In this blog post, we’ll examine the AAA analytical framework for understanding access to healthcare in developing countries and explore various issues that arise during the adoption of medical technology through case studies, while also identifying the conditions necessary for medical technology to actually lead to improved health outcomes.

The Gap Between Medical Technology and Access to Healthcare

In Zimbabwe, in southern Africa, rubber bracelets were once all the rage. These colorful bracelets, sold for about 2,000 won for a set of three, were a fashion item for women. Surprisingly, however, these bracelets were made by repurposing female condoms. At the time, as part of its HIV/AIDS prevention policy, the Zimbabwean government was distributing female condoms for free at clinics and hospitals. Merchants took advantage of this by removing the rubber rings from the condoms, painting them various colors—such as pink, yellow, and red—and selling them at markets. This example demonstrates how a technology can be used in ways its developers never anticipated.
Simply developing high-quality medicines, vaccines, and diagnostic technologies and supplying them at low cost is not enough to improve the health of people in developing countries. Today, the issue of access to healthcare is recognized as a major challenge in the global health sector. Here, access to healthcare refers to the extent to which people can utilize appropriate healthcare services when needed and benefit from high-quality medical technologies.
The case in Zimbabwe, where the government actively distributed female condoms but they were not used as intended, serves as a prime example of insufficient access to healthcare. Furthermore, in some regions, people are mistakenly perceived as infected or face social stigma simply for having undergone an HIV test; there are also reports of patients failing to consistently take medications for chronic diseases such as diabetes or tuberculosis due to insufficient behavioral change. As such, merely supplying medical technologies in sufficient quantities and improving their quality has its limitations in ensuring that patients utilize them appropriately. Let us first examine how access to medical technologies can be analyzed.

Healthcare Access Through the AAA Framework

In the field of global health, the AAA framework (Availability, Affordability, Adoption) is widely used among various frameworks for analyzing healthcare access. Researchers use this framework to analyze diverse situations where healthcare access is limited and to diagnose underlying issues. The AAA framework consists of three elements that constitute access: Availability, Affordability, and Adoption.
Availability refers to a series of supply management processes—including manufacturing, demand forecasting, procurement, distribution, and delivery—that ensure medical technologies are reliably supplied to end users. For example, if a supplier fails to accurately forecast potential demand in a developing country, it may not secure sufficient quantities, resulting in medical technologies not reaching those who need them. In fact, according to WHO data, there was a period in the past when the international supply of praziquantel—a treatment for schistosomiasis—fell significantly short of actual demand, and this supply shortage was cited as a prime example of a barrier to access to healthcare. Although supply has increased significantly since then due to expanded international cooperation and donation programs, supply chain issues persist in some regions.
Affordability means that medical technologies do not impose an excessive financial burden on those who need them. This requires consideration not only of procurement costs for governments and international organizations but also of the individual’s ability to pay as the end user. From the perspective of governments in developing countries, the cost-effectiveness must be sufficient, and from the patient’s perspective, the price must be at a level that allows them to actually purchase or use the product. In particular, when pharmaceutical patents expire, the production of generic drugs becomes possible, which promotes market competition and can lead to lower prices.
However, a medical technology is not necessarily good simply because it is inexpensive. This is because excessively low prices can weaken producers’ incentives to continuously improve product quality. If product quality declines, the technology may ultimately not be selected for use in clinical practice. For this reason, the AAA strategy views “Adoption” as a critical factor in healthcare accessibility. Adoption refers to the process by which various stakeholders trust a medical technology, utilize it in actual clinical practice, and ultimately generate demand for it.

