Did contracting effect the use of primary health care units in Pakistan?

For many years, Pakistan has had a wide network of Basic Health Units spread across the country, but their utilization by the population in rural and peri-urban areas has remained low. As of 2004, in an attempt to improve the utilization and performance of these public primary healthcare facilities, the government has gradually started contracting-in intergovernmental organizations to manage these BHUs. Using five nationally representative household surveys conducted between 2001 and 2012, and exploiting the gradual roll-out of this reform to apply a difference-in-difference approach, we evaluate its impact on BHU utilization. We find that contracting of the BHU management did not have any effect on health care use generally in the population, but it did significantly increase the use of BHU for childhood diarrhoea for the poor (by 4% points) and rural (3% points) households. These increases were accompanied by lower rates of self-treatment and private facilities usage. We do not find any significant effects on the self-reported satisfaction with BHU utilization. Our findings contrast with earlier small-scale studies that reported larger effects of the contracting of primary care in Pakistan. We speculate that the modest additional budget, the limited management authority of the contracting agency and the lack of clear performance indicators are reasons for the small impact of the contracting reform. Apparently critical aspects of services delivery such as location of BHUs, ineffective referral system and medical practice variation in public and private sectors have contributed to the overall low utilization of BHUs, yet these were beyond the scope of the contracting reform

Urbanization, Health and Inequality in the Developing World

Verstedelijking in ontwikkelingslanden leidt niet automatisch tot een betere volksgezondheid. Beleidsmakers in ontwikkelingslanden moeten zich bewust worden van het belang en noodzaak van stedelijke planning om de negatieve gezondheidseffecten van de immense verstedelijking om te buigen. Dat stelt Ellen Van de Poel in haar proefschrift ‘Urbanization, Health and Inequality in the Developing World’. Van de Poel promoveerde op donderdag 24 september 2009. Het aantal inwoners in steden neemt vooral in ontwikkelingslanden zeer snel toe en het is voorlopig nog onduidelijk welke gevolgen dit heeft voor de volksgezondheid. Van de Poel analyseerde databestanden van de Demographic and Health Surveys van 47 ontwikkelingslanden om de verbanden te bestuderen tussen verstedelijking, sterfte en ondervoeding bij kinderen. Daarnaast gebruikte ze data van de China Health and Nutrition Survey om de verbanden tussen verstedelijking en welvaartsziekten in China te onderzoeken. Ook wilde zij het algemene gezondheidseffect van de immense verstedelijking in China meten. Stadsbewoners zijn gemiddeld in een betere gezondheid dan mensen op het platteland, maar deze gemiddeldes verbergen grote ongelijkheden. Kinderen in arme gezinnen in steden, meestal geconcentreerd in sloppenwijken, hebben evenveel en soms zelfs meer kans op ondervoeding en sterfte dan kinderen in arme gezinnen op het platteland. Maar ook buiten de sloppenwijken kan verstedelijking de gezondheid schaden, bijvoorbeeld door milieuvervuiling en een veranderend eet- en leefpatroon. In China neemt met de gigantische urbanisatie, ook de prevalentie van welvaartsziektes zoals diabetes en hypertensie zeer snel toe, en verspreiden deze ziektes zich ook naar minder verstedelijkte gebieden. Beleidsmakers in ontwikkelingslanden moeten zich daarom realiseren dat tenzij verstedelijking gepaard gaat met een goed gepland ruimtelijk en sociaal beleid, dit proces de volksgezondheid niet ten goede zal komen. Ook moeten ze voorzichtig omspringen met het uitzetten van een gezondheidsbeleid op basis van vergelijkingen van gemiddelde gezondheid tussen verstedelijkte en landelijke gebieden. Het is belangrijk dat beleidsprogramma’s de steeds groter wordende arme stedelijke populaties niet langer over het hoofd zien

Measurement of Inequity in Health Care with Heterogeneous Response of Use to Need

We propose a method of measuring and decomposing inequity in health care utilisation that allows for heterogeneity in the use-need relationship. This makes explicit inequity that derives from unequal treatment response to variation in need, as well as that due to differential effects of non-need determinants. Under plausible conditions concerning heterogeneity in the use-need relationship and the distribution of need, existing methods that impose homogeneity will underestimate pro-rich inequity. This prediction is confirmed for four low-middle income Asian countries

What explains the Rural-Urban Gap in Infant Mortality — Household or Community Characteristics?

The rural-urban gap in infant mortality rates is explained using a new decomposition method that permits identification of the ontribution of unobserved heterogeneity at the household and the community level. Using Demographic and Health Survey data for six Francophone countries in Western Sub-Saharan Africa, we find that differences in the distributions of factors that determine mortality – not differences in their effects – explain almost the entire gap. Higher infant mortality rates in rural areas mainly derive from the rural disadvantage in household level characteristics; both observed and unobserved, which explain three-quarters of the gap. Among the observed characteristics, household environmental factors—potable water, electricity and quality of housing materials—are the most important contributors explaining 38% of the gap. Unobserved household level determinants explain 10% of the gap. Community level determinants explain 13% of the gap, including 3% that is due to unobservable community level heterogeneity

