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 18-49 at a public HIV treatment site and two public primary health care facilities from June 2015 to August 2016. 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. Finally, we contextualize SRH spending against a measure of catastrophic expenditure (> 10% of household income). RESULTS Among the 385 women who participated, 94.8% had at least one SRH need in the prior 12 months; 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 - 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. 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's 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.

中文翻译：

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妇女获得综合性健康和生殖健康服务的费用：南非约翰内斯堡的一项观察性研究的结果。

背景技术对实现普遍获得性和生殖（SRH）服务的可持续发展目标的进展进行评估，需要了解个人的健康需求以及什么构成服务的获取。我们研究了南非约翰内斯堡妇女获得性健康和生殖健康服务的成本，并根据家庭收入估算了背景成本。方法我们于2015年6月至2016年8月在公共HIV治疗场所和两个公共初级卫生保健机构对18-49岁的女性进行了观察性研究。访谈评估了女性的性健康和生殖健康需求（避孕，生育力问题，月经问题，更年期症状，性传播感染（STI），亲密伴侣暴力（IPV）经历以及子宫颈癌和乳腺癌的筛查）及相关费用。我们计算了产生费用的女性的平均费用和总费用（包括自付费用，收入损失和花费的时间估计值）。我们还估计了在假定的“完全满足”的一年中满足所有SRH需求的总成本和平均成本。最后，我们将SRH支出与灾难性支出（大于家庭收入的10％）相结合。结果参加调查的385名妇女中，有94.8％的妇女在之前的12个月中至少有一项SRH需求。79.7％的医疗费用。在上一年中，女性平均在性健康和生殖健康方面的花费为28.34美元。不包括一名将其年收入的112％用于不育治疗的HIV阴性女性，HIV阳性女性每年在SRH护理上的平均支出要高于HIV阴性女性。60％的妇女报告至少有一项未满足的SRH需求。如果所有参与者都希望照顾到所有报告的需求，那么他们每名妇女的平均年度费用将上升到52.65美元。只有两名妇女报告了巨额开支-用于治疗不育症。结论性健康和生殖健康的需求在女性一生中都是恒定的。当随时间累计考虑时，小的年度成本可能会变成较大的成本。随着南非和其他国家在普遍获取的原则下努力争取增加获得性健康和生殖健康服务的机会，重要的是要记住，尽管在服务点获得了免费护理，但个人还是要付出成本。解决地理位置邻近性和服务质量的策略对于降低成本和确保完全获得SRH服务至关重要。妇女文学 低收入和中等收入国家获得全面性健康和生殖健康护理的财务和经济成本极为有限，现有文献经常忽略了与旅行，儿童保育和获得服务所花费的时间相关的自付费用。根据对约翰内斯堡一家公共HIV治疗站点和两家公共初级卫生保健机构的385名妇女的调查数据，我们发现几乎所有妇女至少报告了性健康和生殖健康需求，并且超过75％的妇女为此付出了相关费用需求。此外，接受调查的妇女中有超过一半的人报告说无法获得满足其性健康和生殖健康需求的服务，这表明，平均每年要为所有报告的需求获得服务的总费用超过50美元。尽管上一年很少有妇女将其家庭总收入的10％以上用于性健康和生殖健康服务，但需求是恒定的，并且在妇女的一生中都会产生成本，这表明获得满足这些需求的服务可能仍会造成经济负担。随着南非在普遍获取的原则下努力争取越来越多的性健康和生殖健康服务，重要的是要记住，尽管在服务点享受免费医疗服务，但个人还是要承担费用。解决地理位置邻近性和服务质量的政策对于降低成本和确保完全获得服务至关重要。一生暗示获得满足这些需求的服务可能仍会造成经济负担。随着南非在普遍获取的原则下努力争取越来越多的性健康和生殖健康服务，重要的是要记住，尽管在服务点享受免费医疗服务，但个人还是要承担费用。解决地理位置邻近性和服务质量的政策对于降低成本和确保完全获得服务至关重要。一生暗示获得满足这些需求的服务可能仍会造成经济负担。随着南非在普遍获取的原则下努力争取越来越多的性健康和生殖健康服务，重要的是要记住，尽管在服务点享受免费医疗服务，但个人还是要承担费用。解决地理位置邻近性和服务质量的政策对于降低成本和确保完全获得服务至关重要。