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      Access to medicines from a health system perspective

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          Abstract

          Most health system strengthening interventions ignore interconnections between systems components. In particular, complex relationships between medicines and health financing, human resources, health information and service delivery are not given sufficient consideration. As a consequence, populations' access to medicines (ATM) is addressed mainly through fragmented, often vertical approaches usually focusing on supply, unrelated to the wider issue of access to health services and interventions. The objective of this article is to embed ATM in a health system perspective. For this purpose, we perform a structured literature review: we examine existing ATM frameworks, review determinants of ATM and define at which level of the health system they are likely to occur; we analyse to which extent existing ATM frameworks take into account access constraints at different levels of the health system. Our findings suggest that ATM barriers are complex and interconnected as they occur at multiple levels of the health system. Existing ATM frameworks only partially address the full range of ATM barriers. We propose three essential paradigm shifts that take into account complex and dynamic relationships between medicines and other components of the health system. A holistic view of demand-side constraints in tandem with consideration of multiple and dynamic relationships between medicines and other health system resources should be applied; it should be recognized that determinants of ATM are rooted in national, regional and international contexts. These are schematized in a new framework proposing a health system perspective on ATM.

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          Most cited references 80

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          Achieving child survival goals: potential contribution of community health workers.

          There is renewed interest in the potential contribution of community health workers to child survival. Community health workers can undertake various tasks, including case management of childhood illnesses (eg, pneumonia, malaria, and neonatal sepsis) and delivery of preventive interventions such as immunisation, promotion of healthy behaviour, and mobilisation of communities. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers are not a panacea for weak health systems and will need focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. The introduction of large-scale programmes for community health workers requires evaluation to document the impact on child survival and cost effectiveness and to elucidate factors associated with success and sustainability.
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            The concept of access: definition and relationship to consumer satisfaction.

            Access is an important concept in health policy and health services research, yet it is one which has not been defined or employed precisely. To some authors "access" refers to entry into or use of the health care system, while to others it characterizes factors influencing entry or use. The purpose of this article is to propose a taxonomic definition of "access." Access is presented here as a general concept that summarizes a set of more specific dimensions describing the fit between the patient and the health care system. The specific dimensions are availability, accessibility, accommodation, affordability and acceptability. Using interview data on patient satisfaction, the discriminant validity of these dimensions is investigated. Results provide strong support for the view that differentiation does exist among the five areas and that the measures do relate to the phenomena with which they are identified.
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              Overcoming barriers to health service access: influencing the demand side.

               T Ensor (2004)
              Evidence suggests that demand-side barriers may be as important as supply factors in deterring patients from obtaining treatment. Yet relatively little attention is given, either by policy makers or researchers, to ways of minimizing their effect. These barriers are likely to be more important for the poor and other vulnerable groups, where the costs of access, lack of information and cultural barriers impede them from benefiting from public spending. Demand barriers present in low- and middle-income countries and evidence on the effectiveness of interventions to overcome these obstacles are reviewed. Demand barriers are also shown to be important in richer countries, particularly among vulnerable groups. This suggests that while barriers are plentiful, there is a dearth of evidence on ways to reduce them. Where evidence does exist, the data and methodology for evaluating effectiveness and cost-effectiveness is insufficient. An increased focus on obtaining robust evidence on effective interventions could yield high returns. The likely nature of the interventions means that pragmatic policy routes that go beyond the traditional boundaries of the public health sector are required for implementing the findings.
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                Author and article information

                Journal
                Health Policy Plan
                Health Policy Plan
                heapol
                heapol
                Health Policy and Planning
                Oxford University Press
                0268-1080
                1460-2237
                October 2013
                22 November 2012
                22 November 2012
                : 28
                : 7
                : 692-704
                Affiliations
                1Alliance for Health Policy and System Research, World Health Organization, Geneva, Switzerland, 2Health Sector Support Programme, Luxembourg Development, Lao People's Democratic Republic, 3Division of Global Health (IHCAR) and Medical Management Centre (MMC), Karolinska Institutet, Stockholm, Sweden, 4Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland, 5Université Libre de Bruxelles, School of Public Health, Centre de Recherche Politiques et Systèmes de Santé - Santé Internationale, Brussels, Belgium and 6Department of Public Health, Institute of Tropical Medicines, Antwerp, Belgium
                Author notes
                *Corresponding author. Alliance for Health Policy and System Research, World Health Organization, Geneva, Switzerland. E-mail: bigdelim@ 123456who.int
                Article
                czs108
                10.1093/heapol/czs108
                3794462
                23174879
                Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2012; all rights reserved.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by-nc/3.0/), which permits non-commercial reuse, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com.

                Counts
                Pages: 13
                Categories
                Original Articles

                Social policy & Welfare

                medicines, access barriers, health system, analytical framework

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