2.12 Access to health services See Table 2.12 here

Commentary
About the data
Definitions
Data sources

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The Global Strategy for Health for All by the Year 2000, adopted by the World Health Assembly in 1981, marked a radical change in the orientation of health development. The strategy was aimed at attaining a socially and economically productive life for all people by redirecting national health systems toward an approach based on primary care. Equity in the availability of health services is an underlying principle of primary care and thus a critical element in monitoring progress in implementing the strategy.

The strategy includes a list of indicators for global monitoring and evaluation (WHO 1995, annex 2). The health-for-all global indicator of primary health care is expressed as the percentage of the population with access to at least the following:

Safe water in the home or within 15 minutes' walking distance. Adequate sanitary facilities in the home or immediate vicinity. Immunization against the major infectious diseases.

Local health care, including the availability of at least 20 essential drugs within one hour's walk or travel, trained personnel for attending pregnancy and childbirth, and family planning services.

Access to primary health care has been examined through demographic and health surveys in a limited number of countries. These studies note a wide discrepancy between the proportion of the population considered to have access to services and the rate of utilization of these services. This discrepancy indicates problems of community knowledge, perceived need, or motivation to use the services. The widest discrepancy between accessibility and use is noted for family planning services. But many of the constraints on the use of family planning services—transportation costs, difficulty of access, quality of service—also affect the use of other health services.

Most countries have made significant progress in providing access to primary health care; in others there has been little improvement or even a deterioration.

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Data reported here are provided to the World Health Organization (WHO) by member states in the context of monitoring and evaluating their progress in implementing national health-for-all strategies. Reliable, observation-based statistical data for the indicators do not exist in many developing countries, so in most cases the data are estimates. Such assessments often may be biased by a country's inflated or deflated estimates designed to show either progress or a need for international assistance. Thus the resulting data cannot be used for analytical purposes—and are of limited use for monitoring progress in development efforts, national or international.

Access indicators measure the supply of services but reveal little about benefits or rate of use. For example, access to health care provides no information on the quality of health care or on how the consumption of services differs among groups within a country, region, or community. Moreover, such indicators, unless based on survey statistics, are becoming increasingly less informative in many developing countries. For the poor and for many in rural areas, services by nongovernmental organizations play an increasingly important role, widening the gap between official statistics and the actual production and consumption of many essential services. It is not known, however, whether such services truly replace publicly provided services, and if so, how they differ in quantity and quality from public services. Health care facilities also tend to be concentrated in urban areas. Separate figures for rural areas show much lower levels of coverage and access.

Similarly, while information on access to safe water is widely used, it may have different meanings in different countries, despite the official WHO definition (see Definitions). In many countries child immunization is difficult to measure because of data recording practices. Data on births attended by health staff are from the WHO, supplemented by data from UNICEF. They are based on national sources, derived from official community and hospital records; some reflect only births in hospitals and other medical institutions. Sometimes smaller private and rural hospitals are excluded, and sometimes even relatively primitive local facilities are included. Thus the coverage is not always comprehensive, and the figures should be treated with extreme caution. No cross-country comparison should be attempted for any of the indicators.

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• Percentage of population with access to health care is the share of the population covered for treatment of common diseases and injuries, including availability of essential drugs on the national list, within one hour's walk or travel.

• Percentage of population with access to safe water is the share of the population with reasonable access to an adequate amount of safe water (including treated surface water and untreated but uncontaminated water, such as from springs, sanitary wells, and protected boreholes). In urban areas the source may be a public fountain or standpost located not more than 200 meters away. In rural areas the definition implies that members of the household do not have to spend a disproportionate part of the day fetching water. An adequate amount of water is that needed to satisfy metabolic, hygienic, and domestic requirements, usually about 20 liters of safe water a person per day. The definition of safe water has changed over time.

• Percentage of population with access to sanitation refers to the share of the population with at least adequate excreta disposal facilities that can effectively prevent human, animal, and insect contact with excreta. Suitable facilities range from simple but protected pit latrines to flush toilets with sewerage. To be effective, all facilities must be correctly constructed and properly maintained.

• Child immunization measures the rate of vaccination coverage of children under one year of age for four diseases—measles and DPT (diphtheria, pertussis or whooping cough, and tetanus). A child is considered adequately immunized against measles after receiving one dose of vaccine, and against DPT after receiving two or three doses of vaccine, depending on the immunization scheme.

• Births attended by health staff refer to the percentage of deliveries attended by personnel trained to give the necessary supervision, care, and advice to women during pregnancy, labor, and the postpartum period, to conduct deliveries on their own, and to care for the newborn and the infant.

The table was produced using information provided to the WHO by countries as part of their responsibility for monitoring progress toward "health for all" and reported in the WHO's World Health Report 1996. Data for delivery care are from WHO, Progress Towards Health for All: Statistics of Member States.

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