Background: 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's costs of accessing SRH services in Johannesburg, South Africa and contextualized costs based on estimates of household income. Methods: We conducted an observational study of women aged at a public HIV treatment site and two public primary health care facilities from June to August Interviews assessed women's 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 "full needs met" year. Results: Among the women who participated, Sixty percent of women reported at least one unmet SRH need. Only two women reported catastrophic expenditure - for managing infertility. Conclusions: SRH needs are constants throughout women's 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. Literature on women's 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.
