DESK REVIEWS | 02.01. Health system organisation

DESK REVIEW | 02.01. Health system organisation

The Brazilian health system is comprised of a complex and interconnected mix of public-private service providers and purchasers. The system provides healthcare through three sub-sectors: 1) the public – Unified Health System (Sistema Único de Saúde – SUS) – in which services are financed and provided by the state at the three levels of governance (federal, state, and municipal); 2) the private (for-profit and non-profit) in which services are funded by public and private funds; and 3) the private health insurance sub-sector. People may use services in any of these sub-sectors according to their ability to access and pay for them (Paim et al., 2011).


Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797.

The Health System in Kenya is divided into the public sector (largest in terms of number of health facilities), a private for-profit sector and a private not for profit sector. In the private not for profit sector, services are being provided by voluntary organizations, such as faith based organizations (Mugo et al., 2018). According to the 2013 Kenya Household Health Expenditure and Utilization Survey, rural versus urban (66.7% vs 44.1%), (23.5% vs 43.0%), (8.5% vs 8.8%) and (1.3% vs 4.1%) visit public, private, faith based and others facilities (traditional and faith healers and community health workers) respectively to receive outpatient services (Ministry of Health, 2014a).


Ministry of Health. (2014a). 2013 Kenya Household Health Expenditure and Utilization Survey. Nairobi, Kenya.

Mugo, P., Onsomu, E., Munga, B., Nafula, N., Mbithi, J., & Owino, E. (2018). An Assessment of Healthcare Delivery in Kenya under the Devolved System (No. Special Paper No. 19). Nairobi, Kenya.

The Health System in Mexico has been highly fragmented since its creation and health services and users are divided according to the health institution that provides the coverage. There are three main providers: social security institutions, public services offered by the Ministry of Health, and the private sector. These providers offer different benefit and service packages, working independently and in parallel to each other. In addition, they have separate financing mechanisms and rely on different sources of funding (Dantés et al., 2011; OECD, 2016b).

As mentioned above, social protection in Mexico is composed of a fragmented framework of programs and institutions. Social security, available to those employed in the formal market, is further divided into a number of institutions that provide services to workers from different sectors. The Mexican Institute of Social Security (IMSS) covers those employed in the private formal sector, while federal and state level employees are covered by the Institute of Social Security and Services for State Employees scheme (ISSSTE). In addition, other institutions cover people employed in specific sectors such as the national oil company PEMEX and the Armed Forces (military and naval). Social security institutions extend their benefits, in addition to affiliated workers, to their spouses, children, and parents (Gutierrez et al., 2015; Dantés et al., 2011).

The Seguro Popular (Popular Health Insurance) is an income-based health care insurance publicly funded and administered by the Ministry of Health that aims at providing coverage to all those who are not insured by any of the social security institutions, including people who are self-employed, working in the informal sector, unemployed and others who are not participating in formal employment (such as homemakers) (Gutierrez et al., 2015). In 2015 the Seguro Popular provided health insurance to 53.5 million Mexicans, close to 50% of the total population, through services provided by the Ministry of Health. Another 9.2% of the population were covered by the IMSS, 7.7% by ISSSTE, and 1.2% by PEMEX and the Armed Forces social institutions.


Dantés, O. G., Sesma, S., Becerril, V. M., Knaul, F. M., Arreola, H., & Frenk, J. (2011). Sistema de salud de México. Salud Pública de México, 53 Suppl 2(1), s220–s232.

Gutierrez, L. M., Medina-Campos, R. H., & Lopez-Ortega, M. (2015). Present State of Elder Care in Mexico. In W. Vega, J. Angel, K. Markides, & F. Torres-Gil (Eds.), Challenges of Latino Aging in the Americas (pp. 379–392). Springer International Publishing.

OECD. (2016b). OECD Reviews of Health Systems: Mexico. In OECD Publishing (Ed.), OECD Reviews of Health Systems (OECD Reviews of Health Systems). OECD Publishing.

The SUS was implemented in 1990. It is state-funded, it provides health services free of charge to the entire population, and it is one of the largest and most complex health systems in the world (Paim et al., 2011). In 2017, it accounted for 8.3% of national revenue, meaning 1.8% of the Brazilian Gross Domestic Product (GDP) in that year  (Brazilian National Treasure, 2018). The SUS provides a range of health services and interventions spanning the whole life-course (from the gestational period to the end of life). These include the primary, secondary, and tertiary levels of care; urgency and emergency systems; hospital care; health and environmental surveillance; and a pharmaceutical assistance program (Brazilian Ministry of Health, 2019k). The system is the major source of healthcare for low-income groups and those without access to private health insurance (Castro et al., 2019). According to the latest published version of the National Health Survey – 2013 (Pesquisa Nacional de Saúde – PNS), around 70% of the Brazilian population do not have private health insurance and therefore benefit from services provided by SUS or pay directly for private health services (Brazilian Ministry of Health, 2013a). The SUS is informed by local, municipal, state, and federal councils that aim to embed the population’s voices and needs into policy.


Brazilian Ministry of Health. (2013a). Pesquisa Nacional de Saúde 2013: Acesso e Uitlização dos Serviços de Saúde, Acidentes e Violências.

Brazilian Ministry of Health. (2019k). Sistema Único de Saúde (SUS): Estrutura, principios e como funciona.

Brazilian National Treasure. (2018). Aspectos Fiscais da Saúde no Brasil.

Castro, M. C., Massuda, A., Almeida, G., Menezes-Filho, N. A., Andrade, M. V., Noronha, K. V. M. de S., Rocha, R., Macinko, J., Hone, T., Tasca, R., Giovanella, L., Malik, A. M., Werneck, H., Fachine, L. A., & Rifat, A. (2019). Brazil’s unified health system: The first 30 years and prospects for the future. Lancet Health Public.

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797.


The public health services are financed by the Government and regulated by the Food and Health Bureau (FHB), Department of Health (DH), and Hospital Authority (HA) (HKSAR Government, 2019b).

  • Food and Health Bureau (FHB)

It is one of the policy bureaus of the Government responsible for forming policies and allocating resources for health services. It ensures that these policies are carried out effectively to protect and promote public health, and provide lifelong holistic health care to every resident (HKSAR Government, 2019b).

  • Department of Health (DH)

Under the FHB, the Department of Health serves as health adviser and agency to execute healthcare policies and statutory functions. It safeguards the community’s health through a range of promotional, preventive, curative, and rehabilitative services. It also provides subsidised healthcare services through health centres and clinics in each district (HKSAR Government, 2019b).

  • The Hospital Authority (HA)

The Hospital Authority is a statutory body established under the Hospital Authority Ordinance in 1990. It is accountable to the Government through the Secretary of FHB and provides public hospital services for the whole Hong Kong territory. Every Hong Kong resident is eligible for subsidised healthcare services through 43 public hospitals, 73 general out-patient clinics and 49 specialist out-patient clinics operated by HA (HKSAR Government, 2019b; Hospital Authority, 2019a).

The public sector provides most of the secondary and tertiary care services in Hong Kong. Public hospitals under HA manage approximately 80% of all hospital admissions and the share of total bed-days reaches almost 90%. As of 31 March 2019, a total of 28,929 hospital beds were provided in public hospitals. Nearly all critical emergencies are tackled by the accident and emergency departments of public hospitals (Food and Health Bureau, 2017b).

