Timeliness of care includes two elements. First, patients should be able to physically access care with acceptable and reasonable waiting times. Second, hours and days of facility operation should be such that patients can find a time to visit facilities without sacrificing other obligations and duties such as work or childcare and can access care for emergent needs, including on nights and weekends.
Individuals who have obligations (employment, household work, school) during typical facility operating hours are most likely to face barriers to access due to timeliness. As discussed in financial access as well, these patients may face substantial external costs if they must miss work or find alternative child care in order to access services which can in turn lead to catastrophic health expenditure.8
There are many reasons why patients may not be able to access timely care. Some of these include:
Facility hours may be a barrier to care for individuals who work or have regular obligations. This is most often the case when facilities do not offer evening or weekend hours. Few convenient hours of operation can also contribute to long waiting times, short consultations, and provider burnout.
A systematic review of public and private healthcare facilities in LMIC found that across multiple settings, waiting times, operational hours, and availability of staff were more favorable in private clinics compared to public ones.9
Appointment systems – coupled with effective use of resources and high-quality care - may be an effective starting point for ensuring timely access to care. A 2016 review of primary care experiences in six Latin American countries found substantial gaps in performance regarding waiting times and appointment systems: one-fifth of respondents skipped an appointment due to problems with scheduling, one-third had to wait more than five days for an appointment, and 39% could not schedule an appointment by phone.10
Long wait times may be attributable to diverse causes including insufficient human resources, inefficient or absent appointment systems, limited operational hours, and ineffective facility management regarding human resources or facility flow. Facility managers may choose to conduct activities such as process flow mapping (discussed in greater detail in the performance measurement and management module) in order to assess how and why patients are experiencing long waiting times.
To ensure access to care, patients must be able to visit health facilities at times and days that are convenient to them and do not require substantial sacrifice in work or childcare. Because expanded days and hours of service may require more human resources, stakeholders must consider how they can reorganize the health system to accommodate these changes. The suggestions for reducing waiting times below may help facility managers rearrange service delivery to accommodate more hours of operation:
Appointment systems can improve access to services at the point of care. These systems need not be complex but should be easy to use for both patients and providers, appropriately tailored to the internet connectivity and literacy in a given context, and adaptable to anticipate any changes in service delivery. These systems, if supported by a sufficient workforce, can improve waiting times and person-centeredness of service delivery. Appointment system options include:
Even with efficient appointment systems, facility managers should ensure that patients can access care for urgent needs. This may be done by reserving specific days and/or times for walk-in visits or same-day appointments.
While reduced waiting times will improve patient experience and access, they can also contribute to clinic efficiency. Patients who miss their appointments often do so because of long waiting times or the need to select an appointment time that is inconvenient for them.11 Thus, improved systems may reduce no-shows and ensure that the provider time is maximized. It is also important for facilities to have systems for triaging patients once they arrive in facilities. For instance, patients may be triaged between emergency, chronic, and acute care. Assuming that facilities have sufficient human and material resources to address demand, some strategies to make appointments more efficient and reduce waiting times—along with questions stakeholders may use to assess the appropriateness of the strategy for their context—include:
Suggested citation: “Access: Financial Access.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/access/timeliness. Accessed [insert date].
In South Korea, the establishment of the National Health Insurance Service in conjunction with rapid economic development has increased access to services and improved health outcomes over the last few decades. However, there is evidence of high rates of overutilization of hospital services attributable to the absence of weekend access to PHC. In October 2013, South Korea instituted a program that pays General Practitioners (GPs) 30% beyond their normal compensation to provide care on Saturdays. This incentive proved sufficient to encourage GPs to work on Saturdays, improving patient access and reducing the volume of patients on other days of the week.12 Increased access on Saturdays also likely decreased utilization of emergency rooms for conditions treatable in primary care settings, though the evaluation was unable to measure this impact.
Without an efficient appointment system, providers or administrative staff may face difficulties in tracking patients who do not return for follow up or are non-compliant in treatments, compromising coordination and continuity of care. This is particularly important for chronic diseases that require regular monitoring such as HIV or NCDs. There is evidence that one year retention rates for antihypertensive and antidiabetic medications are as low as 2% in parts of Africa. The International Network for the Rational Use of Drugs Initiative on Adherence to Antiretrovirals (INRUD-IAA) piloted an appointment system in Tanzania, Rwanda, and Kenya in conjunction with the HIV/AIDS control programs to improve patient attendance tracking and follow-up.13 In addition to the ability to track patients, these appointment systems facilitated other activities that benefited providers and patients alike. In Tanzania, the appointment system helped reduce waiting times and distribute patients throughout the day. Both Rwanda and Kenya used the appointment and patient tracking system to monitor performance. In Rwanda, these data were linked with performance-based financing related to patient attendance, and in Kenya, data were used to evaluate and plan during staff meetings. Following this pilot, all three countries incorporated appointment systems into national policies.13
Like many LMICs, Nigeria has experienced a shortage of human and material resources in primary care facilities, leading to overcrowding in outpatient waiting rooms, dissatisfaction with care, poor treatment outcomes, and overworked providers. A study in Lagos, a large city in Nigeria, evaluated patient perspectives on the acceptability, feasibility, and willingness to adopt a SMS service for appointment scheduling to increase efficiency of appointments and improve waiting times.14 This feasibility study found widespread support for the technology among providers; most participants indicated that they would pay for and use the service, and even those without a cell phone or with limited literacy indicated that they would be able to find ways to utilize a SMS appointment system. Though this study did not subsequently implement and evaluate such a program, it highlighted the demand and utility of such a service in a resource-constrained setting.
