Evidence that the poor often benefit less from public
spending is well established in the literature (Demery 2000;
Makinen et al. 2000). The reason why the poor do not make
more use of public services is driven by both supply and
demand factors. The report on Macroeconomics and Health
reinforced the need to overcome the substantial barriers to
access that exist for the poorest (Sachs 2001). The focus of
much health policy intervention has been on reducing supply
barriers. Delivery of essential services concentrates on
improving the quality of staff skills, protocols of treatment,
availability of supplies and environment of health facilities.
Yet while these interventions are important, they do not
address many of the barriers to accessing services faced by a
patient in a low-income country. Whether and where to go
for treatment starts well before arrival in a facility and
requires a myriad of complex, and potentially confusing,
choices to be made. Often, health services of a reasonable
quality exist, but few use them. Just as important are the
physical and financial accessibility of services, knowledge of
what providers offer, education about how to best utilize self-
and practitioner-provided services and cultural norms of
In the next section, we review some of the principal demand-
side barriers within the context of an economic framework of
the demand for health care. These are illustrated by evidence
on the importance of barriers in a variety of mainly low- and
middle-income countries. In section three, a description of
actual interventions to reduce demand barriers is presented
together with available, limited, evidence on their effective-
ness. The final section discusses gaps in current knowledge
and ways in which work on demand-side interventions might
2. Demand-side barriers
One illustration of the importance of demand-side barriers is
provided by a survey of obstetric choices in Bangladesh
(Barkat et al. 1995 reported in Piet-Pelon et al. 1999) (Table
1). In this survey, the majority of the most important reasons
for not seeking emergency obstetric care were found to be
Most of the standard economic frameworks of health care
utilization model both supply and demand sides (Table 2). In
this paper, demand-side determinants are defined as those
factors that influence demand and that operate at the indi-
vidual, household or community level. In contrast, supply-
side determinants are those that influence the slope and
position of the supply curve. Supply is determined by factors,
derived from the health care production function, that
interact to produce effective health care services, as follows:
Qs= S(factor prices/availability, technology, management,
Factor prices are the prices of those items required to
HEALTH POLICY AND PLANNING; 19(2): 69–79
Health Policy and Planning 19(2),
© Oxford University Press, 2004; all rights reserved.
Overcoming barriers to health service access: influencing the
TIM ENSOR AND STEPHANIE COOPER
International Programme, Centre for Health Economics, University of York, York, UK
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 vulner-
able groups, where the costs of access, lack of information and cultural barriers impede them from benefit-
ing from public spending.
Demand barriers present in low- and middle-income countries and evidence on the effectiveness of inter-
ventions 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 evalu-
ating 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 prag-
matic policy routes that go beyond the traditional boundaries of the public health sector are required for
implementing the findings.
Key words: demand-side barriers, utilization, financing, interventions
by guest on July 13, 2011
‘produce’ treatment, such as staff time, capital equipment
and buildings, consumables and land. In a market system,
prices signal availability and quality. Within a public distri-
bution system, the role of prices is a little different since they
usually do not rise in response to shortage. Rather, scarcity
is signalled by actual delays in the supply chain and variations
in the quality of supplies. Factors are combined subject to
available technology and management capability of the
provider. The supply price also helps determine the level of
production. In a public system this may be replaced by plans
for a required level of production, which is in turn con-
strained by available budget.
On the demand side, the economic literature is dominated by
adaptations of the Grossman model that analyze individual
investment and consumption decisions to improve health and
utilize health care (Grossman 2000). Demand is influenced
by factors that determine whether an individual identifies
illness and is willing and able to seek appropriate health care.
