Table 1 Guide for data analysis using the Tanahashi framework for effective coverage

Availability

[folder: availability]

• Insufficient number or density of health facilities; [code: facility]

• No outreach mechanisms/ community-based service points; [code: outreach]

• Insufficient supply and appropriate stock of health workers, with the competencies (including through access to ongoing training), and skill‐mix to match the health needs of the population; [code: HW mix and competencies];

• Lack of equitable distribution of health workers taking into account the demographic composition, rural‐urban mix and under‐served areas or populations; [code: HW distribution]

• Lack of medicines responding to population needs; [code: medications availability]

• Scarcity or poor quality of, or insufficient maintenance of necessary equipment (e.g. equipment for exams, wheelchairs for patients, etc.); [code: equipment]

• Weak laboratory system or inadequate cold chain; [code: lab cold chain]

• Services not available in any location perceived as close enough to be realistically reachable, for the given health condition of concern [e.g., cancer or other NCDs services only available in capitol city or abroad, GBV services only available in capitol; [code: no service]

• Inadequate ambulance services and/or transport methods/vehicles for mobile health units/home-care visits; [code: no med vehicle]

• Shortage or poorly functioning basic amenities like electrification, improved water and sanitation, and waste management in health facilities; [code: amenities]

• Lack of adequate computer equipment, IT connectivity and phone services (including for outreach services, telemedicine, by either provider or patient). [code: ITC equipment]

Accessibility

[folder: acessibility]

Geographic and physical:

- Distance and time for travelling to health service point; [code: travel time]

- Lack of appropriate mode of transport; [code: travel method]

- Unsafe terrain or weather conditions, impassable roads due to quality, road blockages due to conflict/insecurity, unsafe location of service point; [code: unsafe conditions]

- physical accessibility of facilities for people with physical and/or cognitive disabilities; [code: accessible for disabled]

Financial – covering both financial barriers and drivers of financial hardship

• Direct: official out-of-pocket expenditures for services (e.g. co-payment for services, laboratory tests, exams); [code: direct service costs]

• Direct: official out-of-pocket for medicines and health products (e.g., assistive devices); [code: direct medprod costs]

• Indirect: transport and accommodation costs linked to using services; [code: indirect transport costs]

• Indirect: opportunity costs (e.g. lost work, costs of child or elder care in absence, paying someone to do one’s job during absence (e.g., manage livestock/farm); [code: indirect opportunity costs]

• Informal payments (cash or in-kind). [code: informal payments]

• Public health service capacity and provider incentive structure influencing patients use of private services; [code: private public interface]

Organizational and informational:

• Attention to opening times in synergy with when people are available to access services; [code: opening times]

• Systems to schedule appointments and waiting times/timeliness; [code: scheduling]

• Administrative requirements for care (e.g. registration in local area); [code: registration]

• Lack of access to culturally and linguistically appropriate health information, which consider some populations’ world views and cultural practices; [code: culturally relevant info]

• Delivery of health information not considering the most appropriate communication modalities influenced by, for example illiteracy rates, limited access to technology and internet connectivity, preferred use of TV or radio over written materials, etc. [code: communication modality]

• Lack of awareness of rights and obligations (demand-side) [code: awareness]

See acceptability for: Barriers related to power dynamics and inequalities (e.g., resulting in lack of autonomy to make decisions about one’s own health) and fear of/previous experiences of discrimination based on gender, ethnicity and other grounds that make people not want to access services

Acceptability

[folder: acceptability]

• Cultural beliefs and preferences (e.g. differing views of health and illness) and coordination/integration with indigenous/traditional medicine systems; [code: culturally acceptable services]

• Gender norms, roles, power and relations which inhibit access (e.g. limited autonomy of some women in deciding when to seek care, patient only being allowed to or wanting to see a same sex provider, or gender norms on masculinity that delay treatment seeking); [code: gender norms]

• Age-appropriateness of services (e.g. are adolescent-friendly services provided); [code: age]

• Services that account for biological differences by sex (e.g., CVD services that account for specific differences in manifestation of symptoms of a heart attack between men and women); [code: biological differences]

• Negative perceptions of service quality (including the quality dimensions of equity, safety, effectiveness, people-centredness, efficiency, timeliness, and integration); [code: quality perceptions]

• Trust in the health system (linked to perceptions of transparency and accountability, and experience with corruption); [code: trust]

• Discriminatory attitudes by providers (e.g. based on sex, gender, ethnicity, marital status, religion, caste, disability, health status, or sexual orientation of the person seeking care); [code: discrimination]

• Extent to which confidentiality is protected; [code: confidentiality]

• Attractiveness compared to alternative/competing options for using one’s time and resources (e.g. health promotion services are available, accessible and acceptable, but less attractive compared to other activities). [code: prioritization]

Contact

Contact coverage refers to the actual contact between the service provider and the user when services are available, accessible and acceptable

Effective coverage [folder: effective coverage]

• Lack of diagnostic accuracy (influenced by lack of diagnostic equipment and other factors such as gender unequal/blind protocols); [code: diagnostic capacity]

• Insufficient provider compliance (e.g. related to low levels of training, lack of supportive system requirements such as protocols and guidelines, and deficient overall quality control mechanisms); [code: provider compliance]

• Weak referral and back-referral systems; [code: referrals]

• Inadequate treatment adherence (e.g. due to unclear instructions, poor patient-provider relationship, mismatch between treatment prescribed and patient compliance ability, adverse social conditions and gender roles/relations); [code: patient adherence]

• Stigmatization caused by service usage that disrupts treatment adherence and/or otherwise negatively impacts patients’ health. [code: stigmatization]

• Dual practice influencing patient pathways and service costs [Code: dual practice]

• Lack of integrated care for people with comorbidities and/or social-health care for person requiring both synergistically [Code: integrated care]

Link to financial hardship dimension of UHC:

Catastrophic or impoverishing expenditures or detrimental sale of assets incurred during the process of care that force the patient to stop treatment before it is completed hence impacting on effective coverage (and looping back to barriers under financial accessibility). [code: financial hardship]