Availability of Health Services and Resource Allocation: Facilitator Notes

OBJECTIVES OF CASE STUDY

  • To develop an understanding of the various factors that together constitute the availability dimension of access; and
  • To develop an understanding of how resource allocation processes can contribute to improved health service access.

PREPARATION FOR CASE STUDY

In preparing for this case study, it is only necessary to familiarise yourself with the range of factors that influence availability. These primarily consist of:

  • The relationship of the location of health care facilities to the location of those who need these services and their transportation options.
  • Health care providers’ transport resources and willingness to provide mobile services or undertake home visits given the location of those in need and sometimes the severity of their illness (e.g. bed-ridden).
  • The compatibility between the hours of opening of health care facilities (and the related issue of whether or not an appointment system operates) and the time when it is feasible to attend these facilities (especially for working adults) or the time when services are needed (as in emergencies).
  • The relationship between the type, range, quantity and quality of health services provided (which is in turn influenced by policy on service packages within different types of facilities; the number, skills, experience and mix of staff within a particular facility; regulations on scope of practice; availability of equipment and medical supplies, etc.), both at the point of first contact as well as at referral facilities (with appropriate referral systems), and the nature and extent of the health needs of the community being served;

The following reading provides an overview of access issues and includes discussion of the availability dimension of access.

Thiede M, Akweongo P, McIntyre D (2007). Exploring the dimensions of access. In: McIntyre D, Mooney G (eds). The economics of health equity. Cambridge: Cambridge University Press.

TIMING OF THE CASE STUDY

No introduction to this case study is necessary, as the key factors influencing availability will be drawn out from discussion of the case study. It is only necessary to divide the class into groups of 4-5 people in each group.

The case study requires approximately 2˝ hours to undertake. One and a half hours should be allowed for group work and one hour for facilitated plenary discussion of the case study questions.

You will need to circulate between the groups and it may be necessary to prompt groups to do some calculations (e.g. workload per nurse, etc.).

KEY ISSUES FOR DISCUSSION

  • The most important message to convey is that availability of, or physical access to, health services is not simply about the geographic distance to health facilities.

Availability assessment

  • There clearly are some geographical distance problems facing this district, particularly for residents of Navo.
  • It should be recognised that there are considerable differences in utilisation of health services in the different communities, with an average of 2.2 visits per person per year in Vongo, 1.8 in Kilifong and only 1.2 in Navo. This suggests particular availability problems (over and above geographic distance) in the Navo clinic.
  • The routine availability of drugs is a problem in Kilifong and particularly in Navo (e.g. malaria is the single biggest cause of illness in Navo but the clinic there is out of stock of anti-malarials for almost a third of the year).
  • The availability of equipment is also a problem, with three of the microscopes being in the hospital in Vongo and one in the Kilifong clinic (but this clinic has no laboratory technician to operate it), but the clinic with the greatest malaria burden (Navo) does not have one.
  • The relative availability of staff is a serious problem. Navo, with more than three times the number of births as occur in Vongo, has no midwives. The consequence of poor physical access to supervised deliveries is seen in the high maternal mortality rate in this community. In addition, the average annual number of outpatient visits per nurse is 4,430 in Vongo hospital, about 9,390 per nurse in Kilifong and 10,820 in Navo.
  • Opening hours are also a problem – the two clinics (Kilifong and Navo) serving over three-quarters of the district population are only open during the day on weekdays. At least in Kilifong, midwives are on call.
  • The scope of practice of staff also poses some problems – although the burden of circulatory system diseases are a minor problem in Navo, those patients with such diseases cannot be treated there as no anti-hypertensives or other relevant drugs are available at the clinic given that nurses are not permitted to prescribe these drugs.

Plan

While each group’s plan will differ, the following issues are likely to be proposed to improve the availability of health services in this district:

  • Given that Navo is sometimes isolated from the rest of the district during the rainy season, it is important that all the equipment, medical supplies and staffing necessary to meet the basic needs of the Navo community should be available at the fixed clinic.
  • Redistribution of nurses – e.g. 10 nurses in outpatient department at Vongo hospital instead of 17; 16 nurses at Kilifong clinic instead of 12; and 8 at Navo clinic instead of 5 (this would achieve a much more even distribution of workload between nurses across the district).
  • Redistribution of midwives – e.g. 2 at Vongo hospital and 3 each at Kilifong clinic and Navo clinic.
  • One of the microscopes could be allocated to the Navo clinic, and a laboratory technician assigned to each of the Kilifong and Navo clinics. Alternatively, the use of rapid diagnostic tests for malaria should be considered for these clinics.
  • Drug supplies need to be drastically improved for Kilifong and particularly Navo clinics. Plenty of drugs should be provided before the start of the rainy season, particularly anti-malarials given the higher incidence of malaria during the rainy season.
  • The availability of emergency and delivery services after hours in Kilifong and Navo should also be considered.