The health status, accessibility, affordability and utilisation of healthcare seem to be related to both social and economic factors. It was therefore essential that a scientific investigation be undertaken to determine whether there was a relationship between accessibility, affordability and the use of health services by urban 22- to 50-year-old mixed-race (coloured) people of the Western Cape. This group, being the largest population group, contributes significantly to the economy of the Western Cape.

In his address on health reforms in the United States of America, President Obama indicated that health reform is a ‘moral obligation’ and, as described further by De Pinto (2009) in a poll of the American people, the Liberals (72%) believe that providing healthcare to all Americans is the government's ‘moral responsibility’. In the early 19th century, an English philosopher, Henry Spencer, issued a stern injunction that preservation of health was not a moral issue but a consequence of economics (Lancet Editorial 1996:1197). Economic growth has been associated with widening poor–rich disparities in health indicators (Houweling et al. 2005:1257). World-wide, less and less emphasis is placed on health as a priority. Houweling et al. (2005) emphasise that this effect may be remedied if public spending on health is increased. In 2004, the total gross domestic product (GDP) for health in Sudan was 4.2%; this declined to 3.6% in 2008, whilst the United States increased from 15.3% in 2004 to 15.7% in 2008. South Africa, being both a developing and a developed nation, has shown a steady decline in the relative expenditure on health from 9.2% in 2004 to 8.6% in 2008 (Trading Economics 2010).

The need to improve the average health status of populations was recognised by the member states of the World Health Organization (WHO) when the Alma Ata Declaration was adopted in the European Region (World Health Organization/United Nations International Children's Emergency Fund [UNICEF] 1978). A strategy of ‘Health for All’ was adopted. In addition, it was decided that by the year 2000, the differences in health status between countries and between groups within countries should be reduced by at least 25%. This could be achieved by improving the health of the disadvantaged nations and groups within countries. To address the ‘Gross inequality in the health status of the people, particularly between developed and developing countries, the WHO focused on PHC as the key to attain the goals of this strategy “Health for all by the year 2000”’ (WHO/UNICEF 1978). However, the United Nations (2000:1) at their Millennium Summit decided on more measurable goals with specific outcomes to ensure more healthy nations by 2015. With reference to these measurable goals with specific outcomes, Dr Margaret Chan, Director-General of the WHO, stated:

I do not believe we will be able to reach the Millennium Development Goals unless we return to the values, principles, and approaches of PHC … Decades of experience tell us that primary health care is the best route to universal access, the best way to ensure sustainable improvements in health outcomes, and the best guarantee that access to care will be fair. (International Council of Nurses 2008:2)

Despite its obvious advantages, the implementation of PHC has to overcome certain structural anomalies in countries like South Africa. Inequalities in healthcare between population groups of South Africa existed during the apartheid era and continue to exist both between and within many population groups, despite government efforts.

According to Kon and Lackan (2008) in their study on ethnic disparities in access to care in Post-Apartheid South Africa, they identified that black South Africans had the least access to medical care during the previous year (40.8%), followed by coloured people (22.9%), white people (10.9%) and Asians (6.9%). In a study conducted by Farmer and Ferraro (2005), individuals who are of a low socioeconomic standing are more likely to suffer from an increase in disease morbidity, higher mortality rates, lower life expectancy, fewer health screenings, reduced access to healthcare and lower rates of health insurance. Furthermore, financial strain as shown in a study was more likely to increase mortality in Black-American older women (Szanton et al. 2008).

According to Swinnerton (2006), poverty has been identified as being the greatest threat to health. The poor, who use public facilities, have less access to healthcare than the more affluent, who are often covered by medical aid insurance.

Yamin (2003) indicates that health services should not only be accessible but should include physical accessibility, as substantiated by the United Nations (2000):

[h]ealth facilities, goods and services must be within safe physical reach for all sections of the population, especially vulnerable or marginalized groups, such as ethnic minorities and indigenous populations, women, children, adolescents, older persons, persons with disabilities and persons with HIV/AIDS.

The use of health services may alter, depending on where the individual lives. Patient factors may be more important than supply factors in explaining the differential use of health services (Van der Heyden et al. 2003).

Bradshaw and Steyn (2001:103) identified a statistical relationship between the health status of the poor and that of the wealthy. They identified that chronic diseases such as asthma, smoking and abuse of alcohol were more prevalent amongst the poor than the rich; poorer areas are still plagued by a high burden of disease. To further substantiate this finding, Stellenberg, Welmann and Groenewald (2008) found a statistical relationship between the health status and the socioeconomic level of the coloured people of the Western Cape.

Bradshaw and Steyn (2001:iv) found that access to and quality of healthcare, measured by the treatment status of hypertension and use of medication in those suffering from asthma, was found to be worse amongst the poor. This is substantiated by the higher relative mortality burden of asthma and stroke amongst this group.