Regarding the proportion of population using public healthcare, the Census and Statistics Department conducted a household survey on the population’s use of doctor consultation, hospitalisation, and dental consultation in 2016/17. While only 29.2% of doctor consultations took place in the public sector, 70.9% of the hospital admissions in Hong Kong were handled by public hospitals under Hospital Authority. Further breakdown of these findings by age and gender can be found from the survey report (Census and Statistics Department, 2017, December).


Census and Statistics Department. (2017, December). Thematic Household Survey Report No. 63. Retrieved from

Food and Health Bureau. (2017b). Report of the Strategic Review on Healthcare Manpower Planning and Professional Development.

HKSAR Government. (2019b, March). Overview of the Health Care System in Hong Kong. Retrieved from

Hospital Authority. (2019a). Clusters, Hospitals & Institutions. Retrieved from

Hospital Authority. (2019b). Hospital Authority Statistical Report 2018-2019.  Retrieved from

The provision of health care to the public is enlisted as State subject in the constitution of India. Furthermore, there are references to health in the Union as well as Concurrent Lists (Government of India, n.d.). This means that the States have the opportunity for unique customization of the Union public health initiatives and introduction of state-specific services. The public health network is monitored by the Indian Public Health Standards (Ministry of Health and Family Welfare (MoHFW), 2012).

Traditionally, the public health care system in India has been rural-centric. A three-tiered network of health facilities consisting of sub centres, primary health care centres, and community health centres caters to the primary and secondary health care needs of the population, mostly in rural areas where about 2/3rd of India’s population live.

  1. A Sub Centre (SC) is the first point of contact between the community and the primary health care system, and it is staffed by nurses and health workers. The minimum requirement of the SC is to have at least one auxiliary nurse midwife (ANM)/female health worker and one male health worker (Ministry of Health and Family Welfare (MoHFW), n.d.-b). SCs provide services in relation to family welfare, maternal and child health (MCH), nutrition, immunization, diarrhoea control, and control of communicable diseases programs (MoHFW, n.d.-b). Existing SCs are being converted to Health and Wellness Centres to provide an expanded range of services at a primary care level as part of the Ayushman Bharat programme (MoHFW, n.d.-b)
  2. A Primary Health Centre (PHC) is the first point of contact between the village community and a medical officer (MO) — an appointed graduate physician trained in allopathic system of medicine (MBBS; Bachelor of Medicine and Bachelor of Surgery) (MoHFW, n.d.-b). Each PHC is recommended to have at least one MO along with 14 paramedical and other staff. PHCs consist of 4 to 6 beds for in-patients and act as referral units for 6 SCs (MoHFW, n.d.-b). Existing PHCs are being converted to Health and Wellness Centres to provide an expanded range of services at a primary care level as part of the Ayushman Bharat programme (MoHFW, n.d.-b)
  3. Community Health Centres (CHCs) function as community hospitals. CHCs are required to staff a surgeon, physician, gynaecologist/obstetrician, and paediatrician (4 medical specialists) supported by additional team of 21 paramedical and other staff (MoHFW, n.d.-b). The CHC works as referrals for PHCs within a block (a group of villages), which is the planning and development unit of a district. The CHC also provides specialist obstetric care and specialist consultations facilities across other disciplines (MoHFW, n.d.-b). CHCs are equipped to provide round the clock emergency obstetric care services and thus, they serve as the First Referral Units (FRU) for reproductive health (MoHFW, n.d.-b).

Sub-divisional hospitals, District hospitals, and Government Medical colleges provide comprehensive speciality and super speciality care to referrals, as these may also serve as FRUs (MoHFW, n.d.-b).

Table 2.1. Size of Rural Public Health Network in India (as of March 2020) (Ministry of Health and Family Welfare, n.d.-b).

Sl. No. Type Level of care Number of centres Denominator Function
1 Sub centre (SC)


* SCs are being converted to HWCs under Ayushman Bharat

Primary 155404 in rural areas 1 SC for every 5000 population in the plains, 3000 in Hilly terrains



(Approx. population of 1 village = 1000)

1st point of contact for the community with the formal health care system. Led by an Auxiliary Nurse Midwife (ANM)/ Multi-purpose Health Worker
2 Primary Health Centre (PHC)


*PHCs are being converted to HWCs under Ayushman Bharat.

Primary 24918 in rural areas 1 PHC per 20000 (tribal)-30000 (plains) population Each PHC is headed by a graduate physician trained in allopathic medicine. The PHCs provide primary outpatient

services, preventive, curative and emergency care services and implementation of national health programmes.


They have 4-6 beds for in-patient care and provide referral support to 6 sub-centres.

3 Community Health Centre (CHC) Primary/ Secondary 5183 in rural areas 1 CHC per 80000-100000 population


(1/ block)

30 bed hospitals.

Staff a surgeon, physician, gynaecologist/ obstetrician, and paediatrician.

Serves as referral centre for 4 PHCs.

4 Sub-Divisional Hospital Secondary 1193 in the country. 821 as First Referral Units (FRUs) Caters to usually 5-6 lakh population Usually 31-100 bed hospitals. Provide specialized services and may serve as the First Referral Unit (FRU) for obstetric emergencies (hold blood storage facilities, essential laboratory services and provide new-born health services).
5 District Hospitals Secondary 810 in the country. 668 as First Referral Units (FRUs) At the district level. Provide comprehensive specialist care at the district level.
6 Government Medical Colleges Tertiary 274 in the country. 118 as First Referral Units (FRUs) Usually located in urban areas. A district may have no, one or several medical colleges. Provide speciality and super speciality (provides care and services in one specialism such as neurology/cardiology etc.) care to all referrals

Source: MoHFW (n.d.-b); Directorate General of Health Services (2012)

Priority health challenges are addressed through an expansive set of health care programs. Traditionally, the focus has been on maternal and child health (MCH) issues and family welfare. In 2005, the National Rural Health Mission (NRHM) brought a paradigm change in the country’s approach (focused attention to ‘weaker’ in terms of infrastructure and/or public health indicators) states, brought programs, and resources under a common banner, decentralised decision making, undertook ‘communitisation’ through a new cadre of community-based health mobilisers (called Accredited Social Health Activists (ASHAs)). Given the success of the NRHM, the approach was extended to both rural and urban areas under the banner of the National Health Mission (NHM) in 2012 with two sub-missions i.e., the NRHM and the National Urban Health Mission (NUHM). Over the years, the focus has expanded beyond MCH to non-communicable diseases, mental health and geriatric care, and a series of state sponsored health insurance schemes (MohFW, n.d.-a)

The NUHM and respective municipal corporations share primary responsibility for providing health services for the urban population. The proposed urban public health infrastructure consists of UPHCs and UCHCs that each cater to approximately 50,000 and 2.5 to 5 lakh population respectively in urban areas to provide equitable and quality care to the urban poor (MoHFW, 2013; MoHFW, n.d.-b).