The model leads to a demand for health care of a given
quality that is determined by individual and community
factors as well as the price of medical care and other similar
goods. This can be written as:
Qd= D(individual/household factors, community factors,
Individual (and household) factors include age, sex, income,
70 Tim Ensor and Stephanie Cooper
Reasons for not seeking care in obstetric emergencies in Bangladesh
Supply or demand? Reason Percentage
Do not know about emergency problems
Financial costs are relatively high
Do not know about the availability of specific service at the facility
Required medicines not always available
Religion does not permit going outside of the house, especially during pregnancy
Facility too far from home
Doctor not available when needed
Poor communication to facilities
Difficult to get admission
Attitude of service providers to clients not very friendly
Source: Adapted from Piet-Pelon et al. (1999)
Supply and demand barriers to utilization of health care
Example of barrier
1) Information on health care choices/providers
Lack of knowledge of providers
Low ability to assimilate health choices and negotiate access to
3) Indirect consumer costs
• distance cost
• opportunity cost
Long and slow travel to facilities
Need for patient and carer to stop working for long periods in order to
Asymmetric control over household resources
Reluctance to seek health care for women outside home; community
resistance to using modern medical care to assist with pregnancy
Patients seek treatment through providers that are inappropriate for
their condition such as drug sellers
4) Household preferences
5) Community and cultural preferences, attitudes and norms
6) Price and availability of substitute products and services
Demand and supply interaction
Direct price of service of a given level of quality (including
High cost of services
Large unofficial payments to staff
Long waits to see medical staff
1) Input prices and input availability
• Wages and quality of staff
• Price and quality of drugs and other consumables
3) Management/staff efficiency
Absenteeism, staff not attracted to the area
Scarcity of supplies, weak cold chain
Inability to treat disease with given technology
Poor quality of management training, lack of management systems
by guest on July 13, 2011
education and knowledge about the characteristics of, and
need for, medical treatment. Community factors include
cultural and religious influences and other social factors that
affect individual preferences. Price is a complex variable
and includes the direct price and distance cost, opportunity
(time) cost of treatment – since treatment can be time
consuming – and any informal payments made to the facility
for commodities or to staff. Also included are prices for
substitute commodities that impact on health (PH), since
individuals have some scope for choosing healthy lifestyles,
safer employment or better nutrition in order to improve
health or reduce the probability of ill health.
The determinants of demand and supply may in turn
generate ‘barriers’ to utilization that arise when factors influ-
ence these determinants in a way that reduces utilization of
services. Some of these barriers are illustrated in Figure 1.
In the paper, we focus on those demand factors that can be
controlled at the community, household or individual level
and are amenable to policy intervention. Individual charac-
teristics that determine need, such as age and sex, are not
considered since they cannot be controlled. The effect of
gender on access to household resources is discussed
however. The analysis does examine the effect of education,
information and non-supply user costs of services since these
are amenable to interventions. It may also be possible to
influence community and cultural factors if they arise as a
result of misinformation or inappropriate service configur-
ation. We do not consider the role of income, although this
is one of the most important factors in determining health
spending and seeking behaviour (Gerdtham and Jonsson
2000). In principle, incomes are amenable to control but they
are assumed to be mainly affected by wider economic policies
outside the specific control of the health sector. We do not
consider the direct price of health services, the price of
alternative health services and the relative prices of other
health-enhancing inputs since these are mostly related to
supply of services.
Education and information
The effect of education and information can be divided into
two categories. First, there is the impact of basic education
on the demand for services. Education, which is often
measured by level or duration of schooling, has been shown
to be the most important correlate of good health (Grossman
and Kaestner 1997). A study in Pakistan, for example, found
that maternal schooling was the most important factor
in determining child survival (Agha 2000). A recent
comparative article examining pre-requisites for successful
development suggested that a high education base is a major
determinant of above-average social development (Mehrotra
Education as a determinant of health care utilization is a
more complex variable. To some extent, education can
improve the ability of individuals to produce health them-
selves through better lifestyles rather than relying on health
services. Yet there is also much evidence that better basic
education can, through general improvements in literacy and
specific health studies, increase desired and actual use of
health services. Studies across a number of countries have,
for example, indicated the importance of maternal education
on the use of obstetric services (Cleland and van Ginneken
1988; Raghupathy 1996).
Education provides the consumer with the basis for evalu-
ating whether they or a dependent require treatment. Infor-
mation on the best places to seek care is additionally
required. While it is sometimes suggested that individuals are
unable to assimilate information on treatment options, this
assumption is challenged by recent work in Tanzania
(Leonard et al. 2001; Leonard 2002). These studies suggest
that, far from being passive consumers, patients actively seek
out not only the best-known provider but the best facility for
a particular illness. Perceptions of quality do, in fact, accord
quite well with technical evaluations.
The second knowledge effect is the specific impact of infor-
mation on health and health care. Both education and infor-
mation may be interlinked since the ability to assimilate
health messages is likely to be determined in part by the level
of general education. The impact of information on treat-
ment options and desirable health seeking behaviour is also
important in determining demand. One study finds that lack
of information on the malign effects of excessive antibiotic
use has a substantial positive effect on a preference for
self-medication over use of health facilities (Okumura et al.
2002). There is also a substantial literature indicating that
demand for family planning services is impeded by a lack of
correct knowledge of contraceptive choices and side-effects
(for example DeClerque et al. 1986; Donati et al. 2000).
