Addressing access barriers to health services: an ...

1 Addressing access barriers to health services: an analytical framework for selectingappropriate interventions in low-incomeAsian countriesBart Jacobs,1* Por Ir,2,3 Maryam Bigdeli,4 Peter Leslie Annear5and Wim Van Damme31 health Sector Support Programme, Luxembourg Development, Ministry of health , Vientiane, Lao PDR,2 Provincial health Department,Ministry of health , Siem Reap, Cambodia,3 Department of Public health , Institute of Tropical Medicine, Antwerp, Belgium,4 Alliance for health Policy and Systems Research, World health Organization, Geneva, Switzerland,5 Nossal Institute for Global health ,University of Melbourne, Carlton, Victoria, Australia*Corresponding author. health Sector Support Programme, Luxembourg Development, Ministry of health , PO BOX 7084, Vientiane,Lao PDR.

2 Tel: 856 20 555 06317. Fax: 856 21 252 084. E-mail: February 2011 While World health Organization member countries embraced the concept ofuniversal coverage as early as 2005, few low-income countries have yet achievedthe objective. This is mainly due to numerous barriers that hamper access toneeded health services. In this paper we provide an overview of the variousdimensions of barriers to access to health care in low-income countries(geographical access , availability, affordability and acceptability) and outlineexisting interventions designed to overcome these barriers . These barriers andconsequent interventions are arranged in an analytical framework , which is thenapplied to two case studies from Cambodia. The aim is to illustrate the use ofthe framework in identifying the dimensions of access barriers that have beentackled by the interventions .

3 The findings suggest that a combination ofinterventions is required to tackle specific access barriers but that theireffectiveness can be influenced by contextual factors. It is also necessary toaddress demand-side and supply-side barriers concurrently. The framework canbe used both to identify interventions that effectively address particular accessbarriers and to analyse why certain interventions fail to tackle specific barriers , interventions , effectiveness, analytical framework , supply side,demand sideKEY MESSAGES A comprehensive overview of all identified access barriers to health care and interventions to address them in low-incomeAsian countries is formulated into an analytical framework . Application of this framework enables policy makers and health planners to identify the different dimensions and aspectsof barriers to access to health services, and to devise the specific intervention or combination of interventions that canbest address these barriers .

4 Conversely, the framework can assist in assessing the appropriateness of existinginterventions as a means to address the identified access by Oxford University Press in association with The London School of Hygiene and Tropical Medicine The Author 2011; all rights Policy and Planning2011;1 13 health Policy and Planning Advance access published May 12, 2011 at World health Organization on July 19, from IntroductionIn low-income countries (LIC), health care and related expend-itures feature prominently as causes of al.(2004) found an incidence of monthlyillnesses per poor household in India. Krishna (2006) identifiedthe cost of treatment for illness to be the cause of 85% of allcases of impoverishment. Van Doorslaeret al.

5 (2006) found thatan additional 78 million people in 11 Asian countries would fallbelow the extreme poverty line if conventional poverty esti-mates incorporated out-of-pocket expenditure for and Lund (2009) found that the costs associatedwith illness among the poor in Pakistan resulted in reducedfood consumption, withdrawal of children from school, sale ofmajor assets, putting children to paid work and even bondedlabour, while only 12% were able to recover from the associatedeconomic this context, a resolution to provide universal cover-age defined as access for all to appropriate promotive,preventive, curative and rehabilitative services at an affordablecost was endorsed by World health Organization (WHO)member states in 2005 (Carrinet ).

6 Recommendedactions to alleviate barriers to access to health care relatedmainly to financial interventions . However, as multiple factorsplay a role, Addressing access costs alone will not ensure accessto health services. The purpose of this paper is to provide anoverview of the various barriers to access and differentinterventions designed to address them in LIC. Followingthe methods section, barriers identified from a review of theliterature are described. The following section provides anoverview of existing interventions to address these barriers . Thevarious dimensions of access barriers and the interventionsdesigned to address them are then arranged into an analyticalframework. The framework is applied to two case studies fromCambodia as an illustration.

7 The final section discusses theframework s strengths and the additional research required tofill identified knowledge gaps. While the paper is not explicitlyfocused on the poor, it has been written with their fate in mindsince they carry the brunt of barriers to health search of the PubMed database was conducted to identifypublished articles on access barriers to health services and theinterventions designed to overcome them. The time-frame forthe searches covered the period from 1998 onwards, as this isthe period for which papers can be retrieved through HINARI,a programme enabling researchers from LIC to access a widerange of medical journals. Key words used were access , barriers , interventions , healthservices , healthcare , demand-side , supply-side , enabling , alone or in combinationfor low-income countries or developing countries.

8 Additionalpeer-reviewed or grey literature was identified from thereference lists of the retrieved papers. The literature searchwas carried out up to the point where the authors deemed thepotential for identifying new types of barriers to be , when similar access barriers or interventions were foundin subsequent papers, only the initial one was al. (1999) categorized three types of scientificinference that are frequently used by policy makers in thehealth sector. When an intervention is ongoing and decisionmakers want to know whether to continue or scale up theinitiative, an adequacy statement suffices since it answersthe question of whether an expected change took place. Theassociated assessments do not require a control.

9 When policymakers want to know whether the observed changes are due tothe intervention and not to external factors or confounding,then a plausibility assessment is considered appropriate . Theinfluence of external factors is restrained by using a the information requested concerns whether an inter-vention or strategy improved health outcome, interventions andcontrols require to be randomized, and a randomized controlledtrial (RCT) is called for. This is termed a probability , for the analytical framework , plausibility or probabilityassessments of interventions to overcome access barriers arenot deemed necessary since adequacy inference is consideredsufficient as it indicates the potential to increase search identified one existing framework for assessingaccess barriers to health services by Peterset al.

10 (2008) and arudimentary framework by Ensor and Cooper (2004) on supply-side and demand-side barriers . These frameworks were com-bined and enriched by findings on barriers from the literaturereview to develop a more comprehensive structure capturingadditional aspects that hinder access to approach was to focus on interventions that can bearresults in the short or medium term and can be implemented atdistrict level, either by the health sector alone or in combinationwith other departments and/or civil society organizations(see below). In some cases, important factors hamperingaccess to care such as lack of social support or femaleautonomy, as highlighted by Rutherfordet al.(2010) wereacknowledged but not included in the framework as theyrequire societal changes that are hard to bring about.