Equity in access through a digital hospital appointment system: a reflexive thematic analysis of frontline registration staff perspectives in Türkiye.

Abstract

Introduction: Digital appointment systems increasingly mediate access to healthcare. However, not all individuals benefit equally from these systems, and the experiences of the frontline staff responsible for operating them remain underexplored. This qualitative study examined how hospital registration staff perceive access inequities, exercise discretion when formal procedures fail to meet patients' needs, and understand equality and equity.

Methods: Semi-structured interviews were conducted with 20 frontline registration staff working in two public hospitals in Central Anatolia, Türkiye. Data were analyzed using reflexive thematic analysis, combining semantic and latent interpretation. Coding was conducted primarily in a data-driven manner, while the multidimensional model of access, street-level bureaucracy theory, and a social justice perspective informed the analytical interpretation.

Results: The analysis generated five interconnected themes. The findings indicate that formally equal access to the appointment system does not translate into substantively equal opportunities to obtain care. Differences in digital proficiency, social support, transportation access, and temporal flexibility shape patients' ability to navigate the system, while social connections may provide additional informal access advantages. Staff exercise discretion to assist patients when formal procedures prove insufficient. However, such assistance may make access dependent on staff members' willingness and capacity to intervene, as well as on organisational approval and available resources. Support for disadvantaged patients is commonly understood not as an institutional right but as an act of conscience and humanity.

Discussion: Overall, the findings reveal a process of conscience-based repair of structurally unequal access: staff attempt to reduce inequities through individual efforts, while the underlying structural conditions remain unchanged. When equitable access is not institutionally guaranteed, responsibility for compensating for these inequalities is partly transferred to frontline staff. Transparent, consistent, and rights-based institutional arrangements are therefore needed to ensure equitable access.