Background
Access to healthcare is central in the performance of health care systems around the world. In fact, the importance of service delivery for people has resulted in measurement of utilisation and access having a prominent role in the health policy literature [
1,
2]. However, access to health care remains a complex notion as exemplified by the varying interpretations of the concept across authors [
3,
4].
Etymologically, access is defined as a way of approaching, reaching or entering a place, as the right or opportunity to reach, use or visit [
5]. Within health care, access is always defined as access to a service, a provider or an institution, thus defined as the opportunity or ease with which consumers or communities are able to use appropriate services in proportion to their needs [
4,
6].
Access has been conceptualised in numerous ways. While the term access is often used to describe factors or characteristics influencing the initial contact or use of services, opinions differ regarding aspects included within access and whether the emphasis should be put more on describing characteristics of the providers or the actual process of care [
7]. Some authors view access more as an attribute of health services, noting the fact that services can be accessed or utilised by those requiring care [
8]. While most authors do recognise the influence of characteristics of users as well as characteristics of providers on access, many put more emphasis on characteristics of health care resources that influence the utilisation of services, acting as a mediating factor between the ability to produce services and their consumption [
9]. Penchansky is amongst those that more explicitly conceptualised access in terms of the fit between characteristics of providers and health services, and characteristics and expectations of clients [
2]. Here, access may be conceived as the interface between potential users and health care resources, and would be influenced by characteristics of those who supply as well as those who utilise the services.
Access has often been defined as the use of health care, qualified by need for care [
10]. It has also been defined as describing the costs incurred in receiving care, as the maximum attainable consumption, or as foregone utility [
11].
Mooney sees access as a function of both supply and demand [
12]. In this view, access to health care is a product of supply factors, such as the location, availability, cost and appropriateness of services, as well as demand factors, such as the burden of disease and knowledge, attitudes and skills and self-care practices [
13‐
15].
This is in line with the notions of predisposing factors to utilisation on one side, and enabling and health system factors on the other [
1]. Predisposing factors include an individual’s perception of an illness, as well as population-specific cultural, social, and epidemiological factors. Enabling factors include the means available to individuals for using health services. Health system factors comprise resources, structures, institutions, procedures, and regulations through which health services are delivered [
1].
Frenk reserves the term access to denote the ability of the population to seek and obtain care. It thus refers to a characteristic of the population of potential or real users of services and is related to the concept of utilization power and resistance [
7]. A theoretically attractive way to see access is to see it as the degree of adjustment between the characteristics of the population and those of the health care resources seeing access as a functional relationship between the population and medical facilities and resources, and which reflects the differential existence either of obstacles, impediments and difficulties or of factors that are facilitators for the beneficiaries of health care [
7].
Although a conceptual vision of fit suggests that both resource and population characteristics can be modified to ensure continuing levels of access, only resources can be modified in the short-term [
7]. In general, obstacles such as price of services, transportation time, and waiting time are more responsive to specific health policies than the broader social and economic characteristics of the population, such as income, transportation resources, or free time [
7].
Andersen, conceptualising utilisation as realised access, has viewed utilisation (type, site, purpose, time interval) as determined by population characteristics (predisposing, enabling, need) and health systems’ characteristics (policy, resources, organization) [
13,
14]. In a similar manner, highlighting the relation between the concepts of utilisation and access, Donabedian highlighted the central role of characteristics of health resources with regards to facilitating or impeding the use of services by potential users [
9]. Table
1 summarizes definitions and dimensions found in the literature.
