In low- and middle-income countries, urban and rural settings are distinct communities with the latter being more likely to have limited resources, particularly in health care services. We assessed the inequality in health care services in urban and rural settings in South Africa, highlighting the disparities between public and private health services, given that the latter are located mainly in urban settings. Rural settings suffer the highest inequality in the availability of drugs and supplies, overcrowding of health care facilities, delays in transporting patients, inadequate emergency medical services, and lack of experienced health care professionals. Rural settings also preferentially have a shortage of various levels of health care services, and increased security threats by criminals. In addition to specific remedies, the overarching key to solving these challenges is socio-economic growth, as well as visionary and compassionate leadership with integrity and accountability, which ensures policy development, implementation, monitoring, and evaluation. (Afr J Reprod Health 2023; 27 [5s]: 87-95).

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Statistics South Africa. Mid-year population estimates 2020.

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Accessed on May 9, 2022.

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http://www.statssa.gov.za/publications/P0302/P030

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pdf

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World bank. New World Bank country classifications by

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income level: 2022-2023. Accessed on April 27,

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https://blogs.worldbank.org/opendata/newworld-bank-country-classifications-income-level2022-2023

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World Population Review. Wealth Inequality by Country

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Accessed on March 11, 2022.

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https://worldpopulationreview.com/countryrankings/wealth-inequality-by-country

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Booysen F le R. Urban–rural inequalities in health care

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delivery in South Africa. Development Southern

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Africa, 2003, 20(5), 659-674.

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https://doi.org/10.1080/0376835032000149298

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Mahlathi P and Dlamini J. African Institute for Health and

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Leadership Development and WHO. Minimum data

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sets for human resources for health and the surgical

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workforce in South Africa’s health system: a rapid

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analysis of stock and migration. Accessed May 20,

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https://www.who.int/workforcealliance/031616sout

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h_africa_case_studiesweb.pdf

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Statista. Share of individuals who are members of medical

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aid schemes in South Africa in 2018, by population

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group. Accessed April 27, 2023.

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https://www.statista.com/statistics/1115752/shareof-medical-aid-scheme-members-in-south-africaby-population-group/

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Naidoo S. The South African national health insurance: a

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revolution in health-care delivery! Journal of Public

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Health, 2012, 34(1), 149-150.

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https://doi.org/10.1093/pubmed/fds008

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115214'  

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Ngene NC, Onyia CO, Moodley J and Titus MJ. Needlestick

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injury in a pregnant inpatient in an overcrowded

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hospital. Southern African Journal of HIV Medicine,

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, 15(2), 66-68.

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https://doi.org/10.4102/sajhivmed.v15i2.23

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115219'  

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International Citizens Insurance. Understanding South

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115220'  

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Africa’s Healthcare System. Accessed on May 20,

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115222'  

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https://www.internationalinsurance.com/health/syst

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115223'  

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ems/south-africa.ph 10. Canadian Council on Social Determinants of Health

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(CCSDH). A Review of Frameworks on the

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Determinants of Health. Accessed on January 9,

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115227'  

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https://nccdh.ca/images/uploads/comments/CCSDH

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_A-review-of-frameworks-on-the-determinants-ofhealth_EN.pdf

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115229'  

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Reid, PP, Compton WD, Grossman JH and Fanjiang G.

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115230'  

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Building a better delivery system: A New

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115231'  

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Engineering/Health Care Partnership. Accessed on

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115232'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115232 ORDER BY metadata_description_id DESC  

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May 20, 2022.

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https://www.ncbi.nlm.nih.gov/books/NBK22832/pd

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115234'  

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f/Bookshelf_NBK22832.pdf

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Ferlie EB and Shortell SM. Improving the Quality of

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Health Care in the United Kingdom and the United

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States: A Framework for Change. The Milbank

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Quarterly, 2001, 79(2), 281-315.

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https://doi.org/10.1111/1468-0009.00206

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115240'  

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Gaede B and Versteeg M. The state of the right to health in

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rural South Africa. South African Health Review,

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, 2011(1), 99-106.

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https://hdl.handle.net/10520/EJC119080

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115244'  

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Kok P and Collinson M. Migration and urbanization in

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South Africa. Statistics South Africa. Accessed on

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May 22, 2022.

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http://www.statssa.gov.za/publications/Report-03-

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115248'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115248 ORDER BY metadata_description_id DESC  

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-02/Report-03-04-02.pdf

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115249'  

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Day C, Gray A and Budgell E. Health and related

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115250 ORDER BY metadata_description_id DESC  

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indicators. South African Health Review, 2011,

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(1), 119-148.

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https://hdl.handle.net/10520/EJC119078

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115253'  

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National Committee on Confidential Enquiry into Maternal

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Deaths (NCCEMD). Saving Mothers and Babies

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115255'  

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-2019: Executive Summary, Plus Final Report

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the Effect of the First Wave of Covid-19 on Use of

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Maternal and Reproductive Health Services and

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115258'  

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Maternal and Perinatal Deaths in South Africa.

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115259'  

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Pretoria: National Department of Health South

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115260'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115260 ORDER BY metadata_description_id DESC  

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Africa; 2020, pp 56.

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115261'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115261 ORDER BY metadata_description_id DESC  

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Ataguba JE, Akazili J and McIntyre D. Socioeconomicrelated health inequality in South Africa: evidence

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115262'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115262 ORDER BY metadata_description_id DESC  

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from General Household Surveys. International

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115263'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115263 ORDER BY metadata_description_id DESC  

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Journal for Equity in Health, 2011, 10:48.

