Access to quality care

TANYA MARCHANT: Access to health care throughout the lifecycle and important gaps in quality of care were essential themes arising throughout this course. An additional perspective to the theme has been inequity, with the poorest getting the least care and the lowest quality of care. And this will be covered both here and in the next step that examines the influence of society and context on health. Especially in low and middle income settings context between women, newborns, and children, and health services for routine care are increasing, for example antenatal care, facility deliveries, and vaccination services.

Although care-seeking for illness is making slower progress, for example care-seeking for children with symptoms of bacterial infection or seeking emergency care for a woman with danger signs during delivery. But there is a gap between families receiving health care and those receiving quality care, meaning that there are missed opportunities to improve health outcomes. Examples of this can be found at each stage of the lifecycle. But it is particularly apparent around the time of birth because of the large burden of deaths at that time. Specifically, women attending health facilities are not always seen by a skilled attendant who has access to the commodities needed to deliver lifesaving care or who provides care with dignity and respect.

For adolescents important demand and supply side barriers to accessing care persist. Across the lifecycle many of the same health care perspectives have been raised repeatedly. And in the following slides we will highlight a few key issues for the individual stage.

So we’ve heard that adolescents and young people around the world are experiencing an increasing burden of mental health disorders and injuries. And that their reproductive health needs, including preventing pregnancy and infections, are different from those of men and women who are raising a family. But the challenge they face is that many countries do not yet have policies in place that address their needs specifically. And without country policy it follows that there will be little in the way of targeted programming or funding, and as a consequence there are insufficient numbers of trained professionals to look after young people.

So alternative solutions are needed, one half which is task shifting so the services that would be delivered by health professionals are shifted to lay or social workers. This requires strategies to be integrated into primary health care structures, including broader community and school structures so we can raise awareness amongst those at risk of delivering problems. We can aim to prevent problems and to diagnose and treat them. But such strategies will have limited effectiveness without national level shifts and regulations that support, for example, reducing access to harmful substances or tools and regulations that improve the readiness of systems to handle injuries when they occur.

Our look at reproductive health focused on contraceptive services. Many countries have made commitment to improve access to contraceptives services, including for teenagers. Indeed, we observed that access to and use of contraception has been increasing around the world. But barriers to access persist. And these are not only the barriers we expect when a health system still needs to be strengthened, for example having an irregular supply chain or a lack of personnel trained to provide appropriate counselling on contraceptives, including about potential side effects. But there are also political and sociocultural factors that create barriers. Country policies and cadre of health workers able to provide different types of services differ.

And in some countries there’s over-medicalisation in that women have to see highly qualified medical personnel to access contraception. And these personnel are harder to reach than lower level cadre. We mustn’t forget, either, that health workers come from the same communities as all of us. So they are susceptible to the same cultural influences and biases that persist in society and may unwittingly restrict access as it is intended in policy, because to them that policy seems inappropriate in their community.

Demand for contraceptive services is similarly affected. Women and young people who have heard about contraceptives and want to use them, perhaps to complete secondary education or to increase the spacing between births all because she has an ambition to do something else, may experience disapproval from family members even before knowing how to get to the services. We will return to this point in the next step.

To reduce the burden of maternal morbidity and mortality we need skilled care in well-equipped facilities together with reliable linking strategies or referrals between home and health facility and hospital so that we could routinely care for all mothers and newborns with respect and are able to prevent, detect, and treat complications. Considerable progress has already been made. And more and more women are now going to facilities to deliver, to the extent that over the last 15 years some countries have experienced a rapid normative transition from home births being expected to women needing to explain and justify why a home birth occurred. But priority work remains to be done.

Women are not always cared for with respect and dignity, so that the user experience compounds societal norms about the status of women and users may ultimately not recommend the service to others. And there are large differences in the competency of skilled birth attendants around the world. And as a result, not all skilled birth attendants are equally capable of providing lifesaving care. And then many facilities don’t have the infrastructure that is needed, such as those required to provide clean water, sanitation, and hygiene during birth. All have the commodities needed to provide even basic essential care to women and their newborns. And finally, the vulnerable who we know to bear the largest burden of mortality, have the lowest access to any care.

And even those reaching care often go on to receive lower quality care than their more wealthy neighbours. And conversely, the quality of care of the least poor women in societies may be jeopardised because they increasingly experience over-medicalised care, for example having unnecessary caesarean sections.

A number of solutions to these issues have been discussed in the maternal health week of the course and include the need for the community participation, for leadership and governance, for stronger health information systems, for financing and human resources, plus further integration between services for the mother, the newborn, and the child.

In the newborn week we heard that universal access to skilled care at birth, essential newborn care, and emergency care for sick mothers and small or ill newborns could save two million lives a year and that there is a triple return on investment improving in care at birth, since it has the highest impact, is highly cost effective, and benefits women, stillbirths, and the newborn simultaneously.

Access to care for the newborn inevitably has a strong overlap with the issues raised on the previous slide for women at birth. But it also includes avoiding stillbirths, which can be considered to be a strong predictor of quality care, and also care for the preterm newborn who needs additional thermal care, feeding, and observation in order to survive and thrive, plus care for newborns who present signs of infection in the first week of life, which are more likely to occur once the newborn is back in the community, so rely strongly on community-based initiatives in many settings. To address these issues five strategic objectives have been defined as part of the Every Newborn Action Plan.

These are to strengthen and invest in care during labour, birth, and the first day and week of life, to improve the quality of maternal and newborn care, to reach every woman and newborn to reduce inequities, to harness the power of parents, families, and communities, and to count every newborn.

As for other stages of the lifecycle coverage of routine care for children has increased. But more progress is needed to increase care seeking for children with symptoms of illness, pneumonia for example. Inequities and the quality of care delivered to those who do seek services remain firmly on the agenda when thinking about access to health care for child health. We’ve heard that half the reduction of child mortality worldwide was due to better control and treatment of infections. And that moving forward there is a need to continue to address preventable child deaths, but also to increase the focus on development, disability, and nutrition.

As the tension shifts in this way towards helping children not only to survive but also to thrive another perspective to consider is the difference between models of scale up with tensions between vertical and horizontal approaches, community and facility based care, and formal health care together with wider intersectoral approaches. Some of the success in tackling the burden of infectious disease in children was due to highly targeted, single disease, vertical delivery systems, for example campaigns to deliver insecticide-treated mosquito nets to prevent malaria.

But moving forward and taking a more holistic approach to child health there will be a need to protect these infection prevention mechanisms, but also for both more integration with existing linked up health services, for more integration with community-based structures where the child spends most of the time, and for more integration with other sectors, for example education and agriculture.

So in summary, with adolescent health priorities as a global public health priority access to care for adolescents need to be purposefully targeted in policy and programmes. For women and children contacts with health services are increasing. But in many settings the quality of care needs to improve and inequities in access need to be addressed. Especially for reproductive, child, and adolescent health task shifting and engaging with sectors more broadly will increasingly be needed in future programming. As we proceed towards the next 15 years there will be a continued need for descriptive, discovery, development, and delivery science and evidence to inform action.