Universal healthcare is an important goal in global health, as described in previous News Blogs. Key to the concept of universal healthcare is the question of access to health. I lead one of three work packages in the NIHR Global Health Unit for Surgery, directed by Dion Morton. Along with Dr Dmitri Nepogodiev, I have recently returned from a series of meetings with influential doctors, policy-makers and community leaders in Oyo and Osun states in Nigeria. Our host was Dr Wally Adisa of Ife University, to whom we extend our sincere thanks.
Dmitri has reviewed the literature on how barriers may be overcome and access to healthcare facilitated. In Figure 1 we have attempted to synthesise the barriers from the literature and meetings in Nigeria. We use the famous Grossman model, which recognises four phases on the pathway linking symptoms to effective treatment: recognition of the need for help; seeking help; transport to a place where appropriate care can be delivered; and then obtaining care in the healthcare institution. Many of the barriers we have identified could have been discerned though intuition: lack of money; poor understanding of disease and how it can be remedied; reliance on traditional healers; etc. However our investigations have identified certain factors we had not anticipated. For instance, many people are reluctant to call an ambulance, even when available, because they are superstitious of entering such a vehicle.
While poverty is an important factor, limiting access, people who need acute care usually make it to hospital eventually. When we probe the reasons for delay among people who eventually did make it to hospital, we find that delay occurs because resources are not in the right place at the right time. In countries with a low tax base, more use should be made of existing networks and community ‘assets’ , to short-cut the barriers. 
Figure 1. Barriers and Facilitators on the Pathway to Acute Care
During our meetings, and in the literature, there is much agreement about what the barriers are: poverty, superstitious beliefs, perceptions (not always erroneous) of poor care in hospitals, lack of facilities with need for further transfer, and so on. Where there is much less agreement, between stakeholders and within the literature, is on the relative importance of the various factors or how they may vary by clinical scenario – obstetric emergency, acute abdomen, trauma, childhood illness, and so on. While Desmond (personal communication) found severe constraints in access due to inadequate transport or ability to pay for transport (phase 3 in Grossman’s model) in a paediatric context in Malawi, Orji found that all the problems were in phase 1 and 2 or 4 in an obstetric context in Nigeria. It is also known that no emergency transport systems are available in 33 (61%) of 54 African countries that answered a recent survey, and many only covered trauma or obstetric emergencies, while few were country-wide. Overall, only 8.7% of the population need could be met. Nor should it be assumed that transport costs are negligible compared to health costs. It is lack of facilities for transport that is the most important problem, not poor roads or hospitals too widely dispersed. Sheer distance can be a problem in some countries, such as Sudan, and lack of roads in other places, such as Ethiopia, but over two-thirds of Africa’s population live within two hours of hospital.
We have produced a list of possible measures to improve access, classified according to whether they stimulate demand or supply. None of these interventions are easy to implement or evaluate. For this reason we plan to engage stakeholders to see what might be feasible, review the literature on what has been tried before, and then develop a health economic model to evaluate the cost-effectiveness of different potential solutions. In a future News Blog we will describe our approach to health economic modelling of this complex, but important, topic.
Factors that may be Tackled by Interventions to Improve Access
|Demand for transfer
||Supply of the means for transfer
|Knowledge of treatable illness, such as meningitis, typhoid, snakebite. Tackled through education. For example, messages targeted at misconceptions were massively influential in eliminating the Ebola epidemic. Many superstitions and beliefs are cultural, so different messages will be needed in different places. People can be influenced through local community and religious leaders, as well as through feedback from people who have experienced services.
||Since most people do reach services, promotion of risk-sharing community schemes or ‘electronic’ wallets to provide resources when and where needed. Women’s participatory groups can also encourage autonomy, making women less reliant on husbands for money or permission.
|Use of eHealth in general and eConsulting in particular to help translate awareness of symptoms to the intention to seek help.
||Public / NGO provision of inexpensive motorcycle taxis, successfully used for labour care in Sierra Leone  and Malawi.
|Interaction with traditional healers to recognise illnesses responsive to ‘modern medicine’.
||Encouraging / investing in small enterprises to promote transport, e.g. Uber-taxi style ambulances deployed in Nairobi.
— Richard Lilford, CLAHRC WM Director & Dmitri Nepogodiev, Doctoral Research Fellow in Public Health.
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