Although access to health care is frequently identified as a goal for health care policy, the precise meaning of access to health care often remains unclear. We present a conceptual framework that defines access to health care as the empowerment of an individual to use health care and as a multidimensional concept based on the interaction (or degree of fit) between health care systems and individuals, households, and communities. Three dimensions of access are identified: availability, affordability, and acceptability, through which access can be evaluated directly instead of focusing on utilisation of care as a proxy for access. We present the case for the comprehensive evaluation of health care systems as well as the dimensions of access, and the factors underlying each dimension. Such systemic analyses can inform policy-makers about the 'fit' between needs for health care and receipt of care, and provide the basis for developing policies that promote improvements in the empowerment to use care.
The World Health Assembly of 2005 called for all health systems to move towards universal coverage, defined as "access to adequate health care for all at an affordable price". A crucial aspect in achieving universal coverage is the extent to which there are income and risk cross-subsidies in health systems. Yet this aspect appears to be ignored in many of the policy prescriptions directed at low-and middle-income countries, often resulting in high degrees of health system fragmentation. The aim of this paper is to explore the extent of fragmentation within the health systems of three African countries (Ghana, South Africa and the United Republic of Tanzania). Using a framework for analysing health-care financing in terms of its key functions, we describe how fragmentation has developed, how each country has attempted to address the arising equity challenges and what remains to be done to promote universal coverage.The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way. To achieve universal coverage, health systems must reduce their reliance on out-of-pocket payments, maximize the size of risk pools, and resource allocation mechanisms must be put in place to either equalize risks between individual insurance schemes or equitably allocate general tax (and donor) funds. Ultimately, there needs to be greater integration of financing mechanisms to promote universal cover with strong income and risk cross-subsidies in the overall health system.
BackgroundMalaria imposes significant costs on households and the poor are disproportionately affected. However, cost data are often from quantitative surveys with a fixed recall period. They do not capture costs that unfold slowly over time, or seasonal variations. Few studies investigate the different pathways through which malaria contributes towards poverty. In this paper, a framework indicating the complex links between malaria, poverty and vulnerability at the household level is developed and applied using data from rural Kenya.MethodsCross-sectional surveys in a wet and dry season provide data on treatment-seeking, cost-burdens and coping strategies (n = 294 and n = 285 households respectively). 15 case study households purposively selected from the survey and followed for one year provide in-depth qualitative information on the links between malaria, vulnerability and poverty.ResultsMean direct cost burdens were 7.1% and 5.9% of total household expenditure in the wet and dry seasons respectively. Case study data revealed no clear relationship between cost burdens and vulnerability status at the end of the year. Most important was household vulnerability status at the outset. Households reporting major malaria episodes and other shocks prior to the study descended further into poverty over the year. Wealthier households were better able to cope.ConclusionThe impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications, influencing household ability to withstand malaria and other contingencies in future. To protect the poor and vulnerable, malaria control policies need to be integrated into development and poverty reduction programmes.
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