The Health Penalty of China's Rapid Urbanization

Rapid urbanization could have positive and negative health effects, such that the net impact on population health is not obvious. It is, however, highly pertinent to the human welfare consequences of development. This paper uses community and individual level longitudinal data from the China Health and Nutrition Survey to estimate the net health impact of China’s unprecedented urbanization. We construct an index of urbanicity from a broad set of community characteristics and define urbanization in terms of movements across the distribution of this index. We use difference-in-differences estimators to identify the treatment effect of urbanization on the self-assessed health of individuals. The results reveal important, and robust, negative causal effects of urbanization on health. Urbanization increases the probability of reporting fair or poor health by 5 to 15 percentage points, with a greater degree of urbanization having larger health effects. While people in more urbanized areas are, on average, in better health than their rural counterparts, the process of urbanization is damaging to health. Our measure of self-assessed health is highly correlated with subsequent mortality and the causal harmful effect of urbanization on health is confirmed using more objective (but also more specific) health indicators, such as physical impairments, disease symptoms and hypertension

Are Urban Children really healthier?

On average, child health outcomes are better in urban than in rural areas of developing countries. Understanding the nature and the causes of this rural-urban disparity is essential in contemplating the health consequences of the rapid urbanization taking place throughout the developing world and in targeting resources appropriately to raise population health. We use micro data on child health taken from the most recent Demographic and Health Surveys for 47 developing countries. First, we document the magnitude of rural-urban disparities in child nutritional status and under-five mortality across all 47 developing countries. Second, we adjust these disparities for differences in population characteristics across urban and rural settings. Third, we examine rural-urban differences in the degree of socioeconomic inequality in these health outcomes. We find considerable rural-urban differences in mean child health outcomes. The rural-urban gap in stunting does not entirely mirror the gap in under-five mortality. The most striking difference between the two is in the Latin American and Caribbean region, where the gap in stunting is more than 1.5 times higher than that in mortality. On average, the rural-urban risk ratios of stunting and under-five mortality fall by respectively 53% and 59% after controlling for household wealth. Controlling thereafter for socio-demographic factors reduces the risk ratios by another 22% and 25%. In a considerable number of countries, the urban poor actually have higher rates of stunting and mortality than their rural counterparts. The findings imply that there is a need for programs that target the urban poor, and that this is becoming more necessary as the size of the urban population grows

Does health care utilization match needs in Africa? Challenging conventional needs measurement

Abstract. An equitable distribution of health care use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub Saharan Africa (SSA). We examine cross-country comparative micro-data from eighteen SSA countries and find that (a) considerable inequalities in health care use exist and vary across countries, but that (b) identifying the extent to which these inequalities are unfair, i.e. do not correspond to inequalities in need, is not straightforward to ascertain with the conventional tools. These tools include rank-based measures such as the concentration index and the index of inequity. The two main concerns when using conventional tools to measure equity are (i) the reporting heterogeneity in self-reported health variables across socio-economic groups and (ii) the weak relationship between need and use. We show that the use of subjective self-reports of health leads to much lower measured degrees of socio-economic inequalities than those obtained using more objective indicators. This leads to an underestimation of the degree of inequity when using self-reported health measures. The observed weak relationship between indicators of ill-health and use of health care does not appear to provide an estimate of the adequate response to needs, which further puts a downward bias on equity measures. In all countries, apart from the more developed Mauritius, health care use is distributed according to wealth rather than to need. A better match of needs and use is realized in those countries with better governance and more physicians but, perhaps surprisingly, not those with greater urbanization. Given the importance of equity in many health policies worldwide, it is vital to develop more robust equity measures relevant to low income settings

Analyses of enrolment, dropout and effectiveness of RSBY in northern rural India

In 2008, the Government of India initiated the Rashtriya Swasthya Bima Yojana (RSBY) to provide inpatient insurance coverage to all below-poverty-line (BPL) households in India. It is one of the most ambitious social protection programmes in the country. Using household level panel data from Uttar Pradesh and Bihar collected in 2012-2013, this paper investigates the determinants of enrolling in and dropping out of the scheme. In addition, we investigate whether participating in the RSBY is associated with a higher probability of using inpatient care and increased financial protection. We find that by the end of our survey period, close to half of our sample is enrolled in RSBY (41% in Bihar, 68% in UP). RSBY coverage is more concentrated among the poor in Bihar, as compared to UP. We find that the presence of chronic illnesses, lower socioeconomic status, belonging to scheduled-castes or tribes (SCST), insurance related awareness and proximity to healthcare facilities are positively correlated with enrolment. SCST households and households with members who have chronic conditions are less likely to drop out. The associations between RSBY membership and healthcare use and financial protection vary across the states. While we do not find that RSBY is associated with increased rates of utilization across the board, we do find insured households in Bihar experience lower out-of-pocket payments and debt following hospitalization. Nearly all hospitalizations among insured patients lead to positive OOP spending. Overall, we conclude that though the RSBY does appear to be pro-poor and is inclusive of disadvantaged minorities such as the SCST, the scheme suffers from adverse selection. The fact that drop-out rates are low might suggest good perceived value for the insured. The RSBY has the potential to play an important role in India’s move towards Universal Health Coverage. However, our analyses suggests that scheme awareness should be increased; that the targeting of the scheme could be improved, and that the programme is not yet providing cashless inpatient care. The differences in effectiveness between both states might be related to the recent development efforts made by the Bihar government, and suggestive of the need for addressing supply side constraints prior to launching an insurance scheme