Access to health care in contexts of livelihood insecurity: a framework for analysis and action

This paper highlights the increasing need for providing high quality goods and service delivery in health care in resource-poor settings, especially in Africa. It further suggests additional efforts for equitable health care access and provision of basic livelihood assets required to initiate treatment seeking. These suggestions are presented through an interdisciplinary framework to provide a comprehensive and structured analysis of access to health care in resource-poor settings by identifying key entry points and targeted actions for health and poverty alleviation in horizontal community-based approaches.

This framework known as the Health Access Livelihood Framework has been designed in the frame of ACCESS Programme which was developed in the context of malaria treatment in rural Tanzania. This framework combines health services and health-seeking approaches and situates access to health care in the broader context of livelihood insecurity. ‘Health-seeking’ studies focus on people, ‘health service’ studies concentrate on factors influencing access to health care and ‘livelihood approaches’ emphasise assets and activities needed to gain and sustain a living under a condition of economic hardship.

The Health Access Livelihood Framework can be summarised as follows. Once people recognise an illness and decide to initiate treatment, access becomes a critical issue. Five dimensions of access influence the course of the health-seeking process: availability, accessibility, affordability, adequacy, and acceptability. What degree of access is reached along the five dimensions depends on the interplay between:

• the health care services and the broader policies, institutions, organisations, and processes that govern the services, and
• the livelihood assets people can mobilise in particular vulnerability contexts

However, improved access and health care utilisation has to be combined with high quality of care to reach positive outcomes. The outcomes can be measured in terms of health status (as evaluated by patients or by experts), patient satisfaction, and equity.