Access to health care in contexts of livelihood insecurity: A framework for analysis and action

Access to health care is a major health and development issue. Most governments declare that their citizens should enjoy universal and equitable access to good quality care. However, even within the developed world, this goal is difficult to achieve, and there are no internationally recognized standards on how to define and measure “equitable access” [1]. Evidently, big disparities exist between the poor and the better off with respect to access to health care services and health status [2–4]. Gaps in child mortality between rich and poor countries are wide, as well as between the wealthy and the poor within most countries. Poor children are not only more likely than their better off peers to be exposed to health risks and have less resistance to disease, they also have less access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Clearly, more of the same is not enough [3]: To improve equitable access, innovative and community-based approaches are needed to better align health care services with poor people’s needs, expectations, and resources. This article presents a framework for analysis and action to explore and improve access to health care in resource-poor countries, especially in Africa. The framework links social science and public health research with broader development approaches to poverty alleviation. It was developed in the frame of the ACCESS Programme, which focuses on understanding and improving access to prompt and effective malaria treatment and care in rural Tanzania as an empirical case study [5,6]. The article first provides a brief outline of three approaches to investigating health care access, focusing either on health seeking, health services, or livelihoods. It then presents a framework that combines the three approaches, exemplified with research findings and interventions of the ACCESS Programme