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Nuancing the need for speed: temporal health system strengthening in low-income countries
  1. Tom Bashford1,
  2. Alexis Joannides1,
  3. Kamal Phuyal2,
  4. Santosh Bhatta3,
  5. Julie Mytton3,
  6. Robert Harrison4,
  7. Peter Hutchinson1
  1. 1NIHR Global Health Research Group for Neurotrauma, University of Cambridge, Cambridge, UK
  2. 2NIHR Global Health Research Group on Burn Trauma, Kathmandu, Nepal
  3. 3NIHR Global Health Research Group on Nepal Injury Research, University of the West of England Bristol, Bristol, UK
  4. 4NIHR Global Health Research Group on African Snakebite Research, Liverpool School of Tropical Medicine, Liverpool, UK
  1. Correspondence to Dr Tom Bashford; tb508{at}

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Summary box

  • Delays in receiving care are of particular relevance to time-critical pathologies, for which quality of care and timely access are fundamentally interlinked.

  • Characterising and improving delays in a health system are complex, and require both quantitative and qualitative understanding.

  • There is mutual benefit to collaboration across clinical, academic and geographical areas of interest in order to understand and reduce delays in accessing care.

Patients with delayed access to medical care often experience worse outcomes. The ‘three delays’ model developed in the context of emergency obstetric care is an important conceptual device for researchers and policy-makers, particularly in resource-poor health systems.1 This model characterises delay in terms of (1) the decision to seek care; (2) arrival at a health facility and (3) the provision of adequate care.

However, ‘access’ is a nuanced term, one that is not simply an issue of geographical resource distribution or population density. A patient may seek care, but be constrained by competing demands or health beliefs. Once sought, the care delivered may be inappropriate. Even after arrival at a healthcare facility that is able to deliver the necessary care, there may still be a clinically significant delay in obtaining it.2

Furthermore, there may be variable prevailing sociocultural attitudes to different conditions, with a biomedical model of time-critical pathology interacting with multiple other narratives.3 Access to care by victims of snakebite may be hampered by a cultural belief …

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