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

Access to healthThis study investigated the introduction of a new primaryhealth care health worker, the Lady Health Worker (LHW),intended to offset gender barriers to health care access inPakistan. It found that male health systems managerssubjected LHWs to managerial abuse, including sexualharassment. LHWs were also not given resources to do theirjobs well and commonly expected to undertake tasks that wentagainst broader societal norms and expectations. Notsurprisingly, therefore, LHWs faced hostility from neighboursand family members for taking on these new jobs. Theconsequences of these experiences only exacerbated existingaccess barriers. They included absenteeism among LHWs,turnover of staff, malpractices (LHWs sometimes imposedinformal charges on patients), and impersonal treatmentof patients.Box 3: Gender dynamics in health care in Pakistan.Source: Mumtaz et al 32failure to follow up, particularly in relation to chronicillness;✜ lower self-reported health status (Box 4) 34 .Policy action to address access barriersGiven the dominant understandings of access, mostinvestigations of health service access have led to policyconclusions about the need to extend the health careinfrastructure to under-served areas or to address financialbarriers to access by user fee exemptions, removing user feesor introducing pre-payment schemes or other formsof insurance 12,35 . However, the many dimensions ofaccess indicate that a wider range of policy interventionsis required.Innovative strategies to increase access reported in bothlow/middle- and high-income countries include: 16✜ “close-to-client” services in the community including thedevelopment of referral networks within and acrosssectors; 36✜ provision of transport subsidies; 37✜ community action to improve access to and use ofpharmaceuticals; 38✜ working with private and traditional providers to improvequality and reduce costs; 39✜ peer empowerment interventions; 40✜ enabling indigenous health systems and promoting anintercultural approach to health care; 41In a national telephone survey of 961 adults in the UnitedStates, reported distrust of the health system, measured on aHealth Care System Distrust Scale was considered relativelyhigh. More importantly there was a significant associationbetween distrust of the health system and self-reportedfair/poor health. While the direction of causality – whethermistrust leads to poor health or whether frequent use of thehealth system because of poor health leads to mistrust – ithighlights an important arena for further research andintervention.Box 4: Self reported health and mistrust in the US health system.Source: Armstrong et al 34✜ improve contact with and involvement of refugee,minority and marginalized communities; paying attentionto the specific needs of minority groups in therapeuticprotocols and services; employment of workers fromminority groups and marginalized communities in thehealth system; and improving the cultural awareness andtraining providers in trans-cultural communication 29 .However, effective action to address access barriers alsorequires that policy interventions act on the broaderorganizational and social influences over them. Suchinterventions are likely to include: strengthening leadershipand management within health services, particularly humanresource management; developing functioning accountabilitymechanisms to bring provider and patient communitiestogether in developing health services; and sustaining thewider social mobilization activities that influence health caredelivery. These in turn will require dedicated funding sourcesand political advocacy to sustain interventions 6,16 . It is alsoimportant to take into account that the way in which newpolicy interventions actions are implemented influencesprovider and beneficiary responses to them. A small butgrowing body of evidence shows that the processes throughwhich policies are developed and implemented themselvesdetermine these responses and the policies’ impacts.Research needsDespite its centrality as a goal of health policy in manycountries around the world, there has been little systematicempirical work directed to the measurement of access toservices and the evaluation of policies aimed at promotingequitable access internationally. A review of the literature hashighlighted that most studies claiming to evaluate access,mainly undertaken in high-income countries, focus onmeasuring differences in health care utilization (rather thanaccess) and on identifying a limited number of factors thatinfluence these utilization patterns 42,43,44 . Research in low- andmiddle-income countries has also focused on assessinginequities in utilization, with a growing number of “Benefit-Incidence Analyses” being conducted, which examine socioeconomicdifferentials in coverage/utilization by specifichealth interventions 45 . Where studies have directly attemptedto “measure” access, these have assessed specificdimensions of access, particularly geography (distance tocare facility), cost (user fees) and ability-to-pay (healthinsurance coverage), rather than adopting an integratedapproach to access. In recent years there has been growinginterest in questions of affordability, covering financialbarriers, including the growing evidence on householdcost burdens and health-seeking behaviour 46 .On the whole, however, the evidence base from which toderive policy conclusions remains weak. More research isneeded on the acceptability aspect of access and how thevarious dimensions of access (availability, affordability andacceptability) interact. There is also need for more discussionon the types of study designs required to assess a broad-basedand comprehensive approach to access. Finally, greaterinteraction between researchers in the field would be valuable.030 ✜ Global Forum Update on Research for Health Volume 4