Transportation and Access to Rural Healthcare in Mt Elias, uMshwathi Municipality

Abstract

Access to healthcare is a crucial factor in achieving health equity. In rural South Africa, geographical isolation and inadequate transportation systems continue to hinder access to healthcare services, despite the existence of progressive national health policies. This study examines the impact of transportation on healthcare access in Mt Elias, uMshwathi Municipality, KwaZulu-Natal. Using a qualitative, exploratory design, semi-structured interviews were conducted with 52 community members. The data were analyzed thematically using ATLAS.ti. The findings reveal several structural barriers, including high transportation costs, long distances to clinics, unreliable ambulance services, poorly maintained roads, and unsafe travel conditions. In Mt. Elias, even when mobile clinics are available, their infrequent visits and fixed locations prevent access for individuals who are sick or those with a disability or living in widely scattered homesteads. Access to healthcare in rural communities is fundamentally shaped by transportation. To achieve universal health coverage, it is essential to improve rural road infrastructure, expand mobile clinic services, subsidize transportation costs, and integrate transportation planning into healthcare policies. Addressing these transportation barriers is not only a matter of service delivery but also of equity, justice, and human rights.

1. Introduction

Access to healthcare is a fundamental component of public health equity and sustainable development. However, disparities in healthcare access persist globally, particularly in rural areas where the geography, poverty, and inadequate infrastructure combine to create systemic barriers (Barjis et al. 2013; Ngene et al. 2023). Globally, more than half the world’s rural population faces barriers to timely healthcare (World Health Organisation 2021), often due to distance, inadequate infrastructure, and limited transportation options (Barjis et al. 2013). In Africa, access to healthcare faces challenges, which lead to poor health, delays in treatment, and higher mortality rates (McLaren et al. 2014; Khuzwayo and Moshabela 2018). South Africa is no exception. Despite its progressive healthcare policies, South Africa faces significant rural-urban disparities in healthcare access, with rural communities often lacking essential health services (Ngene et al. 2023).

Healthcare access is a complex concept that goes beyond simply having available facilities. It includes physical accessibility, financial affordability, availability of services, cultural acceptability, and quality of care (Chinyakata et al. 2021; Moeti et al. 2024). In rural communities, physical access is often the most significant obstacle. Transportation systems, whether formal or informal, play a crucial role in facilitating access to healthcare, particularly in regions like KwaZulu-Natal, where geographical isolation and poor infrastructure are challenges (Clarke and Mars 2015; Mabunda et al. 2020; Fobosi 2023). Importantly, road transport infrastructure provides communities with access to essential services such as ambulances (Pillay 2023). Long distances to clinics, poorly maintained roads, limited or expensive transportation options, and a reliance on informal transit systems can delay or entirely prevent individuals from seeking care (Clarke and Mars 2015; Naidoo and Ennion 2019). Social and economic factors, including unemployment and household income levels, further complicate matters in rural communities (Willie and Maqbool 2023).

National and provincial policies in South Africa acknowledge the importance of rural healthcare. Besides the fixed clinic facilities in communities, mobile clinics are a crucial part of the healthcare system, particularly for remote communities (Akunwafor et al. 2024). In the context of South Africa, a mobile clinic is a vehicle equipped with medical equipment and examination areas, and staffed with trained health professionals, such as nurses, so that they can function as fully operational clinics in remote areas (Nkosi 2024). Mobile clinics are often located at fixed central points and visit only on scheduled days (Callaghan et al. 2025), which does little to meet the daily needs of households spread across the area. Many rural households consist of women, children, elderly people, and persons with disabilities (Statistics South Africa 2024). For people with reduced mobility, accessing even the nearest mobile clinic poses a significant challenge (Clarke and Mars 2015; Nkosi 2024). This limitation reflects a broader disconnect between healthcare planning and the lived realities of rural communities. Although mobile clinics are mentioned in this study, that is not the focus, but rather the services themselves. Instead, mobile clinics are discussed as part of the broader rural healthcare system in South Africa. Mobile clinics serve as one of the few available service delivery models in remote communities. It should be noted that these still require residents to travel to fixed central points; however, the same transportation barriers that affect access to permanent clinics also apply. The references to mobile clinics, therefore, contextualize transportation challenges shaping overall healthcare access in rural communities in South Africa.

