• Step 1: Ensure financial and geographic access

    In order for patients to be able to receive care when needed, services must be both within a reasonable geographic distance – in regard to travel time from patients’ homes -- and not prohibitively expensive. Thus, financial and geographic access should be prioritized and addressed at the same time.

    Step 2: Ensure timely access

    Timely access will not vastly improve utilization of care if financial and geographic access are not first in place. As such, timely care may be a follow-up consideration after financial and geographic access are ensured for all sub-populations.

    At the same itme, ensure attention to high-quality care and social determinants

    While it is outside of the scope of this domain, it is important to note that perceived and actual service quality and provider competence are closely linked to access. Even easily accessible care may be underutilized if patients do not believe they will receive appropriate and high-quality services. Thus, accessible but poor-quality services will also do little to improve outcomes. This phenomenon is well documented in childbirth where women’s perceptions of quality of care are often more salient than both distance or cost in decisions to bypass a facility.3

    Finally, it is important to reiterate the strong impact that social factors can have on access to care. In order to improve equity and reduce discrimination it is imperative that “accessibility” means “accessibility for all.” To achieve this, access must be assessed not just overall in a particular area but by disaggregated sub-groups, including but not limited to gender, sex, sexual orientation, class, caste, race, ethnicity, religion, and age. A useful tool for evaluating disparities in access is the WHO Health Equity Assessment Toolkit (HEAT). HEAT is a software that can help stakeholders explore within-country inequalities.

  • As already noted, this subdomain focuses on access to care from the perspective of the patient. However, there are a number of upstream system-level factors that affect patient access to care. Many of these components, including availability of drugs and supplies, infrastructure, workforce, and health financing, are discussed in other modules (forthcoming). When considering access from the patient perspective, it is necessary to conduct a thorough evaluation of the barriers and facilitators patients face when seeking care. The tools and frameworks discussed below are only a few examples of myriad methods for assessing access and can be used to evaluate financial, geographic, or timely access.

    Tanahashi framework

    The Tanahashi Framework examines health service coverage as an interactive process between a health service (a specific service intended to meet a health need of a population, in this case primary care) and its target population through five successive dimensions: availability, accessibility, acceptability, contact, and effectiveness.45 The percentage of the target population with effective coverage depends on coverage reached in the earlier dimensions.4 Effective coverage depends on the health service’s level and quality of interaction with the target population at each dimension and its ability to transform these interactions into a successful health intervention.4 While some dimensions of the Tanahashi Framework overlap with other components of the PHCPI framework, it is a useful conceptual model for assessing patient-perceived access to care and pathways to comprehensive primary care delivery for all. Using population-specific analysis, the Framework evaluates the bottlenecks and facilitators that subpopulations experience as a way to help identify why some subpopulations access and benefit from the health system and why others do not.4 These barriers and facilitators are influenced by health system barriers and wider contextual issues in which people live, work, and age.5 In this way, the Framework highlights the importance of evaluating access experiences of different sub-populations, including those related to socioeconomic or cultural factors.

    Evaluating barriers and facilitators at each dimension helps to identify operational bottlenecks, the constraining factors responsible for creating these bottlenecks, and ways forward for effective primary care delivery.45 For example, implementers can use the Tanahashi framework to understand how different health system and contextual barriers may preclude access to high-quality care. Implementers might consider the following barriers to effective coverage at each dimension:

    • Availability: subpopulation for whom the service is available, consider availability of resources (adequately skilled personnel, availability of services and health education for different diseases, necessary inputs)
    • Accessibility: subpopulation who can use the service, consider opportunity-costs lost (e.g. child-care, work), limited autonomy, decision making capacity, transport cost and availability, schedules and opening times
    • Acceptability: subpopulation willing to use the service, consider cultural beliefs (are these at odds with the service and the ability of a subpopulation to access effective coverage), gender responsiveness of services (e.g. same-sex provider where desired), risk of social stigmatization or discrimination from the provider, family, or community
    • Contact: subpopulation using the service, consider utilization
    • Effectiveness: subpopulation receiving effective care, consider capacity for treatment adherence (patient compliance ability, poor patient-provider relationships, gender roles and social conditions preventing follow up and management), barriers in diagnostic accuracy (linked to knowledge of the condition and inputs), barriers in health service delivery (poor provider training, poor accountability systems, weak referral systems)

