Health-care facility choice and the phenomenon of bypassing.

Health policy-makers in developing countries are often disturbed and to a degree surprised by the phenomenon of the ill travelling past a free or subsidized local public clinic (or other public facility) to get to an alternative source of care at which they often pay a considerable amount for health care. That a person bypasses a facility is almost certainly indicative either of significant problems with the quality of care at the bypassed facility or of significantly better care at the alternative source of care chosen. When it is a poor person choosing to bypass a free public facility and pay for care further away, such action is especially bothersome to public policy-makers. This paper uses a unique data set, with a health facility survey in which all health facilities are identified, surveyed, and located geographically; and a household survey in which a sample of households from the same health district is also both surveyed and located geographically. The data are analyzed to examine patterns of health care choice related to the characteristics and locations of both the facilities and actual and potential clients. Rather than using the distance travelled or some other general choice of type of care variable as the dependent variable, we are able actually to analyze which specific facilities are bypassed and which chosen. The findings are instructive. That bypassing behaviour is not very different across income groups is certainly noteworthy, as is the fact that the more severely ill tend to bypass and to travel further for care than do the less severely ill. In multivariate analysis almost all characteristics of both providers and facilities are found to have the a priori expected relationships to facility choice. Prices tend to deter use, and improved quality of services to increase the likelihood of a facility being chosen. The answer to the bypassing dilemma seems to be for providers to provide as good quality care relative to the money charged (if any), as other, often further away, providers.

Price elasticities of demand for curative health care with control for sample selectivity on endogenous illness: an analysis for Sri Lanka.

Estimation of demand for health care with samples of only the ill may bias estimates. Additionally, the lack of exogenous information, especially distance, about the alternative care providers causes omitted variable problems. This paper alleviates both problems through geographic mapping of facility information to individuals, combined with joint estimation of illness (health production) and health care demand. The joint estimation full sample demand results are compared to those from one equation estimation for only the ill sample. The results indicate that the selectivity problem is significant, but that for this sample the magnitude of the bias on the price coefficient is small.

Trends in health services utilization in eight provinces in China, 1989-1993.

Continued pursuit of market-oriented reforms in China seems to have resulted in increasing income disparities. This has raised concerns about possible declines in the use of health services by the poor. Using data from three waves of the China Health and Nutrition Survey (1989, 1991, 1993), we examine whether people age 20-45 in eight provinces became less likely to seek care when ill. We carried out three probit estimations of seeking care when ill; the predictor variables include individual and workplace characteristics, a measure of the severity of illness and community level factors. Health care is broadly defined to include basic level clinics as well as urban hospitals. We find no evidence that health care utilization is decreasing. Rather, for people in a community survey reporting mainly mild or moderate illness, health care continues to be accessible. We consider possible limits of our study and discuss extensively the implications of the use of illness reports from the three cross-sectional surveys as health status indicators.

Effect of provider characteristics on choice of contraceptive provider: a two-equation full-information maximum-likelihood estimation.

We use surveys of households and health-care facilities conducted in the same area at the same time to determine which characteristics of providers attract users of contraceptives. By using the full-information maximum-likelihood technique to jointly estimate choice of contraceptive method and choice of provider, we avoid self-selection bias. Results support the need for modeling quality and for jointly estimating the choice of contraceptive method and the choice of provider to avoid biased estimates of coefficients. The results suggest that for the Cebu, Philippines region, small local clinics that focus on family planning tend to be most favored by clients.

Quality of services and demand for health care in Nigeria: a multinomial probit estimation.

