When people talk about access to healthcare, they usually mean proximity. There is a clinic; therefore there is access. But the relationship between a health facility existing and a person being able to use it is far more complicated than that, and flattening it into a single concept has real consequences for how we design health systems and who we design them for.
Access to healthcare has at least four distinct dimensions: geographic, financial, linguistic, and cultural. Each one operates as its own barrier. In many parts of the world, people face all four at once.
Geographic access is the most visible and probably the most discussed. In rural Tanzania, the nearest health facility can be more than 20 kilometers away, with no reliable transport and roads that become impassable during the rainy season. Similarly, across sub-Saharan Africa, over 50% of people live more than 5km from the nearest health facility (WHO, 2021). Distance alone determines whether a woman delivers her baby with skilled assistance or without it, whether a child with severe malaria reaches care in time, or whether a man ignores a symptom until it is no longer ignorable.
Then, there’s financial access, where the gap between policy and lived reality becomes particularly stark. Many low- and middle-income countries offer healthcare that is technically free at the point of use, but the costs that remain, such as transport, registration fees, informal payments, and lost wages from a day off work, are enough to make care inaccessible to those who need it most. Nearly 1 billion people spend at least 10% of their household budget on out-of-pocket health expenses (WHO, 2023). In South Africa, only 16% of the population holds private medical aid, yet the private sector consumes more than half of total health expenditure (Council for Medical Schemes, 2022). The public system absorbs everyone else, and it does so with significantly fewer resources.
Linguistic access receives far less attention than the other dimensions, despite its implications for patient safety and informed consent. South Africa has 11 official languages, yet most public health facilities operate primarily in English or Afrikaans. East Africa has over 400 languages and dialects. When a patient cannot fully understand their diagnosis, their treatment plan, or what they are agreeing to, the quality of care they receive is fundamentally compromised regardless of the technical skill of the clinician delivering it. Additionally, the question of informed consent must be raised too. Studies have consistently shown that patients with limited proficiency in the dominant clinical language are less likely to receive adequate follow-up care and less likely to understand their diagnosis (Betancourt et al., 2003).
Lastly, cultural access is perhaps the hardest to quantify, but its effects show up clearly in health-seeking behaviour. In South Africa, a 2020 report by the South African Human Rights Commission documented widespread reports of patient abuse, discrimination, and neglect in public health facilities, particularly affecting Black women and rural communities. When people have experienced dismissal, disrespect, or care that felt indifferent to their identity or beliefs, they do not return to seek healthcare services. As healthcare professionals, we may consider this to be irrational or illogical behaviour, but it is not. It is a rational response to a system that has not consistently treated them with dignity. In fact, a 2022 Lancet study identified perceived discrimination as one of the leading reasons for delayed or avoided care across low- and middle-income countries.
These four dimensions sit underneath the broader goal of Universal Health Coverage (UHC), which is meant to ensure that everyone, everywhere, can access the health services they need without financial hardship. On paper, it is an ambitious and necessary target. In practice, progress has been slow and uneven. Tanzania scores 42.6 out of 100 on the WHO UHC Service Coverage Index, and South Africa scores 70.9. The global average is 67.5 (WHO Global Health Observatory, 2021). Yet, globally, an estimated 4.6 billion people remain without full coverage of essential health services (WHO, 2023), and at the current rate of progress, the world will not reach UHC by 2030 (UN SDG Report, 2023).
The current gap between the UHC goal and reality reflects what happens when coverage is measured at the system level rather than the local one, and when the existence of a facility is counted as access without asking whether the person who needs it can get there, pay for it, understand it, or trust it.
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