The human capabilities approach provides a basis for analyzing the well-being of people by breaking away from the income-centric traditions of well-being [1]. According to the capabilities approach, to live a dignified life, focus should be on the genuine opportunities that a person has to do things according to what he or she values in life [2-4]. Society‘s role is to provide every person with opportunities to live a dignified life that they aspire to live. The Capabilities Approach considers “a person being able to do certain basic things” [5] as the end, and resources and utilities as only means to this end [6]. Nussbaum’s human capabilities approach looks at the opportunity each person has, resources available and the role of the society in promoting these opportunities and substantial freedoms which people can exercise or not based on their own choices [2]. Therefore, there is a need to expand people’s real opportunities for a healthy life through the provision and access to health care facilities and a healthy lifestyle. Not having access to health care may be an inhibitor of a person’s functioning in terms of their health. Resources are important in the development of capabilities as they are a means to a certain functioning [7].The human capabilities approach points out that in order to tackle capability deprivation of people, it is important to improve people’s access to resources as one of the possible solutions [7].

According to Anand (2009), there are ten central capabilities that all individuals are entitled to, for them to live a minimally just and decent life worth of human dignity [2]. Bodily health is an integral feature for well-being, and it is essential for the realization of other central human capabilities. The problem of denied or lack of access to health care creates a capability deprivation in the area of bodily health, which affects the quality of life for individuals. Capabilities associated with bodily health require the individual to retain the ability to live to the end of human life of normal length, without dying prematurely or experiencing a reduced quality of life, such that life becomes not worth living [8]. Therefore, this study utilizes Nussbaum’s human capabilities theory to articulate issues regarding barriers to access to health care for people in rural settings in the quest to redress the barriers and to ensure opportunities for all individuals to be healthy despite their geographical location.

In this paper, we present the background information on access to health in various contexts and identify the research gap and the research methods utilized. The findings from the data are also presented according to themes, interpreted, and discussed in relation to the existing literature. Recommendations to promote justice and access to health care in a rural setting are also given.

Issues concerning access to health care services for various economic and social groups have been a subject of the WHO for a long time. Access to health care is a major health issue and compromised access affects the performance of health care systems globally [9,10]. Lack of access to health care comprises the opportunity to obtain and appropriately use quality health services and while access does not guarantee good health, it is critical for a person’s well-being and optimal health. Access to health care includes the availability, affordability and acceptability of health services [11]. Different groups have different health statuses, which are often referred to as health inequalities. These inequalities are frequently considered in terms of socioeconomic position, race, ethnicity, geographical location, gender and age [11]. Access to quality health care services is a persistent issue in all countries, but the extent and seriousness of its manifestation differ with each location. The accessibility of health care resources generally declines with the decline in population density and as geographical isolation increases [12]. The above implies that rural areas, smaller populated and more remote areas are often lacking hospitals, specialized care and other health care resources. According to Cordasco, Mengeling, Yano and Washington [13], rural areas and remote communities worldwide often experience high levels of inaccessibility of health care. Concerns over access to health care in rural areas have existed for decades with people living in the rural areas and remote areas facing multiple challenges in accessing appropriate health services [10,14,15].

The technical and social infrastructure in rural areas is much poor, and as a result, the access to doctors, particularly specialists, hospital service, preventative care and emergency services, is limited [16,17]. Such a situation might be further exacerbated by the lack of transport and the long distance to the health care facilities. The lack of access to health care may lead to the poor management of certain illnesses or delayed care in times of emergencies which consequently causes poor health outcomes and at times premature death. Furthermore, according to studies conducted in the United States of America (USA), people living in rural communities are more affected by chronic conditions such as heart disease, cancer, stroke and respiratory diseases [17,18]. Due to geographical location, lower socioeconomic status, higher rates of risky behaviours and decreased access to quality health care, people living in rural areas in the USA experience higher mortality rates, lower life expectancy and higher rates of pain and suffering as compared to their urban counterparts[18-20]. Compromised access to health care in rural America includes the lack of services, paucity of medical practitioners, specialist facilities, hospitals and clinics in the rural area [21-23]. This is further intensified by the fact that rural residents are more likely not to have health insurance nor medical cover, which obstruct them from accessing alternative private care [20].

African countries are also not immune to the challenges associated with access to health care. They are faced with continuous health care delivery and access problems, with less than one health care worker per thousand people [24]. The vast rural areas in Sub-Saharan Africa are either underserved or unserved with reports of lack of or limited access to health care due to shortages of skilled health care workers, geographical accessibility of the health care facilities, long waiting hours, poor service quality, hours and limited resources universal in all the regions of the African continent [25-29]. A study conducted in Eritrea on stakeholders’ perspectives on facilitators and barriers to the utilization and access to maternal health care services showed that poor quality of care, short clinic hours, and shortage of health care workers were obstacles to accessing care [30]. Zimbabwe is one of the countries facing serious health care challenges in Africa due to its economic crisis, which has negatively affected health delivery. Although barriers to access to health care in Zimbabwe are pervasive nationally, the rural population (majority population) is much more affected influenced by long distances and travel times to the health care facilities, financial constraints, lack of infrastructure, shortage in supply of medicines and nurses [31-33]. These scenarios give a true reflection of the state of the health care sector in most African countries.