Table 1
Definitions and dimensions of access to health care
Bashshur et al., 1971 | Accessibility as the functional relationship between the population and medical facilities and resources, and which reflects the differential existence either of obstacles, impediments and difficulties, or of factors that are facilitators for the beneficiaries of health care | |
Donabedian, 1973 | Accessibility comprising the concept of degree of adjustment between resources and populations | |
Salkever, 1976 | Accessibility combining attributes of the resources and attributes of the population | Financial accessibility |
Physical accessibility |
Aday & Andersen, 1974 | Access as entry into the health care system | Predisposing factors |
Enabling factors |
Need for health care |
Penchansky & Thomas, 1981 | | Affordability Accessibility |
Accommodation |
Availability |
Acceptability |
Dutton, 1986 | Utilisation viewed as the product of patients characteristics plus provider and system attributes | Financial |
Time |
Organizational factors |
Frenk, 1992 | Access as the ability of the population to seek and obtain care | |
Accessibility is the degree of adjustment between the characteristics of health care resources and those of the population within the process of seeking and obtaining care |
Margolis et al., 1995 | The timely use of personal health services to achieve the best possible outcomes. | Financial |
Personal |
Structural |
Haddad & Mohindra, 2002 | The opportunity to consume health goods and services | Availability |
Affordability |
Acceptability |
Adequacy |
Shengelia et al., 2003 | Coverage: probability of receiving a necessary health intervention, conditional on health care need | Physical access |
Resource availability |
Utilization: quantity of health care services and procedures used | Cultural acceptability |
Financial affordability |
Quality of care |
Peters et al. 2008 | Access viewed as including actual use of services. A clear emphasis is given to consider both users and services characteristics in evaluation of access. The notion of fit between users and services is identified. | Quality |
Geographic accessibility |
Availability |
Financial accessibility |
| | Acceptability of services |
The disaggregation of access into broad dimensions, such as geographical, economical or social aspects, permits more operational measures through the study of specific determinants of access to health care. However, measuring access is a complex task when trying to include dimensions other than merely availability of services. Access is often perceived as being predominantly an attribute of services and is determined by factors such as the availability, price and quality of health resources, goods and services. This perception could stem from the fact that it is factors amenable to policies and organisational aspects of care that should be targeted to improve access. Meanwhile, utilization, often used as a proxy of access (realised access is easier to measure than potential access) is influenced by the supply as well as the demand for services, including individual attributes such as preferences, tastes and information [
12,
16,
17]. Others have added financial and physical barriers to utilisation as determinants of access to health care [
8]. But access clearly goes further than an availability of health services. A more comprehensive view on access should consider factors pertaining to the structural features of the health care system (e.g. availability), features of individuals (consisting of predisposing and enabling factors) and process factors (which describe the ways in which access is realised) [
4,
18,
19], and pertains to the dimensions of availability, accessibility, accommodation, affordability and acceptability [
2]. Others have proposed dimensions related to factors such as geographic access, resource availability, cultural acceptability, financial affordability, and quality of care to health system coverage [
1,
20].
Despite ongoing preoccupation with access to health care, we consider that health services research and policy continues to be compromised by a lack of clarity of concepts of access and utilisation, lack of consensus on sub dimensions of access, and ongoing blurring of access as a concept and its determinants. The emergence of chronic disease and the increasing realisation that patients have a growing role in chronic care also highlight the need to revisit the concept of access to better incorporate patient-centred perspectives into population and system level approaches. The aim of this paper is to suggest a conceptualisation of access to health care describing broad dimensions and determinants that integrate demand and supply-side-factors and enabling the operationalisation of access to health care all along the process of obtaining care and benefiting from the services.
Conclusions
Access is a concept often referred to and which has been the subject of many discussions. The objectives of this paper are to introduce a conceptualisation of access to health care describing broad dimensions and determinants that integrate demand and supply-side-factors and enables operationalisation of access to health care all along the process of obtaining care and benefiting from the services.
We have defined access as the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use health care services and to actually have the need for services fulfilled. We have suggested five dimensions of accessibility (Approachability; Acceptability; Availability and accommodation; Affordability; Appropriateness) and five corresponding abilities of populations (Ability to perceive; Ability to seek; Ability to reach; Ability to pay; Ability to engage).
The proposed conceptualisation of access raises some challenges. One important challenge is the fact that measuring access is therefore not an easy task. There are of course various indicators available to measure whether or not people receive services in terms of perceived needs, if they know about available services, how they utilise services and the distance that they have to travel, on top of many measures describing the actual characteristics of services. However, a true assessment of access requires the combination of all these measures to truly judge whether the characteristics of services, providers and systems are aligned with people, households and communities capabilities.
Methodological research should enable our field to develop the measurement instruments that will better capture the complexity of access. Adding to the complexity is the fact that various sources of information can inform the varied dimensions of access, but it can be difficult to merge together to draw a complete picture of access. Mixed method analyses of consumer surveys, quality of care data, epidemiological surveys of utilisation, as well as organisational surveys may be necessary.
In addition, there is a need for more research examining the variability of access from both supply and demand-sides and looking at the influence of local health systems and patients’ characteristics. Empirical studies using the framework could also test the relevance of each dimension in different contexts and for different types of health problems and thus assess how the five provider dimensions relate to the five ability dimensions related to patients. This framework highlights the need for evaluation of strategies to improve access.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
JFL designed and carried out the literature review and drafted the manuscript. MH and GR critically revised the manuscript for important intellectual content. All these authors read and approved the final manuscript.