Shared medical appointments are not only more efficient from a facility flow perspective but can also help patients develop supportive communities. This is particularly true for antenatal (ANC) and postnatal care, where women attend group visits with women of a similar gestational age, sharing information and forming relationships within and outside of the facilitated group visit. Compared to individual visits, women are able to spend more time with providers, form relationships with providers and other mothers, and reinforce knowledge with one another.15 A group ANC curriculum was implemented in Ghana using seven lesson modules designed by the American College of Nurse-Midwives. Each of the sessions was 60 minutes and involved story-telling, peer support, and demonstration with a focus on delivering information to women with limited literacy. This design was compared to individual ANC with the same providers, and women who received group ANC care were more likely to discuss delivery arrangements and transportation with midwives, have saved money for birth, report positive exclusive breastfeeding practices, and discuss newborn problems with midwives. Thus, group visits for ANC can contribute to facility efficiency while better equipping women with maternal knowledge.15
Shared medical appointments have been used extensively for NCD management in high income countries to limit repetition of educational medical appointments and build cohorts of patients with similar needs and concerns.16 A study of shared medical appointments for diabetes in The United States found that the success of these programs depended on patients’ motivation and willingness to learn and could contribute to improved patient satisfaction and productivity.16 While there is limited evidence of shared medical appointments for NCDs in LMICs, the success of shared appointments for ANC suggests that shared medical appointments may continue to be a strategy for improving clinic efficiency.
Suggested citation: “Access: Financial Access.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/access/timeliness. Accessed [insert date].
The questions below may be a useful starting place for determining if timeliness is an appropriate area of focus for a given context and how one might begin to plan and enact reforms:
In order to determine how and when services need to be extended, it is important to qualitatively understand patient experience with waiting times before and during appointments and to assess the feasibility and acceptability of potential solutions with them.
Expanding hours or days of operation within a facility is a clear solution if facility operational hours pose barriers to the population. However, this may not be feasible in all settings. It is important for facility managers and assess the existing facility operations and workforce to understand how expanded hours would impact the facility, and it may be useful to begin with a pilot.
Contextual realities such as technology and literacy may be a limiting factor when developing appointment systems. Appointment systems do not need to be complex, but the presence well-designed systems can contribute to improved facility efficiency. It is important to robustly evaluate patients’ access to relevant technologies before implementing a system.
Suggested citation: “Access: Financial Access.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/access/timeliness. Accessed [insert date].
In order for interventions aimed at improving timeliness to be most successful, the following elements of the PHCPI Conceptual Framework should be in place or pursued simultaneously:
Regardless of financial, geographic, and timely access to services, it is unlikely that patients will access care if they perceive that providers lack competence, services are not tailored to their needs, and care is not delivered with trust and respect. Additionally, if patients do seek care that is not high quality, it is unlikely to result in improved outcomes. Thus, if patients are not accessing services, it is important to understand whether it is due to perceived quality of care or accessibility, and if both are lacking, they may have to be addressed in tandem to improve utilization of care and subsequent positive health outcomes and impact.
Certain approaches to improving access require logistical changes within a facility, such as scheduling outreach activities, adopting new appointment systems, or shifting provider schedules to facilitate greater coverage. For all of these changes to be effectively integrated, facilities must have strong leadership and management to communicate, implement, monitor, and adapt necessary changes with internal and external stakeholders.
As with any changes to a health system, it is important to have a clear system in place to evaluate the efficacy of a given intervention. Performance measurement and management systems with clear targets, measurement activities, and plans for improvement should be designed in conjunction with service delivery changes to monitor changes in access and adapt approaches as needed.
As with other service delivery changes intended to improve access to care, improved timeliness may result in an influx of patient demand. Therefore, there must be sufficient human resources within facilities to serve the population. Additionally, workforce organization and establishment of care teams may make services more efficient, thus facilitating timely access.
Improving facility flow or establishing appointment systems requires adequate integration of information systems. Providers or administrative staff who would be responsible for facility planning should have clear information systems use expectations and training. If patients are also expected to use information systems for scheduling appointments, these should be clearly communicated during facility visits or during community-based care.
In addition to engaging community members in the identification of barriers to care and potential interventions to improve access, social accountability mechanisms should be in place to ensure that community members are able to monitor and react to health systems interventions and changes.
Suggested citation: “Access: Financial Access.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/improvement-strategies/access/timeliness. Accessed [insert date].
Brief Overview
Each section includes core principles and relevant background on the topic to help stakeholders understand how this topic relates to other parts of the health system and how to begin improvements.
In-depth exploration
Each section links to various external resources including research papers, toolkits, and implementation guides for readers who would like to learn more.
Diagnostic
Countries that have a Vital Signs Profile can use it to identify gaps in their performance and find improvement strategies that are specifically relevant to their context.
Sharing experience and learning from others
Throughout the model, there are case studies that provide examples of how other countries have implemented reforms and the factors that supported implementation. Additionally, if you think others can learn from improvements in your country, you can submit your experience using the "share your experience" tab.
