Defining Rural – What do we mean by rurality? How rural is your facility?

Scale: most rural (4,07) to least rural (- 3, 65)

What do we mean by rurality?

RHAP envisages a health system in which rural communities access equitable, quality healthcare services.

When RHAP uses the term ‘rural’, we use it in relation to rural health access, characterised by:

  1. Geographical remoteness and long distances between levels of care;
  2. Typographical features that hinder physical access to healthcare, for instance, mountainous landscapes and poor road conditions;
  3. Low population densities;
  4. High cost of service delivery due to lower economies of scale and more expensive travel to facilities;
  5. Difficulties to recruit and retain health care workers because of distance from amenities like shopping malls, internet services, gyms etc;
  6. Often characterised by higher levels of deprivation than urban areas, compounded by intra-district variations in access to care.

For instance, the sub-district of NYANDENI in the OR Tambo District of the Eastern Cape is deeply rural according to the above factors.

Good rural health care is responsive to the needs of rural communities and ensures equitable access by way of appropriate, affordable, quality health care. Services are delivered at various levels of care by multi-disciplinary health care teams, based on Primary Health Care principles. Care begins at the household level and health care users experience a dignified pathway to higher levels of care. Investment in good rural healthcare can be more expensive at the outset because of the particular rural features mentioned above, like lower economies of scale and topographical features that make the provision of adequate healthcare more expensive. Access to good rural health care is implied by our Bill of Rights, and is an essential component of a society envisaged by the Constitution: one based on human dignity and equality.

How rural is your facility?

We developed a rurality index for hospitals to allow us to compare the allocation of resources (e.g. healthcare workers or financial resources) or health care outputs and outcomes between District Hospitals based on their relative rurality. The index ranks South Africa’s District Health Facilities on a scale from most rural to most urban using a quantitative measure. The hospital ranking can be used as a proxy for the sub-district in which the hospital is based as well as for CHCs and clinics in the catchment areas.

As a starting point, we drew on the RHAPs review of ‘Approaches to developing functional definitions of rural for the purposes of policy and planning” (RHAP, 2014). In this review we explored research and literature on approaches to defining rural for health care in order to develop a framework that could be used to develop a fit-for-purpose definition for the South African health care context. That framework identifies four categories of variables that can be used in developing a functional definition of rural and which, as we show later, can be used in developing a quantitative index of relative rurality. The four variable categories included in the framework include:

1. Measures of health need: these include utilisation, clinical and epidemiological measures or proxies of need such as measures of relative deprivation.

2. Measures of geographic accessibility: longer distances in rural areas not only make it more difficult and expensive to access services for rural patients, but also add to the cost of providing such services.

3. Population measures: rural areas tend to have smaller populations with a greater geographic spread, meaning lower population densities.

4. Policy measures: contextual factors relating to historically neglected and marginalised groups in rural settings (based on race or ethnicity)who may have high levels of unmet need. Data sources and the selection of variables

For each category discussed above, we selected variables that were readily available in reliable and publically accessible databases. We narrowed down those sources to ones that are likely to be used in decision-making processes within the public health care system. In the end, all variables selected were available in either the South African District Health Barometer (DHB) data files published online by the Health Systems Trust ( or those sourced from Statistics South Africa (StatsSA) from their online portal. From these sources the following four variables were selected:

  • deprivation index
  • average distance from clinic to district hospital
  • distance from district hospital to nearest regional hospital
  • catchment population

For a full discussion on the rurality index methodology, see: RURALITY INDEX_SOUTH AFRICA

How the Map works

Click on the map to the top right of this page and search for your facility. The rurality score is informed by the position of the rurality index “most rural to least rural”. 0 provides the middle punt, most urban facilities have a high negative, most rural facilities a high positive. For instance, on our index, Greenville Hospital in the Umzimvubu sub-district of the Eastern Cape has the highest rural index score of 4.07. On the other end of the scale, Tshwane district hospital has the lowest score of -3.65 on our rural index scale and could be interpreted as the most urban facility.

You can also look up your facility here: Facility-index-2018 which highlights the rurality of facilities across South Africa. The rankings on the scale do, for the most part, intuitively make sense if one has a good idea of where many of the facilities are located in reality. The facilities at the most rural end of the scale all tend to be located in small towns or villages a long distance from large towns or cities. Those that fall in the middle of the scale, with scores between -1 and 1 on the rural index all tend to be located in larger towns but are still some distance from large cities and metros. Caution must be used when reading the index though. In some instances facilities rank closer to either end of the scale because on one of the two measures they have scores outside the normal range.

RHAP welcomes any comment on our rurality index which will be an on-going project. Please send comments to a relevant staff member (see staff page).