{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T23:57:29Z","timestamp":1792540649298,"version":"4.5.0"},"reference-count":34,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2019,12,1]],"date-time":"2019-12-01T00:00:00Z","timestamp":1575158400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2019,12,16]],"date-time":"2019-12-16T00:00:00Z","timestamp":1576454400000},"content-version":"vor","delay-in-days":15,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000200","name":"United States Agency for International Development","doi-asserted-by":"publisher","award":["AID-674-A-12-00029"],"award-info":[{"award-number":["AID-674-A-12-00029"]}],"id":[{"id":"10.13039\/100000200","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Reprod Health"],"published-print":{"date-parts":[[2019,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n<jats:title>Background<\/jats:title>\n<jats:p>Evaluating progress towards the Sustainable Development Goal of universal access to sexual and reproductive (SRH) services requires an understanding of the health needs of individuals and what constitutes access to services. We explored women\u2019s costs of accessing SRH services in Johannesburg, South Africa and contextualized costs based on estimates of household income.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Methods<\/jats:title>\n<jats:p>We conducted an observational study of women aged 18\u201349 at a public HIV treatment site and two public primary health care facilities from June 2015 to August 2016. Interviews assessed women\u2019s SRH needs (for contraception, fertility problems, menstrual problems, menopause symptoms, sexually transmitted infections (STI), experiences of intimate-partner violence (IPV), and cervical and breast cancer screening) and associated costs. We calculated average and total costs (including out-of-pocket spending, lost income, and estimated value of time spent) for women who incurred costs. We also estimated the total and average costs of meeting all SRH needs in a hypothetical \u201cfull needs met\u201d year. Finally, we contextualize SRH spending against a measure of catastrophic expenditure (&gt;\u200910% of household income).<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Results<\/jats:title>\n<jats:p>Among the 385 women who participated, 94.8% had at least one SRH need in the prior 12\u2009months; 79.7% incurred costs for accessing care. On average, women spent $28.34 on SRH needs during the prior year. Excluding one HIV-negative woman who spent 112% of her annual income on infertility treatment, HIV-positive women spent more on average annually for SRH care than HIV-negative women. Sixty percent of women reported at least one unmet SRH need. If all participants sought care for all reported needs, their average annual cost would rise to $52.65 per woman. Only two women reported catastrophic expenditure \u2013 for managing infertility.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Conclusions<\/jats:title>\n<jats:p>SRH needs are constants throughout women\u2019s lives. Small annual costs can become large costs when considered cumulatively over time. As South Africa and other countries grapple with increasing access to SRH services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to SRH services.<\/jats:p>\n<\/jats:sec><jats:sec>\n<jats:title>Plain English summary<\/jats:title>\n<jats:p>Literature on women\u2019s financial and economic costs for accessing comprehensive sexual and reproductive health care in low- and middle-income countries is extremely limited, and existing literature often overlooks out-of-pocket costs associated with travel, child care, and time spent accessing services. Using data from a survey of 385 women from a public HIV treatment site and two public primary health care facilities in Johannesburg, we found nearly all women reported at least on sexual and reproductive health need and more than 75% of women incurred costs related to those needs. Furthermore, more than half of women surveyed reported not accessing services for their sexual and reproductive health needs, suggesting a total annual cost of more than $50 USD, on average, to access services for all reported needs. While few women spent more than 10% of their total household income on sexual and reproductive health services in the prior year, needs are constant and costs incur throughout a woman\u2019s life suggesting accessing services to meet these needs might still result in financial burden. As South Africa grapples with increasing access to sexual and reproductive health services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to services.