South Africa has a constitutional mandate to fulfill the right to access health care services for everyone living in the country [34]. Despite this mandate and significant progress made as compared to its African counterparts, there are considerable disparities in health status across racial groups and geographical locations, with the poorest groups who are more vulnerable to ill health using health care facilities less [35]. Additionally, several scholars indicate that the health outcomes in South Africa remain polarized, unequal and unfair [35-37], as evidenced by the unequal distribution of health care professionals and facilities among provinces [38,39]. During the apartheid times, these disparities were influenced by policies of racial segregation and exclusion; today this is still visible through the unequal distribution of health resources and differential access to health care services for specific race and class groups [39]. The majority of black South Africans, especially those in rural areas use public facilities and have limited and heavily constrained access to health care than the wealthy, self-paying, medically insured population (minority by far), who have access to private facilities and practitioners that are concentrated in urban areas [39, 11, 40]. The majority of black Africans (75,5% or 25,2 million) rely on the public health sector, which is under-resourced [41]. These disparities in the type of care according to racial groups and geographical location ultimately results in different health outcomes across different subpopulations. This is evidenced by a study on inequalities in access to health care in rural South Africa, which indicated that black South Africans, poor, uninsured and rural respondents experienced the greatest barriers to health care access and reported poor health more than people from other racial groups [42].

Given the disparities in access to health care across geographical locations, it is important to prioritize access to health for the communities which are more deprived of access, especially the rural communities, as a matter of promoting justice. Understanding the barriers to health care access is significant in designing more effective interventions to overcome these barriers for all patients in different geographical locations. Additionally, rural residents have the same rights to quality health care as compared to their urban counterparts; therefore determining the barriers to their health care access is not only necessary in improving their health status but in promoting social justice.

Although research on barriers to access to health care in South Africa exist, there are still large information gaps about access in some rural areas that remain isolated. Research on access to health care from a human capabilities approach in rural South Africa is also limited. As such, we conducted a study in specific rural areas in South Africa to fill these gaps and to examine the access barriers from the key stakeholders in the community.

This study employed an explorative qualitative research design to guide the research process. This approach was used in this study to understand the world of the respondents through their understanding and interpretation. Data were collected in rural settings across three provinces in South Africa. That is Lamberts Bay, a small fishing town in the Western Cape Province with a total population of about 6120 people, Calvinia a small farming town in the Northern Cape Province with a total population of about 9680 people and Philippolis also a small farming town in the Free State Province with a total population of about 950 people.

The participants of the study comprised of a wide range of stakeholders who agreed to share their perceptions on the barriers to accessing health care services in rural settings. These stakeholders consisted of social workers, health workers, child and youth workers, cleaners and police officials who work in the three rural communities. Purposive sampling was used to select the participants of this study working in different departments in the community, for example the Department of Social Development and the Department of Health. A total of 23 stakeholders were interviewed, 13 from Lamberts Bay, 6 from Calvinia and 4 from Philippolis. In Table 1, a summary of the characteristics of the 23 stakeholders that were included in the study is presented.

The study utilized semi-structured interviews to collect data from the stakeholders. The interviews were guided by the interview schedules developed beforehand based on Nussbaum’s 10 Human Capabilities. Examples of questions that were contained on the interview schedule include: how would you describe the health services in the community?; What are the available health services in this community?; Are the health services easily accessible by the community members? Describe your perception towards access to mental health services in this community?; In your view, what hinders many people in this community from accessing health services? Probing questions were asked to follow up on the participants’ responses. The interviews were conducted in English and Afrikaans, which were the predominant languages in the three areas. The interviews ranged between 40 to 70 minutes.

Data were analyzed through thematic analysis. The researchers familiarized themselves with the transcribed data by reading and re-reading the transcripts then after they generated initial codes. After coding was completed, themes generation commenced through sorting different codes into related clusters. Then, themes were named and defined. The coding and theme development were performed by a team of researchers to ensure that the findings are credible.

Six sub-themes were identified under the main theme of barriers to accessing health care: (1) limited/ unavailability of health facilities which has to do with absence or limited hospitals, general and specialist health care facilities, hindering people from getting health care; (2) human resources shortages specifically mental health practitioners and general nurses, impacting on health care delivery; (3) shortage of medicine which led to people going for days without medicine and buying from alternative providers; (4) distrust in the health care providers mainly resulting from perceived lack of quality care and incompetence by the health care providers; (5) opening hours of the facilities which has to do with limited or no access to health care facilities outside the opening hours of the facilities and in times of emergency contributing to care deprivation and at times death; and (6) financial constraints which limited people from accessing private health care and travelling to access hospitals and specialized treatments. Below is the presentation and interpretation of each theme supported by the quotes by the participants.