The cross-sectional study used a descriptive, non-experimental research design with a quantitative approach to investigate and describe the relationship between the accessibility, affordability and use of health services by coloured people of both sexes in the Western Cape between the ages of 22 and 50 years. It was conducted amongst individuals in a well-defined population in order to assess both exposure and disease simultaneously. As described by Burns and Grove (2011:536), this approach ensures that all the characteristics of a single sample are described, including any phenomenon of interest and identification of the variables within said phenomenon.

The hypothesis was that there is a positive relationship between accessibility, affordability and the use of health services by the coloured people of an urban area in the Western Cape.

A purposive convenient sample of 353 participants was drawn from the residential areas defined for the purpose of the study (Table 1). Guided by the statistician, the sample of 353 participants (0.6%) was drawn from a population of 63 004 economically-active people who lived in these suburbs (Statistics South Africa 1996).

The study was conducted in six residential areas of the Northern and Eastern regions of the Cape Metropolitan area in the Western Cape, South Africa, which included all individuals of all socioeconomic levels.

The residential areas selected were categorised with the help of town planners of the municipalities concerned into upper–middle socioeconomic level, lower socioeconomic level (formal housing) and lower socioeconomic level (informal housing), as shown in Table 2.

The design of the sample maximised the chance that all social classes were fairly and equally represented, as the intention was to determine the association between the factors and not the probable size of the different factors in the population.

Respondents, who identified themselves as coloured persons as classified according to the population register during the apartheid era (1948–1994), who were 22 to 50 years old, economically active and gave written informed consent to participate, were included in the research study. The economically-active target group was chosen, as this target group by definition also included the unemployed individuals (Statistics South Africa 2004), who have the potential to contribute to the economy of the province.

The researcher advertised the study through the community leaders of the various residential areas. The purpose of the study was explained and they assisted in identifying individuals who met the criteria for participation in the study. A minimum of 50 persons who met the criteria in a particular residential area, as identified and classified for the study, were thus included in the study through convenience sampling.

A pilot study was conducted to test the feasibility of the study; this included the methodology and administration procedure and the questionnaire so as to check for ambiguity and inaccuracies. A sample of 30 individuals (10%) of the initial planned sample of 300 of the main study was included in the pilot study. These participants were not included in the actual study.

The researcher collected the data personally with the help of two trained field workers (registered nurses) in a structured interview using a structured questionnaire. The questionnaire included questions about residential area, income, employment, types of health services used, accessibility and affordability of health services.

A Statistical Analysis System (SAS) computer program was used to analyse the quantitative data. Descriptive and inferential statistics were applied in the analysis of the quantitative data.

The Chi-square (χ²) statistical test on a 95% confidence interval was applied to determine the significance level of the relationship between the accessibility, affordability and use of health services by the coloured people of the Western Cape in an urban area. This test was most appropriate for determining whether the two variables being examined are independent or related as described by Burns and Grove (2009:499–500).

The open questions were categorised, with common themes being identified and then quantified.

The respondents used a variety of health services (Table 3). If their financial circumstances permitted, a private doctor was consulted, otherwise the comprehensive healthcare centre (CHC) or state health clinic was used.

The majority of the respondents used the state health facilities. The most commonly-used facilities were CHCs (n = 200; 56.7%), followed by private doctor (n = 198; 56.1%) and state hospitals (n = 165; 46.7%). CHCs were used by respondents of all socioeconomic levels: further analysis indicated that CHCs were used by 30 (24.4%) respondents from the upper–middle socioeconomic level, 90 (67.7%) from the lower socioeconomic level (formal housing) 80 (82.5%) from the lower socioeconomic level (informal housing). Only 79 (22.4%) of the respondents indicated that they used private hospitals. Private medical care is expensive and many of the respondents could not afford to use these services. Only 73 (20.7%) of the respondents had medical aid funds that allowed them to use a health service of their choice.

Table 4 shows that just over half (n = 203; 57.5%) of the respondents found the health services (including both public and private services) to be accessible. Using the Chi-square test (χ²), the statistical association between accessibility to health services and the use of health services was found to be significant (p = < 0.01). The association between socioeconomic level and accessibility of health services was also found to be significant (p = < 0.01). Additional analysis indicated that 26 (32.5%) of the respondents from the upper-middle socioeconomic level, 66 (49.6%) from the lower socioeconomic level (formal housing) and 44 (45.4%) from the lower socioeconomic level (informal housing) found their health services to be inaccessible. Amongst those respondents who were employed, 78 (51.5%) found their health services to be inaccessible and 97 (48.5%) of the unemployed individuals responded likewise.

As shown in Table 4, the 150 respondents for whom this question was relevant provided a variety of reasons for why they did not find the health services to be accessible. It is disconcerting to note that a number of the respondents (n = 44; 29.3%) indicated that staff displayed a negative attitude toward the patients and/or clients.

Respondents felt that they were made to feel that a favour was being done for them, because the services were free. More than half (n = 79; 52.7%) of the respondents complained about the length of the waiting period, which averaged 10 hours. Respondents were required to be at the CHC by 06:00. If they arrived by 07:00, it might be too late to be attended to on that specific day.