<\/jats:p>\n<\/jats:sec>","DOI":"10.1186\/s12978-019-0842-2","type":"journal-article","created":{"date-parts":[[2019,12,16]],"date-time":"2019-12-16T19:03:26Z","timestamp":1576523006000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":16,"title":["Women\u2019s costs for accessing comprehensive sexual and reproductive health services: findings from an observational study in Johannesburg, South Africa"],"prefix":"10.1186","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3689-4205","authenticated-orcid":false,"given":"Naomi","family":"Lince-Deroche","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kaitlyn M.","family":"Berry","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cheryl","family":"Hendrickson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tembeka","family":"Sineke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sharon","family":"Kgowedi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masangu","family":"Mulongo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2019,12,16]]},"reference":[{"key":"842_CR1","unstructured":"United Nations Department of Economic and Social Affairs. Sustainable Development Goals [Internet]. Sustain. Dev. Knowl. Platf. 2015 [cited 2015 Nov 26]. Available from: https:\/\/sustainabledevelopment.un.org\/topics"},{"key":"842_CR2","unstructured":"World Health Organization Department of Reproductive Health and Research. Reproductive health strategy. Geneva; 2004."},{"key":"842_CR3","unstructured":"World Health Organization. Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva; 2017."},{"issue":"10140","key":"842_CR4","doi-asserted-by":"publisher","first-page":"2642","DOI":"10.1016\/S0140-6736(18)30293-9","volume":"391","author":"Ann M Starrs","year":"2018","unstructured":"Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress\u2014sexual and reproductive health and rights for all: report of the Guttmacher\u2013 Lancet Commission. Lancet [Internet]. England: Elsevier Ltd; 2018;6736. Available from: http:\/\/dx.doi.org\/https:\/\/doi.org\/10.1016\/S0140-6736(18)30293-9","journal-title":"The Lancet"},{"issue":"2","key":"842_CR5","doi-asserted-by":"publisher","first-page":"127","DOI":"10.1097\/00005650-198102000-00001","volume":"19","author":"Roy Penchansky","year":"1981","unstructured":"Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care [Internet]. 1981 [cited 2013 Nov 17];19:127\u201340. Available from: http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/7206846.","journal-title":"Medical Care"},{"key":"842_CR6","doi-asserted-by":"publisher","first-page":"546","DOI":"10.2471\/BLT.13.125450","volume":"91","author":"DB Evans","year":"2013","unstructured":"Evans DB, Hsu J, Boerma T. Universal health coverage and universal access. Bull World Health Organ. 2013;91:546\u2013546A.","journal-title":"Bull World Health Organ"},{"key":"842_CR7","doi-asserted-by":"publisher","first-page":"179","DOI":"10.1017\/S1744133109004836","volume":"4","author":"D Mcintyre","year":"2009","unstructured":"Mcintyre D, Thiede M, Birch S. Access as a policy-relevant concept in low- and middle-income countries. Heal Econ Policy Law. 2009;4:179\u201393.","journal-title":"Heal Econ Policy Law"},{"key":"842_CR8","unstructured":"UNAIDS. Country: South Africa [Internet]. 2019 [cited 2019 May 5]. Available from: http:\/\/www.unaids.org\/en\/regionscountries\/countries\/southafrica"},{"key":"842_CR9","unstructured":"Health Systems Trust. Medical scheme coverage (%) 1995\u20132014 [Internet]. [cited 2016 Jun 30]. Available from: http:\/\/indicators.hst.org.za\/healthstats\/77\/data"},{"key":"#cr-split#-842_CR10.1","unstructured":"Republic of South Africa. National Health Act, 61 of 2003 [Internet]. Gov. Gaz., No. 26595 South Africa: Cape Town: Government Printer"},{"key":"#cr-split#-842_CR10.2","unstructured":"2004. Accessed 11 Dec 2019. Available from: https:\/\/www.up.ac.za\/media\/shared\/12\/ZP_Files\/health-act.zp122778.pdf"},{"key":"842_CR11","unstructured":"South African National Department of Health. Department of Health Annual Report 2011-2012 [Internet]. 