Table 2.2. Frontline workers in the Public Health System in India

Sl. No. Type Number of Frontline workers
1 Accredited Social Health Activists (ASHAs) in Rural Areas 905047 (NHSRC, 2019)
2 Accredited Social Health Activists (ASHAs) in Urban Areas 64272 (NHSRC, 2019)
3 Auxiliary Nurse Midwives (positioned at both SCs and PHCs) 212593 in position

(March 2020)

In 2018, considerable changes were initiated to improve the existing primary health infrastructure as per recommendations of the National Health Policy of 2017 (National Health Portal, 2019). The Ayushman Bharat was introduced to aid in achieving the goal of Universal Health Coverage (UHC). Under Ayushman Bharat, the concept of Health and Wellness Centres (HWCs) was initiated with the aim of providing comprehensive primary care by transforming existing SCs and PHCs (National Health Portal, 2019). Subsequently, a network of HWCs has been rapidly expanded across Indian under the Ayushman Bharat Yojana. By 17th March 2022, 76,633 HWCs had been operationalised across India (MoHFW, 2022). The 13th Common Review Mission (2019) reports that about 1.5 lakh Sub-Centres and PHCs would be transformed to HWCs by 2022 to provide comprehensive and quality primary health care in both urban and rural areas (MoHFW, 2019). A mid-level health officer (Community Health Officer; CHO) manages the HWCs and is supported by two multipurpose workers (one male and one female) and ASHAs. To strengthen HWCs, staff vacancies are being filled-in, and multi-skilling and capacity building efforts are underway. Infrastructure and logistics are being upgraded along with expansion in the range of medicines and diagnostics, adoption of Information Technology (IT) equipment and applications, telemedicine platforms (MoHFW, 2019). Community outreach and information-education-communication (IEC) efforts are being scaled-up through the HWCs with a focus on promotion of health and wellness (MoHFW, 2019).

Proportion that makes use of public sector services:

The percentage of households that use health care in the public sector has increased from 34% to 45% in 2005-2006 and 2015-2016 respectively (International Institute for Population Sciences (IIPS) and ICF, 2017).


Directorate General of Health Services (2012). Indian Public Health Standards. Guidelines for Sub-District/Sub-Divisional Hospitals. Ministry of Health and Family Welfare. Government of India. Available from:

Government of India (n.d.). Seventh schedule., 1970(5). Retrieved from:

International Institute for Population Sciences (IIPS) and ICF (2017). NATIONAL FAMILY HEALTH SURVEY (NFHS-4) 2015-16 INDIA. Mumbai.

Ministry of Health and Family Welfare (2013). National Urban Health Mission. Government of India. Available from:

Ministry of Health and Family Welfare (2019). 13th Common Review Mission. National Health Mission, Goverment of India. Available from:

Ministry of Health and Family Welfare (2022). Ayushman Bharat-Health and Wellness Centres. Ministry of Health and Family Welfare, Government of India. Retrieved from:

Ministry of Health and Family Welfare (n.d.-a). National Rural Health Mission-Meeting people’s health needs in rural areas: framework for implementation 2005-2012. Government of India. Available from:

Ministry of Health and Family Welfare (n.d.-b). Rural Health Statistics 2019-2020. Statistics Division, Ministry of Health and Family Welfare. Government of India.

Ministry of Health and Family Welfare. (2012). Indian Public Health Standards. Available from

National Health Portal (2019). Ayushman Bharat Yojana. Government of India. Available from:

National Health Systems Resource Centre (2019). Update on ASHA Programme: July 2019. Ministry of Health and Family Welfare. Available from:

Indonesia introduced universal health care through the National Health Insurance System (Jaminan Kesehatan Nasional (NHIS)) in 2014. Services covered under the NHIS can be provided by the government-owned health facilities and registered private providers (Agustina et al., 2019, pp.75,89).

The system was created by bringing together a number of existing, but still fragmented, health insurance and social assistance schemes under the umbrella of a single payer, the Social Security Agency for Health (Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS)) and covers a range of services from simple procedures to ‘open heart surgery […] and cancer therapies’ (Agustina et al., 2019, pp.76,89). Furthermore, reproductive, maternal, neonatal, child health as well as emergency services are fully covered, and medicines and medical supplies can be received without co-payment if the patient adheres to procedures. The system does not cover cosmetic procedures, self-inflicted injuries, and services provided outside pre-approved providers, unless they are emergencies (Agustina et al., 2019, p.89).

The system covers civil servants, private sector employees and provides for socio-economically vulnerable members of the community. Government subsidises for 109.5 million socio-economically vulnerable account for 61 per cent of those with insurance coverage. Civil servants, private sector employees and others providing independent contributions make up 39 per cent of those insured. (TNP2K, 2018, p.83).

By October 2018, the systems served 203 million members, representing the ‘largest single-payer scheme in the world’. In 2017, 223.4 million consultations were recorded, amounting to US$20.15 billion (US$ PPP) (Agustina et al., 2019, p.75).

As over half of members of the BPJS receive government subsidies and among those contributing independently, members often only pay during periods of illness, which poses challenges for the financial sustainability of the programme. It was reported that claims exceeded contributions by 600 per cent in 2014 (TNP2K, 2018, p.84).

The system in Indonesia consists of three main service tiers, these are:

Community health centres (Puskesmas)

The Puskesmas programme was introduced under president Suharto in 1968. By 1970, community health centres were established in all subdistricts (Agustina et al., 2019, p.77). The Puskesmas provide frontline primary health care. From there, patients with more complex needs can be referred to hospitals or other services. In 2015, 9,754 Puskesmas were in operation, covering 92% of subdistricts. However, particularly in the eastern part of the country, some subdistricts did not have Puskesmas. There are also concerns regarding quality. According to Agustina and colleagues (2019, pp.84-95), ‘only 74% of community health centres met preparedness requirements’. Quality standards were found to be better in urban than in rural areas (Agustina et al., 2019, pp.84-85).

Integrated community health service post (Posyandu)

The Posyandu were introduced shortly after the Puskesmas (1980), with a focus on preventive health services (Agustina et al., 2019, p.77). The Posyandu are staffed by a midwife, a nurse assistant, and a vaccinator and are facilitated by health volunteers (kaders) in each community. These teams visit hamlets or village subdivisions on a monthly basis and provide ‘basic reproductive, maternal, neonatal, and child health services’, although later on several Posyandu Lansia focusing on older people’s health have been set up. It is estimated that almost 300,000 Posyandu are held every month (Agustina et al., 2019, p.84).


The number of hospitals almost doubled between 2005 and 2015, from 1,268 to 2,488 (Agustina et al., 2019, pp.84-85). As outlined above, subsidised members can access third-class hospital rooms without co-payments, while self-employed members can access first to third-class rooms in accordance with their insurance plan. Those earning more than $300 a month are entitled to first-class rooms. BPJS members can upgrade their hospital room through payments or private insurance (Agustina et al., 2019, p.89). In the end of 2021, the government has announced the plan to erase this classing system in BPJS, and will only offer a standardised class, following the health equity principle. It will be implemented gradually starting in 2023 (Hasibuan, 2022).

The Ministry of Health further regulates geriatric services in Indonesia’s public hospitals (Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 Tentang Pelayanan Geriatri Di RS), 2014). By 2015, six hospitals on Java Island and one hospital in Bali, Sumatra, and Sulawesi islands provided older people with ‘integrated geriatric services’ (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014, 2016b).

Data from the Ministry of Health shows that the number of private hospitals has grown more rapidly than that of public hospitals. However, private hospitals remain mostly concentrated on the Java islands where there are larger urban and peri-urban centres.


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.

Hasibuan L. (2022). Siap-siap! Kelas 1,2,3, BPJS Kesehatan Dihapus, Ini Gantinya. CNBC Indonesia.

Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 tentang Pelayanan Geriatri di RS), (2014) (testimony of Ministry of Health Republic of Indonesia).

Ministry of Health. 2012–2017. Ministry of Health Annual Health Sector Profile 2011–2016. Jakarta, Indonesia: Ministry of Health.

Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).

Pusat Data dan Informasi Kementerian Kesehatan RI. (2016b). Situasi Lanjut Usia (Lansia di Indonesia).

Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K). (2018) The Future of the social protection system in Indonesia, Jakarta Pusat: Office of the Vice President of the Republic of Indonesia.

63% of the Kenyan population access public health services within a distance of 1 hour walk on foot (Mugo et al., 2018). The public sector in Kenya is composed of the national government, county government, development partners and public corporations. Their main mandate is to strengthen performance and management systems including the capability of public service leadership and to enhance quality and efficiency of public service delivery while transforming the culture and attitude of its employees (Fortune of Africa, 2019).

The public health system is overseen by the Ministry of Health and parastatal organizations. It includes a total of 4,616 health facilities, and consists of different levels of care, including national referral hospitals (level 6 – highest level of care – only four in Kenya (Kenyatta National Hospital, Moi Referral and Teaching Hospital, Mathari Hospital and National Spinal Injury Hospital), county hospitals (level 5), sub-county hospitals (level 4), health centres (level 3), dispensaries (level 2) and communities (level 1). Any higher level facility acts as a referral centre for the lower level facility (see table 2 below). The different levels of care are outlined below (Noor et al., 2006).

Table 2:  Description of health services provided by the Kenyan public sector
Level of service Purpose Services offered % of individuals accessing outpatient public services Expected catchment population
National Referral services (level 6) Serve all Kenyans and act as referral centre for County hospitals Surgical services, internal medicine, and specialty services such as emergency obstetric care (EmOC) and anesthesiology Referral services accessed 5,000,000
County Referral Services (level 5) The intermediary between national referral hospitals and sub-County hospitals.  Their role is to coordinate Sub-County activities while providing some form of specialized care Less extensive surgical services, internal medicine, and specialty services as compared to the National Referral Hospitals
Sub-County (Primary care services) (level 4) These serve as the referral centres for health centres and offer outpatient, inpatient and maternity services, emergency surgery, blood transfusion and laboratory services Antenatal care (ANC) and routine birthing services, formal immunization programs, HIV/ AIDS care, paediatric and Emergency Obstetric Care (EmOC) services   100,000
Health centres (primary health care services) (level 3) Identification of cases that need to be further managed at higher levels of care Preventive and curative services with a focus on primary care services
Dispensaries – primary care health services (level 2) This is the intermediary between the community and health centres. The role is to receive cases directly from the community level for provision of primary health care services. Preventive and curative services with a focus on primary care services   10,000
Community-based services (level 1) Health promotion and demand creation: To prevent affliction and promote good health to avert the need for facility-based care Some of the interventions provided focus on sleeping under insecticide treated mosquito nets to avert malaria. However, when affliction arises, the system expects the first port of call to be the dispensary (Level 2) Prevention services and based on home visits 5,000 per unit

Source: (Kenya Healthcare Federation and Task Force Health Care, 2016; Ministry of Health, 2014e; Mugo et al., 2018)


Fortune of Africa. (2019). Public Sector Profile of Kenya.

Kenya Healthcare Federation and Task Force Health Care. (2016). Kenyan Healthcare Sector: Opportunities for the Dutch Life Sciences & Health Sector. Nairobi, Kenya

Ministry of Health. (2014e). Towards Universal Health Coverage: The Kenya Health Strategic and Investment Plan, 2014 – 2018 – Human Resources for Health Norms and Standards Guidelines for the Health Sector.

Mugo, P., Onsomu, E., Munga, B., Nafula, N., Mbithi, J., & Owino, E. (2018). An Assessment of Healthcare Delivery in Kenya under the Devolved System (No. Special Paper No. 19). Nairobi, Kenya.

Noor, A. M., Amin, A. A., Gething, P. W., Atkinson, P. M., Hay, S. I., & Snow, R. W. (2006). Modelling distances travelled to government health services in Kenya. Tropical Medicine & International Health, 11(2), 188–196.

23.1% of the population used private sector services, 40.1% public services provided by the Ministry of Health, and 36.8% used services provided by social security institutions (OECD, 2017a). Health services in the public (MoH) and social security sectors (i.e. IMSS, ISSSTE, Armed Forces, etc.) are similarly organised.


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

About 82 of every 100 South Africans (i.e., 45 million) are largely dependent on public healthcare  (StatsSA, 2017a), which provides healthcare to 84% of the population (Mahlathi & Dlamini, 2015). This sector is governed by the National Department of Health which is responsible for the development of policies and overall coordination (Mahlathi & Dlamini, 2015). Provincial departments are responsible for providing primary, secondary and tertiary care services through public clinics and hospitals (Mahlathi & Dlamini, 2015).


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:

StatsSA. (2017a). Public healthcare: How much per person? Statistics South Africa: Statistical Release.

The private health sector has been an important part in the provision of care in Brazil and is spread across the country. The private healthcare sector connects with the public sector by providing services contracted-out by the SUS, out of pocket hospital, and ambulatory services, drugs, and through private health plans and insurance. Private healthcare services are financed both by the SUS and private sources. Data from the report “Fiscal Aspects of Health in Brazil” state that 55% of the total expenditure in health comes from private expenditure/sources and 45% comes from public expenditure/sources (Brazilian National Treasure, 2018; OPAS/OMS, 2019).

It is important point out that over 70% of the total population do not count on private insurances for their healthcare needs (>190 million people) (Brazilian Ministry of Health, 2013a). A survey conducted in 2018, commissioned by the Credit Protection Service (SPC Brasil) and by the National Confederation of Store Owners (CNDL), showed that, of the 70% who do not hold a health insurance, nearly 45% report to use SUS whenever they need it, while the remaining proportion reports to pay in cash for their healthcare whenever they need it (Agencia Brasil, 2018). Mostly due to the long waiting time for consultations, some people pay for it privately and then do the exams requested by the clinician through the public health system, for example. Also, most people get their vaccinations done through SUS, and may get their medication free of charge also out from the primary healthcare services (Agencia Brasil, 2018).

By the end of 2018, according to the National Regulatory Agency for Private Health Insurances and Plans (Agência Nacional de Saúde Suplementar – ANS), around 23.3% of the Brazilian population had a private health care insurance (National Regulatory Agency for Private Health Insurances and Plans, 2019b). Main users of private health plans are employees from public and private companies that offer private health coverage. The insurances vary in quality and amenities according to socioeconomic and occupational status of the demanders. Within one company, employees may have different levels of health care coverage depending on occupational hierarchy. Even though people with private health care insurance might benefit from more “premium” health plans, they often receive vaccines, high-cost, and complex services through SUS (Paim et al., 2011).


Agencia Brasil (EBC). (2018, November 5). Tragédia Mariana. Agência Brasil.

Brazilian Ministry of Health. (2013a). Pesquisa Nacional de Saúde 2013: Acesso e Uitlização dos Serviços de Saúde, Acidentes e Violências.

Brazilian National Treasure. (2018). Aspectos Fiscais da Saúde no Brasil.

National Regulatory Agency for Private Health Insurances and Plans, M. (2019b). Caderno de Informação da Saúde Suplementar: Beneficiários, operadoras e planos. Março 2019.

OPAS/OMS. (2019). OPAS/OMS Brasil—Países estão gastando mais em saúde, mas pessoas ainda pagam muitos serviços com dinheiro do próprio bolso.

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797.


