This document discusses the three pillars of health policy: access, quality, and cost. It defines key concepts related to access such as availability, affordability, and acceptability. Models for determining access like Andersen's Behavioral Model and the Eight Factor Model are presented. Quality is discussed in terms of measures like infant mortality and factors like safety, effectiveness, and disparities. Cost drivers and strategies for lowering costs through prevention and care coordination are also examined.

1. Access, Quality, and Cost: The
Three Pillars of Health Policy
Nancy M. Short DrPH, MBA, FAAN
Associate Professor
Duke University School of Nursing

2. What makes a country “developed” ?
International criteria :
Disagreement among authors
Agree on some strong distinguishing characteristics
 High incomes per capita
 High GDP per capita
 Industrial dominance
 U.N. Human Development Index (HDI) ≥ 0.788
o Measures life expectancy and education levels
“A country that allows all its citizens to enjoy a free and healthy life in a
safe environment.” - Kofi Annan, Secretary General of the United
Nations, 2008

3. Patient care is a highly political endeavor!

4. Catalysts for Health Policy
COST
QUALITY
ACCESS

5. ACCESS to healthcare
Complex concept
• “Having access”:
Are services available?
Is there an adequate supply of services
• “Gaining access/Utilization”:
Financial affordability
Physical/organizational accessibility
Social and cultural acceptability

6. ACCESS to healthcare
• Defining access to care
What does “universal” mean?
What does “coverage” mean?
• Measuring access to care
Trends in monitoring access
 Demand & Supply
• Lack of consistency in terminology

7. Concepts within “Access”
Health supply terms
Availability
Affordability
Health demand terms
Utilization
Acceptability
Access =
how much a population can
reach health services
Coverage =
the share of a population eligible
(beneficiaries) for a set of interventions

8. Key points on the concepts :
Use the term universal "access" instead or universal
"coverage"

Avoid benchmarking "universal" in absolute terms
Use of the term "coverage" associated with outcome
(intervention) indicators
The term "universal access" can be completed by its
target expressed in "universal access at 80% of
coverage" for a specific intervention

9. Key points on the concepts (2):
Measuring "access" may actually measure just one or a
few domains of access (like availability, affordability
and/or acceptability), but rarely all of them
Define country targets in national context instead of
focusing on global targets
Define target taking into account the measurability of the
targeted entity (e.g. district or population)
Overall, the concepts of access, coverage and associated
terms are not standardized across programs, so there is
room for flexibility.

10. Concepts within “Access”
Universal
 Qualitatively, it gives a sense of equality, indivisibility
 Quantitatively it can be "all" or "enough for everyone to get a
chance"
Target
 Can be an outcome, prevention, or treatment target
 Scopes of target (global, country)
 Targeted entity: % of population, population group, group at risk,
a group in need, districts, facilities … (measurability)
Scaling-up
 Expand geographically
 diversify
Intervention vs. services

11. ACCESS to healthcare
Models for Determining Access:
1. Andersen’s Behavioral Model of Health
Services Utilization
2. Health Care Access Barriers (HCAB) Model
3. Eight Factor Model

12. Andersen’s Behavioral Model of
Health Services Utilization

13. Carrillo JE, Carrillo
VA,Perez HR,Salas-Lopez D,
Natale-Pereriea A, Byron AT.
(2011). Defining and
targeting health care access
barriers. J Health Care Poor
Underserved. May;22(2):562-
75.
Healthcare
Access
Barriers
Model

14. Measuring “true access”: Eight Factor Model
“Being able to get to and from services, having the
ability to pay for services, and getting your needs met
once in the system.” - Margie Lovett-Scott EdD, RN
and Faith Prather PhD
ACCESS to healthcare

15. Eight Factor
Model

16. COST of Healthcare
Country Health
Expenditure per
capita in US $$
Health
Expenditure as
% of GDP
United States $8,508 17.7
Switzerland $5,643 11.0
Canada $4,522 11.2
United Kingdom $3,405 9.4
Japan $3,213 9.6
Singapore $2,592 4.5
Argentina $1,321 8.3
Russia $1,277 6.5
Saudi Arabia $ 914 4.0
Cuba $ 414 10.2

