Understanding spatial variation in the utilization of health

Utilization of health services are an important policy concern in most developing countries, reflecting both efforts to improve health outcomes and to meet international obligations to make health services broadly accessible. Although many policy and research initiatives have focused on the need to improve physical access, not enough is understood about what factors affect health care choices, and why low levels of utilization persists among certain socioeconomic groups or geographic regions despite improved physical access. Reflecting these concerns, this paper focuses on the role of health care quality in understanding spatial variation in the utilization of both curative and preventive health services in Mozambique. The analysis is based on matched household and facility data, where the sample of household was drawn from the catchment area of each facility. The findings show that health care quality is a significant and important factor in women's choice of delivery location. In particular, both the presence of maternity staff and a broader service range make it more likely that women choose a facility-based delivery. Conversely, the analysis suggests that quality is not a significant determinant in decisions about outpatient visits, while physical access, education, and economic variables are important. The findings hence suggest that the impact of quality may be service specific, and that although certain dimensions of quality may have little or no impact on outpatient visits, they may be important determinants of the use of other health services. As developing countries to continue to face difficult trade-offs between quality and physical access in the allocation of resources, it will be important to deepen our understanding of how individuals make health care choices. The results presented in this paper are a step in that direction.

Sometimes More Equal than Others How the choice of welfare indicator can affect the measurement of health inequalities and the incidence of public spending

In recent years, a large body of empirical work has focused on measuring and explaining socioeconomic inequalities in health outcomes and health service use. In any effort to address these questions, analysts must confront the issue of how to measure socioeconomic status. In developing countries, socioeconomic status has typically been measured by per capita consumption or an asset index. Currently, there is only limited information on how the choice of welfare indicators affect the analysis of health inequalities and the incidence of public spending. The paper focuses on five key health service outcomes in Mozambique. It uses the concentration index approach to measures both socioeconomic inequality in the utilization of health services and the sensitivity of measured inequality to the choice of welfare indicator. The results illustrate that, at least in some contexts, the choice of welfare indicator can have a large and significant impact on socioeconomic inequalities in service use and on the “perceived” incidence of public spending. The findings point at the need to be cautious in measuring inequality, but also to extend and deepen the analysis of service use.

Health care demand in rural Mozambique

Despite rapid economic growth in recent years, Mozambique remains a very poor country. Expenditure-based poverty measures are reflected in widespread food insecurity and poor health status. In recognition of these problems, the Government of Mozambique is promoting expanded and improved quality and equity in access to health care as an important component in the global strategy to fight poverty. Given years of colonial neglect and systematic destruction of health facilities during the civil war, recent government policy has focused on expanding the rural health network. However, insofar as the ultimate objective of the provision of curative services is to ensure that those in need of care receive effective treatment, it is also necessary to think beyond supply. Specifically, we need to consider how individuals behave during episodes of illness, and what factors affect this behavior. This paper provides quantitative evidence on the importance of individual, household, and community characteristics on individuals' care-seeking decisions during episodes of illness. The paper estimates a “flexible” multinomial model of health care provider choice conditional on illness using data from the 1996/97 Mozambique National Household Survey on Living Conditions (IAF). The empirical analysis is underpinned by a basic theoretical framework of utility maximization and household production of health. A number of individual and household characteristics, e.g., age, education, and reported symptoms, stand out as highly significant determinants of health seeking behavior. Also, prices, defined in the model as the composite of user fees and time costs associated with consultations at different providers, are found to be important determinants of choice. The results indicate that the eradication of poverty, independent of improvements in physical access to health care and education, will have only a negligible effect on health care choices.Poverty alleviation. ,Rural health services Mozambique. ,

Health shocks in China : are the poor and uninsured less protected ?

