Economic Accessibilty to
Healthcare: Is it an Issue in
our Publicly-Funded Health
System?
Jeannie Haggerty, PhD
St. Mary’s Research Centre
McGill Research Chair in Family & Community
Medicine at St. Mary’s
Accessibility in Canada
 Commonwealth and Statistics Canada
surveys indicate that healthcare
accessibility has declined in Canada
 We now rank lowest among peer
countries for primary care accessibility
 Improving accessibility has been a
major policy focus in Canada; focus on
wait times.
 Economic accessibility is off the radar
Canada Health Act
 National principles for public health care
insurance plans to qualify for full federal
cash transfers for health
 Public administration, universality,
comprehensiveness, portability,
accessibility
 Accessibility: Insured persons must
have reasonable and uniform access to
services, free of financial and other
barriers.
Accessibility: Definition
 Characteristics of health systems that
impede or promote the utilisation of
services (Donabedian).
 Characteristics of geographic availability,
organisational processes, costs and
acceptability that facilitate people’s capacity
to reach and use services (Thomas & Penchansky)


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Geographic accessibility
Organisatonal accessibility
Economic accessibility
Cultural accessibility
Economic accessibility
 The extent to which direct and
indirect costs represent barriers for
people to reach and use health
services that they need.
Accessibility: core attribute of
primary health care
 First Contact Accessibility: The ease with which a
person can obtain needed care (including advice
and support) from the practitioner of choice within
a time frame appropriate to the urgency of the
problem
 Accessibility-accommodation: The way primary
healthcare resources are organized to
accommodate a wide range of patients’ abilities to
contact healthcare providers and reach healthcare
services (telephone services, flexible appointment
systems, hours of operation, and walk-in periods).
Accessibility: a counter-intuitive
finding
 2002 multilevel survey of primary
health care practice, Quebec
 100 sites, randomly selected: data
from clinics, physicians, patients
 Stratified geographically:
metropolitan, suburban, rural, remote
 Stratified by pratice type: community
health clinic, group clinics, solo
practice
Haggerty, Pineault, Gauthier et al, Multi-level PHC survey,
2002-2004, CHSRF funded
Accessibility: a counter-intuitive
finding
 Patient-reported accessibility
improves with increasing rurality
 First contact – higher confidence in being
seen within one day
 Accommodation – better ratings of
location, opening hours, wait times,
ability to speak to doctor by phone
 Yet: longer distances, fewer local
alternatives, restricted physician
availability.
Explanatory hypotheses:
A programme of research
 The way rural services are organized
makes them more accessible
 Types of organizational models
 Professional practices
 Measurement artefact
 Expectations are lower in rural areas
 Tools not sensitive to rural barriers
Haggerty & Gauthier et al, Accessibility to healtcare for
rural and remote communities, 2004-2009, CHSRF funded
Rural-Urban Measures of
Accessibility: Objectives
 To identify factors in rural areas that
facilitate or impede initiation of firstcontact care, ongoing primary care,
and follow up of referrals to
secondary care
 To develop and validate additional
measurement items of primary and
secondary accessibility that are not
addressed in existing questionnaires.
Haggerty, Levesque, Roberge. Accessibility Measures,
2005-2010, CHSRF funded
Rural-Urban Measures of
Accessibility
Sequential mixed-method study
1. Qualitative exploration of urban and
rural care-seeking trajectories
2. Development and quantitative
validation of new measures
3. Two administrations of measures to
random sample from urban and rural
locations
Qualitative exploration of access
barriers and facilitators in rural
and urban contexts :
Phase 1, 2004, Qualitative study
To identify factors in rural areas that
facilitate or impede initiation of first-contact
care, follow up of referrals to secondary
care, and ongoing primary care
Qualitative exploration
 Focus groups
 Geographic contexts: two types of urban,
two types of rural
 Metropolitan (4), towns (2)
 Rural agricultural (2), scattered villages (3)
 Interview schedule: focus on typical care
trajectory and responses to barriers;
probing for geographic, accommodation,
cost and cultural elements
Results:
 Major barriers/facilitators to access
in typical care-seeking trajectory
1.