    While this example focuses on barriers to accessing effective coverage, it is also important to also note the facilitators that certain subpopulations experience relative to others, to better analyze disparities in comprehensive and equitable health primary care coverage.

    Innov8

    Although not specific to financial, geographic, or timely access, the WHO has developed an approach for evaluating inequities in national health programs, called Innov8.6 In this model, a multidisciplinary team of stakeholders reviews a national health program with attention to barriers and inequities. The eight-step review process includes:

    • Step 1: Complete diagnostic checklist
    • Step 2: Understand the program theory
    • Step 3: Identify who is being left out by the program
    • Step 4: Identify the barriers and facilitating factors that subpopulations experience
    • Step 5: Identify mechanisms generating health inequities
    • Step 6: Consider intersectoral action and social participation as central elements
    • Step 7: Produce a redesign proposal to act on review findings
    • Step 8: Strengthen monitoring and evaluation

    The eight steps, their development, specific tools to complete the steps, and examples of application are discussed in greater detail in the technical handbook. This method may be useful for stakeholders to understand the landscape of inequities of access before implementing or adapting a health program. Attention to inequities in access from the start will result in a more comprehensive and accessible program and help countries achieve universal and equitable health coverage.6

    Triangulation

    When assessing barriers to care, it is important to triangulate using both qualitative and quantitative data. Together, these two forms of data can provide a more nuanced understanding than either one alone.7 The order in which evaluators collect qualitative and quantitative data will yield different information. If community engagement has been prioritized in the health system and stakeholders already have baseline understanding of the type of barriers patients face, it may be useful to collect quantitative data specific to those barriers first and then use qualitative methods such as focus groups of in-depth interviews to understand unexpected data or gain a more nuanced understanding of particularly salient quantitative data. Alternatively, if stakeholders do not have a strong baseline understanding of access barriers, starting with qualitative methods may help them understand what kind of quantitative indicators to subsequently collect and assess. Additionally, using qualitative methods that engage the community can help community members feel that they are contributing to decision-making and that their concerns are being heard. A brief discussion on the value of mixed-methods can be found here.  

  • Here we consider three elements of access: financial access; geographic access; and timeliness. Each of these components of access may be impacted by a wide array of individual and/or community socioeconomic characteristics—including poverty, gender, sex or sexual identity, caste, ethnicity, age, and race. These social determinants may have a significant impact on access within or between countries, and improvement may require concomitant efforts to improve social disparities. Another important element of access that is frequently overlooked is the role of language, particularly among indigenous populations. Global health interventions that fail to incorporate linguistic access for indigenous populations may contribute to widening health disparities.2 Thus, while social determinants and context – political, social, demographic, and socioeconomic – underlie all aspects of the PHCPI framework, they are particularly salient within access.

View case studies for:

Access Thailand

Beginning in the 1970s, Thailand has implemented a series of reforms to improve financial and geographic access and achieve universal health coverage.

Access Afghanistan

During reconstruction in 2001, Afghanistan implemented a series of reforms to increase financial and geographic access to primary care services through partnerships with NGOs and the removal of user fees.

Access Mongolia

The Health Sector Development Program started in 1997 has supported various geographic and financial reforms that have worked to improve access to quality primary health care in both rural and urban areas.