There are 12 private hospitals and 2,146 registered private clinics in Hong Kong (Electronic Health Record Registration Office, 2019) providing hospital service, primary care, and a broad range of specialist services. As of 31st of March 2019, a total of 4,657 hospital beds were provided in private hospitals (Department of Health, 2019b). The Department of Health regulates all private hospitals and clinics under the Medical Clinics Ordinance (Cap.343) on their compliance with relevant regulations by conducting inspections and handling medical incidents and complaints lodged by the public. All Western and Chinese medicine practitioners have to register with the Medical Council of Hong Kong and the Chinese Medicine Council of Hong Kong, respectively (Hospital Authority, 2019a).

Private sector dominates the provision of primary care in Hong Kong, accounting for about 70% of all medical and dental visits (Food and Health Bureau, 2017b). The proportion of the population making use of doctor consultations, hospitalisation, and dental consultations in the private sector in 2016/17 is summarised in Table 2.2 above. Most of the doctor consultations (67.6%), which consisted of 49.5% and 18.1% of Western and Chinese medicine practitioner use respectively, occurred in the private sector. In contrast, only 30.7% of hospitalisation were handled by the private sector (Census and Statistics Department, 2017, December).


Census and Statistics Department. (2017, December). Thematic Household Survey Report No. 63. Retrieved from

Department of Health. (2019b). Health Facts of Hong Kong 2019 Edition.  Retrieved from

Electronic Health Record Registration Office. (2019). Electronic Health Record Sharing Sysem: List of Registered Healthcare Provider – Private Clinics.  Retrieved 11 October, 2019, from Electronic Health Record Registration Office, HKSAR

Food and Health Bureau. (2017b). Report of the Strategic Review on Healthcare Manpower Planning and Professional Development.

Hospital Authority. (2019a). Clusters, Hospitals & Institutions. Retrieved from

About 74% of India’s total health care expenditure is incurred in the private health sector (India Brand Equity Foundation, 2019), a large proportion of this accounts for inpatient care (including advanced diagnostics, major surgical, and critical care services). The formal private providers in India are mostly concentrated in urban areas (metropolitan and bigger cities) and focus primarily on allopathic care (about three-fourths), and on secondary and tertiary care. They operate in both multi- and mono-specialty set-ups (Chokshi et al., 2016).

The formal private health sector in India includes private clinics (usually led by a single doctor or a doctor-couple), poly-clinics nursing homes and private hospitals as well as medical colleges. They range from doctor-owned set ups to those with doctor-manager partnerships to corporate facilities, and from not-for-profit to for-profit national and international ventures. In rural areas the private health sector is relatively unregulated and comprises mostly of non-formal providers and local practitioners.

While the rate of growth of the private healthcare sector is not uniform across India (Hooda, 2015), the private health sector, in general, shows a very rapid growth due to increasing demand (increasing purchasing power of citizens, epidemiological transition, emergence of medical tourism, increasing home health care needs), and supply (increasing number of trained personnel, health technology, policy liberalization leading to increasing foreign direct investment, etc.). The advent of telemedicine and innovative public-private partnership models hold further promises for the growth of the private healthcare industry in India. Simultaneously, there is policy level effort (e.g., the Clinical Establishment Act of 2010 (Ministry of Law and Justice, 2010)) to standardise the private health sector in India.

Proportion that makes use of private sector services:

As per the National Family Health Survey-4 (International Institute for Population Sciences (IIPS) and ICF, 2017), 51% of household were more likely to seek care from the private sector in 2015-2016.


Chokshi, M., Patil, B., Khanna, R., Neogi, S. B., Sharma, J., Paul, V. K., & Zodpey, S. (2016).  Health systems in India. Journal of Perinatology: Official Journal of the California Perinatal Association, 36(s3), S9–S12.

Hooda, S.K., (2015). Private Sector in Healthcare Delivery Market in India: Structure, Growth and Implications. Institute for Studies in Industrial Development Institute for Studies in Industrial Development.

India Brand Equity Foundation. (2019). Healthcare Industry in India, Indian Healthcare Sector, Services. Available from

International Institute for Population Sciences (IIPS) and ICF (2017). NATIONAL FAMILY HEALTH SURVEY (NFHS-4) 2015-16 INDIA. Mumbai.

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

The healthcare infrastructure in Indonesia is dominated by private players. As of 2017, 1,767 out of 2,776 hospitals were privately-owned (Deloitte Indonesia, 2019). After the introduction of the national health insurance programme (JKN), the capacity of the private hospital sector in Indonesia has expanded. Approximately 75% of hospitals contracted by BPJS (social security agency for health) increased the types of services they offer, for instance the number of outpatient and inpatient departments, the number of beds, and investment into equipment (X-ray, CT scan, MRI, and incubator) (Ross et al., 2018).

Key health areas and services include non-communicable diseases (cardiovascular disease diagnosis and management, orthopaedic services, dialysis, cancer diagnosis and management, and chemotherapy), reproductive, maternal and newborn health (antenatal and postnatal services, immunization, family planning counselling and services, obstetric care, C-sections, and neonatal emergency care), tuberculosis services (diagnosis, outpatient and inpatient treatment), and diagnostic tests (X-ray, CT scan, MRI, and GeneXpert).

From 1993 to 2014, the inequality in accessing private hospitals and services has narrowed. In 1993, public and private outpatient care services were utilised at similar level, but private outpatient care utilisation continued to increase until 2014. This includes an increase in utilisation of inpatient care in the private sector by the lowest income group, which in 1993 was virtually non-existent (Mulyanto et al., 2019).


Deloitte Indonesia. (2019). The Clouds Covering the Healthcare Business are not Always Grey: Welcoming the Future of Indonesia’s Healthcare Business in 2019. In Deloitte Indonesia Perspectives (Issue September).

Mulyanto, J., Kringos, D. S., & Kunst, A. E. (2019). The evolution of income-related inequalities in healthcare utilisation in Indonesia, 1993–2014. PLOS ONE, 14(6), e0218519.

Ross, R., Koseki, S., Dutta, A., Soewondo, P., & Nugrahani, Y. (2018). Results of a Survey of Private Hospitals in the Era of Indonesia’ s Jaminan Kesehatan Nasional: Impact of Contracting with National Health Insurance on Services, Capacity, Revenues, and Expenditure.

The percentage of individuals accessing private clinics and hospitals for outpatient services in general was 17% compared to over 58% in public facilities in 2013 (figure 1). However, there is a slightly higher dependence of private facilities in urban areas compared to rural areas  (Ministry of Health, 2014a). Public outpatient visits was prevalent (66.7%) in rural areas followed by private health facilities visits (23.5%), whereas in urban areas, the visits were nearly equally distributed in both public (44.1%) and private (43%) health facilities (Ministry of Health, 2014a).

The quality of care provided in the privately owned facilities (visited by the middle or high socio-economic status individuals) is better in terms of drug availability and services provided including client focus and responsiveness, compared to that provided in public facilities or unlicenced private care facilities (used by the lower socio-economic statius individuals) (Berendes, Heywood, Oliver, & Garner, 2011). The huge disparities in health care service utilization is mainly due to differences in living standards, levels of education, household characteristics and expenditure (Ilinca et al., 2019).

Figure 1: Proportion of individuals accessing outpatient health services, 2013

The private sector is the largest employer of healthcare professionals in Kenya and has a private healthcare market of KES 20.7b (Barnes et al., 2010). The specific health care providers include informal health care providers such as traditional healers and faith healers; and Formal health care providers (disease-specific specialists, medical doctors, clinical officers and nurses) (Barnes et al., 2010).