Evidence from this study points out that there are some factors that act as barriers to accessing health care services in the three rural communities. There were reports that there were limited health care facilities, general and specialist health care services were limited or absent, this is contradictory to the South African Constitution, which guarantees every citizen access to health care services [43]. People had to travel many kilometers to access specialist services and for emergencies. One example identified was that of the absence of mental health institutions and staff who specifically deal with mental health issues which meant that people had to travel to other areas to access these. Travelling to access health care services was also pinpointed as problematic due to the socio-economic status of the community which resulted in some people not affording to travel for these services even when they need them the most. Even though some health services are provided for free, monetary and time costs of travel may result as an important blockade for vulnerable parts of the population, leading to overall poorer health [44]. Data from a study conducted in South Africa indicate that there is limited use of referral hospitals by lower socio-economic groups; with the likelihood of using a health service is far lower for those living furthest from health facilities [11]. This consequently results in poorer management of chronic illnesses and poor health outcomes. Therefore, to promote increased use of specialist services and hospitals, these have to be located where the people can easily access them.

Associated with the lack of or limited health care facilities was the absence of 24-hour health care services and admission facilities in the area. This made people not get services outside of the opening hours of the facilities, which deprived them of their right to be healthy. Due to the absence of 24-hour health care services and admission facilities, people had to go to other areas to access these, which was reported to be leading to fatalities which might have been avoided by having 24-hour facilities which offer admissions for patients. This shows that lack of access may have significant repercussions for premature death [11].

Lack of human resources and understaffing were also noted as a major concern in accessing the health care system in the study context. Lack of health care personnel dealing with mental health issues and specialist doctors were also indicated to be scarce and this compromised the bodily health of people in the community. Local clinics were reported to have shortages of staff nurses, which consequently resulted in long queues, prolonged waiting hours for patients and some of the patients not being attended. The shortage of health care personnel hampers sufficient delivery of health care [45,46]. Developed countries, including South Africa, face shortages of health care personnel with uneven distribution between sectors and geographical areas [35, 47, 48]. The availability of health personnel is also a key element of access to quality health care [11]. This implies that shortages or lack of health care personnel present a barrier for the fulfillment of the right to health care.

Adding on to the problem of the shortage of health care personnel, there are also shortages of medicine in the public health care facilities whereby these facilities sometimes go for long periods without medication. Due to this, some people who need medication to manage their illnesses are turned away. Such a situation resulted in some people not taking medication and others opting to buy their medication from other facilities which again is a challenge especially in a setting where most people are unemployed and depend on social grants. Linked to the above, the costs of utilising private health care in cases where people cannot access the public health care system were also noted as a barrier for many people due to the related costs. Only those who had better-paying jobs were reported to be affording to utilise these. Financial constraints were also cited as a barrier to accessing other distant health care facilities with better resources and specialised care. According to Gaede & Versteeg (2011) [49], many families in rural areas are not able to access health care services due to the costs involved and the higher levels of deprivation.

Even though rural populations are largely dependent on public health facilities, barriers to access health care in rural areas can result in substitute care such as private doctors. Private doctors are an essential component of the health care system. While this is true, the study brought to light issues of distrust in the private health care providers who were described as less responsible and cared less for the well-being of their patients, as evidenced in the reports on giving the wrong diagnosis and not spending time in examining the patients. Such a situation can be attributed to the shortages of doctors in the area, which might make the work overwhelming for the doctor and without competition from others providers the doctors might also be reluctant in providing quality care. According to Douthit, Kiv, Dwolatzky & Biswas (2015), rural doctors often find themselves overburdened and this hinders them from further training which results in the failure to improve or update the care they provide for their patients [16].

In order to minimize these challenges in the health care system of South Africa that continue to persist even after democracy, there is a need for the health department to adopt a needs-based resource allocation mechanism for distributing resources across districts, instead of relying on historical budgeting, which has contributed to entrenching inequalities in public health spending within provinces. Health care reforms should be multifaceted taking into consideration strategies to address infrastructure deficiencies, human resources and medicine shortages to ensure equitable provision of high-quality public services.

Ways to improve access to health care should take into consideration what the real health care needs of that community are, improvements must be tailored to the needs of rural communities. The needs of specific rural communities should be presented at national levels and the issues raised in this study calls for different stakeholders, including policy-makers, government, non-governmental organisations, community leaders and ordinary citizens to come up with solutions and collaborate in implementing the suggested solutions to improve access to health care in rural areas. Further research is also required on issues of user acceptability dimension to access, which is important in determining the use of health facilities by the consumers.

Accessing health care in the rural areas of South Africa continues to be a challenge. As confirmed by the study, there are significant barriers that impede people in rural areas from accessing health care. These include limited or lack of health care facilities and personnel, shortages of medicine, distrust in the health care providers, opening hours of health care facilities and financial constraints. The barriers to health care access significantly impact the bodily health of people in rural areas. To meet the Sustainable Development Goals and ensure social justice, the South African government should ensure the provision of adequate, quality and accessible health care to all people in the country, including those in rural areas.