Access to Healthcare

In this series of public health articles, you will be able to learn about the fundamentals of public health which will serve you well for your medical school interviews. These principles will help you to understand how medicine and public health are intertwined especially as a result of the Coronavirus pandemic.

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Access to healthcare is a multidimensional concept encompassing several overlapping and interlinked factors. Access has often been measured on five key dimensions:

1. Approachability

2. Acceptability

3. Availability and accommodation

4. Affordability

5. Appropriateness

These dimensions together form the foundation and provide a holistic overview of proper patient-centred access to healthcare. Scoping reviews have found that organisational interventions aimed at improving these five dimensions could improve population health outcomes. Further, there are five corresponding dimensions around abilities of persons which interact with the dimensions of accessibility.

Approachability

Approachability denotes that people with health needs can actually identify forms of services, which will improve health, exist and can be reached. Services are responsible for making themselves known among various social and geographical population groups through transparency, providing information and outreach activities to make their services approachable to everyone who needs it. Complementary to this dimension is the notion of ability to perceive need for care which is crucial.

Factors such as health literacy, knowledge and health beliefs determine ability to perceive need for care.

Increasing individual’s ability to perceive need for care and approachability of services will increase the desire for care, resulting in more people willing to approach healthcare services. We can use mental health services as an example to contextualise approachability. Within many social and geographical populations, such as universities, mental health services are not approachable for students who need it. There is limited outreach activities and funding for mental health counselling for students who are often a neglected population group, resulting in fewer students identifying these services and, hence, approaching them.

Acceptability

Acceptability relates to cultural and social factors which affects an individual’s ability to accept or seek healthcare services. For example, a society where there is cultural stigma towards the mingling of men and women would reduce acceptability of care and to seek care for women if services mostly consist of male healthcare providers. This is often why women from certain communities tend not to access sexual health or breast cancer services as they do not want to have consultations with men, particularly regarding such taboo topics. Services which do not consider the acceptability of the community they service limit their accessibility.

Availability and accommodation refer to healthcare services and those within it being reachable both physically and in a timely manner.

Characteristics of facilities, urban contexts, individuals, providers and modes of provision affect availability and accommodation of healthcare. Access is restricted if there are not enough facilities or resources or if resources are not evenly distributed.

Decentralised healthcare services allow more access as individuals do not have to travel far to access services. Ability to reach healthcare is facilitated by better transport systems, occupational flexibility and knowledge about healthcare services. This is where we witness inequalities between socioeconomic status as they may live far from services with limited ability to spend on travel or take time off work.

Affordability

Affordability reflects on the economic capacity for people to spend on resources and services that they need for their health. It is not only affected by the price of healthcare but also by the reduced income due to ill health. Healthcare should be cost-effective, meaning that the price individuals pay for their care should produce effective and wanted outcomes in health. Ability to pay for healthcare results in a lot of health inequalities.

Poverty, social isolation, or indebtedness are examples of factors restricting the capacity of people to pay for needed care. Often free healthcare can limit the effectiveness of care because it can take a very long time to access specialists and consultants. Whereas, private healthcare, which is more costly may give better health outcomes. It is a complex balancing act.

Appropriateness

Appropriateness denotes the net clinical benefit to the patient; the expected health benefit (i.e. increased life expectancy, relief of pain, reduction in anxiety etc) exceeds the expected negative consequences (cost, time off work, mortality, morbidity etc).

Therefore, healthcare services cannot be a ‘one size fits all’, as different services and types of care will be different for each individual and have varying impacts. The ability to engage with services will affect the appropriateness of the service.

Overall, access to healthcare encompasses many interlinking factors. It can be argued that some of these dimensions are too simplified and should relate to access to healthcare. One should not have access to healthcare based on their geographical location or organisational availability and affordability, but rather proper access to healthcare is when individuals can choose acceptable and effective services. Healthcare should be timely, cost-effective, culturally and socially acceptable and inclusive and readily available as and when someone needs it.

Key Points:

• Five dimensions of access to healthcare: 1) Approachability; 2) Acceptability; 3) Availability and accommodation; 4) Affordability; 5) Appropriateness.

• Health inequalities are widened by varying access to healthcare within different ethnic groups, socioeconomic status, geographical locations, gender and age

• Cost-effective care is a complex concept which is rarely easy to obtain

• Ability to perceive, ability to seek, ability to reach, ability to pay and ability to engage affect the five dimensions

Further Reading:

• Access to healthcare in the UK - Doctors of the World

• Patient-centred access to healthcare: conceptualising access at the interface of health systems and populations - International Journal for equity in health

• What does access to healthcare mean? - Journal of health services research

• NHS operational planning and contracting guidance - NHS England

• Access to care - The Kings Fund

• Vulnerable groups and access to healthcare - Department of Health

By Nafisa Insan BSc MPH

PhD Student in Population Health Sciences