What is 'access' to healthcare?

December 12 was the Universal Health Coverage (UHC) Day. The United Nations General Assembly endorsed a resolution on this day in 2012 that everyone everywhere should have access to quality, affordable health care. The fundamental premise to achieving UHC is "accessing" healthcare. Before concepts of quality and affordability are defined, accessing health care itself needs to be explained plainly.

R Penchansky and J W Thomas published a seminal article "The Concept of Access: Definition and Relationship to Consumer Satisfaction" in Medical Care Journal in [1981 Feb;19(2):127-40] where they stated: "'access is a major concern in health care policy." Sadly, in 2022 -- after 40 years -- access to health care still remains a major concern across the world, particularly in most Low- and Middle-income Countries (LMICs) including Bangladesh.

So, what is meant by access after all? In many health policy discussions and dialogues, access is equated with health insurance coverage. However, this may apply to high-income country settings but is not obviously the case in Bangladesh where the health insurance market is not developed yet and most people pay for healthcare out-of-pocket except people of lower socio-economic background who go for free public healthcare or else they seek care from very low-quality and low-cost alternative healthcare providers.

However, few definitions of access have integrated nonfinancial aspects as well; but the importance of each aspect and the interaction between those different aspects must be understood and emphasised by healthcare policymakers.

As conceived by Penchansky and Thomas, access reflects the fit between characteristics and expectations of the healthcare providers (doctors, dentists, pharmacists, nurses, therapists as individuals or institutions/hospitals as organizations), and the patients (may also be called clients or customers as well depending on the type of service they seek).

Characteristics of individual healthcare providers mean their professional profile including education level, certification, training, employment type or contract, practice setting, experience, and skills as well as their socio-demographic profile including age, gender, income level, ethnicity, cultural identity, religious belief or moral values, etc. Whereas expectations of healthcare institutions vary by their ownership (private/public/NGO), profit motive, size, location, etc.

Expectations of the institutions are usually outlined in their organisation's mission, vision, charter, or business statements and objectives. However, the stated and underlying guiding principles and practices may vary substantially in reality.

Now, why the characteristics of patients are also important? The patient population is a composite representation of a country's general population and differs by age, education, gender, education, income, religious belief, and social values, and thereby their expectations of healthcare services also vary broadly and accordingly.

The younger patients may go for quick fixes for their ailments whereas the older groups may need more attention and care over an extended period of time. The rural patients with low literacy and the urban elites with higher education and income have different requests of care the former may come to seek care at a later stage of their disease process after trying all other possible means of cheaper and readily available care whereas the later group will come at an early stage of disease prognosis and will carefully review the providers' profile and professional reputation and may switch the provider if they are not pleased with the quantity and quality of service received or if their disease recovery period is longer than their expectation.  They do have more options to choose from inside and outside the country.

In terms of gender, research shows that female patients have different expectations of care needs. They, when able to afford it, usually come to seek care more often compared to male patients in general and have been reported to be more vigilant about their health status and disease trajectory. On the contrary, in lower socio-economic classes, female members of a family must depend on their male guardians to approve and accompany their care-seeking, and thereby their treatment process is often deferred and delayed.

Access does reflect the fit between characteristics and expectations of the healthcare providers and the patients and this is important for the policymakers, regulators, health professionals, and other health service stakeholders to realiee before they try to package and offer quality and affordability healthcare services. Quality is difficult to define and is defined differently by service seekers to service receivers. The same goes for affordability as depending on the economic profile of the care recipients, a service with the same cost may appear reasonable to a few whereas it may look premier to many others.

The clear interpretation and operationalisation of these important concepts in the healthcare system may help explain existing barriers to accessing healthcare by the population of Bangladesh and may help formulate policies and develop interventions to reduce the prevalent health inequity. 

 UHC Day (December 12) rightfully aims to raise awareness of the need for and availability of quality and affordable healthcare across the world.

 Dr. Hasnat M Alamgir is a Professor and Chair of Public Health at

IUBAT- International University of Business Agriculture and

Technology, Dhaka.

[email protected]