While several studies in South Africa have examined rural healthcare access, particularly in KwaZulu-Natal, significant gaps still exist. Nkosi (2024) examined the role of mobile clinics in rural healthcare in KwaZulu-Natal, but emphasized issues with clinic services (medication, staffing) rather than how transportation to those mobile clinics influenced access. Buthelezi et al. (2025) explored how community healthcare workers provide people-centered care in rural KwaZulu-Natal using a realist evaluation. Their study focused on service delivery and governance structures, while disregarding the physical barriers, such as transportation and infrastructure, that the community faces in accessing healthcare. Ngcobo and Mvuyana (2022) explored healthcare providers’ perceptions of the improvements to service delivery during the National Health Insurance pilot in rural KwaZulu-Natal. The focus was on staff evaluations at healthcare centers rather than transport barriers experienced by the community when accessing services. Despite the growing focus on rural healthcare in South Africa, there is still a lack of community-based, transport-oriented research that prioritises the voices of rural communities.

Research Objective

This research focuses on Mt Elias in the uMshwathi Municipality, highlighting the national effort for universal healthcare services in rural areas. Exploring the connection between transport and healthcare access in this area is not only timely but essential for informing sustainable, context-sensitive interventions that address existing service gaps. Therefore, this study explores how transportation affects access to healthcare services from the perspective of the community members in Mt Elias, uMshwathi Municipality. To achieve this, there are two objectives: (1) to assess the current state of healthcare access in Mt Elias, and (2) to explore how transportation challenges have impacted the community’s ability to access timely and adequate healthcare.

This study forms part of a larger research project on accessing rural transport and its effect on essential services in Mt Elias. This study supports the UN Sustainable Development Goals, especially SDG 3 (ensuring healthy lives and well-being for all). The emphasis is on how to address the critical barriers to inadequate transport systems that prevent access to healthcare clinics and mobile services in rural areas. The lived experiences of the Mt Elias community highlighted policy misalignment, particularly the inadequate mobile clinic model and the lack of integrated rural transport planning.

2. Literature Review

Transport is vital yet often overlooked, a factor that affects access to healthcare (McLaren et al. 2014; Nyande et al. 2025) through several interconnected pathways. For example, transport impacts physical accessibility, determining the time, distance and effort required to reach a healthcare service (Mangundu et al. 2020; Nyande et al. 2025). Transport imposes financial costs, particularly in situations where public transport is absent and private vehicles must be hired (Mangundu et al. 2020; Morrow and Laher 2022). There is exposure to risks associated with transport, such as unsafe routes, unreliable vehicles and long journeys (Porter et al. 2018; Ndibatya and Booysen 2020). In rural areas, long distances to clinics, inadequate roads, unreliable or informal public transport, and high travel costs significantly hinder physical access to healthcare services (Clarke and Mars 2015; Fobosi 2023). Barriers to healthcare access overlap with wider socioeconomic factors such as poverty and household dependency, worsening the challenges faced by vulnerable groups such as the elderly, children, and persons with disabilities (Khuzwayo and Moshabela 2018). Transport not only directly affects health by enabling or restricting access to essential services, but also indirectly shapes broader social and economic determinants, perpetuating or alleviating health disparities depending on its availability and accessibility (Ibeh et al. 2025).

2.1. Theoretical Framework

This study is based on the Social Determinants of Health (SDH) framework developed and promoted mainly by the World Health Organization (WHO). Transport is recognised as a critical social determinant of health because it fundamentally shapes individuals’ ability to access healthcare services, nutritious food, employment, education, and social relationships (Standen et al. 2021; Ibeh et al. 2025). The SDH framework emphasizes that health effects are largely influenced by the social, economic, and environmental conditions in which individuals live (Rekerdres and Giggie 2022; Parikh 2025). These factors play a significant role beyond mere biological or clinical considerations. Social determinants include income, education, employment, housing, social support, and, critically, access to healthcare and transport infrastructure (Chinyakata et al. 2021). In rural South Africa, these factors lead to persistent inequalities in service delivery. Disadvantaged communities are disproportionately impacted by the continuing consequences of spatial inequality and lack of infrastructure development (Malakoane et al. 2020; Ngene et al. 2023). By applying the SDH framework, this study moves beyond a narrow focus on the availability of healthcare facilities to examine how transport-related inequalities affect access to healthcare. The SDH framework supports a comprehensive analysis of how daily lived experiences, infrastructure limitations, and policy gaps converge to influence health outcomes in rural communities (Hamiduzzaman et al. 2021; Parikh 2025).

2.2. Rural Healthcare in the Context of South Africa

The South African government formally recognized healthcare as a constitutional right and has pursued multiple strategies to address rural disparities (Rammutla and Mtapuri 2014). Although South Africa’s constitution enshrines the right to access healthcare for all, rural communities continue to face persistent challenges in realizing this right (Ngene et al. 2023). Healthcare in rural areas is affected by historical inequities, geographical isolation, and chronic underfunding (Malakoane et al. 2020). Rural areas, often located far from urban areas, lack physical infrastructure, shortages of skilled healthcare workers, and weak coordination of health systems (Malakoane et al. 2020; Motsumi and Van Niekerk 2020).