2012. Accessed 11 Dec 2019. Available from: http:\/\/pmg-assets.s3-website-eu-west-1.amazonaws.com\/docs\/121009healthrep.pdf"},{"issue":"2","key":"842_CR12","doi-asserted-by":"publisher","first-page":"377","DOI":"10.1016\/j.jbi.2008.08.010","volume":"42","author":"Paul A. Harris","year":"2009","unstructured":"Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 42:377\u201381.","journal-title":"Journal of Biomedical Informatics"},{"key":"842_CR13","doi-asserted-by":"publisher","first-page":"1453","DOI":"10.1016\/S0140-6736(07)61602-X","volume":"370","author":"E von Elm","year":"2007","unstructured":"von Elm E, Altman D, Egger M, Pocock S, Gotzsche P, Vandenbroucke J. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453\u20137.","journal-title":"Lancet."},{"key":"842_CR14","unstructured":"Statistics South Africa. Labour market dynamics in South Africa, 2015. Labour stat. Pretoria; 2016."},{"key":"842_CR15","volume-title":"Coping with catastrophic health shocks. Conf Soc Prot poverty","author":"N Prescott","year":"1999","unstructured":"Prescott N. Coping with catastrophic health shocks. Conf Soc Prot poverty. Washington, DC: Inter-American Development Bank; 1999."},{"key":"842_CR16","first-page":"613e621","volume":"80","author":"M Ranson","year":"2002","unstructured":"Ranson M. Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat. India: current experiences and challenges Bull World Health Organ. 2002;80:613e621.","journal-title":"India: current experiences and challenges Bull World Health Organ"},{"key":"842_CR17","unstructured":"International Monetary Fund. Consumer Price Index [Internet]. World Econ. Outlook Database. [cited 2015 Apr 9]. Available from: https:\/\/www.imf.org\/external\/pubs\/ft\/weo\/2014\/02\/weodata\/index.aspx"},{"key":"842_CR18","unstructured":"World Bank. Indicators: GDP deflator [Internet]. [cited 2017 Sep 18]. Available from: https:\/\/data.worldbank.org\/indicator\/NY.GDP.DEFL.ZS"},{"key":"842_CR19","doi-asserted-by":"crossref","unstructured":"International Monetary Fund. IMF Exchange Rates [Internet]. 2017 [cited 2017 Sep 18]. Available from: http:\/\/www.imf.org\/external\/np\/fin\/ert\/GUI\/Pages\/CountryDataBase.aspx","DOI":"10.5089\/9781484327234.026"},{"key":"842_CR20","doi-asserted-by":"publisher","first-page":"633","DOI":"10.1057\/gpp.2012.35","volume":"37","author":"JEO Ataguba","year":"2012","unstructured":"Ataguba JEO, Goudge J. The impact of health insurance on health-care utilisation and out-of-pocket payments in South Africa. Geneva Pap Risk Insur Issues Pract. 2012;37:633\u201354.","journal-title":"Geneva Pap Risk Insur Issues Pract"},{"key":"842_CR21","doi-asserted-by":"crossref","unstructured":"Cleary S, Birch S, Chimbindi N, Silal S, McIntyre D. Investigating the affordability of key health services in South Africa. Soc Sci Med [Internet]. Elsevier Ltd; 2013 [cited 2013 May 15];80:37\u201346. Available from: http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/23415590.","DOI":"10.1016\/j.socscimed.2012.11.035"},{"key":"842_CR22","doi-asserted-by":"publisher","first-page":"849","DOI":"10.3934\/publichealth.2016.4.849","volume":"3","author":"CBT Makura","year":"2016","unstructured":"Makura CBT, Schnippel K, Michelow P, Chibwesha C, Goeieman B, Jordaan S, et al. Choropleth mapping of cervical Cancer screening in South Africa using healthcare data from the national laboratory network. AIMS Public Heal. 2016;3:849\u201362.","journal-title":"AIMS Public Heal"},{"key":"842_CR23","unstructured":"Lince-Deroche N, van Rensburg C, Masuku S, Rayne S, Benn C, Holele P. Breast cancer in South Africa: developing an affordable and achievable plan to improve detection and survival. In: Padarath a, Barron P, editors. South African heal rev [internet]. 20th editi. Durban: Health systems trust; 2017. p. 181\u20138. Available from: url. https:\/\/www.hst.org.za\/publications\/Pages\/HST-South-African-Health-Review-2017.aspx. Accessed 11 Dec 2019."