But I don't always make it (to appointments) when they give me the time and maybe the afternoon can be better for me to attend.’ (User, female, 35–49 years, wheelchair user and partially sighted)
‘In my case, a disability person, I send someone in the morning to stand [
In the past, users were seen on a first come, first serve basis, which resulted in long waiting times and people queuing hours before opening time, often in the dark, with concomitant safety risks of traveling from home in the dark. Despite significant positive changes to improve patient flow, negative perceptions continued to dominate the decision of non-users:
‘No, I stopped (going to the clinic). I almost got killed … one of them had a gun against me …’ (Non-user, female, 80 + years, arthritis)
‘… I can't go to clinic – wake up by 4 am while I'm sick – it's a huge risk to my life.’ (Non-user, female, 35–49 years, single parent)
Similarly, the past lack of systematic management of the patient load causing backlogs and frustration still continues to influence decisions of non-users to not use PHC services:
‘I was the first one in and put my medical card on the nurse's desk but as other people came in, their cards piled up on top of mine and I ended up being the last one. I got so upset and ended up slapping one of the nurses.’ (Non-user, female, 80 + years, arthritis)
Users cannot request a specific health care provider, and follow-up appointments are not made with the same provider. In addition, students and community service providers rotate through the services, often on a monthly basis. These practices impacted negatively on continuity of care and led to poor follow up:
‘Last year I went to the clinic to collect the test results of my father with a letter that shows to them what was done, but each and every one sent me to someone else … They show the signs of lack of understanding and incompetence.’ (User, female, 20–34 years, post-polio, HIV and/or AIDS, single parent)
The second most common complaint the community liaison officer at the CHC dealt with was unmet user expectations:
‘… they complain that the doctor did not treat them according to their specifications.’ (Health care support staff, male, 34–49)
‘I was the one expecting them to take an X-ray for my chest pain but they never did that.’ (User, female, 20–34, post-polio, HIV and/or AIDS, single parent)
‘At [
‘Like sometimes they [
In summary, despite efforts to improve adequacy, defined as the organisation of care, and the extent to which services met the expectations of users, such as the introduction of GSA referral systems, the number of clinics and diversity of services provided, extended hours, outreach services, triage systems, preferential treatment for the elderly and PWD, six monthly prescriptions and organising the services into disease specific clinics, users felt that services did not adequately meet their needs.
Some users found providers to be caring, positive, committed and professional and felt that they were treated in an acceptable manner:
‘Some of the staff are very organised and committed to serve people. They treat us equally and they keep your matters confidentially. So far I'm still satisfied about the way they treated me.’ (User, male, 20–34 years, diagnosis unknown)
‘I use the clinic because they give my treatment and explain to me the direction to use and if I cheat [
Other users experienced the services as unacceptable. They felt providers were disrespectful, rude, uncaring and rushed:
‘… the nurses treat them with no respect.’ (User, female, 20–34 years, post-polio, HIV and/or AIDS, single parent)
‘And you end up sacrificing your last money to go to the private doctor to avoid humiliation because of the behaviour of the staff.’ (User, male, 35–49, amputee)
‘When they [
‘… when you tell the doctor what you have like headache, swollen feet and thrush, the doctor response will say, ‘Do not mention everything! You did not come here to do some grocery shopping.’ (User, female, single parent, 15–19 years, HIV and/or AIDS)
Providers had been accused of favouritism and nepotism:
‘… there is favouritism – they treat better their families and friends. When their friends come, they give them folders before us and they finish sooner than those of us who were there from early in the morning.’ (User, female, 20–34 years, post-polio, HIV and/or AIDS, single parent)
When asked about these user comments, providers acknowledged negative attitudes:
‘It is difficult. Let me see. That's a tricky one because in any environment you've got good potatoes and rotten ones so the truth is that you‘ll find those that will really not work well with the patients, you see. But obviously from time to time I will reprimand them you see? Yes, [
Stringent confidentiality policies and practices inadvertently place the health care support staff in a dilemma and portray them as unhelpful or uncaring:
‘… at times a patient might come out the doctor's consulting room, they will come to you – ‘Where must I go now’? The doctor has told the patient to go to a certain place, but as soon as they come out of this door, the first person they meet they ask, ‘Where must I go to now’. And I as a worker here, I do not have the right to open that folder to guide me where is this person supposed to go. I do not have that right. For that person it must be strange for not knowing where must they go, so my answer to that person will be, ‘Go back to the doctor and ask him where you must go to.’ (Health care services staff, non-professional services, female, 50–64 years)
Yet, at the same time, confidentiality is unintentionally breached by the organisation of services:
‘There is no confidentiality because if you are HIV and/or AIDS or diabetic there are different sides for those diseases. I felt that is wrong because if diagnosed with HIV most of the time you are not ready to be known by other people. They embarrass us because they will call loudly saying: ‘Those who came for antiretroviral drugs that side and the result of HIV that side.’ (User, female, single parent, 15–19 years, HIV and/or AIDS)
User behaviour and low morale amongst providers contributes to negative attitudes:
‘So even patients themselves … they can be very bad. You see? Sometimes some of them come drunk … But sometimes you try to understand their problems because this person is hungry, he is coming from poverty he is vulnerable and he is sick … yes, and that person will take it out on the staff. And they even do it to me sometimes … These behaviours are normally seen over weekends and after four … They come smoking, drinking and all those problems … Or they come during gang fights … some of the gangs will be bringing in their friend they will demand that everything stops … that this is the patient that needs to be seen … Yes, that person must be prioritised and others will just drink and shout and swear, you see?’ (Health care support staff, male, 34–49 years)
‘You will find that in terms of caring for them [
Furthermore, assumptions and stereotyping exclude PWD from general healthcare practices and access:
‘Even the HIV and/or AIDS diseases nurse will say: ‘Hee- hee! Where did you get it?’ It does not register to them that you are sexual active and you have blood. Even if you … are pregnant they will asked why are you pregnant, how this person make you pregnant … by saying how many children do you have and when you tell them they make a joke of you and the other patients will laugh at you and you became frustrated and angry, all of that.’ (User, female, 20–34 years, post-polio, HIV and/or AIDS, single parent)
Similar examples of stigma and discrimination included not giving pamphlets on sexually transmitted infections (STI) to a physically disabled person but to others, giving a room number to a partially sighted patient to find unassisted, and disability accessible toilets being used as storage rooms and kept locked.