Health shocks have been shown to have important economic consequences in industrial countries. Less is known about how health shocks affect income, consumption, labor market outcomes, and medical expenditures in middle- and low-income countries. The authors explore these issues in China. In addition to providing new evidence on the general impact of health shocks, they also extend previous work by assessing the extent of risk protection afforded by formal health insurance, and by examining differences in the impact of health shocks between the rich and poor. The authors find that health shocks are associated with a substantial and significant reduction in income and labor supply. There are indications that the impact on income is less important for the insured, possibly because health insurance coverage is also associated with limited sickness insurance, but the effect is not significant. They also find evidence that negative health shocks are associated with an increase in unearned income for the poor but not the non-poor. This effect is however not strong enough to offset the impact on overall income. The loss in income is a consequence of a reduction in labor supply for the head of household, and the authors do not find evidence that other household members compensate by increasing their labor supply. Finally, negative health shocks are associated with a significant increase in out-of-pocket health care expenditures. More surprisingly, there is some evidence that the increase is greater for the insured than the uninsured. The findings suggest that households are exposed to considerable health-related shocks to disposable income, both through loss of income and health expenditures, and that health insurance offers very limited protection.Health Monitoring&Evaluation,Health Economics&Finance,Rural Poverty Reduction,Housing&Human Habitats,Health Law

The Utilization of Curative Health Care in Mozambique: Does Income Matter?

In Mozambique, easily treatable diseases such as malaria, diarrhea, and respiratory infections contribute to a heavy burden of disease. Notwithstanding efforts by the Mozambican government to promote access to health care, many who could benefit from simple cost-effective health care services do not currently receive treatment. Moreover, it is known that the utilization of health services varies considerably across spatial domains and socio-economic groups. This paper is concerned with understanding the determinants of utilization of curative health services, paying particular attention to the role of income. It provides a broad analytical framework for analyzing both the binary decision to seek formal health care in the event of illness, and the multinomial choice of health care provider. The results show that income is not an important determinant of health care choices in Mozambique. Rather, other factors, in particular education and physical access, are more important. Moreover, unlike in some studies, own (time) price elasticity does not vary notably with income. At a methodological level, the analysis shows that the general conclusions are robust to a number of estimation issues that are rarely addressed explicitly in the analysis of health care choices, including sample selection, the potential endogeneity of consumption, and cluster-level unobservables. For the analysis of provider choice, the paper demonstrates the merits of a .flexible. behavioral model. In particular, the paper rejects some of the restrictions of the standard model of provider choice, and shows that both the level of the price elasticity and the extent to which the elasticity varies with income is sensitive to the empirical specification.

Can insurance increase financial risk ? The curious case of health insurance in China

The most basic argument for insurance is that it reduces financial risk. But since insurance opens up new opportunities for consuming expensive high-technology care which permits health improvements that are valued by the insured, and because in many settings the provider is able and has an incentive to exploit the informational advantage he has over the patient, it is not immediately obvious that insurance will in practice reduce financial risk. The authors analyze the effect of insurance on the probability of an individual incurring"high"annual health expenses using data from three household surveys-one a cross-section survey, the other two panel surveys. All come from China, a country where providers have until recently largely been paid fee-for-service (often according to a schedule that encourages the overprovision of high-technology care and the underprovision of basic care) and who are only lightly regulated. The authors define annual spending as"high"if it exceeds 5 percent of average income in the sample and as"catastrophic"if it exceeds 10 percent of the household's own per capita income. The estimates of the effect of insurance on financial risk allow for the possible endogeneity of health insurance in the panel datasets by allowing for a time-invariant fixed effect capturing unobserved risk that may be correlated with insurance status, and in the cross-section dataset by using instrumental variables, where availability of and eligibility for health insurance are used as instruments. The results suggest that during the 1990s China's government and labor insurance schemes increased financial risk associated with household health care spending, but that the rural cooperative medical scheme significantly reduced financial risk in some areas but increased it in others (though not significantly). From the results, it appears that China's new health insurance schemes (private schemes, including coverage of schoolchildren) have also increased the risk of high levels of out-of-pocket spending on health. Where the authors find evidence of health insurance increasing the risk of"high"out-of-pocket expenses, the marginal effect is of the order of 15-20 percent; in the case of"catastrophic"expenses, it is even larger.Health Monitoring&Evaluation,Health Economics&Finance,Rural Poverty Reduction,Health Law,Insurance&Risk Mitigation

