The focus of this report, like the committee's deliberations, is on access to personal health services—the one-on-one interaction of provider and patient. The committee chose five objectives of personal health care to organize its indicators: successful birth outcomes, reducing the incidence of preventable diseases, early detection and diagnosis of treatable diseases, reducing the effect of chronic diseases and prolonging life, and reducing morbidity and pain through timely and appropriate treatment. This specific focus on personal health care does not gainsay the important investments society can make in population-based strategies in such areas as the environment, pollutants, health education, occupational health, and injury control. Policies in these fields could potentially save more lives and have a greater impact on quality of life than programs to extend health services. Nonetheless, the large proportion of the nation's resources being devoted to personal health care has provoked considerable interest in monitoring those investments from the standpoint of equity of access.

The IOM committee's approach to developing indicators was to find measures that would track the use of services known to have measurable effects—for example, prenatal care. An outcome of using these effective services—fewer low birthweight infants—is also an indicator of access to services that can be monitored. Analysis of these indicators would provide information on the effects of health policies; the data could be used in turn in making choices with regard to the three major concerns of health care policymaking: access, quality, and cost.

This study had two key objectives: first, to propose an initial set of indicators that lays the groundwork for the evolution of a monitoring system and, second, to use those indicators to assess the current state of access at the national level. The first objective entailed clarifying what is really meant by saying we want to improve access and translating concerns about who cannot get what type of care into a limited and cohesive set of indicators that can offer reliable and valid measurements. Applying these indicators to produce an assessment about access, the second objective, involved obtaining a decade's worth of data, analyzing the data, and interpreting the meaning of trends.

Although the state of the art of monitoring access is still at an elementary stage, there is sufficient information available to draw some important conclusions. In most instances the basic data bases exist to measure the indicators chosen, but crucial modifications in how and when data are collected are necessary to make them more useful for monitoring. The committee offers numerous recommendations in this report for the data collection and research needed to push the evolution of monitoring forward at a faster, surer pace.



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