The importance of misinterpreting health messages given out
Overcoming barriers to access71
- Price (official, unofficial charge, travel cost,
- Social, household, cultural characteristics
- Knowledge of health care available
- Education (general and health)
- Official price
- Input prices (staff, capital
- Knowledge of technology of
- Management efficiency
Supply and demand barriers to utilization of health care
by guest on July 13, 2011
by staff is demonstrated in a number of studies. One, examin-
ing the reasons for choosing delivery sites in Uganda,
suggests that if a woman is told during ante-natal care that
there are ‘no problems’, this is often interpreted as a sign that
the delivery itself will be normal and that therefore attend-
ance at a facility is not required (Amooti-Kaguna and
Consumer cost barriers
In this section we are concerned with the other costs to
consumers, rather than those incurred when a user is at a
There is much evidence to suggest that distance to facilities
imposes a considerable cost on individuals and that this may
reduce demand. In studies reviewed for this article, transport
as a proportion of total patient costs (including facility costs
not financed by the user) was found to be 28% in Burkina
Faso, 25% in northeast Brazil and 27% in the United
Kingdom (Sauerborn et al. 1995; Frew et al. 1999; Terra de
Souza et al. 2000). Another study in Bangladesh suggested
that it was the second most expensive item for patients after
medicines (CIETcanada 2000).
Location and distance costs are often seen to negatively
impact service utilization. A study in Vietnam found that
distance is a principle determinant of how long patients delay
before seeking care (Ensor 1996). Another, in Zimbabwe,
suggested that up to 50% of maternal deaths from haemor-
rhage could be attributed to the absence of emergency trans-
port (Fawcus et al. 1996). At the same time, distance is also
cited as a reason why women choose to deliver at home
rather than at a health facility; see, for example, studies in the
Philippines (Schwartz et al. 1993), Uganda (Amooti-Kaguna
and Nuwaha 2000) and Thailand (Raghupathy 1996).
The impact of location is not confined to low-income coun-
tries. One US study found that patients living more than 20
miles away from a hospital are much less likely to visit ambu-
latory services for after-care following myocardial infarction
(Piette and Moos 1996). In Japan, one study found that access
to follow-up treatment after treatment for cerebrovascular
disease was considerably influenced by access to suitable
transportation (Tamiya et al. 1996).
Distance may also have a differential impact across income
groups. A study in Australia found that the impact of costs
fell most heavily on the poor (Rankin et al. 2001). Qualitative
evidence in Vietnam suggests that poorer households usually
have access to inferior transport in the event of illness (Segall
et al. 2000).
Consuming health care can be time intensive. Both patients
and relatives may have to give up long periods of work (or
leisure) in order to receive treatment. This represents an
important cost to individuals, particularly during peak
periods of economic activity such as harvest time. A study in
Australia found that indirect costs account for 60% of the
costs of treatment for surgery for patients from rural areas
(Rankin et al. 2001). Convenience of opening hours, an
indicator of the importance of taking time off work, was
found to be important in both Vietnam and Ghana in deter-
mining service use (Bosu et al. 1997; Segall et al. 2000).
Opportunity costs vary for different groups. A recent study
in Pakistan, for example, found that compliance is more
easily improved in those who are not economically active
since they are more likely to have time to attend for
treatment (Khan et al. 2002). In Uganda it was found that
poorer patients were willing to travel considerable distances
searching for better facilities, perhaps because their oppor-
tunity costs (see below) were lower (Akin and Hutchinson
1999). Similar results are borne out in studies of the private
sector in India, where the search for quality (a supply
variable) is often seen to override the distance cost and leads
to complex and lengthy search strategies (Shenoy et al. 1997;
Bhatia and Cleland 1999). These findings must, however, be
balanced by the other effects of lower income that are often
a consequence of lower opportunity costs.
Financial barriers may also interact with other demand
barriers. One study in Kazakhstan, for example, found that
the education of the household head or the care-seeker was
an important determinant of the willingness to travel long
distances to obtain treatment (Thompson et al., forth-
Community and household barriers
The Voices of the Poor cross-country study found general
agreement that men were invariably given preferential access
to health care over women (Narayan 1997). Studies in
Bangladesh, India and Côte d’Ivoire (although not in Peru,
where the opposite result is reported) found that girls were
much more likely to visit health care facilities and benefit
from public and household health care expenditure (Gertler
and van der Gaag 1990; Booth and Verma 1992; Begum and
Sen 2000). Another study in India found that while a bias to
boys existed, this was reduced when the household head was
more highly educated. The reason for these differences is
related to both cultural patterns and social factors within the
household and wider community.
Cultural norms, such as purdah restrictions, can prevent
women from seeking health care outside the home for them-
selves and their children (Rashid et al. 2001). This barrier is
often raised still further when men provide services, and has
been offered as one reason why Asian women living in
Western countries often make little use of health services
(Whiteford and Szelag 2000). Such restrictions may also
interact with other barriers. One study in India found that
distance was a much greater barrier to women than to men
with similar incomes (Vissandjee et al. 1997). This may be
because it is culturally unacceptable for women to leave their
homes for long periods, or it could reflect less access to
household resources to pay for transport.
