A Framework to Study Healthcare Access through Mobility and Disruption
ClimHB integrative framework of health system resilience is built on an adapted combination of the Levesque framework on healthcare access (1) and the DFID framework (2) on the resilience process. It frames health system resilience outcomes through the lens of healthcare access, seen here as an essential outcome of the health system resilience and as one of the determinants of population health.
The strengths of this framework are the inclusion of the population as a component of the health system (demand side), side by side and interacting with the health services and providers (supply side), and the inclusion of the resilience process (exposure, sensitivity, adaptive capacities) and its outcomes (healthcare access and population health). We have chosen to include both demand and supply in this framework to include all dimensions of the health system and access to healthcare.
We choose the transfusion bag (in green in the centre) as a health metaphor to graphically represent the supply and demand interactions. The different components (tube, fluid and bag in the strict sense) are explained on both the right and left sides. We pictured in mirror 1., 2., 3. (demand side) and 4., 5., 6. (supply side) because it shares some similarities in its integration in the framework: 1. and 4. are equivalent of exposure, while 2. and 5. are about sensitivity and 3. and 6. are about the adaptative capacities of the system.
Exposure concerns “the presence of people; livelihoods; species or ecosystems; environmental functions, services, and resources; infrastructure; or economic, social, or cultural assets in places and settings that could be adversely affected”(3) and can be measured as an “assessment of the magnitude or/and frequency” of disturbing events (2).
Sensitivity is the degree to which a system will/might be affected by, or respond to, a disturbing event (2), for example, by climate change or variability (3).
Adaptive capacities and abilities are determined by the abilities of systems, institutions, humans and other organisms to adjust to potential damage, to take advantage of opportunities, or to respond to consequences (3), allowing actors “to anticipate, plan, react to and learn from events” (2).
The system’s capacity to deal with all kinds of disturbance depends on exposure, sensitivity and adaptive capacities, with adaptive capacities interacting with the type and degree of exposure and sensitivity. To better understand the figure, the following section aims to present and explain the different components :
(1) Population (im)mobilities refer to a) all mobilities from daily movements to displacement or long-term migration and b) all situations of immobility, undergone or voluntary. Mobility is represented by the red tube, while immobility is represented by the red tube with the knot. The three symbols above refer to all events disrupting the determinants of population abilities and healthcare access abilities, such as sudden shocks (or sudden events), stresses (long-term trends), challenges and chronic tensions affecting the supply and/or the demand sides.
(2) Determinants of population abilities include all socio-economic characteristics of the individuals and their communities, from empowerment to various capitals and health literacy. The red fluid represents it.
(3) Population abilities to healthcare access encompass the five dimensions of access capturing the demand-side determinants (cited in 2.): the abilities to perceive, to seek, to reach, to pay and to engage. This is represented by the red bag (tube and fluid).
Because the ClimHB project focuses on the context of climate change and population mobilities and immobilities, which might influence other determinants, (im)mobility was highlighted from the list of determinants from Levesque and included in (1.) with a focus on migratory status, in interaction with shocks and events. Due to the numerous categories of mobilities that might interact with each other’s, “(im)mobility” was also kept in the determinants (2.), with a focus on physical capacities (ability to move/stay).
Population (im)mobilities, population abilities and population abilities to healthcare access (1., 2. and 3.) are presented linearly because of 2D but are interconnected in 3D; i.e. population abilities to healthcare access might be influenced and might influence both population abilities and population (im)mobilities. Events may (or not) impact mobilities and population abilities.
(4) Routines and perturbations involve all eventsdisrupting or all events, that could, but are not disrupting (represented by the three symbols above) the supply sides’s normal functioning, routines and habits (healthcare services and providers). This includes sudden shocks, stresses and challenges and chronic tensions, which might originate from climate changes and population (im)mobilities, among other events. The pictured straight blue tube represents the usual functioning (routine) of healthcare access from the supply side, and the second blue tube (with a knot) represents routine perturbations.
(5) Determinants of supply-side capacities include all characteristics impacted by or resulting (or not) from the change following the events, such as the building blocks (4), the hardware and software of health system (5) or from information screening to transparency outreach as defined by Levesque (1). The blue fluid represents it.
(6) Healthcare accessibility encompasses the five dimensions of accessibility of services capturing the supply-side determinants (the health system dimensions in 5.):approachability, acceptability, availability and accommodation, affordability and appropriateness.
Routines and perturbations, health system dimensions and healthcare accessibility (4., 5., 6.) are also presented linearly due to 2D but are interconnected in 3D; routines and perturbations are impacting determinants of supply-side capacities, which interact with healthcare accessibility.
Resilience (7.), pictured in green, is the combination of the demand side (red) and the supply side (blue) of healthcare access across exposure, sensitivity and adaptive capacities (pictured in green). Depending on these three components, the healthcare system resilience can be characterized by assessing its outcome: healthcare access (8.), which might collapse, recover, deteriorate or improve compared to the usual trend (state and dynamic, without effects from disturbing events). Here, population health outcomes (9.) are considered the ultimate outcome of the resilience of the system and as an important result of healthcare access. Other determinants of healthcare access are represented in grey.