This paper investigates the role ofdemand-side barriers in impeding access to the use of healthservices. Demand-side barriers are defined as determinantsof use of health care that are not dependent on servicedelivery or price or direct price of those services. Theyinclude distance, education, opportunity cost, and culturaland social barriers. There is some evidence that thesebarriers are at least as important in determining access toservices as the quality, volume, and price of servicesdelivered by health care providers. The paper is dividedinto two sections. In the first section literature on demandbarriers to accessing services is reviewed. Since theliterature on these barriers is so substantial, the reviewis restricted to an illustrative survey of the main barriersin low-, middle-, and high-income countries. The secondsection surveys studies that report and evaluate methods forovercoming these barriers. The literature here issubstantially less voluminous even when gray and unpublishedsources are included in the survey. Many of the studiesrelate to access to obstetrical and family planning care. Inmost cases evaluation is not rigorous, and it is often hardto separate the impact of the intervention itself from otherconfounding factors. Few of the studies reported have anexplicit poverty focus, although many of the interventionsare conducted in poor areas. There is a clear need forfurther work to examine the most cost effective ways ofreducing barriers to accessing services and in particular toinvestigate what methods are most effective in expandingaccess to essential care among the poor.
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