Another example of culture as a barrier to using services is
the perception among the Alur people of Uganda and the
Bariba tribe of Benin that help with delivery indicates
‘weakness’ (Ndyomugyenyi et al. 1998; Bhatia and Cleland
72 Tim Ensor and Stephanie Cooper
by guest on July 13, 2011
2001), and another is the unacceptability of modern contra-
ception among men in parts of Pakistan (Casterline et al.
A related issue is that men often make decisions on
care-seeking for women. In Senegal, for instance, a study
found that more than 50% of decisions regarding female
treatment were made by men (Post 1997). This is particularly
important since, as one study in Bangladesh, South Africa,
Indonesia and Ethiopia found, male decision-makers often
spend less than women on social items (Quisumbing and
Maluccio 1999). In a number of South Asian societies, the
mother-in-law dominates decisions on childbirth and care
related to pregnancy, particularly in early marriage. In these
circumstances, whether a woman is delivered at home by a
family member, by a traditional birth attendant (TBA) or at
a health facility much depends on the beliefs of the mother-
in-law (Piet-Pelon et al. 1999). At the community level, the
TBA is also vital in influencing demand. One study in
Rajasthan found that more than 90% of women who did not
obtain referral care were advised against such care by the
TBA (Hitesh 1996).
Two important factors influencing the effectiveness of the
female voice in household decision-making are the extent to
which female members are educated and contribute to
household income. Quisumbing and Maluccio (1999) found
that the difference in education between male and female
members is crucial in determining influence. In a survey in
Senegal, researchers found that in more than half of the cases
decisions on care-seeking for women were made by the
husband or other senior family member (quoted in Post
1997). A spokesperson for one Bangladeshi NGO reinforced
“One [women’s] group shared with me that a major
change for their group members was that they were now
included in family discussions, because they were literate
and earning money. If a woman has no voice in the
family, it doesn’t matter whether she knows she needs
medical care or not, the decision will be made by her
parents-in-law and/or her husband”.1
Increasing demand is therefore far more complex than
simply the provision of health education advice or infor-
mation, but is also strongly related to the relative position
and education of family members. As suggested by one
Indian study, when women cannot contribute through
superior education or through income earning, their position
is maintained through household chores (Ramasubban and
Rishyasringa 2000). The completion of these duties may
mitigate against them receiving care in the event of illness.
This reinforces opportunity cost as a factor in reducing
demand, not so much through any significant effect on total
household earnings but in the lost position within the house-
3. Intervening to reduce barriers
In this section we review available literature on the nature
and impact of actual demand-side interventions. A review
was carried out based on a structured search of key electronic
databases, websites of international agencies and non-
government organizations and a series of key informant
contacts with researchers working in related fields. More
details of the strategy are provided in Ensor and Cooper
Justification to intervene to reduce demand barriers can be
divided into market failures and pursuance of social equity
(Hurley 2000). Even once an efficient competitive provider
network has been established, two key market failures may
impede effective demand for health care. A key assumption
for the efficient functioning of a market is that adequate and
symmetric information is available to both buyers and sellers
of the commodity. Yet often in health care markets, the lack
of information or inability to assimilate and utilize the infor-
mation on health care means that consumers are unable to
make informed decisions. Providing education and infor-
mation to individuals, households and communities is a way
of dealing with informational gaps.
A further market failure issue is that health care markets are
underpinned by considerable uncertainty, which means that
consumers often find it difficult to spread risk and make
sufficient resources available at the time of ill-health. It is
well established that even in countries where insurance and
capital markets are well developed, market failure that
prevents the adequate coverage of catastrophic costs often
persists. The problem is generally more acute in low- and
middle-income countries where these markets are under-
developed or nearly nonexistent.
The second main justification to intervene is where other
means to allocate economic resources to individuals on an
equitable basis have failed. In this case, some groups in
society will be unable to meet their health care needs because
of either the underlying income distribution or differences in
intra-household bargaining power. This might lead to inter-
ventions to target resources at those in need but unable to
Most of the barriers discussed in the previous section can be
related to one or more market or equity failure (Table 3,
adapted from the demand determinants listed in Table 2).
Information and education are related to failures either in
the form of knowledge of health care choices or in the ability
to utilize this information in an effective way. To some extent,
cultural and community barriers may also be related to infor-
mation failures where they arise as a consequence of a lack
of information about what constitutes medical provision and
how patients will be treated once at a facility. So, for
example, information might be used to reassure female
patients that they will be treated by a female doctor.
