|
Citation
|
Bashford T, Joannides A, Phuyal K, Bhatta S, Mytton J, Harrison R, Hutchinson P. BMJ Glob. Health 2019; 4(4): e001816. |
|
Abstract
|
Patients with delayed access to medical care often experience worse outcomes. The ‘three delays’ model developed in the context of emergency obstetric care is an important conceptual device for researchers and policy-makers, particularly in resource-poor health systems.1 This model characterises delay in terms of (1) the decision to seek care; (2) arrival at a health facility and (3) the provision of adequate care.
However, ‘access’ is a nuanced term, one that is not simply an issue of geographical resource distribution or population density. A patient may seek care, but be constrained by competing demands or health beliefs. Once sought, the care delivered may be inappropriate. Even after arrival at a healthcare facility that is able to deliver the necessary care, there may still be a clinically significant delay in obtaining it.2
Furthermore, there may be variable prevailing sociocultural attitudes to different conditions, with a biomedical model of time-critical pathology interacting with multiple other narratives.3 Access to care by victims of snakebite may be hampered by a cultural belief that the bite is ‘a manifestation of witchcraft or deity displeasure’.4 Alternatively, in the context of neurotrauma, the religious significance of the date for a planned operation may mandate that the procedure be delayed, even after patients and their families are made aware that this could be detrimental to the outcome (unpublished data).
Clearly, quantifying the presence and effect of a delay, while an important step, is only descriptive; improvement mandates a deeper understanding. Delays in accessing care, either in the community or once in an appropriate centre, can arise from a myriad of reasons—financial, logistical, political, procedural and cultural.5 For time-critical pathologies, such as neurotrauma, burns, polytrauma and snakebite, systems strengthening requires these issues to be accounted for alongside the clinical services required to deliver definitive treatment. In 2018, a systematic review in The Lancet by Kruk et al6 suggested that ‘access is no longer the only binding constraint for improving survival in low-income and middle-income countries—health system quality must be improved simultaneously’. We would go further to suggest that, at least for certain pathologies, considering access as a different entity to quality is a false dichotomy: good quality care is meaningless if access to it is not timely ...
Language: en |