Access

Addressing financial barriers to care is critical to improving financial access to care which is a core component of access. There are many different barriers to address when looking at financial access. “Financial coverage” addresses the presence of comprehensive financial protection schemes; these methods may not necessarily ensure access in practice if co-payments, deductibles, and/or transportation and other indirect costs remain high. Financial access, by contrast, concerns financial realities from the perspective of the patient. A patient may be enrolled in a financial protection scheme but lack financial access due to prohibitive remaining medical costs or external costs related to seeking care.

Key activities

Health systems level

• Removal or reduction of user fees: multiple settings have found that when user fees are implemented, there is a consistent accompanying decrease in access – particularly among the poor.³ There are three ways that countries can address the removal or reduction of user fees. First, countries may choose to abolish or reduce user fees for all individuals. This is of course dependent upon available financial resources and has serious financial implications including loss of discretionary revenues at facilities. Some strategies that may facilitate the removal or reduction of user fees will be addressed in the forthcoming Health Financing module.¹³ Second, certain populations may be specifically selected for exemption through the use of waivers. These populations might be determined by socioeconomic status or demographics. For instance, the poorest members of society, pregnant women, or children under five are common recipients of free or reduced fee services. Finally, the removal of user fees may apply only to specific services such as antenatal care. These methods are not mutually exclusive, as exemptions may apply for both specific groups and selected services. It is important to note that the removal of user fees is likely to increase utilization of services which may overwhelm health systems that are not prepared to provide the volume and quality of services being demanded. In order to facilitate a smooth transition, the World Health Organization provides four important preconditions and considerations for health systems removing user fees¹⁶:
  • “Sufficient financial resources need to be provided and effectively transferred to the facility level to compensate for both the loss of revenue at the provider level…and for the desired increase in the use of services.
  • Provider payment and financial transfer methods must be in place – prior to the policy coming into being – through which the promised free services are effectively purchased and through which health workers are incentivized.
  • Efforts are needed to improve and make health services available, bringing them closer to the most distant and vulnerable population groups
  • Policymakers need to look for synergies in implementation and ensure that reform initiatives lead towards a coherent health financing architecture.”

District & facility level

• Use of conditional cash transfers (CCTs): CCTs are a demand-side financing mechanism that can be used to improve financial access to care as the payments can be used to help individuals overcome financial barriers to care such as out-of-pocket payments, travel costs, or childcare.⁴ In CCT programs, individuals or families receive payments contingent upon a certain behaviour – in the case of health, it is often the utilization of specific services. CCTs have been implemented extensively in LMIC.¹⁷ Even if the conditions tied to CCTs are not health-related, the payments can also be used to help individuals overcome financial barriers related to accessing health services, such as out-of-pocket payments, travel costs, or childcare.¹⁷ A systematic review of such programs found that they can, but do not always, improve access to health services and ultimately health outcomes.¹⁷ Important considerations for the success of a CCT program include: 
  • Efficient targeting of poorer groups – specific individuals or leaders within a community may be made responsible for the identification of eligible households. Alternatively, there may be existing social security programs that have similar eligibility criteria as the intended program, and implementers can use their existing lists.
  • Monitoring systems to ensure requirements are being met – implementers must plan programs with consideration of how they will ensure that individuals or households are fulfilling the required behaviours. Examples of monitoring strategies include check-ins with patients and providers during facility visits or home visits. Regardless of the method, however, monitoring will necessarily incur costs and require human resources to implement but is important to ensure that the program is being implemented with fidelity.
  • The presence of high-quality services and resilient staff and systems to withstand increased demand – as with interventions that remove or reduce user fees, health systems must be capable of providing high-quality care both at baseline and when demand increases as a result of the program.¹⁷
• Voucher Programs: A second, demand-side method for improving financial access to health services is vouchers. During voucher programs, vouchers are distributed to a specific subset of the population and these are used to obtain free or reduced fee services at the point of care. The facility is subsequently reimbursed. These programs are especially common for antenatal care or delivery. Some of the benefits of voucher programs include:
  • Voucher programs enable the targeting of low-income or high-risk individuals through distribution.
  • By making vouchers only redeemable at facilities that meet specific quality standards, vouchers may encourage quality improvement processes at non-qualifying facilities.
  • Voucher programs require the use of an information system to track the distribution and collection of vouchers. These data can be used to monitor providers.¹⁹