When too many patients attended the health service on a particular day, rapid screening was done by the registered professional nurse and even if a respondent was there at 06:00, he or she could be told to come back the next day. This could have financial implications such as losing a day's wages. The patients might also not have money for transport to return the next day. In addition, frequent days off work could result in conflict between employer and employee and consequent loss of employment. An ultimate result of these factors might be delayed health-seeking behaviour.

Some of the respondents (n = 17; 11.3%) also reported unhygienic conditions (such as unhygienic toilets) in state health institutions, which made the long waiting hours unpleasant.

Table 4 shows that 44 (29.3%) of the respondents reported that the availability of services was so poor that an appointment system was practised at certain CHCs so as to alleviate overcrowding. The members of the public were turned away if they did not have appointments. There were no CHC services in one of the residential areas, thereby forcing the residents to use a taxi and a train to get to the recommended CHC. Inaccessibility as a result of geographical distance can also result in delayed health-seeking behaviour, which could aggravate health problems; an example of this is a respondent who developed a foot infection after a motor vehicle accident, but who could not get to a CHC because of unemployment and eventually, nine months later, required urgent medical attention and hospitalisation.

Many similar cases of delays in seeking medical assistance may occur as a result of health services being inaccessible. Delayed health-seeking behaviour takes its toll, not only on the health status of the individual, but also in terms of becoming a financial burden for the state.

The majority of the respondents (n = 184; 52.1%) found their health services to be affordable; however, most of this group were not paying for their health services. An analysis according to socioeconomic level indicates that the respondents who found the health services to be most affordable were from the lower socioeconomic (informal) level (n = 63; 60.8%), followed by the upper-middle socioeconomic level (n = 72; 58.5%) and the lower socioeconomic (formal) level (n = 53; 39.9%). All of the respondents who found that health services were not affordable indicated that they were forced to use the CHC because private doctors were too expensive. The statistical association between affordability and the use of health services was significant (p = < 0.01).

Only 73 (20.7%) of the respondents belonged to a medical aid fund. This explains the overcrowding at CHCs, as 200 (56%) of the respondents were using the services of a CHC, as is shown in Table 3. A breakdown of the figures shows that respondents who had a medical aid fund came from all socioeconomic levels: 58 (47.2%) from the upper–middle socioeconomic level, 9 (6.8%) from the lower socioeconomic (formal) level and 6 (6.2%) from the lower socioeconomic (informal) level.

The association between the affordability of medical services and belonging to a medical aid fund was of statistical significance (p = < 0.01), as tested with the Chi-square test. Further analysis also showed a statistically-significant association between the residential area and the respondents who had a medical aid (p = < 0.01).

In response to an open-ended question, the respondents gave the following reasons for not using their health services: 28 (51.9%) indicated that access problems, such as long queues of people and long waiting hours at CHCs, prevented them from using their health services; 15 (27.8%) had no taxi and/or train fare to get to the CHC; and 11 (20.3%) indicated that they did not require such a service.

The introduction of a payment service to improve the health service was suggested by 17 (15%) of the respondents, as the country is already burdened with existing financial constraints and cannot afford to give a free health service to the majority of its citizens. Re-evaluation of this policy should thus occur. Payment for services might not only benefit the country, but the patients as well, as they would learn to take responsibility for their own health. Cognisance should be taken of the valuable input made by patients, as they are the consumers of such a service.

The hypothesis set for this research was accepted as the research showed that there was a positive relationship between accessibility, affordability and the use of health services by the coloured people in an urban area of the Western Cape.

A pilot study was conducted to test the feasibility of the study; this included pre-testing the instrument for inaccuracies and ambiguity in support of its validity and reliability. Experts in research methodology, statistics and computer science evaluated the instrument. In addition, the content of the instrument was evaluated by a nursing science specialist, a sociologist and members of the ethics and postgraduate committee. Reliability was further assured by using two well-trained assistants together with the researcher and using standard instructions for all participants for the data collection.

A review of the free medical service is recommended. A small payment will promote a sense of responsibility and free medical service should then be reserved for senior citizens, the severely disabled and children.

CHCs are currently required to serve the majority of the communities. The study showed that 56.7% of the respondents used CHCs, but the number of patients reporting to CHCs will in all likelihood increase rather than decrease as a result of the global economic crisis.

A significant portion of respondents (66.4%) indicated that the services were poor, aggravated by long waiting times and unhygienic conditions. Many respondents (29.3%) complained about the attitude of nurses, who made patients feel that they were doing them a favour because of the free medical care. In addition, 17.3% of respondents indicated that the CHCs are overcrowded because there is a staff shortage. These problems could explain the complaints of patients regarding the negative attitude of the staff.

Functioning in the trying circumstances described above is not conducive to quality healthcare delivery as the limited staff are pressurised to get through large numbers of patients.