2.
3.
4.
Regular source of care
Organizational accommodation
Geographic access
Personal resources (economic,
educational)
 Consequences of barriers to care
Why is observed accessibiliy better
in rural areas?
 Social networks in rural areas result
in better organizational
accommodation and flexibility
compared to urban areas
 Long wait for appointment is the
norm, as is individual accommodation
 BUT: processes are not formalized, so
not everyone has equal access.
 Socio-economic status affects
organizational and geographic access
Organizational Accommodation:
 Information about the options
 Role of practice secretary: assess urgency, suggest
care alternatives, give health advice, facilitate
 Personal information agency : individual’s capacity to
obtain information by own means; independent
facilitator for access
 Organizational flexibility
 Secretary accommodates individual requests to make
shorter waits for care: squeeze in between
appointments, telephone consultation
 Social network matters
Geographic accessibility: getting to
care
 Expressed in travel time and local
availability of alternatives
 Perception of distance as a barrier depends
on:
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Personal mobility
Personal access to transportation
Type of problem
Acceptability of provider
Other opportunity costs
 Not usually an issue in rural areas – except
for those with few personal resources
Conclusion:
 Low socio-economic status as generic
barrier to health services (social
exclusion)
 Low personal information agency
 Lack of personal transport makes
geographic distance a barrier
 Restricted social network reduces
organizational accommodation
 Indirect and direct costs impede care
Conclusion
 Persons at risk of social exclusion are
also at risk of poor accessibility
 In Canada, little exploration of
economic barriers to access
Development and quantitative
validation of new measures:
To develop and validate additional
measurement items of geographic,
organizational and economic accessibility
that are not addressed in existing
questionnaires.
 Explore the prevalence of economic
barriers to care
Development of new measures
 Codes for barriers or facilitators from
qualitative analysis developed into
quantitative « items »
 Consequences, indicators of problem
access: nuissance, emergency room, unmet
needs, problem aggravation
 Telephone administration to 750
respondents in metropolitan rural
(Longueuil), agricultural (Montérégie), and
remote areas (Côte-Nord)
Validation: analysis
 Exclusion of bad items (>5% missing, no
variation).
 Exploratory factor analysis to identify
constructs and sub-scales
 Predictive modelling against consequences:
nuissance, unmet needs, emergency room
use, problem deterioration
 Item response modelling to identify
discriminatory capacity of items and
differential item functioning by rural-urban
Quantitative component: test of
new subscales, new instrument
 Refinements made in light of analysis
and new cognitive testing
 Self-administered format
 Mailed to 368 of previous
respondents who accepted to be
contacted (86% responded)
Results
Accessibility Measure
Indicators of problem access
 Can be divided into minor (nuissance)
and major problems
 Provide a good portrait of health care
accessibility
 Nuissance
 Use of emergency room for system
reasons
 Unmet needs for care
 Problem aggravation due to delay
Organizational accommodation:
Description
 New items (more discriminating for rural)
 Ease of getting information to solve health problems
 Ease of contacting the clinic by phone
 Ease of getting medical advice by phone
 Ease of getting shorter-than-usual wait for
appointment for urgent care
 Available structures for rapid care


Rating of usual wait for appointment
Ease of talking to doctor by phone
 Each unit increase in accessibility associated
with decreased likelihood of
 Nuissance (OR=0.47)
 Unmet needs (OR=0.34)
 Problem aggravation (OR=0.40)
Effect
stronger in
rural areas
Geographic accessibility:
Description
 5-items
 Perceived proximity of clinic
 Ease of getting there for urgent care and for
routine care,
 Travel time
 Number of local alternatives
 Distance to clinic cited as reason for ER
use (6%) and unmet need (10%)
 Each unit increase in accessibility,
decreased likelihood of :
Effects stronger
 Nuissance (OR=0.42)
 Unmet need (OR=0.44)
in the poor
Prevalence of Economic Barriers
 Payment for services (labs, exams or
not covered by public insurance
 20%
 Usually have revenue loss when
getting healthcare
 22%
 Usually have significant indirect costs
when getting healthcare
 24%
Economic accessibility:
 Frequency cost-related unmet needs or
difficulty (% ever among all vs. lowincome)
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Don’t take prescribed meds
Don’t do lab tests or exams
Don’t get uninsured services
Difficulty from income loss
Difficuty from indirect costs
 Items scored dichotomously (never vs.