Issues Arising in the Adoption Process of Medical Technologies

In the past, when supplying medical technologies to developing countries, the focus was often solely on availability and price affordability. However, as the AAA strategy demonstrates, factors determining access to healthcare are not limited to economic elements such as supply volume and cost. For medical technologies to be used in practice, the adoption process—in which various stakeholders accept them—is of paramount importance.
First, problems can arise during the process by which healthcare professionals—the direct providers of medical technology—adopt new technologies. When deciding whether to use a specific medical technology, healthcare providers consider various factors, including supply conditions, the clinical practices of fellow healthcare professionals, product prices, health insurance systems, and institutional policies. Additionally, they may refrain from using new technologies if they judge that the product’s quality and reliability have not been sufficiently established.
A prime example is the use of rapid diagnostic tests for malaria in some African countries. Although healthcare providers had access to rapid diagnostic tests, there were instances where they prescribed antimalarial drugs to patients who tested negative, regardless of the test results. This was because there was insufficient confidence in the accuracy of the tests, and it was difficult to be certain of the quality of diagnostic kits that had been transported in hot and humid environments. Furthermore, existing medical practices—which had long relied solely on clinical symptoms to diagnose malaria—also hindered the adoption of new technologies.
However, conducting diagnostic tests without utilizing the results can lead to a waste of funds invested by the government and international organizations. Therefore, even after a medical technology has been rolled out, continuous quality assessment must be conducted, and this must be accompanied by ongoing education for healthcare providers and patients on the necessity of treatment based on test results.

Factors Hindering End-User Adoption

Various barriers also exist in the process of end-users appropriately utilizing medical technologies.
A prime example is the introduction of Norplant, a long-acting contraceptive device. Norplant is a contraceptive implant inserted under the skin that can be removed at the user’s discretion; at the time, it was expected to bring about a major shift in contraceptive methods. However, in practice, users became increasingly dissatisfied because removal services were not sufficiently available. This was because, although the product was rapidly distributed, healthcare providers did not receive sufficient training. At the time, while many countries included insertion methods in their training curricula, removal procedures were not always mandated as part of the training. As a result, patients sometimes experienced pain or scarring during removal, and in some countries, this even led to class-action lawsuits.
This case demonstrates that even if a medical technology is excellent in itself, its adoption can fail if the supporting service system is not established alongside it.

Sociocultural Factors Also Determine Access to Healthcare

End-users’ sociocultural perceptions also significantly influence the adoption of medical technology.
For example, in Tanzania, some mothers tended to be reluctant to have their children treated for febrile illnesses at government healthcare facilities. According to research, this phenomenon was analyzed as being influenced more by traditional perceptions of the disease, socially constructed beliefs, and an understanding of the severity of the illness than by economic reasons.
Conversely, there are also cases where the sociocultural environment promotes the adoption of medical technologies. In 2001, the Keru region of Burkina Faso recorded a child vaccination rate of nearly 100 percent. This was because the region’s traditional healing practices harmonized relatively well with the modern concept of vaccination. Traditionally, mothers in the Keru region would take their children to herbal healers, who would make small incisions in the skin to allow medicinal herbs to come into contact with the blood, in the belief that this would improve their health. Thanks to this cultural background, vaccines were also naturally accepted as a method of disease prevention.
As shown here, sociocultural perceptions can sometimes hinder the introduction of new medical technologies, but conversely, they can also serve as important factors that facilitate their successful dissemination.

Conditions Necessary for Medical Technology to Save Lives

Even today, scientists are constantly developing medical technologies to prevent and treat various diseases more effectively. However, the mere fact that advanced technologies have been developed does not mean that the world’s health problems will be solved.
When disseminating medical technologies to developing countries, it is essential to consider not only the technical sophistication of the technology but also the end-users’ behavioral patterns and sociocultural values. From the very beginning of the technology’s introduction, various stakeholders—including not only the technology developers but also international experts, national policymakers, healthcare providers, and end-users—must participate in an integrated manner. As seen in the examples discussed earlier, the success or failure of a medical technology depends on how faithfully it reflects the characteristics and environment of actual users, starting from the product development stage.
The “Eureka” moments experienced by scientists are undoubtedly important. However, they alone cannot guarantee the health of people in developing countries. For medical technologies to be effective in actual clinical settings, three factors—availability, affordability, and acceptance—must all be met. The AAA analytical framework, which provides a comprehensive understanding of access to healthcare, will continue to serve as a vital analytical tool for ensuring that medical technologies deliver tangible benefits to a wider population.