Relevant resources

Many tools and resources focused on access have been created over the last decade. Below is an interactive resource that provides the most useful documents within the context of our defined scope of geographic access, financial access, and timeliness.
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  • Geographic access
  • Financial access
  • UHC
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  • Monitoring and evaluation
  • Refugee and migrant health
  • Social determinants of health

A spatial database of health facilities managed by the public health sector in Sub-Saharan Africa WHO, 2019

"This master list of health facilities was developed from a variety of government and non-government sources from 50 countries in sub-Saharan Africa. It uses multiple geocoding methods to provide a comprehensive spatial inventory of 98 745 public health facilities."
Tags: Geographic access

AccessMod5 WHO, 2020

"AccessMod is a free toolbox that has been developed by WHO in order to assist countries to examine the geographic aspects of their health system using the analytical capacities of Geographic Information Systems. It specifically addresses the first three layers of a well-known framework developed by Tanahashi (1978) to evaluate health service coverage (the specific three layers being: the target population, availability coverage and accessibility coverage)."
Tags: Geographic access

Can people afford to pay for health care? New evidence on financial protection in Europe WHO, 2019

This report brings together data on unmet need and financial hardship to assess whether people living in Europe can afford to pay for health care. It then identifies the key features shared by health systems with strong financial protection and low levels of unmet need. It concludes with a summary of actions that policymakers and planners can take to reduce unmet need and financial policy as well as actions to be avoided.
Tags: Financial access

Closing the gap: health coverage for non-poor informal sector workers R4D and JLN, 2015

This paper synthesizes the experiences of five countries in covering the non-poor informal sector as a part of an effort to achieve UHC. The case studies focus on the challenges that many countries face in "Closing the Gap" and extending health coverage to non-poor informal sector workers and ther families. The approaches countries have employed can be used to inform targeted efforts to improve coverage for these populations.
Tags: Financial access, UHC, Private and multisectoral engagement

Developing inclusive health systems in crisis-affected settings Rebuild consortium, 2017

This policy brief was developed to inform key issues around developing inclusive health systems in crisis-affected settings. Specifically, it highlights ways in which health systems reinforce the marginalization of certain groups, and then summarizes the effects of crises on inclusiveness and the interventions that can protect and enhance equity for those marginalized.
Tags: Geographic access, Financial access, Timeliness, Fragile and conflict affected settings

Enhanced Access: Providing the Care Patients Need, When they need it Safety Net Medical Home Initiative, 2013

This implementation guide outlines 'change concepts' or ideas that can be used to stimulate specific, actionable steps that lead to enhanced access within the organizational structure and context. It provides changemakers with case studies on strategies to enhance access to care and additional resources to help guide the implementation of these strategies.
Tags: Timeliness

Going universal: how 24 developing countries are implementing UHC reforms from the bottom up World Bank, 2015

This report assesses the implementation experiences of 24 countries' UHC programs. It aims to guide policymakers in the implementation of various reforms for UHC, including topics related to service coverage, health financing, quality of health care provision, and stakeholder accountability. It concludes with a series of policy options and their implications for the UHC agenda.
Tags: Geographic access, Financial access, Timeliness, UHC, Responsiveness to people

How to move towards universal health coverage in crisis-affected settings: lessons from research ReBUILD Consortium, 2018

This policy brief was developed to inform key issues around achieving UHC in crisis-affected settings. Specifically, it reviews the meaning of UHC and summarizes key lessons for achieving UHC in crisis-affected settings.
Tags: Geographic access, Timeliness, Financial access, Fragile and conflict affected settings, UHC

Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations WHO, 2010

This document outlines a series of 16 evidence-based recommendations to support the recruitment, deployment, and retention of workforce in remote and rural areas. It also provides guidance for policymakers on how to choose and implement the most appropriate interventions for their context and how to monitor and evaluate impact over time.
Tags: Geographic access, Responsiveness to people, Monitoring and evaluation

Innov8 approach for reviewing national health programmes to leave no one behind: technical handbook WHO, 2016

