DESK REVIEWS | Is access to health services universal? What are the potential barriers? Are there specific geographical areas or population groups for which access to health care is problematic?

DESK REVIEW | Is access to health services universal? What are the potential barriers? Are there specific geographical areas or population groups for which access to health care is problematic?

Yes, universality is one of the principles of SUS. The SUS is based on three doctrinal principles: universality (any Brazilian citizen has the right to access health services in Brazil – this right is well stablished by the Federal Constitution, 1988), equity (aims to diminish health inequalities), and integrated care (regarding person-centred care) (Brazilian Ministry of Health, n.d.-b).

Potential barriers for universal access to health are geographical (related to distance and transportation costs to health care units), financial (the more expensive the services are, the less accessible they become), managerial (quality of personal, waiting lists etc.), and informational (related to education, self-perception of health etc.).

Access to health services is more problematic in some areas, such as riverside communities and in the countryside. Difficult access to these remote areas, in  addition to poor working conditions discourages health professionals to work in such places (Brazilian Society for Medical Clinic, 2019). As an attempt to overcome this barrier, the government developed strategies such as the fluvial family health strategies (where family health teams go to riverside communities by boat) to expand access in places like Amazonia. In addition, the National Policy for Primary Care expands the coverage of health services provision through the creation of UBSs (Basic Care Units) and emergency care units (UPAs) (Brazilian Ministry of Health, 2012). Access to health services is also problematic among indigenous people due to difficulties regarding geographical access, cultural aspects etc. Therefore, the Ministry of Health put together a specific unit responsible for delivering health services for indigenous people (Brazilian Ministry of Health, 2019p).


Brazilian Ministry of Health. (2012). Política Nacional de Atenção Básica.

Brazilian Ministry of Health. (2019p, June 20). Secretaria Especial de Saúde Indígena.

Brazilian Ministry of Health. (n.d.-b). Princípios do SUS. Retrieved December 3, 2019.

Brazilian Society for Medical Clinic. (2019). Médicos para as áreas remotas. Sociedade Brasileira de Clínica Médica.


Hong Kong’s health system provides universal access to a wide range of public healthcare services, including inpatient care, general and specialist outpatient care, health protection and promotion, prevention services, and community services. Yet, like in many developed countries, affordability is a significant barrier to effective use of healthcare services in Hong Kong. In particular, inequity is most apparent in access to outpatient services. Long waiting time is a huge and common issue for public specialist outpatient services and accident and emergency services (Leung & Bacon-Shone, 2006; Our Hong Kong Foundation, 2018). Such long waiting times disproportionately impact patients with a lower income who have difficulty affording private care or are left living with diminished access to public health services (Yam et al., 2011).


Leung, G. M., & Bacon-Shone, J. (2006). Hong Kong’s health system: Reflections, perspectives and visions: Hong Kong University Press.

Our Hong Kong Foundation. (2018). Fit for Purpose: A Health System for the 21st Century. Retrieved from

Yam, C. H., Liu, S., Huang, O. H., Yeoh, E., & Griffiths, S. M. J. B. h. s. r. (2011). Can vouchers make a difference to the use of private primary care services by older people? Experience from the healthcare reform programme in Hong Kong. 11(1), 255.

Access to health services remains varied (Baru et al., 2010). Several equity indicators, such as gender, literacy, geographic location (e.g., rural versus urban), and socioeconomic status, influence this (Baru et al., 2010). These operate through complex inter-woven pathways of awareness (e.g., sensitivity to symptoms; services needed), availability (e.g., service provisioning at point-of-care; distance), affordability (e.g., public versus private versus unregulated/informal care providers; generalist versus specialist care), and acceptability (e.g., basket of choices offered, quality of care, provider profile). It has been observed that access is also determined by the profile of the health condition (Kasthuri, 2018). Those with minor ailments, for example, are likely to use care since this is available at the primary level at low cost without the need for specialist opinion and advanced diagnostics (Barik and Thorat, 2015).

