Despite some serious past efforts to clarify its multiple dimensions and meanings, access to health care has remained a rather elusive concept, hampering the work of health care policymakers and professionals as they endeavor to effect meaningful health care reform. This article provides perhaps the most detailed clarification of the access concept, especially the crucial linkages among the various access dimensions, and presents a comprehensive conceptual framework for evaluation and planning activities as they relate to people's access to health care services. The proposed conceptual model recognizes access as the outcome of a process involving the interplay between the characteristics of the health care service system and of potential users in a specified area, and moderated by health care related public policy and planning efforts. An elaborate typology of access, incorporating four pairs of access dimensions, is also derived. This atomization of the concept allows us to focus on specific aspects of the access to health care problem, and to develop precise outcome indicators of health system performance for evaluative purposes. Further, it enables the access concept and its pertinent dimensions to be put into proper perspective when assessing the health care access situation in a specific national or regional context. The relevance of the proposed access model and the typology to health care planning in general, and to spatial planning of health care service systems in particular, is also discussed.

Access to health care. A conceptual framework and its relevance to health care planning

The field of collaborative health planning faces significant challenges created by the narrow focus of the available information, the absence of a framework to organise that information and the lack of systems to make information accessible and guide decision-making. These challenges have been magnified by the rise of the 'healthy communities movement', resulting in more frequent calls for localised, collaborative and evidence-driven health related decision-making. This paper discusses the role of decision support systems as a mechanism to facilitate collaborative health decision-making. The paper presents a potential information management framework to underpin a health decision support system and describes the participatory process that is currently being used to create an online tool for health planners using geographic information systems. The need for a comprehensive information management framework to guide the process of planning for healthy communities has been emphasised. The paper also underlines the critical importance of the proposed framework not only in forcing planners to engage with the entire range of health determinants, but also in providing sufficient flexibility to allow exploration of the local setting-based determinants of health.

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Rethinking health planning: a framework for organising information to underpin collaborative health planning

Accuracy of the information in health care database systems is essential throughout the health care system for functions such as planning and research. This study examines the reliabihty of the HMRI database, recently amalgamated under the CIHI. It compares selected data items from the in-patient hospital discharge database against a re-abstracted set of data items from the original health record in a sample of six Vancouver acute care hospitals for the fiscal year 31 March 1986 1 April 1987. Cases were restricted to acute care medical and surgical cases. A total of 606 cases using the ICD-9 classification system were re-abstracted using the original health record. Results demonstrated nondiagnostic variables demonstrated an overall agreement of 92.4%. The agreement for the Most Responsible Diagnosis (MRD) to four-digits is 61.4%, while individual hospital scores ranged from 52.0 to 69.6%. For the MRD to three-digits agreement increased to 72.1%, with individual hospitals ranging between 62.4 and 79.4%. The Principal Procedure (PP) agreement to three-digits was 64.8% with individual hospital scores ranging from 56.3 to 75.6%. For the PP at two-digits, agreement was 72.9%, with individual hospitals ranging from 61.4 to 85.4%. Denominators for secondary diagnoses and secondary procedures reflect the total number of diagnoses and/or procedures recorded. Secondary diagnoses to four-digits had agreement scores of 67.4% by number of diagnoses recorded and secondary procedures to three-digits of 80.7% by number of secondary procedures recorded. Total diagnoses and procedures combined demonstrated an overall agrement score of 68.3% with individual hospitals ranging from 61.8 to 73.1%. Agreement by case, where all relevant diagnostic and procedural codes in the entire record matched, dropped significantly to 34.5% for secondary diagnoses and to 59.7% for secondary procedures. The greatest frequency overall for the type of discrepancy was for clerical errors, especially for code books not used properly to determine specificity of the diagnosis. Specificity of the code is required, the information is available in the record, but specificity is not determined by the coder. The greatest frequency of discrepancy for the MRD was 73.1 % for clerical errors. For the PP, 46.9% of discrepancies were in the selection of principal procedure and 42.9% for clerical errors. This study did not demonstrate a significant difference between individual coders by years of experience, by credentials or by years of experience and credentials. It was deterrnined that the data are unsuitable for a quality of care study where the data are utilized beyond the individual hospital site. Care must be taken when utilizing those data for research purposes.

Reliability of the HMRI (CIHI) database : a re-abstracting study

In an overall framework uniting program planning and evaluation, process evalua tion can assist community-based health promotion programs in establishing participa tion objectives, monitoring their achievement and the quality of interventions used, and translating these into useful information for managing and developing programs. This research reports on efforts by the Minnesota Heart Health Program to develop a system that permitted tracking educational program contacts, its implementation, and its use to make management decisions about program activities. The system was devel oped as part of a planning and evaluation framework with specific criteria for develop ing and tracking educational programs drawn from the social-learning literature. Over all, the system helped to make participation objectives more concrete, aided decision making about allocation of personnel and material resources, and encouraged the development of innovative programs.

Measuring and Tracking Education Program Implementation: The Minnesota Heart Health Program Experience

This Working Paper reviews the recent international debates on the role of the state in health
system governance, and uses those discussions to establish the legitimate role of the state in
ensuring the appropriate use of evidence for health policy making. Specifically it examines the
concept of stewardship which has emerged within recent global health governance debates,
applying this concept to the stewardship of evidence. The stewardship function of national
ministries of health was originally introduced by the World Health Organization in the 2000 World
Health Report, but has been subsequently debated by authors who have associated the concept
with a range of government and service provision functions. This paper develops a clearer and more
nuanced understanding of the concept of stewardship to differentiate it from the related, yet
distinct, concept of governance. We argue that the unique, and therefore conceptually useful,
aspect stewardship lies in the way it allocates a single ultimate responsibility for the health of the
population. The WHO has further established that it is national ministries of health, specifically,
which possess the legitimacy to assume the functions as stewards of population health. The
stewardship concept has been established with a range of functional characteristics, including the
appropriate use of information to guide health planning and decision making. Taken together, these
elements have direct implications for conceptualising how to ensure appropriate use of evidence in
health policy. Ministries of health, as population health stewards, tasked with appropriate
information use, possess a responsibility to ensure health system decisions are appropriately
informed by evidence. In order to do this, they must establish institutional structures and
procedures that function to synthesise, disseminate and apply health information and research
evidence for use in policy making.

David F. Bergwall

Papers

Introduction to health planning