A key issue is the unequal distribution of healthcare resources, where rural districts have fewer clinics, longer wait times, and inadequate referral systems compared to their urban counterparts (McLaren et al. 2014; Khuzwayo and Moshabela 2018). In addition, socioeconomic conditions such as poverty, low education levels, and limited mobility further restrict rural communities’ access to available services (Olajide 2022). These issues are worsened by insufficient infrastructure, including poor road networks and limited public transport, which can turn a simple health visit into an expensive and time-consuming experience (Fobosi 2023; Richards et al. 2024).

In South Africa, there are initiatives currently in place to address and reduce inequalities in healthcare, for example, outreach teams, mobile clinics, and community health workers (CHWs). The CHWs have become essential in connecting underserved rural populations to formal health systems. The CHWs serve a crucial role in promoting health, preventing diseases, facilitating patient referrals, and supporting chronic disease management, especially in areas where there is a shortage of healthcare professionals and limited resources. Buthelezi et al. (2025) present a realist perspective, indicating that CHWs are most effective when their roles are clearly defined and aligned with the broader primary healthcare strategy. Their integration into Ward-Based Primary Healthcare Outreach Teams (WBPHCOTs) has helped expand health service coverage in remote communities, but issues such as inconsistent supervision, lack of training, and resource limitations remain obstacles (Khuzwayo and Moshabela 2018). Despite their importance, CHWs frequently operate under informal or precarious conditions. They are often underpaid, face heavy caseloads, and lack opportunities for professional advancement (Buthelezi et al. 2025). These challenges undermine motivation and threaten the sustainability of healthcare interventions.

Mobile clinics have become a practical solution for extending basic healthcare services to remote and underserved areas (Khuzwayo and Moshabela 2018; Rousseau et al. 2021; Nkosi 2024). Mobile clinics are medically equipped vans or trucks that bring healthcare directly to communities that lack fixed facilities (Nkosi 2024; Callaghan et al. 2025), reducing the barriers related to distance, cost, and infrastructure. Research shows that to some extent, mobile clinics improve accessibility and equity for marginalized groups such as women, children, and the elderly. For example, Nkosi (2024) reports that in the rural area of KwaMachi, KwaZulu-Natal, mobile health services were positively received by patients, who cited reduced travel burdens and more convenient access to chronic medication, maternal care, and health education. However, mobile clinics also face operational challenges (Callaghan et al. 2025), which include limited staff, vehicle maintenance issues, and inconsistent funding. In theory, these offer flexible healthcare access, but in practice, these are often stationed at central points. This model assumes that community members can walk or travel to these temporary locations. However, in many communities, reduced mobility among the elderly, people with disabilities, or chronically ill patients is a major barrier (Porter et al. 2018). Even short distances can pose challenges where there is uneven terrain, limited public transport options, or a shortage of personal caregivers (Nkosi 2024). Consequently, those who most need health services may still face exclusion, thus reinforcing health inequities.

2.3. Rural Transport Infrastructure and Services

In African countries, rural transport remains a significant development bottleneck (Sewell et al. 2019). Rural areas are often underserved by public transport, making mobility difficult, expensive, and sometimes unsafe (Pillay 2023). Most rural communities rely on informal or semi-formal transport modes, such as minibus taxis, animal-drawn carts, walking, or bicycles, due to the absence of formal transit systems (Ndibatya and Booysen 2020). These options are frequently unreliable and not integrated into national transport planning, resulting in limited connectivity between rural communities and critical services, such as healthcare, education, and markets (Ebot Eno Akpa et al. 2016; Fobosi 2021).

Poor road conditions further restrict rural mobility. During rainy seasons, many gravel roads become impassable, cutting off entire communities from service delivery. Transport constraints in rural communities have broad implications for development, including access to emergency healthcare, maternal and child health services, and chronic disease management (Ayodele et al. 2021; Nyande et al. 2025). Despite growing recognition of the role of transport in sustainable development, rural transport systems remain underfunded and fragmented, often overshadowed by urban-focused infrastructure priorities.

In South Africa, the challenges of rural transport reflect the broader issues of underdeveloped infrastructure across the continent. Many rural communities in provinces such as KwaZulu-Natal, Eastern Cape, and Limpopo are geographically isolated, with poor road infrastructure and minimal investment in public transport (Venter et al. 2014; Fobosi 2023). Rural communities often depend on the minibus taxi industry, which dominates informal public transport but is characterized by unpredictability, high costs, safety concerns, and limited regulations (McKay et al. 2024).

