Access to Emergency Care. The 5 A’s

Access to care is not well described in literature and is sometimes defined as the entry point into the health system and other times as the factors influencing use of care.
I prefer the concept by Penchansky and Thomas (1981) who described five interrelated dimensions including both entry point and the factors influencing choice to access care. The combination is holistic with access being only as strong as the weakest link in the system.
From a systems view, access to care is the fit between the system and the individual.

Case example: a baby sustains serious burn wounds at home.
Mapping it from injury until appropriate facility is reached the following may support or hinder access to care within the dimensions of the 5 A’s

1. Availability of care
Available technology to call for help (telecommunication system)
Local or community knowledge to render first aid: community first responder programs
Available infrastructure and resources to render first aid: in this case availability of onsite water source, well water, bore pipe or preferably running tap water to cool the burns
Coordinated means to access care: availability of prehospital system with emergency telephone numbers for police, fire, health services and target times to respond and access patient
Availability of transportation to health facility: formal or informal (taxi, bicycle, ox wagon or ambulance)

2. Accessibility
Refers to geographic accessibility – rural, peri-urban or urban setting
Infrastructure allowing transportation to access and transfer child (roads, maps, signage of roads, traffic congestion)
Distance covered by ambulance service as it has an impact on time to initial treatment, time in transit and time to definitive care
Access to a facility that is able to manage the patient and the specific problem, not all facilities are created equal. This is referred to as appropriate facility

3. Accommodation
Operating hours of ambulance service and health care clinics, availability to manage after hour emergencies
Ambulance service: formal method to prioritize calls and dispatch an adequate level of care dispatched
Trained ambulance practitioners that are able to render care during transportation
Ability of health facility to provide level of care thus appropriate facility

4. Affordability
Means to pay for transport whether cash, credit or covered by insurance
Means to pay for care rendered
Means to purchase medication
Means and logistics for both facility and ambulance service to afford medication and equipment needed to render care

5. Acceptability
Equity in obtaining care
Propensity to access care; culture and beliefs about first aid, medical care and natural remedies (Traditional practice)
Trust in health care workers capacity to guarantee anonymity, confidentiality, dignity, right to choose and participate in treatment (Batho Pele principles)

In summary
At first sight this may seem like a wide and disjointed list, so what does it imply? For one it means that improving access to care is complex and needs to be approach from more than one angle simultaneously. It means that policy makers, funders and managers at facility level need to look at a wider picture and realize how factors that fall outside of their direct control impact on their patient care, policies and decision. It again demonstrates the case for horizontal system strengthening initiatives.

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