},{"key":"842_CR24","doi-asserted-by":"publisher","unstructured":"Rayne S, Lince-Deroche N, Hendrickson C, Shearer K, Moyo F, Michelow P, et al. Characterizing breast conditions at an open-access breast clinic in South Africa: a model that is more than cancer care for a resource-limited setting. Tbd [Internet]. BMC Health Services Research; 2016;TBD:1\u201310. Available from: http:\/\/dx.doi.org\/https:\/\/doi.org\/10.1186\/s12913-016-1959-4","DOI":"10.1186\/s12913-016-1959-4"},{"key":"842_CR25","unstructured":"Statistics South Africa. Income and Expenditure of Households 2010 \/ 2011 [Internet]. Pretoria; 2011. Available from: http:\/\/www.statssa.gov.za"},{"key":"842_CR26","doi-asserted-by":"publisher","first-page":"339","DOI":"10.1016\/j.contraception.2015.06.029","volume":"92","author":"N Lince-Deroche","year":"2015","unstructured":"Lince-Deroche N, Constant D, Harries J, Blanchard K, Sinanovic E, Grossman D. The Costs of accessing abortion in South Africa: Women\u2019s costs associated with second-trimester abortion services in Western Cape Province. Contracept. 2015;92:339\u201344.","journal-title":"Contracept"},{"issue":"2","key":"842_CR27","doi-asserted-by":"publisher","first-page":"72","DOI":"10.1016\/j.contraception.2017.03.013","volume":"96","author":"Naomi Lince-Deroche","year":"2017","unstructured":"Lince-Deroche N, Fetters T, Sinanovic E, Blanchard K. Accessing medical and surgical first-trimester abortion services: Women\u2019s experiences and costs from an operations research study in KwaZulu-Natal Province, South Africa. Contraception. 2017;96(2):72\u201380. https:\/\/doi.org\/10.1016\/j.contraception.2017.03.013","journal-title":"Contraception"},{"key":"842_CR28","unstructured":"Bankole A, Oye-Adeniran BA, Singh S, Adewole IF, Wulf D, Sedgh G, et al. Unwanted Pregnancy And Induced Abortion In Nigeria. New York, NY: Guttmacher Institute; 2006. Available from: https:\/\/www.guttmacher.org\/sites\/default\/files\/pdfs\/pubs\/2006\/08\/08\/Nigeria-UP-IA.pdf. Accessed 11 Dec 2019."},{"key":"842_CR29","unstructured":"Singh S, Darroch JE, Ashford LS, Vlassoff M, Costs T, Health N. Adding it up: the Costs and benefits of investing in family planning and maternal and newborn Health 2009. New York, NY: Guttmacher Institute and United Nations Population Fund; 2009."},{"key":"842_CR30","unstructured":"Singh S, Darroch JE. Adding it up: Costs and benefits of contraceptive services 2012 [internet]. New York, NY: Guttmacher Inst. UNFPA; 2012. Available from: https:\/\/www.guttmacher.org\/report\/adding-it-costs-and-benefits-contraceptive-services-estimates-2012. Accessed 11 Dec 2019."},{"key":"842_CR31","unstructured":"Darroch JE, Singh S, Weissman E. Adding It Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health 2014\u2014Estimation Methodology. New York, NY: Guttmacher Institute; 2016."},{"key":"842_CR32","unstructured":"Singh S, Darroch JE, Vlassof M, Nadeau J. Adding It Up: The benefits of investing in sexual and reproductive health care. New York, NY: Guttmacher Institute; 2003."},{"key":"842_CR33","unstructured":"Reproductive Health Supplies Coalition. Global Contraceptive Commodity Gap Analysis 2018 [Internet]. Brussels; 2018. Available from: https:\/\/www.rhsupplies.org\/activities-resources\/commodity-gap-analysis\/cga2018\/. Accessed 11 Dec 2019."}],"container-title":["Reproductive Health"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12978-019-0842-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/article\/10.1186\/s12978-019-0842-2\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12978-019-0842-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,12,15]],"date-time":"2020-12-15T00:46:06Z","timestamp":1607993166000},"score":1,"resource":{"primary":{"URL":"https:\/\/reproductive-health-journal.biomedcentral.com\/articles\/10.1186\/s12978-019-0842-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,12]]},"references-count":34,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2019,12]]}},"alternative-id":["842"],"URL":"https:\/\/doi.org\/10.1186\/s12978-019-0842-2","relation":{},"ISSN":["1742-4755"],"issn-type":[{"value":"1742-4755","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,12]]},"assertion":[{"value":"30 July 2018","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"3 December 2019","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"16 December 2019","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Approval for data collection was obtained from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand for protocol number M140212. Permission to perform the research was also obtained from the City of Johannesburg and the study clinics. All participants provided written informed consent.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"179"}}