The South African government has recognized these limitations and has initiated programs such as the Rural Transport Strategy (RTS) and Integrated Transport Plans (ITPs) at the municipal level. However, the implementation of these initiatives has been inconsistent and lacks adequate resources (Fobosi 2021; Buthelezi et al. 2024). Furthermore, these plans seldom incorporate planning of healthcare access, despite clear evidence that transport is a significant cause of rural health outcomes (Clarke and Mars 2015; Richards et al. 2024). Addressing rural transport is therefore not just a priority but a matter of healthcare equity and social justice.

Mt Elias, located within the uMshwathi Municipality of KwaZulu-Natal, highlights the difficulties of accessing rural healthcare in the country (see Figure 1). Dispersed settlements, high poverty rates, and limited formal infrastructure characterize Mt Elias. Healthcare access is shaped not only by the availability of clinics and hospitals but also by how residents can physically reach these services. Transport is a crucial factor influencing health outcomes, affecting both the timeliness and frequency of healthcare access in rural areas such as Mt Elias (Rammutla and Mtapuri 2014; Mangundu et al. 2020; Buthelezi et al. 2024).

3. Materials and Methods

This study forms part of a larger research project on rural transport access in Mt Elias and its effects on access to essential services. The research was conducted in Mt Elias, a rural community located within the uMshwathi Local Municipality in the KwaZulu-Natal province of South Africa. Mt Elias is not recognised as a discrete statistical unit in the national census or administrative datasets. As a result, disaggregated demographic, socioeconomic, crime, and health facility data specific to Mt Elias are not available from Statistics South Africa or provincial health databases. This area has a challenging terrain that impacts the daily travel experiences of learners. Many households are scattered throughout the landscape, particularly in the valley, where accessibility to schools can be hindered by long distances and uneven surfaces. The valley’s steep inclines and poorly maintained paths pose safety risks, further complicated by the intermittent availability of informal transport options. Households in these remote areas frequently rely on informal travel methods, which expose them to various hazards, including environmental and social risks. To illustrate the spatial distribution of households in this community, Figure 1 shows steep terrain, gravel roads, and dispersed rural homesteads that are common in the study area and contribute to limited transport access to healthcare services.

3.1. Research Philosophy and Paradigm

This study adopts an interpretivist phenomenological approach to explore how community members in Mt Elias experience transport barriers to healthcare access. Interpretivism emphasizes understanding social phenomena from the perspectives of those who experience them, recognizing that meaning is constructed through lived experiences and social interactions (Merriam and Tisdell 2017). Phenomenology, as a methodological orientation, describes and interprets the essence of experiences as they are lived by individuals (Creswell and Poth 2019). This paradigm is particularly appropriate for this research, as it prioritizes community voices and situates transport challenges within the context of participants’ daily realities, enabling a nuanced understanding of how structural barriers intersect with individual circumstances to influence healthcare access.

3.2. Research Design

Rural communities are characterized by low population density. Quantitative or mixed-method research was considered unsuitable. Mt Elias is a sparsely populated rural area. A small number of residents with varying literacy levels created practical barriers to administering standardized questionnaires. This presented challenges for written surveys, increasing the risk of incomplete or inaccurate responses. For these reasons, a qualitative, exploratory research design was employed to investigate the research objectives. This approach allows for an in-depth exploration of complex, context-dependent phenomena and is appropriate for research questions that require detailed, rich data from community members (Patton 2015). The exploratory nature of the design helps identify emergent themes and unexpected findings that might not be apparent through predetermined frameworks. Semi-structured interviews were selected as the main data collection method, enabling flexibility in questioning while maintaining consistency throughout the research process.

3.3. Sampling and Participants

The study comprised 52 participants residing in Mt Elias. Their age range was from 21 to 65 years. Women made up a higher proportion of participants, reflecting their main role as caregivers and primary users of healthcare services in the community. Most women were the heads of households. Male participants were fewer and mainly household heads or adult dependents. The highest number of participants had completed high school, while a few reported having tertiary qualifications. Unemployment was widespread among the participants, and they relied on government social grants to support their households. These included child support grants, old-age pensions, and disability grants. A few participants reported part-time or informal employment, such as farm work, road maintenance, domestic work, or small-scale self-employment. Stable full-time employment is limited.

A purposive sampling strategy was employed to recruit participants from Mt Elias, uMshwathi Municipality. Purposive sampling allows researchers to select participants who possess specific knowledge or experience relevant to the research objectives (Merriam and Tisdell 2017). The inclusion criteria were (1) aged 18–65 years and (2) permanent residents of Mt Elias for at least one year. The exclusion criteria included individuals with severe cognitive impairment or acute medical conditions that would prevent meaningful participation. The participants’ profiles included household heads, caregivers, children’s guardians, elderly people, and individuals with chronic conditions, ensuring diverse perspectives on transport and healthcare access within the community.