Are health shocks different ? evidence from a multi-shock survey in Laos

In Laos health shocks are more common than most other shocks and more concentrated among the poor. They tend to be more idiosyncratic than non-health shocks, and are more costly, partly because they lead to high medical expenses, but also because they lead to income losses that are sizeable compared with the income losses associated with non-health shocks. Health shocks also stand out from other shocks in the number of coping strategies they trigger: they are more likely than non-health shocks to trigger assistance from a nongovernmental organization and other households, dis-saving, borrowing, asset sales, an early harvest, the pawning of possessions, and the delaying of plans; by contrast, they are less likely to trigger assistance from government. Consumption regressions point to only limited evidence of households not being able to smooth consumption in the face of any shock. However, these results contrast with households'own assessments of the welfare impacts of shocks. The majority said they had to cut back consumption following a shock and that shocks considerably affected their welfare. Only health shocks are worse than a drought in terms of the likelihood of a family being forced to cut back consumption and in terms of the shock affecting a family's well-being"a lot."The poor are especially disadvantaged in terms of the greater damage that health shocks inflict on household well-being. Health shocks stand out too in leading to a loss of human capital: household members experiencing a health shock did not recover their former subjective health following the health shock, losing, on average, 0.6 points on a 5-point scale. The wealthier and better educated are better able to limit the health impacts of a health shock; the data are consistent with this being due to their greater proximity to a health facility.Health Monitoring&Evaluation,Health Systems Development&Reform,Housing&Human Habitats,Rural Poverty Reduction,Economic Theory&Research

Health facility surveys : an introduction

Health facility surveys come in various guises. One dimension in which they vary is their motivation. Some seek to understand better links between households and providers. Others seek to understand better provider behavior and performance. Still others seek to understand the interrelationships between providers, while yet others seek to shed light on the linkages between government and providers. Health facility surveys differ too in the data they collect, in part due to the different motivations. Surveys also vary in the way they collect data, some relying on direct observation, some on record review, and some on interview. Some quality data are collected through clinical vignettes. Facility data have been put to a variety of uses, including planning and budgeting; monitoring, evaluation, and promoting accountability; and research. Lindel and Wagstaff review some of the literature under each heading and offer some conclusions regarding the current state of health facility surveys.Health Monitoring&Evaluation,Public Health Promotion,Health Systems Development&Reform,Early Child and Children's Health,Housing&Human Habitats,Health Monitoring&Evaluation,Health Systems Development&Reform,Agricultural Knowledge and Information Systems,Housing&Human Habitats,Health Economics&Finance

TO SERVE THE COMMUNITY OR ONESELF: THE PUBLIC SERVANT'S DILEMMA

Embezzlement of resources is hampering public service delivery throughout the developing world.Research on this issue is hindered by problems of measurement. To overcome these problems we use an economic experiment to investigate the determinants of coorupt behaviour. We focus on three aspects of bahaviour; (i) embezzlement by public servants; (ii) monitoring effort by designated monitors; (iii)voting by community members when provided with an opportunity to select a monitor. The experiment allows us to study the effect of wages, effort observability, rules for monitor assignment, and professional norms. Our experimental subjects are Ethiopian nursing students. We find that service providers who earn more embezzle less, although the effect is small. Embezzlement is also lower when observability (associated with the risk of being caught and sanctioned) is high, and when sevice providers face an elected rather than randomly selected monitor. Monitors put more effort into monitoring, when they face re- election and when the public servant receives a higher wage. Communities re-elect monitors who put more effort into exposing embezzlement. Framing - whereby players are referred to as 'health workers' and 'community members' rather than by abstract labels - affects neither mean embezzlement nor mean monitoring effort, but significantly increases the variance in both. This suggests that different types of experimental subject respond differently to the framing, possibly because they adhere to different norms.

The Performance of Health Workers in Ethiopia Results from Qualitative Research

Insufficient attention has been paid to understanding what determines the performance of health workers and how they make labor market choices. This paper reports on findings from focus group discussions with both health workers and users of health services in Ethiopia, a country with some of the poorest health outcomes in the world. We describe performance problems identified by both health users and health workers participating in the focus group discussions, including absenteeism and shirking, pilfering drugs and materials, informal health care provision and illicit charging, and corruption. In the second part of the paper we present four structural reasons why these problems arise: (i) the ongoing transition from health sector dominated by the public sector, towards a more mixed model; (ii) the failure of government policies to keep pace with the transition towards a mixed model of service delivery; (iii) weak accountability mechanisms and the erosion of professional norms in the health sector; and (iv) the impact of HIV/AIDS. The discussions underline the need to base policies on a micro-analysis of how health workers make constrained choices, both in their career and in their day to day professional activities.health worker performance, human resources for health, corruption