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115264'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115264 ORDER BY metadata_description_id DESC  

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https://doi.org/10.1186/1475-9276-10-48

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115265'  

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Cane RM, Melesse DY, Kayeyi N, Manu A, Wado YD,

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115266'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115266 ORDER BY metadata_description_id DESC  

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Barros A and Boerma T. HIV trends and disparities

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115267'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115267 ORDER BY metadata_description_id DESC  

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by gender and urban–rural residence among

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adolescents in sub-Saharan Africa. Reproductive

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115269'  

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Health, 2021, 18(Suppl 1), 120.

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https://doi.org/10.1186/s12978-021-01118-7

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Moyo S, Ismail F, Van der Walt M, Ismail N, Mkhondo N,

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115272'  

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Dlamini S, Mthiyane T, Chikovore J, Oladimeji O,

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115273'  

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Mametja D, Maribe P, Seocharan I, Ximiya P, Law

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I, Tadolini M, Zuma K, Manda S, Sismanidis C,

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Pillay Y and Mvusi L. Prevalence of

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bacteriologically confirmed pulmonary tuberculosis

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in South Africa, 2017–19: a multistage, clusterbased, cross-sectional survey. Lancet Infectious

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Disease, 2022, 22(8), 1172-1180.

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https://doi.org/10.1016/S1473-3099(22)00149-9

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Ataguba JE, Day C and McIntyre D. Explaining the role of

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the social determinants of health on health inequality

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in South Africa. Glob Health Action, 2015, 8:28865.

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https://doi.org/10.3402/gha.v8.28865

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Maphumulo WT and Bhengu BR. Challenges of quality

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improvement in the healthcare of South Africa postapartheid: A critical review. Curationis. 2019, 42(1),

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e1-e9. https://doi.org/10.4102/curationis.v42i1.1901

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Cheteni P, Khamfula Y and Mah G. Gender and poverty in

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South African rural areas. Ricart Casadevall S, ed.

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Cogent Social Sciences, 2019, 5(1), 1586080.

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https://doi.org/10.1080/23311886.2019.1586080

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Ly DP, Blegen MB, Gibbons MM, Norris KC and Tsugawa

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Y. Inequities in surgical outcomes by race and sex in

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the United States: retrospective cohort study. British

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115294'  

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Medical Journal, 2023, 380, e073290.

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https://doi.org/10.1136/bmj-2022-073290

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115296'  

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Kluge H, Azzopardi-Muscat N, Figueras J and McKee M.

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115297'  

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Trust and transformation: an agenda for creating

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resilient and sustainable health systems. British

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Medical Journal. 2023, 380:651.

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https://doi.org/10.1136/bmj.p651

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115301'  

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Econex. Reform note 1: The role of primary healthcare in

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health reform. Accessed on March 27, 2023.

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https://econex.co.za/wpcontent/uploads/2015/04/econex_health-reformnote_1.pdf

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Gumede DM, Taylor M and Kvalsvig JD. Engaging future

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healthcare professionals for rural health services in

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South Africa: students, graduates and managers

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perceptions. BMC Health Services Research, 2021,

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(1), 220. https://doi.org/10.1186/s12913-021-

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-w

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Macrotrends LLC. South Africa Rural Population 1960-

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115311 ORDER BY metadata_description_id DESC  

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Accessed on March 24, 2023.

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https://www.macrotrends.net/countries/ZAF/southafrica/rural-population

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MC Alexander. Infographic: South Africa’s rural and urban

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population from 1960 to 2016. Accessed on March

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115315'  

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, 2023. https://southafricainfo.com/infographics/infographic-south-africasrural-urban-population-1960-2016/

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van Rensburg HC. South Africa’s protracted struggle for

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115317 ORDER BY metadata_description_id DESC  

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equal distribution and equitable access – still not

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115318'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115318 ORDER BY metadata_description_id DESC  

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there. Human Resources for Health, 2014, 12(1), 26.

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115319'  

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https://doi.org/10.1186/1478-4491-12-26

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115320'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115320 ORDER BY metadata_description_id DESC  

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Schoeman S, Smuts C, Faber M, Van Stuijvenberg M,

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115321'  

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Oelofse A, Laubscher JA, Benade AJS and Dhansay

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MA. Primary health care facility infrastructure and

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115323'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115323 ORDER BY metadata_description_id DESC  

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services and the nutritional status of children 0 to 71

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months old and their caregivers attending these

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115325'  

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facilities in four rural districts in the Eastern Cape

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115326'  

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and KwaZulu-Natal provinces, South Africa. South

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115327'  

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African Journal of Clinical Nutrition, 2010, 23(1),

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-27.

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https://doi.org/10.1080/16070658.2010.11734254

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115330'  

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115330 ORDER BY metadata_description_id DESC  

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Moyimane MB, Matlala SF andKekana MP. Experiences

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115331'  

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of nurses on the critical shortage of medical

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115332'  

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equipment at a rural district hospital in South Africa:

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(mysql): SELECT * FROM metadata_descriptions WHERE assoc_type = 1048579 AND assoc_id = 115333 ORDER BY metadata_description_id DESC  

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a qualitative study. Pan African Medical Journal,

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, 28, 100.

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https://doi.org/10.11604/pamj.2017.28.100.11641

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(mysql): SELECT * FROM citation_settings WHERE citation_id = '115336'  

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Health Systems Trust. The national health care facilities

baseline audit: National summary report 2012.