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

Access to healthUnderstanding health serviceaccess: concepts and experienceArticle by Lucy Gilson (pictured) and Helen SchneiderCreating access is generally understood to be a centralgoal of health systems. However, there is globalrecognition that health systems in many low- andmiddle-income countries are far from achieving reasonablelevels of access to essential health care 1,2 . Equally important,there is increasing evidence to show that the distribution ofhealth service coverage within low- and middle-incomecountries is highly inequitable 3,4,5 . Inequitable accessproduces systematic differences between population groupsin the use and experience of health care 6 . Access barriersdeter or delay the search for care, particularly among poor ormarginalized groups, with consequences for individuals,households and communities.Commonly, access is understood to be a function of policydecisions such as those about where to locate facilities orhow to finance health care-making; that is, decisions aboutthe supply of health care. However, recent research showsthat this is a narrow approach. Here we, first, present abroader understanding of access as well as a framework forthinking through the potential policy responses to accessproblems. Second, we discuss in more detail an often ignoreddimension of access, cultural access or acceptability. In thesediscussions we draw on some recent conceptual thinking aswell as presenting relevant research findings. Finally, weconsider policy interventions relevant to access barriers andthe research needs in this field.An access frameworkThere are three key elements to defining access. Firstly,drawing on Donabedian’s 7 concept, access is the “degree offit” between the health system and those it serves; a dynamicprocess of interaction between health system (or supply-side)issues and individual or household (or demand-side) issues.Secondly, access has a number of dimensions: 8,9,10✜ Availability (sometimes referred to as physical access)refers to whether or not the appropriate health servicesare in the right place and at the right time.✜ Affordability (sometimes referred to as financial access)refers to the “degree of fit” between the cost of healthcare and individuals’ ability-to-pay.✜ Acceptability (sometimes referred to as “cultural” access)is the social and cultural distance between health caresystems and their users.Within each dimension, there are a number of supply- anddemand-side factors and multiple layers of determinantsunderlying each factor. For example, availability includes thelocation of services, hours during which care is provided andthe type, range, quantity and quality of services, eachconsidered relative to the health needs of the populationserved. The range of services is in turn influenced by the typeof staff working in that facility and the scope of practice ofeach category of health worker, which in turn, are influencedby human resource policies, and so on. The multidimensionalnature of access has been well articulated byAitken and Thomas 11 in the context of the Nepalese SafeMotherhood Programme (see Box 1).Thirdly, the concept of access is distinct from that ofutilization. Access is the opportunity or freedom to use ahealth service while utilization is when an empoweredindividual makes an explicit and informed decision to exercisehis/her freedom to use health care. Our definition of access issummarised in Figure 1.The nature and influence of acceptabilitybarriersConcern about poor provider attitudes and behaviourstowards patients has generated growing interest in theacceptability dimension of access – both in high-income 13,14and middle- and low-income countries 15 . However, theacceptability definition provided earlier clearly indicates thatacceptability concerns go beyond patient-providerinteractions. A recent review 16 of available evidence onAccess is enabled in an environment that encourages people toutilize health services, within any given social context. At itsbest it is a dynamic, participatory process based on goodpractice. Access advantageously uses local knowledge,perceptions and values, relevant traditional practices,preferences and beliefs, to enhance knowledge and awareness.Access encourages self-confidence, voice and agency,especially among women. Access embraces financial,institutional and infrastructure factors, including but notlimited to funding, transportation and education. Access reliesupon good provider attitudes, trust, honesty, responsiveness,accountability and good quality service delivery, both atestablished facilities and through outreach programmes.Access engages socially marginalized and vulnerablecommunities, is inclusive and empowering.Box 1: Multidimensional nature of access. Source: ref. 11, pg8028 ✜ Global Forum Update on Research for Health Volume 4