3.4. Data Collection

The researchers conducted semi-structured face-to-face interviews between May and August at venues convenient to participants, including their homes. An interview protocol guided discussions with open-ended questions exploring participants’ experiences accessing healthcare, transport challenges, costs, time burdens, and coping strategies. Interviews ranged from 30 to 60 min and were audio-recorded with participant consent and transcribed verbatim. Field notes documented non-verbal communication and contextual observations. Interviews were conducted in English or isiZulu, with translations facilitated by trained interpreters where necessary.

3.5. Data Analysis

Data were analyzed using thematic analysis informed by Braun and Clarke’s (2022) six-phase model and facilitated through ATLAS.ti software (Version 25). Thematic analysis is suitable for interpretive, phenomenological research that examines how people construct meaning through narrative. It is also methodologically flexible and capable of handling the complexity of relationships, while still ensuring rigour and transparency in analytic decisions. Initial coding involved systematic line-by-line examination of interview transcripts to identify meaningful units and preliminary concepts. Open coding generated descriptive codes reflecting participants’ language and experiences. Codes were subsequently organized into families and hierarchically within ATLAS.ti, where semantic relationships were mapped and interrogated. Through iterative refinement, coded segments were clustered into candidate themes representing patterns across the data. These were reviewed against original transcripts to ensure coherence and representation. Data were validated through memo writing and analytic triangulation, comparing emergent findings against existing literature on rural transport and healthcare access.

3.6. Trustworthiness

Credibility was enhanced through prolonged engagement with participants, member checking where preliminary findings were discussed with selected participants, and peer debriefing with research supervisors. Dependability was established through transparent documentation of methodological decisions and audit trails within ATLAS.ti, enabling external review of analytical processes (Guba 1981). Confirmability was ensured through reflexive practice, where researchers acknowledged potential biases and positionality. Transferability was supported through a rich, contextual description of Mt Elias and participant demographics, enabling readers to assess applicability to other rural contexts. Positionality was an important component of trustworthiness. The researchers did not have direct community ties to Mt Elias. After each interview, reflections were documented to ensure that participants’ perspectives guided the analysis.

3.7. Ethical Considerations

Ethical approval was obtained from the Department of Transport and Supply Chain Management Research Ethics Committee before data collection. Informed written consent was obtained from all participants. Participants were assured of their rights to withdraw without penalty. Confidentiality was upheld by anonymizing transcripts and securely storing audio files and data on encrypted, password-protected devices. Participants were assigned pseudonyms in all reporting. No identifiable information linking participants to their responses was retained beyond the analysis phase. Given the sensitive nature of health experiences and socioeconomic vulnerabilities, particular care was taken to ensure interviews were conducted with cultural sensitivity and that participants experienced no harm or distress.

4. Findings

This study focused on understanding how transportation barriers affect healthcare access for rural residents in Mt. Elias, uMshwathi Municipality. Through interviews, four key themes emerged that highlight the significant challenges faced by the community in accessing healthcare: (1) Financial Constraints, (2) Infrastructure and services gaps, (3) Physical Accessibility, and (4) Safety Concerns. These themes highlight how structural, financial, physical, and safety-related obstacles severely limit healthcare access for rural communities.

In this study, the terms “van” and “bakkie” are used interchangeably. Both refer to small, light-duty vehicles commonly used in rural areas for deliveries, informal passenger transport, or mixed-use travel. Although not officially part of the public transport system, these vehicles are frequently used by rural residents to reach healthcare facilities due to the lack of formal transport options.

4.1. Theme 1: Financial Constraints

The study found that most households rely on social grants such as disability grants, child support grants and older persons’ grants while some depend on their pension funds. In Mt Elias, there is a high unemployment rate and the active population in the economy ends up depending on their elderly parents or children who are receiving government grants. Participants consistently reported that they rely on private transport to access clinics and hospitals. This dependency mainly exists because clinics are not within the community. During emergencies, ambulances are often unavailable, slow, or unreliable, which forces the community to hire private transport. The cost of hiring transport, ranging from R300 to R700 depending on the distance, was described as burdensome, especially for families without a stable income.

“We are forced to hire a car for R500 to the hospital,” said Participant 11.

These costs are often paid using elderly grants, diverting social support meant for subsistence.

“We take it from her grant money,” admitted Participant 3.

Some community members are of the opinion that public transport lacks dignity, especially for the elderly or ill. They are forced to pay more for private transport for their elderly parents.

“They argue that since she gets an older person’s grant, we need to do better with her money,” Participant 3 added that “Sometimes the cars are unavailable. Sometimes they raise the price due to high demand,” shared the same respondent.

