Put simply, the cost of healthcare is widely understood to be a key barrier to access for some and, therefore, a contributor to health inequality. But it isn't just the cost of treatment. Research which examined children's access to healthcare found that travel costs are the main barrier to children accessing healthcare - 13% of respondents in Ghana, Malawi and South Africa cited travel costs as a reason for not having attended a health service when they were sick.

Distance is also a factor. Children from urban and peri-urban areas in Ghana and Malawi were more than twice as likely to have visited a health facility as rural children in the last twelve months. Similarly, in Ghana, studies on access to maternal and newborn health care found that women who live less than 15 minutes from a facility are more than three times more likely to travel there when in labour than those living more than an hour away.

A different study looking at the factors that hinder the completion of TB diagnosis in Yemen found that adults - predominantly women – also faced multiple barriers, including social, cultural, and health systems related, in addition to cost and distance barriers. The study identified that whilst structural reform was needed to address many of these barriers, some could be resolved at local level with more straightforward, patient-centred approaches such as education, clear pricing policies and more flexible opening hours. Indeed, ensuring that, where services are available, they meet the needs of the communities they serve can be a key component of increasing access.

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Whilst many people recognise the benefits of access to health services, within some communities there can be great anxiety and suspicion of particular kinds of health services. A history of abusive policies, such as the forced sterilisation programmes in India for example, can affect the use of services. Thus, the theory goes, participation of the community, particularly the most vulnerable individuals and groups, may help to identify the structures, methods, and content of health services that will best suit a particular context.

The importance of community participation was confirmed by several studies in the ESRC-DFID portfolio that looked at the inclusion of local primary health care workers and local community representatives in the design and effective implementation of health services.

In one study, it was found that lack of engagement with local communities and organised community mobilisation resulted in poor outcomes for HIV/AIDS programmes aimed at prevention, care and treatment. Whilst in Kenya, findings from a study on community health workers (CHW) confirmed that their inclusion in the design and implementation of health improved effectiveness. Another study concluded that the 'voice' of CHWs should be a central component for programme design and implementation, as CHWs are able to provide locally specific information, data and advice.

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The quality of the healthcare offered is also likely to be a factor in the level of access to services and there has been a lot of interest in the provision of incentives - either to healthcare workers or users - as a means of improving health service performance or health outcomes. This is due partly to the initially impressive results of incentive schemes in some locations.

The Rwandan Pay-for-Performance (P4P) scheme is one such intervention. It operates by providing more resources and incentivising health care providers to focus on specific activities. But it was unclear whether it was the incentive structures or increased access to resources that has the more significant effect on performance. To address this, a recent study evaluated the impact of a P4P scheme on individual and couple HIV testing and counselling (HTC) in Rwanda and found a positive effect which shows that incentive payments can be an effective method by which to increase patient participation. The interventions also increased institutional performance, the number of preventive care visits by young children, and better quality prenatal care.

Another study in Rwanda evaluating the effects of P4P on the quality and usage of preventive care for children and prenatal care found that it works best when services had higher payment rates and required less effort from providers.

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Another widely studied aspect of effective and equitable access to health services is the role of the policy and expenditure frameworks provided by governments. Policy and expenditure decisions across the government as a whole, not just within the health sector, can have implications for health access. It is important to recognise that addressing issues of inequality in access to health services requires an approach which encompasses all sectors within government, not just the health sector alone.

Several projects from the ESRC-DFID portfolio examined the ways in which governance directly impacts upon health. In some cases, regulatory frameworks were shown to be an important factor. In India and Nepal, ineffective drug regulation and the resulting pharmaceutical misuse was found to potentially have had a negative impact on health outcomes, hindering efforts to reach health-related MDGs. One paper in this project found that oxytocin, a natural hormone used to induce labour in pregnant women, is used inappropriately, flouting clinical guidelines, with potential adverse outcomes for mother and baby. Over-prescription and misuse of anti-depressants was also found.

Another set of research in Zambia examined the reasons behind the high prevalence of unsafe abortions in the country, despite the provision of legal and safe abortion services. Women who have terminated their pregnancy in a hospital setting and those who have used unsafe and illegal services were interviewed, and it was found that improved awareness about the legality of abortions and access to improved contraceptive services is needed. Making these improvements could potentially reduce costs to the health service through a reduction in unsafe abortion complications and unwanted pregnancies.

Regional organisations, such as the Southern African Development Community (SADC) and Union of South American Nations (UNASUR), are embedding health mandates in their frameworks and governance, and research suggests that these organisations could help develop coherent health policies in an increasingly complex global health governance system. Finally, one factor that should not be overlooked is the need for better access to high quality data, which would help countries to focus on addressing the broader factors impacting on health and increased use of evidence in policy, and therefore reduce poverty.

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