Understanding Access to Care in Zimbabwe: A 3 Delay Model

Introduction: The 3-delay model was first used to describe delays leading to maternal mortality in Malawi. Patient barriers to care can be identified and stratified using this model. We aim to identify unique barriers to care for otolaryngology (ENT) patients in Harare, Zimbabwe.

Methods: Interviews were conducted at three general ENT clinics in Harare in October 2022. The patient population included children and adults presenting to either government or private clinics. Via interpreter, informed consent was obtained and six standardized questions were discussed with each patient. Survey responses were used to categorize patients into each of the 3 types of delays and was agreed upon by two reviewers.

Results: 46 patients participated in this survey, the average age was 21.7 years old. The average time from problem presentation to treatment in this population was 16.3 months. 39% of patients had more than one type of delay contribution (n=18). The most common type of delay was type 3, a delay in receiving care (n=35, 76%). Examples include inadequate referral patterns to providers who were unable to provide appropriate treatment.
Furthermore, some patients reached appropriate facilities but were unable to receive timely treatment due to lengthy scheduling delays up to 2 years. Type 1 delays in seeking care affected 16 patients (35%). Notable causes were fear of doctors, preference for traditional healing, or ignorance to a treatable problem. Type 2 delays in reaching appropriate healthcare facilities were also reported (n=13, 28%). The average reported distance to the hospital was 33 miles, taking 50 minutes on average with majority reporting travel by public transportation. Patients who reported type 2 delays on average lived 50 miles away.

Conclusions: ENT patients in Zimbabwe experience a myriad of delays to receiving appropriate care. Systematic issues including backlogged surgical lists, convoluted referral patterns and poor transportation infrastructure are significant contributors to patient delays. The 3-delay model is a useful tool to identify barriers to care for future efforts to improve patient access.