Access to care is poor in the empowered action group states (states in central and north-central belt of India that have traditionally had poor health and development indicators) (Kumar and Singh, 2016). Access to care services is also challenging for the urban poor residing in slums and urban settlements (Gupta and Mondal, 2015).

With respect to access to particular health care services, maternal health care service delivery has been strengthened for pregnancy and childbirth related care; however, access to postpartum services and follow up, and care services for sick new-borns (especially institutionalised care) is patchy (Paul et al., 2011). Whereas geriatric care, including home-based care and institutional facilities for adults, is limited across the country, sparing the metropolitan cities (ARDSI, 2010).

The Government of India (GOI) is committed towards addressing these challenges and achieving the goal of Universal Health Coverage (UHC) for its population, especially for the poorest, through Ayushman Bharat (Ayushman Bharat-HWCs and Ayushman Bharat-PMJAY). The Government has also made efforts to cap the cost of items (such as essential scheduled drugs, certain medical devices, consumables etc.) and regulate establishments (the Clinical Establishment Act of 2010) to secure affordability and quality in the private health sector (Ministry of Law and Justice, 2010; National Pharmaceutical Pricing Authority, 2013). However, these have coincided with failure of the private health sector and single-doctor facilities to thrive and sustain. Since most of the urban care provision is delivered by the private sector and the per capita annual public budget commitment to health (and as proportion of the national GDP) (NHSRC, 2021) by India continues to be amongst the lowest in the world, the health sector is headed for complex evolution.


Alzheimer’s and Related Disorders Society of India (ARDSI). (2010). THE DEMENTIA INDIA REPORT  2010: Prevalence, impact, cost and services for dementia. New Delhi. Available from

Barik, D., & Thorat, A. (2015). Issues of unequal access to public health in India. Frontiers in public health3, 245.

Baru, R., Acharya, A., Acharya, S., Kumar, A. S., & Nagaraj, K. (2010). Inequities in access to health services in India: caste, class, and region. Economic and political Weekly, 49-58.

Gupta, I., and Mondal, S. (2015). Urban health in India: who is responsible? The International Journal of Health Planning and Management, 30(3), 192–203.

Kasthuri, A. (2018). Challenges to Healthcare in India – The Five A’s. Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine, 43(3), 141–143. Available from:

Kumar, V., & Singh, P. (2016). Access to healthcare among the Empowered Action Group (EAG) states of India: Current status and impeding factors. The National medical journal of India29(5), 267.

Ministry of Law and Justice. (2010). The Clinical Establishments (Registration and Regulation) Act. Government of India. Available from:

National Health System Resource Centre (NHSRC). (2021). National Health Accounts-Estimates for India: 2017-2018. Ministry of Health and Family Welfare, Government of India. Available from:

National Pharmaceutical Pricing Authority. (2013). List of Notified Prices. Department of Pharmaceuticals, Ministry of Chemical and Fertilizers. Government of India. Available from:

Paul, V. K., Sachdev, H. S., Mavalankar, D., Ramachandran, P., Sankar, M. J., Bhandari, N., … & Kirkwood, B. (2011). Reproductive health, and child health and nutrition in India: meeting the challenge. The Lancet, 377(9762), 332–349.

Despite its recent introduction (2014), the NHIS is reported to have reached almost 70 per cent of the population (Agustina et al., 2019, p.76).

However, there appear to be substantial gaps in terms of coverage of the so-called ‘missing middle’, even though considerable subsidies and improved access to health care for those living in poverty have been established. This ‘missing middle’  represents approximately 34.4 million people who are working in informal employment but not living in poverty. While some argue that this group does not seek insurance cover due to the required premiums, others suggest that ‘availability of services and poor understanding of health insurance’ stops people from signing up (Agustina et al., 2019, p.94)

Agustina and colleagues (2019, p.76) further report that the availability and quality of primary care services, drugs, and medical supplies as well as the poor and disassociated health information systems pose challenges to the provision of universal health care in Indonesia.


Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102.