This study attempts to empirically answer three important policy questions for a population sample from Ogun State, Nigeria: 1. Would price (fee) increases for health care lead to large reductions of care usage or to shifts across types of care used? 2. Would price increases lead to net increases in revenues for the health system? 3. Would the price increases have larger impacts (in the form of reductions in health care usage) on lower income members of the population? Household data are combined with data on prices and quality of care, collected directly from facilities, to estimate the demand for outpatient health care. Many of the statistical problems of demand estimation with micro level data are avoided by an innovation--the first use of the multinomial probit estimation method for health demand. A separate but related problem, that the price data used in such studies are usually endogenous (in fact usually are expenditures, which are to a great degree determined by the actual care choice) is avoided by the collection of a specific exogenous price variable directly from the health providers. Because the health care 'good'--outpatient health care--can vary to such a degree across providers, quality of care must be controlled in order that the coefficients on prices and other variables will not be biased. A strong circumstantial case can be made that past estimation efforts probably underestimated the impact of prices of care on provider choices, because those providers charging higher prices also tend to provide higher quality care and those charging lower prices to provide care of lower quality. Because of this fear of bias on the extremely important price coefficient, effective control of the quality of the care available at the alternative accessible care providers is almost certainly at this time the most important marginal innovation to demand estimation. Most past researchers simply have not had available to them exogenous quality of care information collected via a facility (provider) survey. This study tried several health care provider quality variables and finally used three distinct variables which were statistically significant: (a) expenditure per person in population served; (b) percentage of times drugs are available; and (c) interviewers evaluation of the physical condition of the facility. Price of a visit to the facility is also included, and also is an exogenous variable collected directly from the alternative available providers. For the variables of most interest for this study, price and quality of care, the results are quite reasonable and much as expected.(ABSTRACT TRUNCATED AT 250 WORDS)

Nutrition, lactation, and birth spacing in Filipino women.

The Cebu Longitudinal Health and Nutrition Survey is used to examine the roles of women's nutrition and infant feeding in determining time from birth to menses and time from menses to conception. The analysis sample includes 2,648 Filipino women followed for 24 months postpartum. Recently devised statistical estimation techniques to control for unobserved heterogeneity and endogeneity are employed in estimating a two-state hazard model. Low body mass index and lower dietary fat intake are associated with increased duration of postpartum amenorrhea. Contraceptive use, high dietary fat consumption, higher parity, and absence of spouse predict a longer waiting time to conception once menses have returned. Simulation of the hazard model is used to examine the effects of the key nutrition and lactation factors.

Influences on the extent of breast-feeding: a prospective study in the Philippines.

There has been much controversy about the impact of the health sector and the infant food industry on breast-feeding behavior. This study links causal factors to breast-feeding decisions, using a longitudinal survey of more than 3,000 Filipino mother-infant pairs. Most factors decreasing the likelihood that mothers will breast-feed seem to be related to family economics. Delivery in a private hospital, urban residence, high income, absence of spouse, and having worked for wages affect adversely the initiation of breast-feeding. Formula advertising and distribution of samples appear to have relatively little impact on feeding decisions.

The production of infant health: input demand and health status differences related to gender of the infant.

The authors collected data on all births between May 1, 1983, and April 30, 1984, in the Cebu City area of the Philippines island of Cebu. Some 3,080 mothers were studied in order to "test the effects of gender preferences on infant health within the context of a well-defined model. This model considers the mechanisms by which sociocultural and biological factors affect infant health." The authors conclude that although there are some minor gender-related differences in health input demands, they should have little impact on the cohort's actual health outcomes.

Breast-feeding and diarrheal morbidity.

This study used a unique longitudinal survey of more than 3000 mother-infant pairs observed from pregnancy through infancy. The sample is representative of infants from the Cebu region of the Philippines. The sequencing of breast-feeding and diarrheal morbidity events was carefully examined in a longitudinal analysis which allowed for the examination of age-specific effects of feeding patterns. Because the work controlled for a wide range of environmental causes of diarrhea, the results can be generalized to other populations with some confidence. The addition to the breast-milk diet of even water, teas, and other nonnutritive liquids doubled or tripled the likelihood of diarrhea. Supplementation of breast-feeding with additional nutritive foods or liquids further increased significantly the risk of diarrhea; most benefits of breast-feeding alone or in combination with nutritive foods/liquids became small during the second half of infancy. Benefits of breast-feeding were slightly greater in urban environments.

Changes in breast-feeding in the Philippines 1973-1983.

Only limited research has been conducted on the patterns and determinants of changes over time in the extent and duration of breast-feeding. Methods are used that allow the examination of the effects of changes in population characteristics and behavioral factors on breast-feeding outcomes. Comparable national surveys are employed to examine the factors associated with the combination of a decline in the extent of and an increase in the duration of breast-feeding between 1973 and 1983 in the Philippines. Important differences are found in the factors explaining the extent and duration of breast-feeding between 1973 and 1983.

Breastfeeding trends in the Philippines, 1973 and 1983.