This technical handbook provides detailed guidance on the eight-step Innov8 approach to reviewing national health programs to leave no one behind. Health professionals can use this approach to identify health equities in different country contexts, and to corrrect them by recalibrating health programs and interventions that affect patient access to care. It is adaptable to the varied needs of different countries and programs.
Tags: Geographic access, Financial access, Timeliness, Responsiveness to people

Innovations to Champion Access to Primary Care for Immigrants and Refugees Wellesley Institute, 2017

This report describes three promising case studies for facilitating better access to care for immigrants and refugees. Each case study takes an integrated appraoch to addressing access barriers, including: mobile clinics, workplace outreach models for care, and language and cultural brokers. Policymakers and planners can use these lessons to inform targeted interventions for improving access to care for these populations.
Tags: Geographic access, Financial access, Timeliness, Refugee and migrant health

PHC on the road to UHC WHO, 2019

The global monitoring report documents global gaps and progress in expanding access to essential health services. Specifically, it highlights the global coverage of health services and financial protection and addresses gender and equity related challenges. It concludes with a series of key messages, metrics, and strategies for leveraging investments in strong PHC to change the trajectory toward UHC.
Tags: Geographic access, Financial access, Timeliness, UHC

Public-Private Integrated Partnerships Demonstrate The Potential To Improve Health Care Access, Quality, And Efficiency Sekhri et al., 2011

This article describes innovative public-private partnerships undertaken by developed- and develoing-country governments to improve health care access, quality, and efficiency. It presents three case studies that demonstrate innovative design and outlines benefits and risks and key lessons to guide policymakers in the effective use of the public-private partnership model to improve quality, access, and efficiency outcomes.
Tags: Geographic access, Financial access, Timeliness, Private and multisectoral engagement

The health equity measurement framework: a comprehensive model to measure social inequities in health Dover et al., 2019

This paper was developed to fill the gaps in existing frameworks on the social determinants of health (SDOH), by presenting a framework focused on measuring health equity. The Health Equity Measurement Framework is intended to aid planners and decision makers address these gaps by providing a more comprehensive view of the SDOH, drivers of health service utilization, and intervention areas to be influenced by strategic public policies.
Tags: Geographic access, Financial access, Timeliness, Social determinants of health

Tracking UHC: 2017 Global Monitoring Report WHO and World Bank, 2017

"This report looks at how many people globally lack access to essential health services and how many are pushed into poverty or spending too much of their household budgets on health care expenses." It intends to advance global knowledge about gaps in achieving UHC and how different countries are bridging them, in efforts to identify what needs to be done the world's path toward UHC.
Tags: Geographic access, Financial access, Timeliness, UHC

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​

References:

  1. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally [Internet]. The Commonwealth Fund. 2014. Available from: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf
  2. Flood D, Rohloff P. Comment Indigenous languages and global health. Lancet Glob Heal [Internet]. 6(2):e134–5. Available from: http://dx.doi.org/10.1016/S2214-109X(17)30493-X
  3. Tappis H, Koblinsky M, Doocy S, Warren N, Peters DH. Bypassing Primary Care Facilities for Childbirth: Findings from a Multilevel Analysis of Skilled Birth Attendance Determinants in Afghanistan. J Midwifery Womens Health. 2016;61(2):185–95.
  4. Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ. 1978;56(2):295–303.
  5. Leaving no one behind in the context of subnational health system strengthening in Mongolia [Internet]. 2016. Available from: http://www.wpro.who.int/mongolia/publications/20171214-mongolia-report-leaving-no-one-behind.pdf
  6. World Health Organization (WHO). Innov8 approach for reviewing national health programmes to leave no one behind: technical handbook. 2016;246. Available from: http://www.who.int/life-course/partners/innov8/innov8-technical-handbook/en/
  7. Reynolds H. Mixed-Method Evaluations Lend Rigor to Design [Internet]. MEASURE Evaluation. [cited 2018 Sep 19]. Available from: https://www.measureevaluation.org/resources/newsroom/blogs/mixed-method-evaluations-lend-rigor-to-design