Health systems

Inequality in access to health services

Research shows the importance of improving access to health services to address health inequalities.

A health worker fills out health records during an immunization event in Mozambique. © 2014 VillageReach, Courtesy of Photoshare
Edited by Alan Stanley
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Having access to health services - the provision of vaccinations/immunisation, basic emergency surgery and public health information etcetera - can be life-saving. However, millions of people in low to middle income countries (LMICs) for many reasons do not access these services and this contributes to unequal rates of mortality and disease that are entirely preventable.

Since 2005, the ESRC-DFID Joint Fund for Poverty Alleviation Research has funded 69 research projects about health and health services in LMICs, mostly in Sub Saharan Africa and South Asia. The evidence from this research points to the importance of improving access to health services as a means of addressing these health inequalities and suggests possible interventions for improving access to health services. 

Continue reading: Barriers to access

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Leah Murphy 

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Barriers to access

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.


Children’s mobility in Ghana: An overview of methods and findings from the Ghana research study
Society, Biology and Human Affairs, 2011
This paper is part of a collection forming A Special Issue, which covers selected themes from a larger project on child mobility in Ghana, Malawi and South Africa. The themes are those which individual members of the Ghana research team identified as of particular interest and on which they have reflected, drawing on material collected and analysed by the team as a whole.
A Moving Issue: Children and young people’s transport and mobility constraints in Africa
International Forum for Rural Transport and Development, 2010
Children and young people are rarely at the forefront of transport studies, despite the fact that their ability to access health and educational facilities is crucial to the achievement of internatioanl development goals. To address this knowledge gap a collaborative research project gathered evidence of the specific mobility constraints experienced by children in Ghana, Malawi and South Africa as they attempt to access the facilities and services that are important to their lives.
Geographical access to care at birth in Ghana: a barrier to safe motherhood
BMC Public Health, 2012
Appropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many high burden regions. Despite its importance, geographical access is rarely audited systematically, preventing integration in national-level maternal health system assessment and planning.
Barriers to completing TB diagnosis in Yemen: services should respond to patients’ needs
PLoS ONE, 2014
Obtaining a diagnosis of tuberculosis (TB) is a prerequisite for accessing specific treatment, yet one third of estimated new cases are missed worldwide by National Programmes.

Local community participation in Primary Health Care service delivery

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.


How can community health programmes build enabling environments for transformative communication? Experiences from India and South Africa
London School of Economics, 2010
This paper seeks to characterise the social environments in which community-led health programmes are most likely to facilitate effective and sustainable health improvements, using three dimensions to characterise social contexts: material, symbolic and relational. Drawing on secondary sources, the authors compare two well-documented case studies of HIV/AIDS management projects. Both sought to use technical communication about HIV/AIDS as a springboard for developing transformative communication skills amongst marginalised women.
What do community health workers have to say about their work, and how can this inform improved programme design? A case study with CHWs within Kenya
Global Health Action, 2015
Community health workers (CHWs) are used increasingly in the world to address shortages of health workers and the lack of a pervasive national health system. However, while their role is often described at a policy level, it is not clear how these ideals are instantiated in practice, how best to support this work, or how the work is interpreted by local actors. CHWs are often spoken about or spoken for, but there is little evidence of CHWs’ own characterisation of their practice, which raises questions for global health advocates regarding power and participation in CHW programmes.

Providing incentives to improve service performance

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.


Using provider performance incentives to increase HIV testing and counseling services in Rwanda
World Bank Publications, 2013
Paying for performance provides financial rewards to medical care providers for improvements in performance measured by specific utilisation and quality of care indicators. In 2006, Rwanda began a paying for performance scheme to improve health services delivery, including HIV/AIDS services.
Promoting cardiovascular health in the developing world: a critical challenge to achieve global health
Institute of Medicine, 2010
Cardiovascular disease (CVD), once thought to be confined primarily to industrialized nations, has emerged as a major health threat in developing countries.
Paying primary health care centers for performance in Rwanda
World Bank Publications, 2010
Paying for performance (P4P) provides financial incentives for providers to increase the use and quality of care. P4P can affect health care by providing incentives for providers to put more effort into specific activities, and by increasing the amount of resources available to finance the delivery of services.This paper evaluates the impact of P4P on the use and quality of prenatal, institutional delivery, and child preventive care using data produced from a prospective quasi-experimental evaluation nested into the national rollout of P4P in Rwanda.

Strengthening governance for health

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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Governance for health equity: taking forward the equity values and goals of Health 2020 in the WHO European Region
World Health Organization WHO File, 2014
With its distilled lessons, this publication provides a situation analysis of why policies and interventions to address social determinants of health and health inequities succeed or fail. It also discusses important features of governance and delivery systems that increase likely success in reducing inequities.A systems checklist for governing for health equity as a whole-of-government approach is put forward. This is intended for further discussion and as a framework to support strengthening how countries govern for health equity in practice, through action on social determinants.
Intrapartum oxytocin (mis)use in South Asia
Journal of Health Studies, 2009
Oxytocin is a natural hormone with uterine stimulant properties that plays a prominent role in obstetric practice. Clinical guidelines for oxytocin use intrapartum emphasise that injudicious use has serious potential for adverse outcomes for mother and baby. Oxytocin is readily available in South Asia and widely used in ways that flout these guidelines. Yet recommendations for active management of third stage of labour include the administration of oxytocin to prevent post-partum haemorrhage.
Pregnancy termination trajectories in Zambia
International Union for the Scientific Study of Population, 2014
Unsafe abortion is a significant, but preventable cause of maternal mortality in Zambia. The authors compared the trajectories of women seeking safe abortion with those receiving care following unsafe abortion. They interviewed women accessing care in a large government hospital about their experiences. The study captured a third termination trajectory in which women received medical abortion outside the study hospital from qualified (legal) and unqualified providers.
Cost of abortions in Zambia: A comparison of safe abortion and post abortion care
Global Public Health, 2015
Unsafe abortion is a significant but preventable cause of maternal mortality. Although induced abortion has been legal in Zambia since 1972, many women still face logistical, financial, social, and legal obstacles to access safe abortion services, and undergo unsafe abortion instead.This study provides the first estimates of costs of post abortion care (PAC) after an unsafe abortion and the cost of safe abortion in Zambia. In the absence of routinely collected data on abortions, the authors used multiple data sources: key informant interviews, medical records and hospital logbooks.
Multi-level pro-poor health governance, statistical information flows and the role of regional organisations in South America and Southern Africa
Poverty Reduction and Regional Integration, 2016
Health governance has become multi-layered as the combined result of decentralisation, regional integration and the emergence of new actors nationally and internationally. Whereas this has – in principle – enhanced the installed capacity for health response worldwide, this complexity also poses serious challenges for health governance and policy-making.This paper focuses on one of these challenges, namely the organisation of statistical information flows at and between governance levels, and the emerging role that regional organisations play therein.