Combining health and social protection measures to reach the ultra ...

Access to health
Determinants
Availability
Supply-side factors
Affordability
Context
Acceptability
CCESS
Demand-side factors
Figure 1: A framework on access. Source: adapted from Thiede et al 12
acceptability outlines three central elements:
1. The fit between lay and professional health beliefs –
covering both patient’s perceptions of the effectiveness of
treatment and the extent to which their constructions of
health and healing match health care provider
understandings on these issues.
2. Patient-provider engagement and dialogue – with
particular emphasis on the communication practices of
providers, the extent to which patients are themselves
given opportunities, and are able, to discuss their own
care and whether or not providers demonstrate prejudice
towards patients, perhaps simply by stereotyping them
and their needs rather than listening to each patient.
3. The ways in which health care organizational
arrangements influence patient responses to services – for
example, fees for service systems often generate patient
concern that the provider is more interested in making
money than in addressing their needs fully.
All of these elements are themselves influenced by a wider
range of socio-cultural factors. In seeking care, people always
draw on advice from others in their local community – and
this advice is shaped by health beliefs, the reputations of
particular providers and rumours about them, trust in medical
technology, as well as cost and perceived quality 17-20 . Provider
behaviours are, meanwhile, shaped by the emotional
demands of their jobs, as well as workloads and other aspects
of their organizational and social environments. Poor human
resource management practices often frustrate providers and
lead them to take their frustrations out on their patients 21 .
Providers working in authoritarian cultures are also likely to
act in authoritarian ways towards their patients, preventing
client-centred approaches to chronic illness care 22 . Indeed,
the way in which the power relationship embedded within the
provider-patient interaction is managed at both personal and
organizational levels is a central influence over whether or not
the patient trust in providers that is necessary to effective care
is built (see Box 2) 23 . Such trust is not only vital to
Over the last 13 years, South Africa has acted to strengthen its
health system and address the health and health care inequities
it inherited from the past. The range of policies implemented
vary from strengthening the primary health care infrastructure to
removing fees for primary and maternal health care services and
implementing a new Patients’ Rights Charter to enable stronger
provider-patient relationships. A series of studies 26-28 has,
however, shown that, whilst supporting many of the policies in
principle, South African health workers are frustrated by the new
policies. They commonly feel that these policies are imposed on
them without any prior consultation or even warning, requiring
them to change their practices and often resulting in increased
work. This use of managerial power makes health workers feel
that there is a lack of care for them in their workplaces, and they
identify poor managerial style as a key factor underlying low
motivation levels. Some studies have also shown that health
workers themselves admit that, as a result of these experiences,
they sometimes then take out their frustrations on their
patients, abusing their relationship of power with patients. Not
surprisingly, therefore, patients and community members
commonly criticize health workers for behaving badly and
demonstrating little care towards them. Expressed patient trust
in providers appears to be quite limited, and public criticism of
the declining quality care provided in the public health sector is
widespread.
Box 2: Trust and access to health care in South Africa
acceptability but also to protecting patient dignity and the
wider social value derived from health care by marginalized
groups 24,25 .
Some research evidence also shows that acceptability
barriers do directly influence health service equity. In all
countries, socially disadvantaged and marginalized groups
are most likely to bear the burden of discriminatory provider
attitudes and poor communication practices 29,30 , least likely to
be able to engage with providers during health care
encounters 10,14 and most likely to have different health beliefs
from those that are dominant within traditional bio-medical
health care systems 31 . Indeed, negative health care
experiences are an aspect of marginalization within any
society. A wide range of evidence, for example, specifically
demonstrates the gender dimensions of these experiences, as
well as of provider experiences, and their consequences for
access (Box 3) 32,33 . European experience meanwhile clearly
indicates that despite the wide geographic availability of
services and well established risk protection mechanisms,
acceptability barriers underpin systematic differences in
health care utilization between socio-economic groups as well
as between minority groups/migrants and non-migrants, and
women and men 30 .
The impacts of acceptability problems are, finally, seen in
population level health inequities. Acceptability problems are
linked, for example, to:
✜ patient unwillingness to reveal past medical history,
making diagnosis and treatment difficult;
✜ lower rates of referral to secondary and tertiary care, and
lower rates of intervention relative to need;
✜ limited patient adherence to advice or treatment, and
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