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      Women’s costs for accessing comprehensive sexual and reproductive health services: findings from an observational study in Johannesburg, South Africa

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          Abstract

          Background

          Evaluating progress towards the Sustainable Development Goal of universal access to sexual and reproductive (SRH) services requires an understanding of the health needs of individuals and what constitutes access to services. We explored women’s costs of accessing SRH services in Johannesburg, South Africa and contextualized costs based on estimates of household income.

          Methods

          We conducted an observational study of women aged 18–49 at a public HIV treatment site and two public primary health care facilities from June 2015 to August 2016. Interviews assessed women’s SRH needs (for contraception, fertility problems, menstrual problems, menopause symptoms, sexually transmitted infections (STI), experiences of intimate-partner violence (IPV), and cervical and breast cancer screening) and associated costs. We calculated average and total costs (including out-of-pocket spending, lost income, and estimated value of time spent) for women who incurred costs. We also estimated the total and average costs of meeting all SRH needs in a hypothetical “full needs met” year. Finally, we contextualize SRH spending against a measure of catastrophic expenditure (> 10% of household income).

          Results

          Among the 385 women who participated, 94.8% had at least one SRH need in the prior 12 months; 79.7% incurred costs for accessing care. On average, women spent $28.34 on SRH needs during the prior year. Excluding one HIV-negative woman who spent 112% of her annual income on infertility treatment, HIV-positive women spent more on average annually for SRH care than HIV-negative women. Sixty percent of women reported at least one unmet SRH need. If all participants sought care for all reported needs, their average annual cost would rise to $52.65 per woman. Only two women reported catastrophic expenditure – for managing infertility.

          Conclusions

          SRH needs are constants throughout women’s lives. Small annual costs can become large costs when considered cumulatively over time. As South Africa and other countries grapple with increasing access to SRH services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to SRH services.

          Plain English summary

          Literature on women’s financial and economic costs for accessing comprehensive sexual and reproductive health care in low- and middle-income countries is extremely limited, and existing literature often overlooks out-of-pocket costs associated with travel, child care, and time spent accessing services. Using data from a survey of 385 women from a public HIV treatment site and two public primary health care facilities in Johannesburg, we found nearly all women reported at least on sexual and reproductive health need and more than 75% of women incurred costs related to those needs. Furthermore, more than half of women surveyed reported not accessing services for their sexual and reproductive health needs, suggesting a total annual cost of more than $50 USD, on average, to access services for all reported needs. While few women spent more than 10% of their total household income on sexual and reproductive health services in the prior year, needs are constant and costs incur throughout a woman’s life suggesting accessing services to meet these needs might still result in financial burden. As South Africa grapples with increasing access to sexual and reproductive health services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to services.

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          Most cited references5

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          Universal health coverage and universal access.

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            The Impact of Health Insurance on Health-care Utilisation and Out-of-Pocket Payments in South Africa

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              Accessing medical and surgical first-trimester abortion services: women's experiences and costs from an operations research study in KwaZulu-Natal Province, South Africa

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                Author and article information

                Contributors
                naomi.lince.deroche@gmail.com
                berrykm1@bu.edu
                chendricksosn@heroza.org
                tsineke@heroza.org
                skgowedi@heroza.org
                Masangu.Mulongo@righttocare.org
                Journal
                Reprod Health
                Reprod Health
                Reproductive Health
                BioMed Central (London )
                1742-4755
                16 December 2019
                16 December 2019
                2019
                : 16
                : 179
                Affiliations
                [1 ]ISNI 0000 0004 1937 1135, GRID grid.11951.3d, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, , University of the Witwatersrand, ; 39 Empire Road, Parktown, Johannesburg, South Africa
                [2 ]ISNI 0000 0004 1936 7558, GRID grid.189504.1, Department of Global Health, , Boston University School of Public Health, ; 801 Massachusetts Ave. 3rd Floor, Boston, MA 02118 USA
                [3 ]GRID grid.415447.7, Right to Care, , Helen Joseph Hospital, ; Perth Road, Westdene, Johannesburg, South Africa
                Author information
                http://orcid.org/0000-0003-3689-4205
                Article
                842
                10.1186/s12978-019-0842-2
                6916226
                31842904
                3ea16299-5bc8-48a5-b665-0b87b843d168
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 30 July 2018
                : 3 December 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000200, United States Agency for International Development;
                Award ID: AID-674-A-12-00029
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2019

                Obstetrics & Gynecology
                contraception,cervical cancer,breast cancer,menstruation,fertility,menopause,gender-based violence,economic,affordability

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