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.

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BackgroundSouth Africa’s maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country’s Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, “patient-oriented” barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services.MethodsA mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers.ResultsAccess to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care.ConclusionsTo move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these “patient-oriented” barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.

Dans le domaine de la santé, l'approche traditionnelle en planification des ressources humaines accorde une très grande importance aux effets des changements démographiques sur les besoins en ressources humaines. La planification est largement basée sur la taille et la composition démographique de la population, appliquées à de simples ratios population/fournisseur de soins ou population/utilisation des soins. Dans cette étude, nous proposons un cadre d'analyse plus large basé sur la production de services de soins de santé et sur les multiples facteurs qui déterminent les besoins en ressources humaines. Nous posons comme hypothèse que les besoins dépendent de quatre facteurs distincts : la démographie, l'épidémiologie, les standards de soins http://www.utpjournals.press/doi/pdf/10.3138/9R62-Q0V1-L188-1406 -Thursday, May 10, 2018 10:05:55 AM -IP Address: 54.149.104.195 S2 S. Birch, G. Kephart, G. Tomblin-Murphy, L. O'Brien-Pallas, R. Alder and A. MacKenzie CANADIAN PUBLIC POLICY -ANALYSE DE POLITIQUES, VOL. XXXIII, SUPPLEMENT/NUMÉRO SPÉCIAL 2007 et le niveau de productivité des fournisseurs de soins. Pour illustrer notre propos, nous appliquons le cadre théorique à des scénarios hypothétiques concernant l'ensemble de la population des provinces atlantiques canadiennes.Traditional approaches to health human resources planning emphasize the effects of demographic change on the needs for health human resources. Planning requirements are largely based on the size and demographic mix of the population applied to simple population-provider or population-utilization ratios. We develop an extended analytical framework based on the production of health-care services and the multiple determinants of health human resource requirements. The requirements for human resources are shown to depend on four separate elements: demography, epidemiology, standards of care, and provider productivity. The application of the framework is illustrated using hypothetical scenarios for the population of the combined provinces of Atlantic Canada.

The objective of this study was to assess if interaction between users and producers of research is associated with a greater level of adoption of research findings in the design and delivery of health care programs. Responses to the dissemination of a research report on breast cancer prevention were compared between two groups of public health units in Ontario, Canada. Although all public health units received the report, only a subset of units was involved in the development of the report, while others were not. Research utilisation was conceptualized in terms of stages, including reading the report, information processing, and application of findings for public health units' policies and programs. Using a multi-case study design, three units that contributed to the report's production (the interacting units) were compared with three units were not involved in producing the report (the comparison units) on the basis of research utilisation. Data collection involved group interviews and document review. Results demonstrated that interacting units had a greater understanding of the report's analysis and attached greater value to the report. However, interaction was not associated with greater levels of utilisation in terms of application. Both interacting and comparison units used the research findings to confirm that their on-going program activities were consistent with the research findings, and to compare their program performance relative to other units. In conclusion, interaction influenced the understanding of the research, and intent to use the research findings, but applied use was independent of interaction between producers and users of research.

Objective To evaluate trials of acupuncture for osteoarthritis (OA) of the knee, to assess the methodologic quality of the trials and determine whether low‐quality trials are associated with positive outcomes, to document adverse effects, to identify patient or treatment characteristics associated with positive response, and to identify areas of future research. Methods Eight databases and 62 conference abstract series were searched. Randomized or quasi‐randomized trials of all languages were included and evaluated for methodologic quality using the Jadad scale. Outcomes were pain, function, global improvement, and imaging. Data could not be pooled; therefore, a best‐evidence synthesis was performed to determine the strength of evidence by control group. The adequacy of the acupuncture procedure was assessed by 2 acupuncturists trained in treating OA and blinded to study results. Results Seven trials representing 393 patients with knee OA were identified. For pain and function, there was limited evidence that acupuncture is more effective than being on a waiting list for treatment or having treatment as usual. For pain, there was strong evidence that real acupuncture is more effective than sham acupuncture; however, for function, there was inconclusive evidence that real acupuncture is more effective than sham acupuncture. There was insufficient evidence to determine whether the efficacy of acupuncture is similar to that of other treatments. Conclusion The existing evidence suggests that acupuncture may play a role in the treatment of knee OA. Future research should define an optimal acupuncture treatment, measure quality of life, and assess acupuncture combined with other modalities.

General international agreement has emerged that acupuncture appears to be effective for postoperative dental pain, postoperative nausea and vomiting, and chemotherapy-related nausea and vomiting. For migraine, low-back pain, and temporomandibular disorders the results are considered positive by some and difficult to interpret by others. For a number of conditions such as fibromyalgia, osteoarthritis of the knee, and tennis elbow the evidence is considered promising, but more and better quality research is needed. For conditions such as chronic pain, neck pain, asthma, and drug addiction the evidence is considered inconclusive and difficult to interpret. For smoking cessation, tinnitus, and weight loss the evidence is usually regarded as negative. Reviews have concluded that while not free from serious adverse events, they are rare and that acupuncture is a relatively safe procedure.

Researchers examining the efficacy of medical procedures make assumptions about the nature of placebo. From these assumptions they select the sham interventions to be used in their trials. However, placebo is not well defined. A number of definitions are contradictory and sometimes misleading. This leads to problems in sham-controlled studies of medical procedures and difficulties interpreting their results. The author explores some of the contradictory definitions of placebo and assumptions and consequences of these. Principal among these is the assumption that the placebo is inert when it is not, which introduces bias against the tested medical procedures and devices. To illustrate the problem, the author examines the use of sham procedures in clinical trials of the medical procedures surgery and acupuncture in which the sham was assumed to be inert but was not. Trials of surgery and acupuncture should be re-examined in light of this.