The introduction of UHC, named “Afya Care” described above supports only 5% of the population (4 counties) during its pilot phase. In 2022, the World Bank funded programme will be rolled-out across all counties (Kariuki, 2019). In addition to the four counties covered by ‘Afya Care’, one county that is not among the trial counties has implemented‘Makueni care’ which covers access to public health services. This leaves 42 counties to rely on NHIF.  In those counties, members (formal and informal workers) have to either make monthly contributions in order to access either public or private health care or pay at the hospital similar to other community members. NHIF has contracted hospitals under three categories (A, B and C) for contributors. Under category A (government hospitals), members enjoy full and comprehensive cover (maternity and medical diseases including surgery). Category B (some private and mission hospitals), members receive a comprehensive cover but in case of a surgery, the member would co-pay.  Category C (private), members pay specified daily benefits (NHIF, 2020). If the fee in a particular hospital exceeds the insurance limit, patients are required to pay the balance. Patients are therefore encouraged to visit hospitals that are within the NHIF cover.

To become members, those working in the informal sector can opt to pay a monthly premium of 500 Kenya Shillings (about $5.00 US dollars) per household to access both outpatient and inpatient services or directly pay for the services at the point of care. The formal sector contributions are based on salary scales (representing 2.4% of the gross salary) (Okungu, Chuma, & McIntyre, 2017). In addition to issues around health care inaccessibility due to distance to health care providers (geographical characteristics)  and inability to pay for the health services (individual characteristics), quality of care is also impaired in many counties as several facilities cannot supply sufficient amounts of drugs for non-communicable diseases and also experience inadequate staffing levels (Barker, Mulaki, Mwai, & Dutta, 2014; Turin, 2010). Data collected in 2010 from a nationally representative sample of public health centers and dispensaries across all 8 provinces (before devolution) in Kenya revealed evidence of pro-rich inequalities for electricity and laboratory services, and for availability of drugs and qualified staff. Less than 20% facilities had all drugs on the tracer list in stock. These resources provide salient inputs into the quality of care provided at health facilities (Toda et al., 2012). Societal (social and cultural) factors can also influence health seeking behavior, for instance, past interactions with a favorable view of services may result in continuing visit to the same provider. Similarly, stigma around certain conditions is a contributor to where and how people seek or avoid seeking care (Turin, 2010). Provider characteristics also provide a range of actions that a person can take when in need of care (Awiti, 2014).


Awiti, J. O. (2014). Poverty and health care demand in Kenya. BMC Health Services Research, 14(1), Pp. 560.

Barker, C., Mulaki, A., Mwai, D., & Dutta, A. (2014). Devolution of healthcare in Kenya assessing county health system readiness in Kenya: a review of selected health inputs. Washington, D.C.

Kariuki, S. (2019). World Health Day: Universal Health Coverage – Everyone, Everywhere – Celebrating Kenya’s journey towards universal health coverage.

NHIF. (2020). Inpatient services.

Okungu, V., Chuma, J., & McIntyre, D. (2017). The cost of free health care for all Kenyans: assessing the financial sustainability of contributory and non-contributory financing mechanisms. International Journal for Equity in Health, 16(1), 39. JOUR.

Toda, M., Opwora, A., Waweru, E., Noor, A., Edwards, T., Fegan, G., … Goodman, C. (2012). Analyzing the equity of public primary care provision in Kenya: variation in facility characteristics by local poverty level. International Journal for Equity in Health, 11(1), 75.

Turin, D. R. (2010). Health Care Utilization in the Kenyan Health System: Challenges and opporunities. Inquiries Journal, 2(9), 2–3.

Social protection in health is granted to all Mexicans as a right by the fourth article of the Constitution. However, different issues make access unequal and undermine the achievement of universal coverage that the Mexican government strives for. Among these issues is the absence of a universal national health system, access to health service (and social security) based on employment and insurance status, as well as unequal social and economic development throughout the states that results in differences in the development of the infrastructure and human resources available. Thus, unequal access and quality of care between urban and rural areas, northern and southern states, and between those covered by social security, public and private sector insurance schemes are observed (OECD, 2017a).