Community and cultural factors are clearly more complex
and may also necessitate combined supply and demand-side
interventions to bring appropriate services to the community,
such as the door-to-door delivery of contraceptive services or
provision of a skilled attendant at a home delivery. Consumer
costs are the result partly of income distribution and partly
Overcoming barriers to access73
by guest on July 13, 2011
of lack of mechanisms to spread risk across the population or
across time (so that individuals can pay for care when they
can afford it rather than at the time of illness). The effect of
household choices in preventing access to care to certain
members is likely to be mainly the result of intra-household
Two qualifications are important in discussing interventions.
A first qualification is that barriers to consumption do not
necessarily indicate market failure. Consumers will always
bear some cost of consumption even where income is equit-
ably distributed and good mechanisms for risk-pooling exist.
Similarly, community reluctance to use care may partly or
fully represent a rational, informed choice not to use services
offered. Secondly, even where a market failure does exist, it
may turn out that the costs of reducing the consequent
barrier exceed the benefits. This highlights the importance of
closely monitored pilot interventions to determine whether
it is in the interests of the population as a whole, and not just
a particular community or individual, to intervene.
Interventions to reduce demand-side barriers arising from
these market failures could be of either a demand or supply-
side nature (see columns 4 and 5, Table 3). Distance costs can
be minimized either by providing community-based financ-
ing to meet the immediate costs of travel (demand-side inter-
vention) or by providing an emergency transport service
(supply-side intervention). Similarly, cultural concerns about
the appropriateness of services might be alleviated partly by
information (demand-side) but also by making services
themselves more appropriate to the community (supply-
One of the difficulties in evaluating evidence on demand
barrier impact is that the setting for the natural experiments
often makes it difficult to attribute causation to the inter-
vention being tested. Ideally, the intervention should be
implemented either at a time when few other factors are
changing or when these factors can be measured and their
confounding impact adjusted.
A striking aspect of the search was that while much literature
was found on barriers, far less was uncovered on the means
to reduce these barriers. Still fewer studies provided
74 Tim Ensor and Stephanie Cooper
Types of intervention to reduce demand barriers
Example of interventions
SupplyDemand Example of barrier Possible market failure
1) Information on health
Lack of knowledge of
Information & education Staff conduct outreachProvide information on
when to seek care and
range of providers;
to indicate better
Improve access to primary
education, particularly for
Stimulate demand using
financial incentives to
to provide services
2) Education Low ability to assimilate
health choices and
negotiate access to
Information & education
3) Indirect consumer costs
• distance cost Long and slow travel to
Uncertainty & equityProvide an emergency
transport service with
increase outreach work
and numbers of
more flexible working
Lower user charges for
Transport loan funds;
provision of cheap/
• opportunity cost Need for patient and
carer to stop working
for long periods in
order to seek care
Uncertainty & equity Incentives to reduce cost of
4) Household preferences Asymmetric control overEquity Target subsidies at members
of household with least
access to services
Information to correct
5) Community and
attitudes and norms
Reluctance to seek health Information & education Culturally sensitive
care for women outside
resistance to using
modern medical care to
assist with pregnancy
Patients seek treatmentInformation
through providers that
are inappropriate for
their condition such as
health care delivery
6) Price and availability
of substitute products
Information on best
treatment for disease
by guest on July 13, 2011
documented evidence of the impact of the interventions. The
studies obtained during the search were dominated by repro-
ductive health examples, many from the obstetric care litera-
ture, and this is reflected in the literature discussed below.
The studies examined are divided into the same three
sections used in Section 2.
Education and information
The concept of demand barriers is well recognized in the
literature on maternal health, which has been formalized in
the delays model (Maine 1997). This proposes three barriers
to accessing care: delay in the decision to seek care, delay in
getting to the facility and delay in obtaining the appropriate
care once at the facility. The first two delays can be classified
as demand barriers. The first delay is largely an issue of infor-
mation and education, although it is also likely to be a
decision based on availability of resources at time of need
and so relates to lack of risk-pooling and intra- and inter-
household equity, too. The second delay is likely to be largely
a financial issue relating mainly to availability of resources.
It could also be determined by ignorance of appropriate
transport or means of accessing funds to pay for the costs.
A variety of interventions have been conducted to overcome
these delays. Many of them were implemented through the
Prevention of Maternal Mortality (PMM) network, although
there is also evidence from a range of other sources.2
Interventions aimed at improving education and information
have frequently centred on the training of community
educators. These are generally women living in the target
communities who can convince families of the need to obtain
maternal care and help to facilitate admission to hospital in
an emergency. Three such schemes in Nigeria, Sierra Leone
and Ghana all led to a substantial increase in admission to
hospital for normal and complicated deliveries (Kandeh et al.