Language barriers existed. The majority of the nursing, administrative and support staff spoke isiXhosa, compared to only one of the rest of the professional staff and interns. Although users did not report language to be a barrier, providers frequently did. Since there are no formally trained interpreters, bilingual staff act as interpreters and inadvertently increase their own and other staff-members’ workloads:
‘Sometimes the issue of the language. Maybe the doctor … they [
In general, many users experienced barriers with regards to the acceptability of services, particularly in the form of provider attitudes and the impact of diagnoses-based organisation of services on confidentiality and poor communication. Acceptability of service delivery was compromised for service providers through negative user behaviour, language as barriers, short contact sessions and fragmentation of services.
Considering the historical context of a fragmented and inefficient healthcare system with poor capacity,
Despite full staff complements according to DHS guidelines, daily availability was compromised by a lack of human resources, with providers seemingly under pressure. Care was punctuated by rushed consultations, long waiting times, fragmentation and poor continuity, which together with limited time for patient education culminated in errors and perceptions of poor quality care and a lack of satisfaction amongst users and providers.
Long waiting times seem to be characteristic of the SA healthcare system.
PHC services are largely nurse-driven, but for many users this impacts on adequacy and acceptability of services. Previous studies on nurse-driven services
Large numbers of patients are effectively managed and waiting times reduced through organising services into diagnostic clinics such as HIV, diabetes, hypertension and arthritis clinics. However, such organisation impacted negatively on user privacy and confidentiality and the acceptability of the services. Merely attending a specific clinic or unit robbed the user of confidentiality as their health status was publically displayed. Such unintentional breaches in confidentiality may act as powerful deterrents to accessing public health care services. In addition, this constitutes an impairment-oriented approach that depersonalises the user,
Acceptability of the services was limited as users were disempowered through lack of choice, thus affecting quality of care and satisfaction.
Unmet expectations fuelled perceptions of inadequacy and unacceptability. According to Dixon-Woods and colleagues,
Past studies
Overall the behaviour of both providers and users in this study demonstrated little mutual respect, empathy and tolerance. Unfortunately negative attitudes and unprofessional behaviour of providers noted in this study have all too often been documented within the SA health care literature.
Ongoing trust relationships form the foundation of client centred healthcare
In summary, providers experience significant stressors in their efforts at providing satisfactory heath care, despite many positive features and favourable impressions of the services reported by users. These were, however, quickly overshadowed by negative experiences and perceptions, leaving users feeling disempowered and voiceless, victimised and betrayed by the very system that is supposed to enhance their well-being. Their desperation can be summarised by the lament of this user who responded as follows when her health care needs were not met:
‘My heart is becoming broken.’ (User, female, single parent, 15–19, HIV and/or AIDS)
The qualitative nature of this study limits the generalisability of the results to a wider context.
The language and cultural barrier between the primary researcher and the participants may have affected the depth of experiences explored, especially where an interpreter was used or both parties conversed in their second language.
Considering the limitations of this study and the multi-dimensional facets of health care access, recommendations pertain to the study site only. Some of the recommendations may be applied in other settings after careful consideration of contextual differences and similarities.
Whilst the recommendations are based on the service dimension only, the authors second the need for research in the development of context-specific patient-provider models
In particular, the lack of communication about the service structure and function seems to be an important factor which perpetuates negative perceptions of the services. Community information strategies
Codes of conduct for users (Patient Rights Charter)
The study showed that efficient administrative and logistical organisation of health care service and systems does not automatically translate into adequate and acceptable services from a user's perspective. The balance can be restored by changing how services are delivered and how users are informed. Service delivery should include a patient-centred approach with consideration of aspects such as choice, comprehensive individualised care, continuity of care, shared consultation and participative decision making, non-discrimination, as well as good communication with a focus on mutual respect and courtesy.
Restoring the balance between service provision and user demands should facilitate universal access and equitable health care service delivery, particularly for vulnerable groups, and ensure that the public PHC services become the key to the management of health, as was stated by one of the participants:
‘The clinic is a very most important place to be because it is the key to any health centre or doctor.’ (Non-user, female, 35-49, single parent)
This research was funded by the European Commission Framework Programme 7: Project Title: Enabling universal access to healthcare for vulnerable people in resource poor setting in Africa; Grant agreement No. 223501. With gratitude to all the participants and service providers who willingly shared their experiences.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
E.S. (University of Stellenbosch) did the data collection and analysis and drafted the article. S.V. (University of Stellenbosch) was involved in project design and made conceptual contributions to the article and M.S. (University of Cape Town) was involved in project design and made conceptual contributions to the article.