Program-based health care also has meant that health care provision focuses on some illnesses, age groups or conditions (pregnancy and birth, diabetes, hypertension, reproductive health), leaving some age groups, such as older adults, and conditions such as AD and other dementias, underserved. As such, those who access the private sector could get a consultation with a geriatrician or dementia specialist any time, while referrals to these specialists in the public sector are practically inexistent given the low number of public posts of these within the public sector.


OECD. (2017a). Estudios Económicos de la OCDE México (OCDE Publishing, Ed.). OCDE Publishing.

The South African healthcare sector is characterised by inequality in terms of access to care services and resources (human, financial and technologies) between provinces, with more facilities and services concentrated in more urban areas (Competition Commission SA, 2018; Department Planning Monitoring and Evaluation, 2017; Mahlathi & Dlamini, 2015), despite the majority of the population (64.7%) living in provinces that are largely characterised as more rural (Mahlathi & Dlamini, 2015). Most patients access health care via the Public District Health System where healthcare is free, however overburdened by catering for the service needs of 84% of the population (Mahlathi & Dlamini, 2015), and further characterised by:

  • Poor management and governance;
  • Shortages of key health care professionals, and skewed between the public and private sector;
  • Weak service delivery platform with poor quality of care and delivery of healthcare services;
  • Lack or inconsistent supply of medical products and health technologies;
  • Fragmented and unequal healthcare financing; and
  • Poor information management (Department Planning Monitoring and Evaluation, 2017).

The legacy of Apartheid perpetuates the racial disparities and inequitable access to care, despite active redresses of the past. Ninety percent (90%) of South Africans are said to live within 7 kilometres from a public healthcare facility, and about two-thirds live within 2 kilometres (Fusheini & Eyles, 2016). However, for most South Africans the cost in time and money to travel to the nearest healthcare facility poses a significant barrier (Fusheini & Eyles, 2016). With regards to population groups, it is estimated that 15% of black South Africans live more than 5km away from the nearest healthcare facility, as compared to 7% coloureds and 4% whites (Mclaren et al., 2013). Poorer South Africans live furthest from facilities and are characterised by poorer health, with a tendency for men to utilise health care facilities less than women (Mclaren et al., 2013).

Barriers in accessing care within the private sector relates to the escalating costs of care, despite having medical insurance. Medical scheme coverage rates often have to be supplemented by out-of-pocket payments, decreasing the range and depth of services accessed (Competition Commission SA, 2018). There are 8 million South Africans that are currently covered by a medical aid scheme (Abraham et al., 2012). More so, 21.3% of households in the metropolitan areas have some form of medical health insurance, compared to only 5.4% of households in more rural areas (DOH, 2011). Access to private health care services in rural areas is limited.


Abraham, M., Dreyer, K., Giuricich, M., & Ramjee, S. (2012). Healthcare Expenditure in the Last year of Life: The Experience of South African Medical Schemes. (Issue 5). Available from:,%20Shivani%20Ramjee%20-%20HEALTHCARE%20EXPENDITURE%20IN%20THE%20LAST%20YEAR.pdf

Competition Commission SA. (2018). Health market injuiry. Available from:

Department Planning Monitoring and Evaluation. (2017). Socio-Economic Impact Assessment System (SEIAS) Final Impact Assessment (Phase 2): White Paper on National Health Insurance (Issue May).

DOH. (2011). HUMAN RESOURCES FOR HEALTH SOUTH AFRICA (HRH) Department of Health. Available from: Publications/hrh_strategy-2.pdf

Fusheini, A., & Eyles, J. (2016). Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of health care provision. BMC Health Services Research, 16(1), 1–11.

Mahlathi, P., & Dlamini, J. (2015). MINIMUM DATA SETS FOR HUMAN RESOURCES FOR HEALTH AND THE SURGICAL WORKFORCE IN SOUTH AFRICA’S HEALTH SYSTEM: A rapid analysis of stock and migration. Available from:

Mclaren, Z., Ardington, C., & Leibbrandt, M. (2013). Distance as a barrier to health care access in South Africa.