Private health facilities are distributed all over the country with majority being medical clinics (2098), dispensaries (196) and nursing homes (150) (Ministry of Health, 2012).


Barnes, J., O’Hanlon, B., Feeley, F., McKeon, K., Gitonga, N., & Decker, C. (2010). Private Health Sector Assessment in Kenya. 193(1). Washington, D.C.

Berendes, S., Heywood, P., Oliver, S., & Garner, P. (2011). Quality of private and public ambulatory health care in low and middle income countries: systematic review of comparative studies. PLoS Medicine, 8(4).

Ilinca, S., Di Giorgio, L., Salari, P., & Chuma, J. (2019). Socio-economic inequality and inequity in use of health care services in Kenya: evidence from the fourth Kenya household health expenditure and utilization survey. International Journal for Equity in Health, 18(1), 196.

Ministry of Health. (2012). Transforming Health: Accelerating attainment of Universal Health Coverage. The Kenya Health Sector Strategic and Investment Plan (KHSSP), (July 2014), 100.

Ministry of Health. (2014a). 2013 Kenya Household Health Expenditure and Utilization Survey. Nairobi, Kenya.


Access to private medical care is largely contingent on whether South Africans have access to medical insurance, for which only 17 of 100 persons (i.e., 12.7 million) are able to make use of these services (StatsSA, 2016, 2017a), providing services to only 16% of the population (Mahlathi & Dlamini, 2015). The sector consists of services provided by general practitioners, medical specialists, and private hospitals, and tend to be located in more urban areas (Mahlathi & Dlamini, 2015). This sector is largely under-regulated and has limited accountability at various levels (Competition Commission SA, 2018). In the absence of value-based purchasing, shortfalls include ineffective constraints on rising healthcare rates and insurance cover, while consumers are generally uninformed and disempowered (Competition Commission SA, 2018). The sector is furthermore characterised by a lack of integrated care models, with an enduring preference for solo practices and fee-for-services (FFS) billing that incentivises practitioners to provide more services than needed, especially in an unregulated pricing environment (Competition Commission SA, 2018).

Private healthcare in South Africa is extremely expensive and unaffordable for most of the population. Medical practitioners drive health care expenditures in the sector in two ways: (1) through their own activities (i.e., diagnosis and treatment); and (2) through referral for further investigation, treatment and hospitalisation (Competition Commission SA, 2018). The Competition Commission of South Africa found that despite rulings that doctors may not negotiate collectively, there are specialist groupings that operate collectively to resist joining service provider networks and introduce/adapt codes to inflate prices – without noticeable improvement in the quality of care offered. General practitioners form Independent Practice Associations (IPAs) that promote inclusion in preferred provider networks. These networks include quality assessments that are not publicly available, with no evidence of consequences for practitioners who do not meet standards (Competition Commission SA, 2018). Specialists join related (specialist) societies and associations, protecting their interests. Regulation within this sector is inadequate to inform and empower (and protect) the healthcare user.


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

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:

StatsSA. (2016). General Household Survey. Available from:

StatsSA. (2017a). Public healthcare: How much per person? Statistics South Africa: Statistical Release.

Every resident in Hong Kong can access primary care services directly by walking-in or making a telephone appointment. Private practitioners are distributed over nearly every community for convenient access. The Government has established the Primary Care Directory which is a web-based electronic database containing contact details, practice information, and professional qualifications of primary care providers in Hong Kong. This facilitates the public to search for suitable family doctors, dentists, and Chinese medicine practitioners in the community (Food and Health Bureau, 2019c). For public healthcare, since the general outpatient clinics are usually overloaded by older adults and persons with chronic illness who need regular follow-up, citizens who cannot afford private doctor consultations or insist in using public primary care have to walk in and queue up for a daily quota early in the morning or they can make a telephone booking for an appointment in the next 24 hours. The Telephone Appointment System of public general outpatient clinics operates 24 hours a day. In 2016, the Government introduced the Electronic Health Record Sharing System (eHRSS), a territory-wide, patient-oriented electronic sharing platform, for both authorised public and private health practitioners to access and share participating patients’ health records to enable more timely diagnosis and treatment, and reduce duplicate diagnostic tests (HKSAR Government, 2019, October). For emergency services, the public ambulance service 999 is free for anyone in Hong Kong. For access to secondary and tertiary care, either public or private, referral from a general practitioner is necessary.


Food and Health Bureau. (2019c, October 1). Primary Care Directory. Retrieved from

HKSAR Government. (2019, October). Electronic Health Record Sharing System. Retrieved from

In rural areas, frontline workers i.e., the ASHAs (Accredited Social Health Activists) facilitate contact with the public health sector. These act as community-based mobilizers that receive performance-linked incentives for service access and utilisation by their catchment population (usually, a village of 1,000 population) (NHSRC, 2019). The Anganwadi Workers from the Women and Child Development Department of the Government of India serve as the other community-based village-level frontline workers that help with maternal child health nutrition and immunization services, and in community mobilization.

The Auxiliary Nurse Midwife (ANM) at the sub-centre serves as the first contact with the formal public health sector (MoHFW, n.d.-b). Even though referral linkage exists between the facilities at the different tiers, care seekers in India most commonly use ‘walk-in’ services. In-patient admissions happen through out-patient and emergency departments. Many health services in rural India are also accessed through the non-formal practitioners, whose services are unregulated, with concerns regarding the quality of care offered (unsafe injection practices, multi-pharmacy, steroid, and antibiotic abuse, etc.) (Gautam et al., 2014). Frequently, these local practitioners serve as the first point of contact for health care seekers and cover up for the unavailability of formal providers. They also refer patients to formal health facilities for care, but often with delay and complications.

In urban areas, for critical cases, people frequently choose to seek care in the private sector. The perception of better care quality, convenience, staff availability, and system responsiveness are some of the reasons for people preferring the private sector over the public health sector (Barik and Thorat, 2015). However, care in the private sector is costlier than the public sector. Drugs and services in the latter are usually subsidised.

Schemes like the Employee State Insurance Corporation, the Central Government of Health Services, Corporate Empanelment Schemes, and Ayushman Bharat serve as the other major routes of health access to public and private health care providers for individuals and families (Table 2.4).

The most recently (2018) launched an insurance scheme under Ayushman Bharat known as the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), which is a government funded health insurance scheme offering socioeconomically disadvantaged families a benefit cover of Rs 5 lakh per year for hospitalizations (National Health Authority, 2022b). With PMJAY, several neurological diseases that require secondary and tertiary care are also covered such as meningitis, epilepsy and stroke, and care can be accessed in both public and private facilities (Paul, 2019). In addition, in September 2021, the Ayushman Bharat Digital Mission (ABDM) was introduced, with the aim of improving digital health infrastructure and bridging current gaps within the country (National Health Authority, 2022a). ABDM will be able to facilitate access of patients to their own health records, allow patients to share their health records with health care providers, provide the ability to access health services via tele-consultations etc. (National Health Authority, 2022a).

Table 2.4 Schemes related to health care

Name of the scheme Details Nature of health issues Coverage Source
Ayushman Bharat



Two components, which are:

Establishment of Health and Wellness Centres

AB-Pradhan Mantri Jan Arogya Yojana (PM-JAY) –PM-JAY

AB-PMJAY provides financial protection to the socioeconomically disadvantaged. It will offer a benefit cover of Rs. 500,000 per family per year (on a family floater basis).