1997; Nwakoby et al. 1997; Opoku et al. 1997). An NGO in
Bangladesh trained TBAs to provide advice on referral and
to assist women in getting to hospital when necessary
(Barbey et al. 2001), whilst an education initiative in Malawi
reported a three-fold increase in use of hospitals or clinics for
postpartum care and a doubling in delivery care (Gennaro et
al. 2001). Another campaign, in Kebbi State, Nigeria,
reported a positive impact on awareness of obstetric compli-
cations but no impact on referrals (Gummi et al. 1997). One
problem was that other factors, particularly a decline in real
incomes, was thought to confound the positive impact on
utilization arising from the education. Unfortunately, no
attempt was made to adjust for these factors.
One cross-country project implemented community edu-
cation, transport and training for TBAs in Indonesia, Bolivia
and Guatemala in order to stimulate use of essential obstet-
ric care (EOC) (Kwast 1995; 1996). Although no results are
reported for the Javan interventions, substantial increases in
referrals are reported in both Guatemala and Bolivia. The
projects’ aim was to highlight the improvements that could
be made to referrals and maternal mortality through
community level (demand-side) interventions. No infor-
mation is provided in the studies on the costs of intervening.
Consumer cost barriers
A variety of interventions helped to reduce the delay in
reaching a facility. In northwest Nigeria, a project worked
with transport unions to provide reliable and affordable
transport (Shehu et al. 1997). A seed fund for the cost of fuel
was provided, which was replenished with contributions from
users. Drivers were trained to be respectful to those using the
transport by avoiding smoking, talking loudly or showing
impatience. A project in Sierra Leone provided radios to
summon vehicles to take women to hospital in the case of
obstetric emergency (Samai and Sengeh 1997). Both inter-
ventions report a substantial increase in the number of
people visiting hospital.
Another group of interventions have helped to develop
community loan funds which are used by those who need to
pay for transport as well as other costs of health care. One of
the studies, in Sierra Leone, compared a district that devel-
oped such funds with non-intervention communities and
found a doubling of obstetric admissions in the former
compared to no change in the latter (Fofana et al. 1997). The
report suggests that only two out of six communities initially
targeted actually succeeded in establishing funds because of
relatively stronger leadership. In Nigeria, an evaluation of a
loan project concentrated solely on the number of loans
given and their repayment (more than 93%) within the first
year (Chiwuzie et al. 1997; Essien et al. 1997). The project is
considered a success within these relatively narrow
parameters, although concerns have been raised about fund
depletion and the need to raise the rate of interest to offset
the cost of loan defaulters. A breakdown of costs indicates
that project money spent on loans accounts for around 58%,
implying a relatively high administrative cost. Start-up and
ongoing costs are not separated, so it is hard to measure the
recurrent costs of administration.
A further intervention used to overcome distance barriers is
to establish maternity waiting homes near district hospitals.
Two such interventions in Zimbabwe and Ethiopia report
high use of hospitals and low rates of complications for the
subsequent delivery (Poovan et al. 1990; Spaans et al. 1998).
No attempt was made to check for possible selection bias
arising from certain types of women using these facilities. In
two other countries, Ghana and Zaire, similar interventions
were less positively received, largely because the facilities
were situated in rather desolate surroundings without good
facilities for preparing meals (Hildebrandt 1996; Post 1997).
These studies emphasize the importance of consulting with
the community on the potential intervention before an
investment is made.
That transport networks are important in influencing
demand is recognized by the increasing number of social
protection loan projects that are financing some upgrading of
local road networks. Examples were found, for example, in
World Bank social protection projects in Argentina, Georgia,
Burundi, Madagascar and Vietnam (see World Bank project
website http://www.worldbank.org/ and go to ‘projects and
programs’). However, only one of these (Burundi) had
specific reference to investment in roads as a way of improv-
ing access to health care.
Overcoming barriers to access75
by guest on July 13, 2011
The proliferation of community insurance schemes, in prin-
ciple, provides a way of addressing demand-side barriers by
incorporating these costs into the overall benefits package.
Yet none of the recent reviews of community schemes
mention that such costs are, in practice, covered (see for
example Atim 1998; Bennett et al. 1998). One exception is a
scheme in Samburu district, Kenya, which covers transport
costs as high as US$60 per year for a household premium of
US$5 per year (Macintyre and Hotchkiss 1999). The scheme
is only evaluated in terms of numbers of members and no
evidence of the effect on utilization is offered.
