ACCESS TO HEALTH CARE IN CONTEXTS OF LIVELIHOOD INSECURITY: A FRAMEWORK FOR ANALYSIS AND ACTION
Access to health care is a major health and development issue. Most governments declare that their citizens should enjoy universal and equitable access to good quality care. However, even within the developed world, this goal is difficult to achieve, and there are no internationally recognized standards on how to define and measure “equitable access”  . Evidently, big disparities exist between the poor and the better off with respect to access to health care services and health status [2–4] . Gaps in child mortality between rich and poor countries are wide, as well as between the wealthy and the poor within most countries. Poor children are not only more likely than their better off peers to be exposed to health risks and have less resistance to disease, they also have less access to preventive and curative interventions. Even public subsidies for health frequently benefit rich people more than poor people. Clearly, more of the same is not enough  : To improve equitable access, innovative and community-based approaches are needed to better align health care services with poor people’s needs, expectations, and resources.
This article presents a framework for analysis and action to explore and improve access to health care in resource-poor countries, especially in Africa. The framework links social science and public health research with broader development approaches to poverty alleviation. It was developed in the frame of the ACCESS Programme, which focuses on understanding and improving access to prompt and effective malaria treatment and care in rural Tanzania as an empirical case study [5,6] . The article first provides a brief outline of three approaches to investigating health care access, focusing either on health seeking, health services, or livelihoods. It then presents a framework that combines the three approaches, exemplified with research findings and interventions of the ACCESS Programme.
Access to Health Care from Three Perspectives
Health-seeking studies focus on people [7–10] . They apply pathway models and follow sick persons step by step from the recognition of symptoms through different types of help seeking until they feel healed or capable of living with their condition. Health-seeking studies provide a deeper understanding of why, when, and how individuals, social groups, and communities seek access to health care services, and investigate interactions between lay persons and professionals  . In this perspective, social actors are the potential driving force for improving access to effective and affordable health care, but they are often constrained by politics and the economy on national and international levels [12–14] .
Health service studies concentrate on factors influencing access to health care, which they commonly define as utilization rates [15–17] . They apply determinants’ models and consider access as a general concept summarizing a set of more specific dimensions, such as availability, affordability, accessibility, adequacy, and acceptability. Although they take into account demographic characteristics of health service users, their knowledge about the disease, and, more recently, wealth as measured by household assets, health services studies tend to pay more attention to the supply than the demand side [18,19] . They search for policy interventions to reduce supply barriers and improve the delivery of services, including availability of health facilities, equipment, and qualified staff, staff skills, protocols of diagnosis, treatment, and quality of care. Moreover, they are less oriented towards health-seeking processes. Interventions on the demand side are commonly limited to information, education, and communication (IEC) campaigns.
Livelihood approaches—as the name implies—emphasize assets (including material and social resources) and activities needed to gain and sustain a living under conditions of economic hardship [20–25] . Access is a key issue for sustainable livelihoods  . Recent studies applying the Sustainable Livelihood framework of the United Kingdom Department for International Development to study HIV/AIDS  and malaria (J. Chuma, unpublished PhD thesis) demonstrate the many difficulties people face in gaining access to household and community assets and how this constrains their strategies to cope with the disease. In other words, not only possession, but mobilization of household and community assets is a critical factor influencing people’s access to health care and other health-related services. Interventions target communities and social groups, emphasize solidarity and empowerment, and try to improve livelihood conditions.