Health care delivery means getting the right care, to the right person, at the right time, safely and respectfully. A poor outcome is rarely caused by one problem alone. Behaviour, population characteristics, environment, household resources, staff, supplies, leadership and referral systems can combine to delay care or reduce its quality.
- Classify behavioural, demographic, environmental, social and health-system factors affecting delivery.
- Apply the three-delays model to emergency situations.
- Explain equity and person-centred care in the presence of barriers.
- Identify practical EMT actions and system issues that require escalation.
| Factor | How it affects delivery | Provider response |
|---|---|---|
| Health literacy | People may not recognise danger signs, understand instructions or know where to seek help. | Use plain language, demonstrations and teach-back: “Please show me how you will do this at home.” |
| Beliefs, stigma and fear | May delay care for mental health, HIV, sexual health, substance-related problems or violence. | Listen without judgement, protect privacy and explain urgency respectfully. |
| Risk behaviours | Unsafe driving, alcohol/drug use, violence, poor diet and poor treatment adherence can increase illness or injury. | Treat urgent problems first; offer brief prevention advice only when safe and within role. |
| Communication barriers | Language, hearing/vision impairment, low literacy or cognitive impairment may lead to errors. | Adapt communication, allow time, use accessible methods and authorised support where appropriate. |
| Gender and power relations | A person may be unable to decide, travel or pay independently. | Respect autonomy, assess safety and link to appropriate support without exposing the patient to harm. |
Age, sex, pregnancy, disability, household composition, occupation, migration, population density and location shape both health need and service use.
- Children: can deteriorate quickly; require size-appropriate equipment, dosing within scope, warmth and caregiver communication.
- Pregnancy and postpartum period: requires rapid recognition of bleeding, severe headache, convulsions, sepsis and obstructed labour danger signs.
- Older persons: may have multiple conditions, atypical presentation, polypharmacy, falls risk and social isolation.
- People with disability: may face physical access barriers, communication barriers or discriminatory assumptions.
- Mobile/displaced populations: may lack records, social support, a usual facility or secure transport.
| Factor | Effect on care | EMT / facility preparation |
|---|---|---|
| Distance, terrain and road condition | Delays response/referral; makes transport unsafe. | Know routes and alternates; communicate early; stabilise before transfer. |
| Floods, rain and heat | Interrupt access, increase injury and alter disease patterns. | Maintain PPE, water safety, emergency contacts and surge plans. |
| Water, sanitation and housing | Increase diarrhoeal disease, infection risk, burns, injury and outbreaks. | Use infection prevention and report suspected clusters through proper channels. |
| Workplace/community safety | Injury, violence, chemical exposure and unsafe scenes. | Scene safety first; request relevant support; never enter avoidable danger. |
| Electricity/telecommunications | Disrupt oxygen, diagnostics, cold chain, lighting, communication and records. | Check contingency arrangements and keep clear, portable documentation. |
Care depends on trained staff, essential medicines, functional equipment, diagnostics, beds, blood, transport, financing, leadership, data and a reliable referral system. Failure in one area may make all other work less effective.
- Delay in deciding to seek care: poor recognition, fear, stigma, cost concerns, beliefs or lack of household decision-making power.
- Delay in reaching care: distance, transport, weather, road condition, security, communication or referral barriers.
- Delay in receiving quality care: crowding, staff shortage, poor triage, missing oxygen/medicines, delayed assessment, weak communication or unavailable definitive care.
One patient may experience all three delays. The model is especially useful for maternal and newborn emergencies but also explains trauma, sepsis, asthma, stroke and other time-critical conditions.
He delays coming because he fears police involvement and has no cash. Heavy rain later makes transport difficult. On arrival, the facility has no working suction and the referral hospital was not called.
- Delay 1: fear and financial concern.
- Delay 2: rain and transport.
- Delay 3: equipment and communication failure.
- EMT action: scene/primary assessment, authorised emergency support, early escalation and fact-based documentation of equipment and referral gaps.
The waiting area is crowded. Staff repeatedly call the patient’s name but she does not respond and is left waiting.
- This is an access and equity problem, not patient “non-cooperation.”
- Adapt communication, ensure triage is based on clinical need, preserve dignity and avoid assumptions.
Equity means reducing unfair and avoidable differences in health and access. Equal treatment is not always equitable treatment. A patient with disability, language barrier, remote residence, poverty or unsafe home situation may need additional support to obtain the same chance of a good outcome.
- Ask: “What stopped you from coming earlier?” rather than blaming the patient.
- Ask: “Can you reach the referral facility? Do you understand the plan? Who can support you?”
- Keep clinical priority separate from payment status, social standing or personal connection.
- Protect privacy and consent while seeking family/support involvement appropriately.
- Perform structured patient and scene assessment; recognise time-critical conditions.
- Remove immediate barriers you can safely address: clear explanation, privacy, warmth, positioning, pain relief within scope and early referral communication.
- Escalate stock-outs, failed equipment, unsafe routes, violence risk and delayed transfer.
- Document facts—not blame—and safeguard confidential information.
- Use service data, drills and incident reports to support prevention and improvement.
- Factors affecting delivery may be behavioural, demographic, environmental, socioeconomic or health-system related.
- The three delays are decision to seek care, reaching care and receiving quality care.
- Equity requires attention to barriers; it is not simply identical treatment for everyone.
- Scene safety and communication are determinants of both patient and staff safety.
- Give three behavioural factors that delay care.
- Explain the three delays using an obstetric or trauma example.
- How can environmental conditions affect both access and disease pattern?
- Why is a patient with disability at risk of inequitable care?
- List five health-system factors required for safe referral.