Women’s access to health care for non-communicable diseases in South Africa: A scoping review.

Search strategy and selection of studies

The authors searched for primary literature from the following databases: Scopus, Web of Science, and PubMed, based on the criteria described above and the search strategy described in Table 1. The reference lists of included studies were also hand-searched for other relevant studies. All retrieved articles were uploaded into EndNote to remove the duplicates. The articles were then uploaded to Rayyan QCRI (Copenhagen: The Nordic Cochrane Centre, Cochrane),²² where titles and abstracts were assessed independently against the inclusion criteria by three reviewers. Disagreements on selected studies were discussed and resolved by consensus or the intervention of a fourth reviewer when necessary. Thereafter, full texts of studies were screened to verify their conformance with the inclusion criteria by three reviewers. Details of excluded studies at this stage and reasons for their exclusion are presented in Figure 2.

Figure 2. Flow of studies included in the review.

Charting the data

Data from eligible studies was charted using a standardised data abstraction tool designed for this study. Macro descriptive data included: Author (s); Title-; Publication year-; study type and the microdata included: Study location; Aim of the study; Study population/sample size; Study design; Duration of the study; type of data analysis used; Study intervention/s; NCD studied; Outcome measured; barriers. Three reviewers independently charted the data from each eligible article. Any disagreements were resolved through discussion between the reviewers or further adjudication by a fourth reviewer.

Collating, summarising, and reporting the results

Both quantitative and qualitative data extracted were summarized in tables or charts (as appropriate) in line with the review questions. The studies were grouped by the specific NCD, and summarized by the type of settings, populations, interventions, study designs, outcome measured, women’s life stage of focus. Identified barriers were mapped onto Levesque’s framework¹ (five supply-side/health system dimensions and five demand-side/population dimensions) on access to health care to determine which points along the chain to accessing NCD-related health care among women are mostly adversely impacted (Figure 1). No additional quantitative analysis was conducted, other than that which was reported in the included source of evidence.

Characteristics of included studies

Of the included studies, two were conducted in Western Cape (WC) province, one study was conducted in Gauteng (GA) province, one was conducted in Mpumalanga, Gauteng, and Limpopo, one study was conducted in Northern Cape (NC) and KwaZulu-Natal, one study was conducted in Eastern Cape (EC) province only, and one study was conducted in all nine provinces of SA. Of the seven included studies, six were published between 2011 and 2021 and one was published in 1997 (Table 2). For primary result articles, two studies included only women, while five studies also included men, but the proportion of women was significantly higher than that of men. Three studies reported barriers of access to T2D-related health care, two studies reported barriers of access to HPT-related health care, while two studies reported barriers of access to both HPT and T2D related health care. No studies reported barriers of access to obesity health care. A descriptive summary of the included studies is presented in Table 2.

Supply-side and demand-side barriers of access to NCD health care

The first dimension of accessibility from a health system perspective in the Levesque’s framework is the approachability dimension, relating to the fact that health care services are identifiable and visible to people facing health needs (Figure 1). In this review, two studies reported barriers that impacted the notion of approachability to services (Table 3). The barriers included women lacking knowledge about services available related to HPT and T2D care²³; miscommunication was identified as a health administration issue in management of maternal HPT.²⁴

Complementary to the dimension of approachability is the demand-side dimension; the person’s or population’s ability to perceive need for care (Figure 1). One study reported barriers impacting the ability to perceive dimension (Table 3). In this study, it was reported that women’s self-awareness of their HPT status was low.²⁵

The second dimension of accessibility from a health system perspective in the Levesque’s framework is acceptability (Figure 1). Acceptability relates to cultural and social factors that impact the person’s possibility to accept different aspects of NCD-related health care services. The barrier related to the acceptability dimension was reported in one study (Table 3). The barrier reported was mistrust of physicians at private hospitals where T2D care is provided arising from treatment fee charges.²⁶

The corollary dimension of acceptability is ability to seek health care, relating to the concepts of individual autonomy, personal capacity to choose to seek NCD-related health care (Figure 1). One study reported barriers that affected this dimension of access to NCDs health care (Table 3), and these included: concerns about confidentiality and perceived discrimination hindering one’s ability to seek health care.²⁷

The third dimension of accessibility from the health system perspective in the Levesque’s framework is availability and accommodation (Figure 1). The dimension relates to the fact that health care services, either the physical space or health care personnel, are reachable both physically and in a timely manner. Six studies reported barriers that impacted on the availability and accommodation dimension of accessibility (Table 3). Physicians’ heavy workloads, and travelling longer distances to reach health facilities²³; medicine and pharmaceutical stock-outs^27,28; poor health facilities in public hospitals^24,26; limited availability of testing equipment, inadequate staffing, and lack of transportation to physically reach service providers,²⁷ transport and safety issues²⁹ are the barriers that impacted availability and accommodation dimension. No barriers were reported to be impacting the demand-side dimension of ability to reach health care.

Affordability is the fourth supply-side dimension of accessibility, and it relates to people’s capacity to spend resources and time to use appropriate services (Figure 1). The dimension captures the direct costs of services and opportunity costs. The barriers related to affordability dimension were presented in two studies (Table 3) and they included: unaffordable transport costs²⁸; and the cost of transport and services being borne by women.²³ The corollary dimension for affordability dimension is the ability to pay for health care, and it describes the capacity of a person to generate economic resources to pay for health care services (Figure 1). One study presented poverty as a barrier to ability to pay for diabetes health care services.²⁸

The fifth supply-side dimension of accessibility is appropriateness, relating to alignment of health care services with patients’ needs, the timeliness and quality of services provided (Figure 1). Three studies presented barriers that impacted appropriateness dimension of access to HPT and T2D care (Table 3). Inefficiently longer waiting times^26,27; and delayed referral and management at an inappropriate level of health care are the factors that adversely affected the appropriateness dimension of access to T2D and HPT care. No barriers were reported to be impacting the demand-side dimension of ability to engage health care.