The unpredictability of availability and fluctuating costs, especially during emergencies, adds emotional and financial stress.

The financial constraints that the community faces highlight how poverty and limited transportation options exacerbate health inequalities. Households are forced into unsustainable spending to secure basic healthcare access, undermining their financial stability. The reliance on grants used for transport suggests systemic failure: social welfare is being used to compensate for the absence of functioning public services. Financial constraint is not merely about costs but survival choices, dignity, and the reallocation of scarce household resources.

4.2. Theme 2: Infrastructure and Service Gaps

The community consistently reported that transport infrastructure and healthcare were a failure. Healthcare services, such as ambulances, were reported to be delayed or absent.

“Sometimes you call in the morning and they come in the afternoon,” said Participant 20.

“It takes five hours or more,” confirmed Participant 19.

Many rely on mobile clinics, which are inconsistent, poorly distributed, or stationed at central points, such as schools. However, centralising mobile clinics can result in unequal access to healthcare services, especially for those with mobility disabilities, the elderly and the sick. Community members may have to walk long distances to access a mobile clinic.

“The mobile clinic comes once a month, sometimes, and it’s too far. I take two taxis to get to the clinic in eFaye,” Participant 20 explained.

Poor roads compound these challenges. When it rains, gravel roads become muddy, making it difficult for transport operators. As a result, drivers demand higher fares or simply decline to offer services.

“Taxi drivers complain that the gravel road destroys their taxis,” said Participant 41.

“The government takes years to grade the road,” echoed Participant 36.

Even basic devices, such as a wheelchair, that assist mobility are absent or inadequate.

“The wheelchair is not made for the road,” noted Participant 1.

Many communities simply lack clinics altogether:

“We don’t have a nearby clinic,” said Participant 29.

The lack of government investment in rural infrastructure and healthcare services has created a spatial inequality where rural communities remain locked out of the systems that urban residents access more freely. The infrastructure and service gaps are indicators of systemic neglect. Poor roads, absent clinics, and unreliable ambulances all send the same message to rural communities: you are on your own. This reality makes healthcare access not just inconvenient but often impossible, reinforcing patterns of rural exclusion and inequality. Participants mentioned mobile clinics; however, the findings broadly explore healthcare access. Mobile clinics are included in the study to illustrate how transport barriers limit access to this service delivery model. The focus of the findings remains transportation as a determinant of healthcare access in Mt Elias.

4.3. Theme 3: Physical Accessibility

For most participants, to reach healthcare facilities requires hours of walking, often having to negotiate steep pathways, muddy river crossings or flooded terrain. Most participants reported walking between 1 and 3 h each way. This situation is made worse by a lack of accessible transport for the elderly, those with a disability or with chronic conditions.

“I walk for 2 h and 30 min to the clinic,” said Participant 12.

“My mother cannot use a taxi. She lost one leg”, explained Participant 32.

“We borrow a wheelchair from someone in the community,” the same Participant added.

After heavy rainfalls, rivers flood and roads become impassable.

“We use a wheelbarrow during emergencies to reach the main road,” said Participant 13.

When public vans are available, they operate only once daily, often at 8 a.m. If a resident misses this, there are no other options.

“If you miss the 8 a.m. van, there’s no other option to go back to the clinic,” shared Participant 35.

Barriers related to physical accessibility expose how deeply geographical conditions, infrastructure, and physical health interact to undermine healthcare access. In Mt Elias, distance is not just a measure of kilometres but lived barriers shaped by rain, terrain, age, and disabilities. The routine act of going to the clinic becomes a test of endurance and resilience. When residents must rely on borrowed wheelchairs, wheelbarrows, or have to walk, it signals a breakdown in the very systems meant to protect the most vulnerable.

4.4. Theme 4: Safety Concerns

The community expressed fear and anxiety about personal safety when accessing healthcare. Many must travel through isolated, forested, or bushy areas, often on foot. Robbery, animal attacks, and even reports of violence were common.

“We pass through forests, cross rivers, and there are robbers,” said Participant 21.

“Dead bodies have been found in the bush,” warned Participant 41.

“There are no houses on the way to the clinic; the route is too bushy. The clinic is far from people,” echoed Participant 50.

Women were particularly vulnerable. Participant 25 noted: “My aunt was attacked. They took her phone. Public transport is often unsafe too. Vans are overcrowded, in poor condition, and sometimes operated by reckless drivers”.

“The overload is dangerous. Some vans carry people, goats, cement, and groceries together,” said Participant 35.

“We are squashed in the vans… the vans are not in good condition,” shared Participant 41.