Launched in 2018. Over 2,89,23,388, hospital admissions have been covered as of 28th February 2022 (National Health Authority, 2022b). National Health Portal of India (2019)
Employees’ State Insurance Scheme Employees of factories and other establishment’s where 10 or more persons are employed. Cover incidences of sickness, employment injury related death and provides medical care to insured persons and their families. Benefits about 2.13 crore insured persons/ family units. National Portal of India (2020)
Central Government Health Scheme For Central Government employees. The medical facilities are provided through Wellness Centres (previously referred to as CGHS Dispensaries) / polyclinics. Approximately 35 lakh beneficiaries are covered by CGHS in 71 cities all over India. MoHFW (2020a)



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

Gautham, M., Shyamprasad, K. M., Singh, R., Zachariah, A., Singh, R., & Bloom, G. (2014). Informal rural healthcare providers in North and South India. Health policy and planning29(suppl_1), i20-i29.

Ministry of Health and Family Welfare. (n.d.-b). Rural Health Statistics 2019-2020. Statistics Division, Ministry of Health and Family Welfare. Government of India.

Ministry of Health and Family Welfare. (2020a). Central Government Health Scheme.

National Health Authority (2022a). Ayushman Bharat-Digital Mission. Government of India. Available from:

National Health Authority (2022b). Ayushman Bharat-Pradhan Mantri Jan Arogya. Government of India.

National Health Portal (2019). Ayushman Bharat Yojana. Government of India. Available from:

National Health Systems Resource Centre (2019). Update on ASHA Programme: July 2019. Ministry of Health and Family Welfare. Available from:

National Portal of India (2020). Employee State Insurance Scheme. Government of India. Available from:

Paul, V. (2019). Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PMJAY): Hope for Millions and Exciting New Prospects for Neuro-Healthcare. Neurology India67(5), 1186.

Patients access primary care practitioners through the Puskesmas. There is a maximum ratio of 5,000 patients per primary care practitioner to encourage quality of care. Furthermore, primary care practitioners have been trained on ‘standard care competencies for the most common 144 diagnoses and 11 medical conditions’ by the Indonesian Medical Council. Where patients present with other conditions, they receive a referral to a specialist based in a lower-class hospital. Only from there, patients can be referred to higher class hospitals (Agustina et al., 2019, p.89).

Lack of knowledge on how to access services has been reported among subsidised members of the National Health Insurance System (NHIS) (Agustina et al., 2019, p.94).


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.

Approximately 63% of Kenyans access public health facilities. The facilities are unequally distributed across the 47 counties, with a national average facility density of 22 health facilities per 100,000 populations. The average distance between places of residence and nearest low level health facilities is about 3 kilometers (an average time of one hour by foot), which becomes a hindrance to uptake of health services (Mugo et al., 2018). Considerable distance to the nearest formal health provider acts as an important barrier to access for Kenyans from rural communities, who are therefore more likely to rely on traditional healers rather than seek care services in health facilities.

Nearly a third of the population in Kenya access levels 1-3 levels of care (further described in table 2) which form 80% of public health facilities as they are focused on primary health care services, while the hospitals (rest of the facilities) provide specialized services (Mugo et al., 2018). The national health sector referral strategy aims to improve client access to services and provides clear guidelines on referral processes through (Ministry of Health, 2014d):

  • Realization of the capacity of health care providers to make appropriate referrals
  • Development of protocols that will lead to referral system efficiency and effectiveness
  • Promotion of information use and communication technology (ICT) to manage referral processes
  • Promotion of research and innovation for referrals

Another initiative by the national government to increase access to health care services includes implementation of the Universal Health coverage (UHC), called “Afya Care” which is part of the Big Four Agenda. The Big Four Agenda has been implemented by the Kenyan government to ensure (i) the Expansion of the Manufacturing Sector, (ii) Affordable Housing, (iii) Affordable Healthcare and (iv) Food Security.

The pilot phase of the UHC (launched in 2018 with a national roll-out out expected in 2022) is covering 4 out of 47 counties with a high disease burden, (Kisumu, Machakos, Nyeri and Isiolo – which represent about 5% of the Kenyan population) and involves the removal of user fees at all public health facilities (including levels 4 and 5). It also ensures ‘commodity security’ that is, uninterrupted supply of quality and affordable medicines through KEMSA. This pilot phase encourages uptake and utilization of community Health Volunteer (CHVs) services and strengthening health systems in the other 43 counties by ensuring efficient and appropriate use of health funds in preparation for scale-up (Kariuki, 2019). Provision of health services will cover emergency, community, outpatient, and inpatient services for both communicable and no-communicable illnesses including mental health and maternity care. Furthermore, there is a focus on improving access to quality primary health care services by supporting operation and maintenance costs. There is only one out of the 43 non-pilot UHC counties (Makueni County), that has introduced some component of universal health care (Makueni Care), where a family (household) pays an annual fee of Kshs. 500 ($5 US dollars) to cover both preventive and curative services as well as free access to health care services (without payment) for individuals above 70 years. However, most hospitals are located far from people’s homes and only a small percentage of the population is able to access extensive services at higher levels of care (table 2). For instance, the risk of developing multiple illnesses and requiring long-term support is higher among older people, yet some of these services and medications can only be accessed at higher levels of care (levels 4-5) and are therefore inaccessible to a large population. In other non-pilot UHC counties, access to health care is limited. Out-of-pocket costs for registration upon first visit to the health facility and limited supply of medication at the public facilities create barriers to access and quality of care.


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

Ministry of Health. (2014d). Kenya Health Sector Referral Strategy. Ministry of Health Division of Emergency and Disaster Risk Management Afya House.

Mugo, P., Onsomu, E., Munga, B., Nafula, N., Mbithi, J., & Owino, E. (2018). An Assessment of Healthcare Delivery in Kenya under the Devolved System (No. Special Paper No. 19). Nairobi, Kenya.

Mexico does not have a universal-access National Health System. The health system is highly fragmented among different institutions that provide services depending on affiliation. For those formally employed, social security and health services are provided by two institutions, the Mexican Social Security Institute (IMSS) for those in the private sector, and the Institute for Social Security and Services for State Employees (ISSSTE) for those employed in the national or state-level public sector. In addition, the Ministry of Health provides health services for those who are employed in the informal sector or those who did not accrue enough time in formal employment to be eligible to services at IMSS or ISSSTE.

Within all these sub-systems, services are organised and accessed within a gate-keeping system where people have access to primary care clinics with general or family doctors (equivalent to GPs) as the first point of contact. They conduct first assessments, diagnoses, and treatment and, when necessary, refer patients to specialist physicians, laboratory or diagnostic tests, and major procedures such as hospitalisation or treatments that are provided within a hospital setting.

All private services can be accessed at the point of service, irrespective of service needed such as diagnosis/care of specialist physicians, diagnostic tests, or hospitalisation. These services have to be paid directly to the provider through out-of-pocket payments or insurance policies where insurance companies cover the costs or reimburse the patient, depending on the plan they contracted.

All public (MoH) and social security institutions are based on a reference system (gatekeeping), where primary care units –usually named family medicine clinics—are the main point of access and where care is provided by primary care physicians. When needed, they refer patients to any laboratory or diagnostic tests.

