Date Published: October 23, 2007
Publisher: Public Library of Science
Author(s): Brigit Obrist, Nelly Iteba, Christian Lengeler, Ahmed Makemba, Christopher Mshana, Rose Nathan, Sandra Alba, Angel Dillip, Manuel W Hetzel, Iddy Mayumana, Alexander Schulze, Hassan Mshinda
Abstract: The authors present a framework for analysis and action to explore and improve access to health care in resource-poor countries, especially in Africa.
Partial Text: Access to health care is a major health and development issue. Most governments declare that their citizens should enjoy universal and equitable access to good quality care. However, even within the developed world, this goal is difficult to achieve, and there are no internationally recognized standards on how to define and measure “equitable access” . Evidently, big disparities exist between the poor and the better off with respect to access to health care services and health status [2–4]. Gaps in child mortality between rich and poor countries are wide, as well as between the wealthy and the poor within most countries. Poor children are not only more likely than their better off peers to be exposed to health risks and have less resistance to disease, they also have less access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Clearly, more of the same is not enough : To improve equitable access, innovative and community-based approaches are needed to better align health care services with poor people’s needs, expectations, and resources.
Health-seeking studies focus on people [7–10]. They apply pathway models and follow sick persons step by step from the recognition of symptoms through different types of help seeking until they feel healed or capable of living with their condition. Health-seeking studies provide a deeper understanding of why, when, and how individuals, social groups, and communities seek access to health care services, and investigate interactions between lay persons and professionals . In this perspective, social actors are the potential driving force for improving access to effective and affordable health care, but they are often constrained by politics and the economy on national and international levels [12–14].
The Health Access Livelihood Framework combines health service and health-seeking approaches and situates access to health care in the broader context of livelihood insecurity (Figure 1).
Access becomes an issue once illness is recognized and treatment seeking is initiated. Five dimensions of access influence the course of the health-seeking process: Availability, Accessibility, Affordability, Adequacy, and Acceptability (see Table 1).
Sick persons and caregivers seek help not only in health facilities or private practice, but also in drug shops and pharmacies as well as from healers representing a wide array of medical traditions. Access to these health care service providers is governed by cultural norms, policies, laws and regulations, which themselves are influenced by broader trends in society, global health policy, research, and development.
Whether people actually recognize an illness and seek treatment in drug shops or through other health care services depends to a large extent on their access to livelihood assets of the household, the community, and the wider society. These livelihood assets comprise human capital (local knowledge, education, skills), social capital (social networks and affiliations), natural capital (land, water, and livestock), physical capital (infrastructure, equipment, and means of transport) and financial capital (cash and credit) . The availability of these assets is influenced by forces over which people have little control, for instance economy, politics or technology, climatic variability or shocks like floods, draughts, armed conflicts or epidemics. Such factors may be referred to as their vulnerability context.
Depending on access to health care services and to livelihood assets, people develop multiple and changing health care utilization strategies. They may take no action at all or use different service providers simultaneously or in sequence. However, even if they gain access and health care utilization takes its course, the outcome in terms of health status (as evaluated by experts or by patients), patient satisfaction, and equity (defined as equal access to health care by those in equal need ) is subject to the technical quality of care. In a broad sense, technical quality of care includes provider compliance and diagnostic accuracy, safety of the product, and patient compliance (or adherence; see Figure 1).
Even the most powerful diagnostic tests, drugs, and vaccines have little public health impact if they do not reach the poor. Providing the goods, as well as the services to deliver them, and ensuring that goods and services are of high quality, are major challenges by themselves, especially in a resource-poor setting. But unless additional efforts are made to enable poor people to gain access to these goods and services, as well as to more basic livelihood assets required to initiate treatment seeking, equitable access remains an empty formula of politicians and experts. This is an aspect of the illness–poverty trap that is often overlooked. While it has been increasingly acknowledged that ill-health contributes to poverty because health costs deplete people’s meager resources, it is hardly recognized that people often cannot even gain access to health services because they cannot mobilize critical livelihood resources. This article presents an innovative framework that pulls together the strength of social sciences, public health research, and development studies. Through this combination of perspectives and expertise, a more comprehensive, but structured analysis of access to health care in resource-poor settings can be achieved, which will lead to the identification of key entry points and targeted action for health and poverty alleviation in horizontal community-based approaches.