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Table 5 Major findings and their impact on abilities and attributes of framework to access by Levesque et al

From: “Everything is provided free, but they are still hesitant to access healthcare services”: why does the indigenous community in Attapadi, Kerala continue to experience poor access to healthcare?

Findings Community Health System Impact
Marginalisation of culture and traditions • Deprived them of use of first line home remedies
• Beliefs around birthing on country, death rituals etc. had impact on access to healthcare
• Dismissed culture and traditions as mere superstitions
• Was unsure of how to handle or integrate it into healthcare delivery
 • To perceive, to seek
 • Acceptability
Lack of community involvement • None of the village chiefs consulted on service delivery mechanisms
• In stark contrast to traditional decision-making mechanisms in the community
• Consultation was more symbolic
• Involvement of village chiefs and elders more to ensure compliance to programmes
 • To perceive, engage
 • Approachability, engagement
Centralisation of healthcare services • Led to spatial exclusion and isolation of community from facilities
• Delayed care seeking
• Compromised quality of care
• Promoted centralisation on the premise of providing better care Abilities
 • reach
 • Availability
Forced compliance • Resented forced compliance to programmes and directives
• Lead to fear and lack of trust in the health system
• Pointed out this was used as last resort for the benefit of the community Abilities
 • To engage, to seek
 • Acceptability
Stigma and Discrimination • Reported universally by Indigenous community
• Larger approach by everyone including health system
• Unconscious bias which was picked up by community
• Led to lack of ownership about health system and impacted trust
• Non-Indigenous health personnel denied any stigmatising attitudes or practise
• Indigenous healthcare providers confirmed that differential treatment and attitudes were a reality
 • To seek, to engage
 • Acceptability
Addressing the broader determinants of health • Raised the importance of land and access to larger social determinants • Some awareness of the impact but pointed out most of the action required was out of the mandate of the health system Not addressed by Levesque et al. but emerged as important in the context of the Indigenous communities.
Financial protection • Aware of free healthcare including referrals
• Aware of reimbursements of indirect expenses and other schemes
• Implemented a complete financial protection package to take care of both direct and indirect costs Abilities
 • To pay
 • Affordability