Interventions that cover the indirect opportunity costs to
users have been stimulated by a growing appreciation that
one of the inhibitors to the continuation of treatment is the
need to regularly present for therapy. Payments may
compensate patients for time off work, travel and general
inconvenience. One review of studies, mostly from the
United States, found that in 10 out of 11 studies, meeting
certain criteria payments had a positive impact on compli-
ance (Giuffrida and Gravelle 1998).
Treatment of tuberculosis is particularly suited to this type of
intervention since treatment is extremely intensive and the
externalities of non-treatment are significant. A recent
review identified 26 separate schemes, across low-, middle-
and high-income countries, which offer inducements includ-
ing food and transport subsidies in return for clinic attend-
ance. One project in Haiti made financial payments to cover
travel, nutrition supplementation and income lost during
treatment (Farmer et al. 1991). Evaluation indicated that all
those receiving treatment recovered, whereas 46% of those
in a control group still had the disease after 1 year.
Community, household barriers and supply-side responses
It is difficult to identify interventions that are primarily
focused on the alleviation of cultural or household demand
barriers. Many of the interventions appear to address a
number of market failures caused by a variety of factors. A
number of supply-side responses to demand barriers appear
to address consumer cost and information barriers and in
addition provide services to a community that are more
Many of the efforts to stimulate demand for family planning
services have focused upon the delivery of services within the
community. This strategy, usually known as community-
based delivery, takes supplies into the villages, and even the
homes, of potential users. The strategy may help to overcome
a multiplicity of demand-side obstacles, including ignorance
of family planning products, cultural reluctance by men and
women to seek contraceptives in public facilities and mini-
mization of household costs. It may also motivate people to
use other services. In India, for example, family planning
workers help to stimulate the demand for child health
services at the same time as offering family planning advice
(Srivastava and Bansal 1996). One review of community
delivery in Africa suggested a generally positive impact on
contraceptive prevalence (Phillips et al. 1999). Little atten-
tion was given to the cost-effectiveness or sustainability of
The strategy of doorstep delivery of family planning services
to rural households in Bangladesh is increasingly being seen
as a successful way of overcoming consumer cost and social
objections to women obtaining services outside the home
(Arends-Kuenning 1997). It is now felt that significant
improvements in the contraceptive prevalence rate have
rendered this expensive policy unnecessary. Recent changes
in policy have begun re-orientating the focus of delivery to
community clinics rather than door-to-door provision (GOB
1998). It is not yet known what impact this will have on use
The review in Section 2 indicates the importance of demand-
side factors in determining access to services. The findings in
Section 3 suggest that evaluation of effective ways to reduce
these barriers is an under-researched area, but one where the
policy implications are potentially substantial. The evidence
suggests that interventions can be successful in raising
demand, provided that supply is also improved. It suggests
that in designing interventions, the communities should be
fully involved in order to ensure that the resulting solution is
socially acceptable. Further conclusions are hampered first,
by the general lack of evidence and, secondly, where studies
have been carried out, by weaknesses in study design,
meaning that findings are often not sufficient to enable their
generalization to other settings. Concerns include inadequate
evidence on effectiveness and costs, a lack of clear goals for
demand-side policy and evaluation of their cost-effective-
ness, the need to pay greater attention to cross-sector
collaboration and a greater focus on the interventions that
benefit the poor.
(i) Inadequate evidence on effectiveness and costs
In trials of clinical interventions it has become standard to
conduct a randomized control trial, preferably double-
blinded. No such standard exists for trials of health system
interventions such as those addressing demand-side barriers
discussed in this paper. This is unsurprising given that some
of the standards of RCTs, such as blinding, are extremely
difficult or even impossible to implement. Yet the size of the
interventions suggests that a similar consistent standard is
The initial intention to conduct a systematic review was
dropped when it became clear that very few studies would
meet the minimum criteria for inclusion. The main weak-
nesses revealed were biases occurring from the method of
inclusion into the study and the inadequate costing of most
interventions. It was difficult, for example, even where costs
were included, to distinguish capital from recurrent costs.
There is a general lack of rigour or consistency in the evalu-
ation of evidence of the interventions’ effectiveness in most
of the studies reviewed. Many of the interventions found in
both the published and unpublished literature were largely
descriptive. Some of the interventions carried out limited
evaluation, but in most cases these evaluations did not
control for confounding factors. Cost information is
extremely scarce and most studies do not differentiate
76 Tim Ensor and Stephanie Cooper
by guest on July 13, 2011
between capital and recurrent costs. Few studies provide
sufficient information to carry out even a rudimentary cost-
(ii) Aims of intervention and relative cost-effectiveness
Many of the interventions appear to have the increase in
utilization of services as an over-riding objective. So, for
example, one study measures the numbers covered by a
transport scheme (Macintyre and Hotchkiss 1999), another
the number of loans provided through an obstetric loan fund
(Chiwuzie et al. 1997), while a further study examines admis-
sion rates to hospitals and clinics (Gennaro et al. 2001).
