How can the concept of `access' be researched in a policy-relevant way?

Date: Wednesday 31 October 10.45–12.15
Source: Forum 11
Authors: Stephen Birch, Professor, Department of Clinical Epidemiology and Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, Canada
with Diane McIntyre and Michael Thiede

Abstract

The objective of this paper is to outline a useful conceptualization of `access', how it may be used for empirical investigation of access, and how this may inform policy initiatives to promote equitable access. In order to develop appropriate policies, there needs to be greater clarity on what access means and barriers to access need to be identified through detailed research.

While there is consensus in the literature that access is a multi-dimensional concept, there is little agreement on what dimensions constitute access. In addition, there is frequently an exclusive focus on `supply-side' issues when considering access. We argue, first, that access has both health system (supply-side) and household or individual (demand-side) aspects. Access is fundamentally about the interaction, or `degree of fit', between the health system and the individual or household. Second, given the multitude of factors influencing access, it is necessary to identify key dimensions of access to act as `entry points' for empirical investigation in a specific country context. The dimensions suggested by Penchansky in the late-1970s are a useful starting point, but we suggest modifying them into three key dimensions: 1) availability ­ i.e. whether or not the appropriate health services are available in the right place and at the time that they are needed; 2) affordability ­ i.e. the `degree of fit' between health care costs and individuals' ability to pay; and 3) acceptability ­ i.e. the relationships between providers and patients, which are influenced by their attitudes towards and expectations of one another.

While there are considerable interrelationships between these dimensions, they are sufficiently distinct to allow their use as separate entry points into a comprehensive empirical consideration of access. Such an evaluation would require both quantitative measures and qualitative assessment.

We believe that in order to avoid the prevalent tendency to (inappropriately) adopt utilization as a proxy for access, a structured set of entry-points is needed to facilitate the direct evaluation of access and in order to inform the development of appropriate policy.