There are several important considerations for stakeholders when planning a voucher program: 

• Coverage of vouchers – Implementers must consider the services and individuals eligible for a transportation voucher. Vouchers may be provided for specific services such as antenatal care/delivery or emergency services or to certain portions of the population, most often poor individuals or other high-risk groups. Sometimes, vouchers are used specifically for transportation, in which case specifics related to the cost of vouchers and whether they are flat-rate or flexible often must be negotiated with local transportation organizations. 
• Method for identifying recipients and distributing vouchers – after identification of the target population, systems must be put in place to distribute vouchers. This may occur in communities as part of proactive population outreach or in facilities. For instance, transportation vouchers for delivery may be distributed when women attend antenatal care visits. However, in these cases, it is important to identify the target individuals who may qualify but are unable to seek care in these settings and reach them through alternative means.
• System for detecting fraud and tracking vouchers – Implementers should ensure that there are ways to detect fraudulent vouchers and track the distribution and use of vouchers. As always, any data management tool should be easy to use and compatible with the available infrastructure. 
• Buy-in – In order to ensure the use of vouchers, community members must be aware of the conditions for use. This may be achieved through community meetings, discussions at clinics, radio shows, or other accessible means of communication.²⁰
• Facility capacity – As with other interventions to improve access, patients must be met by competent providers and effectively run facilities in order to ensure that patients receive high-quality and timely care. These facilities must be sufficiently resilient to respond to increased demand.

Individual & community-level

• Community-based health insurance (CBHI): CBHI is generally considered a means for improving financial access among these populations that are often overlooked by other insurance schemes. These schemes are likely to include benefit packages that are closely aligned to community values and needs⁵⁶Community-based health insurance is a decentralized health insurance scheme that has been used in a number of LMICs. While CBHI schemes are established by communities and are therefore quite diverse, some common qualities include pooling of risks and funds at the community level, not-for-profit payment plans most often at a flat rate and not dependent upon health risk, community control in setup and management, and voluntary membership.⁵⁶ CBHI has often been implemented in areas where there is a significant poor and/or informal worker population, and revenue collection for health insurance administered at the national level would be challenging. As such, CBHI has generally considered a means for improving financial access among these populations that are often overlooked by other insurance schemes. 
• Community engagement Community engagement is the inclusion of local health system users and community members in all aspects of health planning, provision, and governance. It is a central component of ensuring that the services delivered are tailored to population needs, priorities and values, which can be achieved through the involvement of communities in the design, financing, governance, and implementation of PHC. To ensure that the needs of all community members are met, it is important that community engagement efforts include representation from diverse members of the community. This may require multiple mediums for engagement, to best capture the needs and opinions of traditionally underrepresented community members.  and participation: by valuing the voices, opinions, and expertise of end-users, health services will be more acceptable, accessible, and appropriate to the communities they serve.

Related elements

• Purchasing & payment systems
• Funding and allocation of resources
• Adjustment to population health needs
• Population health management
• Information and technology
• Management of services

Issues of distance, transportation, rough terrain and other geographic challenges act as barriers to patients when trying to access a health facility and can prevent them from being able to access care altogether. Geographic access is a core component of access and must be addressed in order to improve access to primary care services, in general.

