How Do Clients and Providers Together Shape Access to Care in a Context of Poverty? : A Case of HIV Services in North-Central India

Background: Access to health care is a complex concept that includes both client and provider factors. Clients and providers face severe constraints in accessing and providing health services in resource-constrained environments with rampant poverty. For clients, barriers to access to care may include, but are not limited to, affordability, geographic access, and socio-cultural acceptability of the care. On the provider’s end, access requires that the services have relevance, quality and effectiveness for clients.

          Women living in poverty with HIV face severe barriers to access, complicated by lack of education, health information and face challenges such as poor transportation facilities to hospitals or lack of community supports.  While women’s barriers to access are well known, there is limited evidence about which behaviors on the client-end and provider-end facilitate, and which hamper, access to health services, especially for populations living in poverty.  To address this gap in literature, we present a contextual analysis of how clients and health-providers mutually facilitate or hamper access to HIV/AIDS health services in a district in north-central India.

Methods: The analysis is based on narratives from 33 women living with HIV and 15 health care providers in a district in north-central India. Women and health workers separately participated in semi-structured, in-depth interviews lasting from one to 3 hours. Access to participants was gained through non-profit agencies directly serving local communities. Women were asked questions about difficulties in accessing services and health workers were asked about difficulties in the provision of services. Data were thematically coded in Atlas-ti qualitative software and an audit-trail, member-checks and peer-debriefing were applied to ensure rigor. A post-hoc analysis of data revealed fit with Gullifard and Morgan’s (2013) conceptualization of access to care and ‘resilience’ at an individual level. 

Results:Women’s resilient actions and behaviors such as positive management of threats of stigma and discrimination, prudent decision-making about how and with whom to share their HIV-status, and engagement in financial savings towards health management enhanced access to care.  However, women’s uncritical acceptance of health messages delivered by health workers to women, impeded women’s access to care.

        From the provider’s end, health workers encouraged women to maintain high ART adherence, but they had limited involvement in identifying and addressing women’s psychosocial needs which impeded women’s access to care. Health workers worked to improve gender balance among staff to improve socio-cultural acceptability of women’s interactions with health workers during the home visit which improved access to care. Yet, health workers preferred not to visit clients at home which led to limited opportunities for women’s needs to be assessed and addressed, thereby impeding women’s access to care.

Implications and Conclusions:This study has implications for the utilization of women’s resilience as an underexplored aspect of client service utilization that plays an important role in the receipt of services in poverty-stricken contexts.  Provider’s implementation of ‘short-cuts’ lead to simplistic solutions that sometimes fail to address and resolve clients’ problems. We urge complete biopsychosocial assessments including barriers to care that affect clients in resource-constrained settings.