Measurement of these process and output indicators is
understandable in the context of each of the projects, where
more sophisticated indicators would have taken longer and
been more difficult to measure. The problem with this
approach is that without clearly establishing the reason for
the intervention and the limits of the market or distributional
failure, it becomes hard to decide on what basis to extend the
scheme. If, for example, the reason for intervention is mainly
informational, then extending the intervention to an entire
community may be justified. On the other hand, if the reason
is one of equity, then only poorer groups might be targeted.
From a policy perspective, further information is required to
decide on the extent to which the benefits in terms of
improved outcomes or increased outputs match the costs
(iii) Recognition of the need for cross-sector collaboration
Many of the barriers discussed in Section 2 are likely to be
amenable to interventions that are beyond the scope of the
health sector. Typically, a Ministry of Health may have rela-
tively little influence over many of the demand barriers.
While spending on training for doctors or improvement of a
clinic is possible, budget flexibility may not extend to improv-
ing a rural road or expanding access to schooling, even if this
actually represents the main barrier to increasing utilization.
In many cases, successful demand strategies will often
require assistance both from donors and other ministries.
A further cross-sector issue is that in a number of cases,
particularly those related to cultural barriers, health care
access is just one facet amongst many social issues. The fact
that in some communities women have inferior access to
resources and may be prevented from making their own
choices, has implications for health and also for all other
aspects of an individual’s lifestyle. It relates to the general
need to empower weaker members of society to make inde-
pendent choices. It suggests that much more impact could be
gained by attempting to address some of these social issues
across government, rather than from the narrow perspective
of a sector ministry. It reinforces the importance of using
cross-sector initiatives, such as HIPC3and PRSP, to address
some of the barriers to access that cannot be addressed by
the public health sector alone.
(iv) Focusing on poverty
An aspect lacking in most studies is an explicit focus on inter-
ventions which target the demand barriers most affecting
poorer populations. In most cases interventions do not
differentiate between their impact on poor and non-poor
groups. This is important, given that many of the inter-
ventions are designed to reduce financial barriers, which are
likely to be higher for the poor. It is clear that many of the
interventions aim to target entire communities, with the aim
of enlisting general community support for the purpose of
reducing maternal deaths. In this case it is clear that a direct
targeting approach would not be appropriate. Yet infor-
mation on the actual beneficiaries of the intervention is still
needed by policy-makers wishing to concentrate resources on
those least able to afford health services.
In some cases interventions are designed for particular
groups, all, or most, of whom are likely to fall into vulnerable
groups. Interventions to increase compliance in TB treat-
ment, for example, may benefit vulnerable groups dispro-
portionately, as well as having a wider public health function.
Yet evaluation data on the beneficiaries would still be useful,
if only to convince governments and donors of the desirabil-
ity of the interventions.
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We are grateful to a number of people and organizations for provid-
ing information on demand-side barriers and initiatives. They
include: Jayshree Balachander, Oona Campbell, Ramon Abel
Castano-Yepes, Lesong Conteh, Kiran Dev Pant, Priti Dave Sen,
Nel Druce, Maria Goddard, Davidson Gwatkin, Sara Joseph,
Barbara Klugman, Jack Langenbrunner, Kenneth Leonard,
Benjamin Loevinsohn, Di McIntyre, Adilet-Sultan Meimanaliev,
Kate Marsden, Anne Mills, Valeria Oliveira-Cruz, Kris Prenger,
Dzhamilya Sadykova, Rachel Tolhurst, Catriona Waddington,
Pongsadhorn Pokpermdee, Christian Aid, CARE International. We
would also like to thank two anonymous referees for their comments
on an earlier draft. The World Bank provided funding to carry out
Tim Ensor, BSc, MA, DPhil, is currently a senior research fellow in
the Dugald Baird Centre for Reproductive Health, University of
Aberdeen and principal economist, Oxford Policy Management. He
undertook this work while at the University of York, where he has
taught and researched health financing issues in low- and middle-
income countries for the last 10 years.
Stephanie Cooper, BA, PG Diploma, works in the Centre for Health
Economics, University of York, on the implementation research
work-programme of the Initiative for Maternal Mortality
Programme Assessment run by the University of Aberdeen. She is
active in the development community and is currently completing a
Correspondence: Tim Ensor, International Programme, Centre for
Health Economics, University of York, Heslington, York, YO10
5DD, UK. Tel: +44 (0)1904/433716. Fax: +44 (0)1904/432701. E-mail:
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