Key activities

Health systems level

• Increase availability of human resources: implement strategies to effectively and equitably retain, recruit, and station skilled providers, such as via workforce deployment policies. 
• Strengthen the capacity of the PHC system to serve as the first point of contact, such as by improving the distribution of facilities and the services they deliver in rural areas, providing community-based care, and conducting outreach activities in communities

District & facility level

• Empanelment: establishing panels based on pre-established geographic or municipal boundaries may help stakeholders understand where and why certain groups are experiencing geographic barriers to care and begin the process of developing infrastructure to remedy these gaps.
• The use of telehealth: telehealth can facilitate access to care in areas where clinics are inaccessible but sufficient technological infrastructure is in place. 
• Team-based strategies to care: implementing staggered shifts and creating a manageable and even distribution of work

Individual & community-level

• Utilize community health workers (CHWs): CHWs can be a valuable resource for increasing geographic access to health services and have been shown to effectively provide high-quality preventative and some curative care in remote areas where access to facilities is challenging
• Proactive population outreach: Certain health activities (diagnosis, referral, treatment of certain illnesses, health education, immunization etc.) can be effectively delivered directly in communities, decreasing geographic barriers to care.⁸

Related elements

• Policy and leadership
• Multi-sectoral approach
• Adjustment to population health needs
• Physical infrastructure
• PHC workforce
• Information and technology
• Organization of services
• Service availability and readiness

Geographic access is defined as the absence of barriers including distance, transportation, and other physical challenges in accessing care when needed. This is influenced in part by decisions made in the allocation of resources, equity, and investments into infrastructure. It is important to note that geographic barriers are best measured and discussed by the amount of time it takes to travel to services rather than physical distance; travel time can account for terrain and transportation availability. Most often, individuals who live in hard-to-reach areas, rural areas, or conflict zones face the greatest barriers in geographic access to care. However, it is also possible that access reforms target these groups specifically, leaving gaps elsewhere. Access barriers may also align with social characteristics. If there are restrictions on the movement of groups of people, – for instance, women are unable to travel without accompaniment, people living with disabilities, and/or people residing in areas of ongoing conflict – geography may disproportionately disfavour these groups. The following includes the biggest reasons why patients might face geographic barriers to care:

A lack of human resources to meet demand

Worldwide, there is a substantial shortage of health workers to provide comprehensive primary care services to all populations.¹  An adequately sized and competent health workforce is a precondition for ensuring geographic access to health services. Providers must exist and be appropriately distributed both in quantity and cadre. However, there are certain workforce considerations that are particularly salient to geographic access. There are three ways that a country may be experiencing a shortage of providers that would contribute to geographic inaccessibility: 

• A national shortage characterized by an overall low provider-to-population ratio across all geographic regions
• A shortage specific to certain geographic areas of a country where the provider-to-population ratio is substantially lower than in other areas—often seen in remote and rural regions
• A shortage or misdistribution of certain cadres where the ratio of physicians to that specific cadre (such as doctors, nurses, or community health workers) is inadequate to meet demand or to provide specific services

All of these workforce concerns may impact patients’ experiences with geographic access to care, and adequate attention to the distribution of the health workforce can increase patients’ trust in the health system and its governing structures.²

Inadequate facilities

While certain health activities can be provided in community centres or homes, others require supplies, equipment, and/or technology that must be housed within a physical clinic. In areas with very low population densities, it may be logical to rely more heavily on community-based health services with systems for ready access to emergency care and referral systems for ensuring access to higher levels of care when needed. Mobile clinics are also often used to meet gaps in the availability of facilities. However, it is important to note that by nature of being mobile, these clinics may not always contribute to the formation of continuous relationships between patients and providers. 

Transportation barriers

Even in areas where clinics are close to communities, if there is not adequate transportation to reach them, accessibility is compromised. The same barriers experienced by patients may also apply to providers and influence their ability to access facilities to provide care. For instance, in Iraq, one study found that doctors faced many transportation barriers including checkpoints, curfews, and inadequate transportation, resulting in widespread absenteeism.³ Similar to areas with inadequate facility distribution, transportation barriers can be mitigated through the implementation of community-based services -  often delivered by CHWs – for non-acute care. Community-based care is discussed in greater detail in the population health management module. 

