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Dear Francisco, Your question, to which you answered "yes", was " it believable that “almost all” Chilean children have access to clean water, electricity, sanitation and schools?" However, does that really tells us that much about inequalities in 'access opportunities' faced by Chilean children? A little project is being carried out at UNICEF, investigating ways to assess how non-financial (e.g. social) barriers to access can be identified, and then incorporated as a practical and actionable part of the routine planning process undertaken by district health managers. Being early days, we were discussing just what ‘access’ means, and how to measure it. We offer no potential answers, but our questions may have a few practical implications for an assessment of the equality (or equity?) of opportunity to access. For example, was access defined as: "ever accessed", "accessed once within a certain period of time"; "accessed the last time it was sought/needed"; “accessed consistently over a period of time”; etc. Its definition shapes its measure, and how equality of opportunity will be judged. Yet definitions vary greatly across different survey methods. Going further, the equality of opportunity seems to be a product of a series of access opportunities, as well as the appropriateness and quality of each of them, instead of simply the current measure of opportunity. One well known aspect is that equality of nominal access is not synonymous with equality in its utilization. What if, for instance, the only option provided a sub-population was to access mostly curative services, i.e. they were systematically denied over time the opportunity to use promotive and preventative services? Legal barriers may have forbidden unescorted women to seek preventive care, allowing complications of pregnancy to be fatally under-diagnosed. Another aspect is the appropriateness of the accessed interventions. Perverse incentives may drive health providers to focus on curative, instead of preventive interventions, particularly where primary health care for the poor is free of user fees. Nor is it uncommon to see too few resources spent on reaching at-risk groups with culturally effective promotive services, to motivate healthier behaviours. Was it really a lifestyle choice if the messaging on alternatives never reached someone? (much of Roy Penchansky’s report on defining access is still relevant 1). Even if the interventions were appropriate and utilised, does that signal equal opportunity existed? A measure of access still may mask over inequality in the effectiveness of coverage; that is, the quality and thus impact of interventions may vary inequitably across sub-groups and over time. Poorer and more rural areas often have a lower quality health product, with less-trained and inexperienced staff, leading to a correspondingly lower likelihood of reducing incidence or severity of illnesses. The net effect of skewed and low quality access would progressively concentrate an inequitable burden of illness in certain groups. This seems the case in the mounting inequities in health outcomes within countries, despite overall national progress towards health MDGs in the aggregate. This explains in part the interest in finding ways to help district health managers diagnose financial and non-financial (e.g. social) barriers to access faced by various at-risk groups, and across the full continuum of care. A driver of equity in opportunities for healthy outcomes will be (in part) local managers working across nutrition, health, education and other social welfare programs to identify and help overcome social barriers. This still would need to be coupled with empowering civil society groups to give the excluded the voice and power to demand appropriate and quality health services. Achieving universal coverage with all needed primary health services will require more research, including investigating how health managers closest to the ‘poorly-reached’ and ‘never-reached’ can identify what is going wrong, and what to do about it, through very user-friendly approaches reliant on local data collection and analysis. 1. Defining and Measuring Access to Essential Drugs, Vaccines, and Health Commodities, 2000