Conclusions below; full text is at http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3156.2010.02497.x/full
Improving access to health care holds great potential for the reduction of child death rates in SSA. Although ecological studies and community intervention trials have suggested a protective effect of health service access against child death, investigations that provide more convincing associations are rare in SSA. Moreover, studies that have investigated specific access factors have historically done so primarily through traditional variables, such as distance and health care cost. Their findings have been inconclusive. Qualitative research emphasises the importance of additional barriers, but these are frequently overlooked in quantitative research, and their exact impact remains unknown. However, several recent studies, which have investigated additional facilitators and barriers, including social support and autonomy, show strong associations between these factors and child death. These findings suggests that they are at least as important as traditional barriers.
In this review, we employ a definition of access that includes variables beyond cost and distance to a health facility. This broader understanding of health care access needs to be distinguished from that of health-seeking behaviour. Health-seeking behaviour has a large literature, albeit mostly ethnographic (Baume et al. 2000; Mbagaya et al. 2005; Ahorlu et al. 2006; Kamat 2006; Rutebemberwa et al. 2009) and the measures considered may overlap with those that reflect access. However, the focus is different and may be best explained by understanding access to be concerned only with obstacles in the way of those who would otherwise choose to seek health care. It is also important to note that we focus on a single endpoint, mortality, avoiding issues associated with disease-specific foci.
We contend that access to health care is multidimensional, and both traditional and additional barriers need to be considered by those planning health care services. Clearly, there is a need for more large-scale, longitudinal research that evaluates the impact of health care access on child health outcomes in SSA. Future research should assess traditional and additional variables in the same study within a structured framework, adopt measures that accurately reflect the total geographic and financial barriers to health care and include indicators culturally relevant to the research setting. If Millennium Goal IV is to be achieved, greater insights are required into the factors that influence access to health care to facilitate meaningful and effective interventions.