Important barriers of access to T2D and HPT care

Six out of the seven studies included in this review explored the availability and accommodation dimension (supply-side) of accessibility as depicted in Levesque’s framework of access to health care (Figure 1). This suggests that access to HPT and T2D care may face obstacles right in the middle of the care access process. The findings indicate that from the health system and provider perspective, challenges exist regarding pharmaceutical stock-outs, inadequate staffing, limited availability of testing and screening equipment and poor health facilities.^24,26–28 These factors have been highlighted as key barriers to the management and control of NCDs in SSA and globally.^30–34 Efforts have been undertaken to augment the number of healthcare workers and enhance their capacity to deliver NCD care in SA; however, inadequacies persist in both health care worker availability and the health system’s capacity to cope with the escalating T2D and HPT burden.^35,36 Insufficiency and overstretched staff could benefit from community health workers programmes since such programmes have been reported to be effective in HPT and diabetes control in low- and middle-income countries (LMICs).^36–38 Further, integration of NCDs care services with existing HIV programmes have been reported to be effective in increasing the availability of NCDs care at primary and community health centers.³⁷

Travelling longer distances and limited availability of means of transportation to reach health facilities were also reported as supply-side barriers to access of HPT and T2D care. This is similar to findings from related studies that have been conducted in LMICs.^39,40 It has being reported in SA that the poorest tend to reside furthest from the nearest clinic and their inability to bear travel costs constrains them to lower quality health care facilities.⁴¹ Since distance plays a significant role in mediating health care utilisation behaviour, more research is needed to quantify the relationship between the growing need for NCD care and access to this care nationally among women to support implementation decisions.

Further, two studies cited barriers related to the affordability dimension of access to health care which included unaffordable transport fares incurred by the women during the process of accessing services and all the costs are borne by the patient.^23,28 In a bid to promote equitable financial access to health care services, SA has implemented different health financing policies such as user fee abolitions. Indirect costs such as transport, however, have continued to be highlighted as significant barriers for the poor. Poverty remains a constraint in accessing NCD care, mainly due to the inability to afford transport fares, and recommended medication.^28,42 Similar findings have been reported in other LMICs which have implemented different forms of user fee abolition.^34,39

Women’s lack of information about available HPT and T2D services was highlighted as a barrier impacting the approachability dimension of access to health care.²³ Inadequate knowledge about health care services available limits women’s choice and directly impacts utilisation of the services. Availability of clear, correct, and timely information about NCD services increases women’s abilities to perceive need for care and seeking out for services. This demands more efforts to raise user awareness about HPT and T2D health care services available through use of mass media like radio and television, which has been associated with better use of health services in other LMICs.^43,44

Furthermore, one study reported a low self-awareness of HPT status among women, which negatively impacted their ability to perceive a need for care.²⁵ People’s lack of awareness about NCDs and risk factors especially HPT and T2D is not uncommon in SA and globally.^6,30,45 The lack of knowledge about NCDs and their risk factors among the women and the general population makes it challenging to reduce the burden of NCDs. Adopting of a multisectoral approach such as community health workers raising NCD awareness through health education, and integration of NCD education in school curriculum could assist in behaviour change, increased knowledge about NCD risk factors and care available among women.^37,46

Longer waiting times and delayed referral were cited as barriers that impacted the appropriateness dimension of access to HPT and T2D care.^26,27 Longer waiting periods are largely influenced by the large number of people seeking a specific service and the number of HCWs available to offer the service.^47,48 Given the scale of NCDs burden, integration of the management of diabetes, and HPT into primary health care (PHC) represents a feasible, affordable, and equitable option for addressing women’s needs for NCDs care in a timely manner.⁴⁹ This is because PHC is the most frequent entry point for the general population to the health system, hence offers a great opportunity for early detection and management of high-risk women visiting health services for other reasons such as antenatal care.⁵⁰

Limitations of the review

The concept of health care access is comprehensive, and its definition and influencing factors are still evolving globally. Firstly, as this was a scoping review, the quality of the methodology used in the selected studies was not assessed. Therefore, the summarized findings should be interpreted cautiously, although the consistency of reported barriers across some studies despite the setting, and NCD explored lends some credibility to our findings. Secondly, not all the included studies used the Levesque’s framework when exploring barriers to access, potentially resulting in under- or over-reporting of certain barriers. Thirdly, findings from quantitative and quality studies were not synthesized separately mainly because few studies were included in this review, and the goal of the review was only to summarize barriers to access explored irrespective of any quantitative measures conducted. Fourthly, only studies published in English were included in this review, therefore this may have led to omission of other relevant studies not published in English. Despite these limitations, this scoping review highlights the complexity of access to HPT and T2D care in SA, revealing a paucity of research on healthcare service access related to HPT, T2D, and obesity in South Africa, particularly among women.

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Extended data

Figshare: Review protocol for “Women’s access to health care for non-communicable diseases in South Africa: A scoping review”. https://doi.org/10.6084/m9.figshare.20292480.v1.⁵¹

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).