In the private sector, access is mostly through specialist doctors, responding to a specific need –either from previous diagnosis or expected need. Since a change in legislation in the year 2001, a segment of the private sector that has significantly increased is the use of pharmacists who provide “health orientation” by General Practitioners (medico general) and have profited from the parallel sale of medications (Gutierrez et al., 2014).


Gutiérrez, J. P., García-Saisó, S., Dolci, G. F., & Ávila, M. H. (2014). Effective access to health care in Mexico. BMC Health Services Research, 14(1).

Rationed by waiting lists and queuing systems, public healthcare services are accessed via a District Health system, as the preferred government mechanism for primary care service provision for the majority of South Africans (Mahlathi & Dlamini, 2015). Services are accessed through public clinics, public hospitals, community health centres/clinics and ambulance services, and governed by the use of Norms and Standards.

The PHC sector has around 3500 clinics and health centres across the country that is accessible within 5km to more than 90% of people living in South Africa (McKenzie et al., 2017).

Private healthcare services are accessed by those who have medical insurance, or those who pay the private rates and fees attached to these private and specialist services, via private practices and hospitals.


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:

McKenzie, A., Schneider, H., Schaay, N., Scott, V., & Sanders, D. (2017). Primary Health Care Systems (Primasys). In World Health Organization and Alliance for Health Policy and Systems Research. Available from:

The primary care system is conceptualized for acting as a gatekeeper system. This is one of the aims in the provision of health care in Brazil. The primary care model is in line with the provision of universal access and comprehensive healthcare, it aims to coordinate  the access to specialist and hospital care, and it promotes actions for health promotion and disease prevention (Paim et al., 2011). Investments and organisational strategies, such as the establishment of the Community Health Agents Programme and the Family Health Strategy – FHS, have been carried out and have been helpful to reorganize primary care clinics to focus on the community and to integrate medical care with health promotion and public health actions (Brazilian Ministry of Health, 2019d; Paim et al., 2011).

In addition, more investments in decentralized and computerized regulatory systems have been made by municipalities. These result in the possibility of monitoring of waiting lists for specialized care, increase of service supply, introduction to clinical guidelines, and use of electronic medical records. These strategies end up integrating primary healthcare with the network of specialised services (Paim et al., 2011). According to a study conducted in four Brazilian capitals, referrals to secondary care services that come from family health care teams are usually more effective and have shorter waiting times (Almeida et al., 2010). Although all these advances have been achieved, it is necessary to remember that the primary care system in Brazil may be circumvented by people willing to pay out-of-pocket to access services immediately.


Almeida, P. F. de, Giovanella, L., Mendonça, M. H. M. de, & Escorel, S. (2010). Desafios à coordenação dos cuidados em saúde: Estratégias de integração entre níveis assistenciais em grandes centros urbanos. Cadernos de Saúde Pública, 26(2), 286–298.

Brazilian Ministry of Health. (2019d). Estratégia Saúde da Família (ESF).

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health system: History, advances, and challenges. The Lancet, 377(9779), 1778–1797.

Primary care is the first point of contact for continuing the healthcare pathway in Hong Kong. Primary care practitioners act as gatekeepers making recommendations and referrals to specialists according to the patients’ health care needs (Kung et al., 2007; Ng, 2006). While there is a long waiting time for public specialist outpatient services, patients can opt for private specialists in hospital and clinics at their own expense for a shorter waiting time.


Kung, K., Lam, A., & Li, P. (2007). Referrals from general practitioners to medical specialist outpatient clinics: effect of feedback and letter templates. Hong Kong Practitioner, 29(9).

Ng, W. (2006). Primary Healthcare. Healthcare Policy Forum/Hong Kong Democratic Foundation.

The public health system in India accommodates direct walk-ins and referred patients at facilities across all levels of care (primary, secondary, and tertiary level facilities). Nevertheless, there is a form of gatekeeping in place, in which public primary care facilities provide referrals to secondary/tertiary facilities. However, in rural areas, due to delays in access, poor availability and quality of services, individuals who can afford private care choose to directly seek secondary/tertiary care services privately after their initial primary care consultations. Whereas, in urban areas, the public is likely to directly access secondary/tertiary facilities because of higher demand for care by specialists and the perception that quality of care is better at higher level facilities (Faizi et el., 2016; Mohan and Kumar, 2019; Rural Health Information Hub, 2021).

In the public health care system in India, a referral chain arrangement exists where community-based providers and facilities provide referral advice for care seeking at the next or ever higher level on a case-to-case basis. The referral linkages are bidirectional and rather more evident for maternal health services, where first referral units have been clearly identified. Although health policies and program designs call for referral-based rationing at different tiers of the system, in practice, care can be directly sought at any health kiosk without referral from lower-level health care provider. For example, in urban areas where tertiary care settings are overburdened, the public prefers these facilities as there is a higher demand for care by specialists than by primary care physicians. It is a prevalent perception that quality of care at higher-level facilities is better than the one available at lower levels. On the other hand, in rural communities, it has been noted that care-seekers usually divert to the private providers after an initial consultation with the primary level facilities, as referral care is perceived as costly and inconvenient (Faizi et el., 2016; Mohan and Kumar, 2019; Rural Health Information Hub, 2021).


Faizi, N., Khalique, N., Ahmad, A., & Shah, M. S. (2016). The dire need for primary care specialization in India: Concerns and challenges. Journal of family medicine and primary care5(2), 228–233.

Mohan, P., & Kumar, R. (2019). Strengthening primary care in rural India: Lessons from Indian and global evidence and experience. Journal of family medicine and primary care8(7), 2169–2172.

Rural Health Information Hub. (2021). Healthcare access in rural communities. RHI Hub. Available from:

Yes. The health service delivery system in Kenya is organized across six levels of care, with the first level at the community level and continuing through primary care services, which include dispensaries (level 2) and health centres (level 3), and county referral health services (level 4 & 5) all the way to the national referral health services (level 6). Higher health care facilities act as referral centres for lower-level facilities. For instance, level 1 is the foundation of health care service delivery and referral to a higher level of care is performed to seek additional services such as diagnosis, treatment, admission or to seek expert opinion (Ministry of Health, 2014d). However, sometimes patients bypass the low-level facilities depending on proximity and go directly to higher levels of care resulting to high caseloads. In some circumstances, referral by a health worker from higher to lower levels of care (except level 1) is made, particularly if the higher health facility is far from the client’s home and the client has been prescribed medicines that are available at a nearby lower health facility.

In terms of private health care, the referral chain is not structured as access to health services is based on proximity and the ability to pay for the services. Some community members access the services of community health providers (residing within their communities) while others visit nearby private clinics where referral to a specialist is made if necessary. However, patients can go directly to a specialist without a referral.


Ministry of Health. (2014d). Kenya Health Sector Referral Strategy. Ministry of Health Division of Emergency and Disaster Risk Management Afya House.


Yes, within the public system (MoH and social security institutions), gatekeeper systems are in place (primary care, secondary, high specialisation), but not in the private sector.

Patients receiving care from the public sector access services via a primary health care facility (e.g., community clinics, day-hospitals) and they can access secondary and tertiary care via referral (via the general practitioner or district surgeon). Similarly, within the private sector, specialist services at secondary and tertiary levels are accessed via referral from a local practicing general practitioner. This is enforced by medical insurance service providers, where patients will only be covered/insured for secondary and tertiary services with supporting referral documentation from the PHC authority (e.g., general practitioner), and with prior authorisation for in-hospital treatment and care.

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.