18. Why does it matter how much we spend
on sickness and health care?
COST of Healthcare

19. Included Not Included
What’s Included in “Cost”?
 Fixed costs
o Facilities
o Utilities
 Variable Costs
o Labor
o Benefits
o Risk
 Payments for services
 Losses from non-payments
 Payments for goods
o Distribution costs
 Opportunity costs
o Loss of productivity
 Costs of educating health
professionals
 Bureaucracy
o Government
o Insurance
o Lobbying
 Research & Development
 “Black market” for health
care
 Negative externalities
o Hospital waste
 Expenditures on health
determinants

20. Life Expectancy at Birth (years) and
Health Spending by Country, 2010

21. Why Can’t We Keep On Spending
More and More?
Adverse employment effects in United States
RAND predicts 10% increase in health care cost =
120,800 jobs lost
Loss of Employer Sponsored Health Insurance
Shifting costs to employees
Employer Health Care Burden
Health benefit costs as a share of hourly pay in US =
13%, in Germany = 6.5%, in Japan = 3.7%, Canada =
4.5%

22. How to Lower Costs?
Eliminate care of little to no value
o Limit technology acquisition
Eliminate redundant tests
o Incentivize providers
Eliminate medical errors
o Greater information technology
Improve prevention and coordination
Funding innovation (pay for performance?)

23. Measuring cost of care
is easier than measuring
the VALUE of that care
COST of Healthcare

24. Quality of Healthcare
Measuring “quality”
 Health status of a country
 Population density
 Infant mortality
 Death rates
 Levels of communicable disease
 Ability to respond to health emergencies
“Although most of us probably believe that low quality is primarily a
reflection of inadequate financial resources, there is good evidence
that quality can be enhanced in a number of ways even in the absence
of additional resources.” -- Richard Skolnik, Director of International
Programs for the Population Reference Bureau

25. Quality of Healthcare
Variation in care: Geography is Destiny
 Access to care
 Compliance with evidence based guidelines
 Monitoring effectiveness of care
Types of Errors:
Underuse of services
Overuse of services
Misuse of services

26. Quality of Healthcare
The Institute of Medicine has identified six aims of quality medical care:
1. Safety: ensure that the medical care intended to benefit patients is
not causing harm.
2. Effectiveness: Medical treatments must be based on scientific
knowledge, and must produce beneficial, measurable results.
3. Patient-centered: Care must be tailored to individual patient
preferences, needs and values. Patients should have authority over
their own medical care, and their input must guide clinical decision-
making.
4. Timeliness: Patients requiring medical attention should have access
to timely healthcare and follow-up care to avoid potentially harmful
delays in treatment.
5. Efficiency: Quality health care avoids wasting finances, time,
equipment, and energy. Efficiency maximizes the impact of global
health organizations.
6. Equitability: The quality of medical care must be consistent across all
patients, irrespective of gender, ethnicity, socioeconomic status, and
other personal characteristics.

27. Quality of Healthcare
Disparities in quality of healthcare
 Data collection and reporting varies from country to country
 “Racial or ethnic differences in the quality of health care that
are not due to access-related factors such as insurance
coverage, or clinical needs, preference and appropriateness
of intervention.”
United States
 National Healthcare Quality Report and
 National health Disparities Report available at:
http://www.ahrq.gov/qual/measurix.htm#quality

28. Quality of Healthcare
Are all disparities in health related to “disparate”
health care or access?
All people are not born equal. Individual differences in
genetic endowment may well control differences in life-
expectancy. Even if all individuals are subject to the same
environmental influences, they would not flourish, age, and
dies at the same rate. -George Orwell

29. Quality & Safety
Institute for Healthcare Improvement in U.S.
National Institute for Clinical Excellence in U.K.
Joint Commission International
International Association of National Public Health
Institutes
International Society for Quality Health Care (ISQua)
WHO, Pan American Health Organization, Canadian
Council on Health Services Accreditation , others
IOM

30. What Can Leaders Do?
 Shift focus from management to leadership
 Decentralize care delivery…greater focus on
primary care
Strive to level the “playing field” between the
impoverished and the affluent ( equal healthcare
for all)
 Adopt and implement mhGAP (WHO program
toward achieving better outcomes in mental health
care)
 Monitor outcomes including Disability Adjusted
Life Years (DALYs) and Years of Life Lost (YLL)
measures due to communicable and non-
communicable diseases and conditions

31. What Can Leaders Do?
 Promote wise use of antibiotics
 Promote appropriate immunization to achieve
herd immunity
 Support prevention:
 methods for preventing HIV/AIDS
 control of disease vectors (insects,rodents)
 Health in All Policies approach
 Promote research and development
 Consider unintended consequences related to
the interrelatedness of Access/Quality/Cost