title: The household costs of health care in rural South Africa with free public primary care and hospital exemptions for the poor.
abstract: OBJECTIVE
  To measure the direct cost burdens (health care expenditure as a percent of total household expenditure) for households in rural South Africa, and examine the expenditure and use patterns driving those burdens, in a setting with free public primary health care and hospital exemptions for the poor.
  
  
  METHODS
  Data on illness events, treatment patterns and health expenditure in the previous month were assessed from a cross-sectional survey of 280 households conducted in the Agincourt Health and Demographic Surveillance site, South Africa.
  
  
  RESULTS
  On average, a household experiencing illness incurred a direct cost burden of 4.5% of total household expenditure. A visit to a public clinic generated a mean burden of 1.3%. Complex sequences of treatments led 20% of households to incur a burden over 10%, with transport costs generating 42% of this burden. An outpatient public hospital visit generated a burden of 8.2%, as only 58% of those eligible obtained an exemption; inpatient stays incurred a burden of 45%. Consultations with private providers incurred a mean burden of 9.5%. About 38% of individuals who reported illness did not take any treatment action, 55% of whom identified financial and perceived supply-side barriers as reasons.
  
  
  CONCLUSIONS
  The low overall mean cost burden of 4.5% suggests that free primary care and hospital exemptions provided financial protection. However, transport costs, the difficulty of obtaining hospital exemptions, use of private providers, and complex treatment patterns meant state-provided protection had limitations. The significant non-use of care shows the need for other measures such as more outreach services and more exemptions in rural areas. The findings also imply that fee removal anywhere must be accompanied by wider measures to ensure improved access.
authors.affiliation: University of Witwatersrand, Johannesburg, South Africa. jane.goudge@gmail.com
authors.forename: Jane
authors.initials: J
authors.lastname: Goudge
authors.forename: Lucy
authors.initials: L
authors.lastname: Gilson
authors.forename: Steve
authors.initials: S
authors.lastname: Russell
authors.forename: Tebogo
authors.initials: T
authors.lastname: Gumede
authors.forename: Anne
authors.initials: A
authors.lastname: Mills
mesh_terms: D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000191:economics*; D005249:Fees and Charges; D005102:Health Expenditures; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D010342:Patient Acceptance of Health Care; D011320:Primary Health Care / Q000191:economics*; D012423:Rural Health; D019035:Rural Health Services / Q000191:economics*; D013019:South Africa