Safety is a critical but often overlooked aspect of healthcare access. In Mt Elias, unsafe routes and unreliable vehicles create a climate of fear that deters clinic visits, especially among women, children, and the elderly. This risk is not only physical but psychological, adding trauma to an already difficult process. The findings highlight how the lack of infrastructure is not impartial; it produces danger, erodes trust, and compounds health risks. When considering healthcare access, it is not just the distance, but the safety and dignity of the journey. Vans are commonly used in Mt Elias to transport passengers, but it is a problematic mode, associated with high safety risks, discomfort, and overcrowding. Vans frequently carry too many passengers or goods at once. Their use reflects how scarce basic transport is and how the community has adapted to the limited transport options.

4.5. Summary of Themes and Key Codes

Table 1. Themes and codes.

Theme	Codes	Number of Mentions
Financial constraints	High transport	40
	Social grants	37
	Car hire	36
	Financial burden	46
Infrastructure and services	Ambulance	35
	Emergency response delay	25
	Mobile clinic	24
Physical accessibility	Long waiting time for transport	39
	Long walking time	42
	Road condition	52
	Walk all the way to clinic	35
	Crossing river	41
Safety concerns	Unsafe routes	35
	Robbery risk	25
	Use of “van”	30
	Bushy areas	41
	Overload and mixed load	35

presents the number of mentions for each major theme across all interviews. Frequencies represent the number of coded quotations and do not imply statistical prevalence.

5. Discussion

This study explored how transport affects community members’ access to healthcare services in Mt Elias, uMshwathi Municipality. To achieve this, the two objectives were (1) to assess the current state of healthcare access in Mt Elias, and (2) to explore how transport challenges impacted the community’s ability to access timely and adequate healthcare. The findings are presented and discussed in alignment with these objectives. The SDH framework emphasizes that social, economic, and environmental conditions significantly impact healthcare results and access to healthcare. Transport is a crucial yet often neglected factor that affects not only an individual’s ability to reach healthcare facilities but also the timeliness, frequency, and quality of the care they receive.

5.1. The Current State of Healthcare Access in Mt Elias

The findings demonstrate that accessing healthcare in Mt Elias is hampered by distance to facilities, limited healthcare infrastructure, and economic hardship. Clinics and hospitals are located far from the community, with no permanent healthcare facilities within immediate reach. Ambulance services are unreliable and mobile clinics are infrequent, often arriving only once a month and stationed at central locations which are inaccessible to people with reduced mobility. These findings align with national assessments showing persistent rural–urban disparities in healthcare access across South Africa, despite constitutional guarantees of universal healthcare (McLaren et al. 2014; Ngene et al. 2023). In Mt. Elias, even when mobile clinics are available, their infrequent visits and fixed locations prevent access for individuals who are frail, disabled, or living in widely scattered homesteads. As individuals age, their mobility becomes increasingly limited, while their reliance on and frequency of visits to healthcare facilities increase (Porter et al. 2018). This dynamic has significant implications for the accessibility and effectiveness of fixed-point service delivery.

The reliance on private transport with costs ranging from R300 to R700 per trip highlights the economic burden of seeking care. For most households, depending on social grants, this expenditure diverts resources from basic needs (Willie and Maqbool 2023). This extends to SDH applications, showing how transport affects socioeconomic vulnerability, resulting in daily challenges. The reliance on social grants to hire transport illustrates how poverty directly delays medical care, a pattern documented in other rural contexts (Naidoo and Ennion 2019). Similar patterns have been observed in other rural South African communities, where transport costs are one of the major barriers to accessing care (Chinyakata et al. 2021; Fobosi 2023). This is consistent with Naidoo and Ennion’s (2019) study, which found that people with a disability in rural communities frequently fail to access rehabilitation services because it is prohibitive to hire private transport. In this way, financial limitations together with geographical isolation, create several exclusionary factors.

The absence of functional public transport, coupled with gravel roads, further undermines service accessibility. Poorly maintained gravel roads become impassable during heavy rains, making even emergency care unreachable. The lack of infrastructure has been widely documented as a major reason for inequalities in rural health in Africa (Sewell et al. 2019; Pillay 2023). Healthcare in Mt Elias remains technically available but practically inaccessible in daily life. Interpreted through the SDH framework, these findings reaffirm that healthcare access is determined not merely by the presence of facilities but by the social and structural conditions. Transport availability, road conditions, household income, disability status and physical terrain are causes that affect healthcare access (Chinyakata et al. 2021). Even though there are practical ways to bridge rural health gaps, such as mobile clinics, the findings demonstrate that these clinics at fixed central points and infrequent visits leave some households without service.