ever) and summed to indicate number of
problems (range 0 to 5)
Economic Accessibility:
 Each unit increase in reported cost problem
(poor economic accessibility) associated
with increased likelihood of:
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Nuissance: OR=1.8
(1.5
ER use:
OR=1.9
(2.4
Unmet neet: OR=2.8
(3.3
Problem aggravation: OR=3.4
in poor)
in poor)
in poor)
(5.9 in poor)
Examination of economic
accessibility in an
independent sample
Cohort of approximately 2500 adults
in four Quebec local health networks,
2010.
Compare poor and non-poor
Haggerty & Fortin, At the interface of the community and the
Health system, 2008-2013, CIHR
Measure of self-perceived
financial status
 What word best describes your
current financial situation





Very comfortable
Comfortable
Tight
Very tight
Poor
« poor »
Bottom 25%
Health Status of poor vs. Nonpoor
Poor
Number of chronic illnesses
Non-poor
3.5
2.5
56%
44%
Physical component
44
49
Mental component
45
50
3+ chronic illness
Functional health status
Prevalence of cost related
unmet needs: poor vs non-poor
Experienced difficulties in access
because of costs
Don’t take prescribed meds
Don’t do lab tests or exams
Don’t get uninsured services
Difficulty from income loss
Difficulty from indirect costs
Poor
Non-poor
18%
5%
10%
4%
25%
13%
21%
8%
13%
3%
80% of poor report at least one vs. 20% of
non-poor
Indicators of problem access:
Nuissance
 Did you have to make several attempts
to get the healthcare you needed?
Poor
Non-poor
Never
39%
47%
Rarely
47%
43%
Sometimes/often
14%
10%
 But poor experienced lower
organizational accessibility.
Indicators of problem access:
Use of Emergency room in last year
 32% overall
 16% for system-related reasons only
 20% poor vs. 15% non-poor
 Top reasons (rank order)
 No family physician or own not available
 Clinic not open when I could go
 Difficult to get appointment or wait too
long
 To get tests or see specialist within
reasonable time
Indicators of problem access:
Unmet needs for care
 Needed healthcare but didn’t get it
 21% overall
 17% poor vs 14% non-poor
 Top reasons (rank order)
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
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Wait for appointment too long
Difficult to make appointment
Regular doctor or clinic not available
Clinic hours not convenient
Indicators of problem access:
Problem aggravation
 Health problem became more serious
because it took a long time to get
healthcare
 9% overall
 15% poor vs. 7% non-poor
 30% with at least one major access
problem (ER use, unmet need, problem
aggravation)
 37% poor vs. 28% non-poor
Findings are coherent with
other studies
 Commonwealth Survey 2001
 Difficulty getting care off-hours, 19%
poor vs. 13% non-poor
 Difficulty seeing specialist 20% poor vs.
15% non-poor
 Did not fill a prescription 22% poor vs.
7% nonpoor
 Did not get needed dental 42% poor vs.
15% non-poor
 Situation may be better in Quebec for
some issues
Conclusion
 Accessibility to healthcare has
declined in Canada
 Our study confirms this
 Policy focus is on organizational
accessibility
 BUT important inequities in access
persist
 The poor get systematically poorer
access to health services
Accessibility:
the Canada Health Act
 In Quebec’s public insurance system,
poor people face more financial,
geographic and organizational barriers
to getting timely services despite having
greater health needs
 We are not achieving uniform access to
services as per the Canada Health Act
 Liberalization of the CHA framework
unfairly affects the poor
Conclusion and Implication
 Economic accessibility IS an issue in our
publicly-funded system
 To make this a policy focus, we need to
shake the myth that we have solved the
problem of economic accessibility for
necessary medical services in Canada
 We need to evaluate the performance of
the system in how well it does for those
with limited ability to advocate for
themselves