Financial access means that there are no or few cost barriers to receipt of care, including prohibitive user fees, out-of-pocket (OOP) payments, or other costs associated with care seeking such as transportation or childcare costs. Ensuring financial access can be addressed by a number of approaches ranging from community to national-level interventions. Financial access is distinct from financial coverage. While financial coverage means having adequate financial protection, financial access focuses on the local success of interventions to ensure financial access from the patient perspective. An individual may have financial coverage through health insurance, but if he or she must use significant financial resources to access care in practice, financial access is not achieved.

While financial coverage means having adequate financial protection, financial access focuses on the local success of interventions to ensure financial access from the patient perspective. An individual may have financial coverage through health insurance, but if he or she must use significant financial resources to access care in practice, financial access is not achieved.

While the impact of reforms to improve timeliness will vary by context, timely access to services may help countries to achieve various goals and outcomes important for health system strengthening, such as:

• Financial protection Financial protection means that individuals and households do not experience catastrophic or impoverishing expenditure as a consequence of paying for health care. for patients: Financial access interventions can help to remove or reduce financial barriers at the point of care, such as prohibitive user fees, out-of-pocket payments, or other costs.
• Improved utilization and health outcomes: Removing or reducing financial barriers helps to ensure that patients can access care when they need it, in turn improving health outcomes.
• Universal health coverage: Financial access is central to efforts to ensure equitable access to high-quality PHC and ultimately, to achieve Universal Health Coverage.

Financial access is a key component of achieving universal access to high-quality PHC. For more information on measuring “access”  in a PHC system, visit  PHCPI’s measurement page. 

Who is not accessing care due to financial reasons?

In order to develop a targeted intervention, it is important to understand who is not accessing care due to financial constraints. These populations may not always be the most marginalized in society, since financial protection schemes often (but not always) target these individuals specifically. For instance, populations that are often overlooked by financial access reforms include informal sector workers, those who are near-poor but do not meet various benchmarks to be considered impoverished, and migrant populations.¹ The Joint Learning Network for Universal Health Coverage has developed a relevant report compiling lessons on how countries have ensured health coverage for non-poor, informal-sector workers. The populations who are facing financial access barriers will differ between contexts, but their identification will help decision-makers better understand gaps in existing financial protection systems.

After identifying who is not accessing care for financial reasons, stakeholders must understand why. Most fundamentally, there may be no financial protection systems in place. Financial protection Financial protection means that individuals and households do not experience catastrophic or impoverishing expenditure as a consequence of paying for health care. can encompass a number of approaches including but not limited to free care, reduced user fees, or health insurance. However, even in places where there are financial protection systems, these efforts may not adequately reach all populations or may not be designed with contextual realities in mind. For instance, a community project in Burundi - discussed in greater detail in “learn from others” - significantly reduced user fees to improve access to services. However, the financial realities of the target community were not adequately considered, and the reduced user fee still posed a substantial barrier for many individuals.² In some instances, public sector transactional cash flow delays (such as those for facility reimbursement) may result in unexpected cash or supply shortages at the facility level. These shortages may be passed to the patients in the form of user fees or other costs. Thus, a benefit scheme must be designed and implemented with consideration of local realities in order to result in tangible and reliable improvements.   

Out-of-pocket payments for care are not the only costs that patients incur when seeking care. Individuals may face prohibitive external or indirect costs related to seeking care such as transportation, lost wages from the patient and/or caretaker missing work to make an appointment, lodging, and childcare or elderly care costs.³ Thus, the cost of care reported by patients and by providers may be discordant. These external costs are less commonly addressed by health system-focused interventions despite posing significant barriers. When assessing the cost of care and catastrophic health expenditure, it is important to ensure that these indirect costs are considered.⁴