Urban–rural inequalities in access to health care services continue to persist in South Africa, and in almost all cases discriminate against the poor. In certain cases disparities are even worse in urban areas, although levels of service delivery admittedly are consistently worse in rural areas. People in rural areas are generally more dependent on public and other health care services than on private services, compared with people living in urban areas. There is limited evidence of substantial intra-urban disparities, with inequality being worse in smaller urban settlements (i.e. towns) as opposed to larger ones (i.e. small cities and metropolitan areas). The article emphasises the important role the envisaged future decentralisation of selected health services to local government is likely to play in addressing these inequalities and the lack of service delivery at this level.