5.2. How Do Transport Challenges Impact the Community’s Ability to Access Timely and Adequate Healthcare?

Transport difficulties have a direct and profound impact on the timeliness and adequacy of healthcare access in Mt Elias. Participants described walking for up to three hours there and back to reach healthcare services, facing difficult terrain, unpredictable weather, and personal safety risks. This finding mirrors the challenges in sub-Saharan Africa regarding rural healthcare access, where long walks to transport routes or services pose significant obstacles, particularly for older individuals, those with disabilities, and during rainy weather along difficult terrain (Porter et al. 2018). The physical burden delays routine healthcare visits and deters individuals from seeking healthcare until their condition becomes severe. These are consistent with findings from other rural areas. For example, McLaren et al. (2014) observed that greater distances to healthcare facilities are strongly associated with delayed or missed treatment, particularly for chronic illnesses. Similarly, it was found that travel problems significantly affect children’s timely hospital admissions in rural areas (Richards et al. 2024). Transport barriers to healthcare access are more severe for people with disabilities and low-income households (Myers and Standley 2024; Gulati et al. 2025). These barriers can lead to poorer health conditions among vulnerable groups.

In emergencies, the absence of reliable ambulance services and affordable transport options severely compromises one’s health. Participants reported waiting several hours for ambulances or resorting to expensive private cars. This situation is similar in the Eastern Cape, with limited availability of ambulances in rural areas (Willie and Maqbool 2023). These delays are not just inconvenient but life-threatening, particularly for patients with acute conditions, pregnant women, and the elderly. Comparable findings in rural KwaZulu-Natal and Limpopo show how inadequate transport systems lead to higher maternal and child mortality rates and delayed emergency responses (Buthelezi et al. 2024; Nkosi 2024). Unpredictable and unsafe transport makes the problem worse. Overcrowded vans, poor vehicle conditions, and unsafe walking routes discourage seeking timely care, especially among women, children, and people with disabilities. Ndibatya and Booysen (2020) highlight that safety concerns reduce attendance at healthcare facilities in rural communities, causing the vulnerable to be excluded. Transportation systems should not only be functional but also support users with a sense of security, self-worth, and autonomy.

5.3. Implications and Recommendations

The evidence from this study highlights the urgent need to address transportation as a fundamental aspect of rural health policy, which involves improving and maintaining rural roads, enhancing physical accessibility, subsidizing transportation costs for rural households to reduce financial barriers and expanding and decentralizing mobile clinic services to reach remote communities. Additionally, it is essential to integrate transport and healthcare planning at the municipal level and strengthen emergency response systems to ensure timely ambulance services. Implementing these interventions would not only improve access to healthcare but also align with national goals of universal health coverage and global health equity initiatives.

5.4. Limitations

The study did not include perspectives from healthcare providers, transport operators, or local government officials. Including these groups could have provided a more comprehensive understanding of systemic barriers and potential policy solutions. This research was conducted in a single rural community, Mt Elias, in uMshwathi Municipality. While this allowed for in-depth exploration of local experiences, it limits the generalizability of the findings to other rural areas. Healthcare access and transport conditions may vary across regions due to differences in infrastructure, geographical terrain, and local governance.

6. Conclusions

Without reliable, affordable, and safe transport, health services remain inaccessible to those who need them most. To improve healthcare access in rural areas, practical interventions and partnerships are required, especially between community health worker programs, telehealth, transport providers and local organizations. Telehealth bridges geographic and transport barriers, which improves healthcare access in rural areas. Integrating transport providers in rural areas with the healthcare system can enhance service reliability and patient access to healthcare. The findings reveal a gap in policy implementation. For instance, national frameworks such as the Rural Transport Strategy and mobile clinic programs have not effectively translated into accessible healthcare for rural communities. These initiatives often prioritize the provision of healthcare facilities without incorporating transport planning, leading to fragmented and ineffective service delivery. Bridging this gap requires a comprehensive approach that connects health services, transport infrastructure, and community needs. Mt. Elias exemplifies how the absence of such integration continues to perpetuate rural marginalization and health inequities. If transport challenges are effectively addressed, they can serve as a powerful tool for improving health outcomes and promoting social justice in rural areas. Future research could focus on how gender and community dynamics interact with rurality to shape health outcomes. Future research could also develop and validate rurality indices that integrate geographic and social complexity for SDH research.

This study supports the UN Sustainable Development Goals, especially SDG 3 (ensuring healthy lives and well-being for all). By addressing a critical barrier to healthcare access in rural South Africa, the study emphasises how inadequate transportation systems prevent access to clinics and mobile services. By capturing the lived experiences of the community of Mt Elias, the study highlights policy misalignment, especially the inadequate services of current mobile clinics and the lack of integrated rural transportation planning.