This paper examines comparable national surveys of breastfeeding from the Philippines carried out in 1973 and 1983. The probability of breastfeeding at selected infant ages is estimated, using the weighted life table. The conclusions are that a 5 per cent decline in the proportion of infants ever breast-fed occurred during the referenced period, and that median length of breastfeeding remained essentially the same.

The effect of economic factors on contraceptive choice in Jamaica and Thailand: a comparison of mixed multinomial logit results

In this study the sensitivity of specific potential users and user groups to the prices charged for contraceptives was investigated. The results of the author's estimations explaining the choice to use priced contraceptive sources when free sources are available, for those who choose to purchase methods, are much hypothesized. In both Jamaica and Thailand, factors other than prices tend to dominate in determining whether a woman or her partner will purchase contraceptives, given free availability. In separate analyses for Jamaica and Thailand, the results explaining the choice of a specific method for those who choose to purchase contraceptives are consistent with expectations based on economic theory. Money prices and time costs are found to be negatively related to the choice of contraceptive method, but for several of the priced contraceptives, the effects of money prices are seen to be small in magnitude. The policy implications for these results are large and obvious. They suggest that decreases in subsidization of the money price of low elasticity contraceptives (the pill, IUD, sterilization) will not significantly alter the pattern of choice of contraceptive methods. Other methods, including condoms in both Jamaica and Thailand and injections in Jamaica, are found to be relatively sensitive to money price, and the results suggest that price increases would substantially decrease their use. (AU)

Price and income elasticities of demand for modern health care: the case of infant delivery in the Philippines.

PIP: In the Philippines most women choose to deliver at home despite the presence of modern facilities. Policy-making requires a knowledge of the factors that determine that choice, especially in terms of variables like price and location, which are amenable to policy intervention. Over 2/3 of the babies born in low-income countries are delivered by traditional birth attendants who are uneducated and have no formal training. They are, however, available in rural areas, whereas 70-90% of the modern practitioners are in the cities. Recently efforts have been made to expand modern obstetrical services in developing countries, but few surveys are available documenting the impact of modern facilities on delivery patterns. The present survey collected data from 3075 women who had singleton births on the island of Cebu between 1983 and 1984, as well as data from 48 modern public and private health facilities and 88 modern and traditional health practitioners. For the analysis of these data an economic demand model was built, using the mixed multinomial logit technic to estimate relationships between delivery characteristics, mothers' characteristics, and delivery choice. Money prices were not a significant factor in the choices, but time prices were a significant consideration for the rural sample. Hours of availability were a significant factor for both urban and rural mothers, and availability of drugs was significant for the urban sample. Both rural and urban women preferred delivery by a midwife, trained or not, to delivery by a combination of doctors, nurses, and midwives. With few exceptions, income was not a significant factor, and having insurance (10% of the sample) increased the probability of choosing a modern private practitioner. Money price effects were inelastic; i.e., a price increase by modern facilities would not have much effect on the choice of these facilities, and lowering the price of modern public delivery services would do little to increase demand for them. Locating more public practitioners and facilities in rural areas could effectively increase the use of modern facilities by rural women. Both urban and rural women would increase their use of modern public away-from-home facilities if these facilities would increase their hours of operation. Having drugs available would also increase the use of the public away-from-home facilities. In both urban and rural samples, trained midwives were the practitioners of choice. Among rural women a rise in income would increase the likelihood of their choosing public and private away-from-home deliveries and home deliveries by private practitioners. From the point of view of public policy, the most significant implications of the study are: 1) decreasing travel time for rural women by locating modern facilities and practitioners in rural areas would increase the use of modern delivery services; 2) increasing hours of operation, increasing the availability of drugs, and providing trained midwives at public facilities would increase the use of modern delivery services; 3) decreasing money prices would not increase use of modern public delivery services; and 4) increasing the price for cost recovery would not decrease the use of modern public delivery services.^ieng

Accessibility, quality of care and prenatal care use in the Philippines.

The patterns and determinants of prenatal care are examined through the use of a randomly selected sample of 3000 rural and urban women who were studied prospectively during pregnancy and at three or four days postpartum. A large number of policy factors were found to influence the choice of most frequently used type of traditional, modern public or modern private prenatal care and the number of visits to each type of care, but few affected the first month of visit. The quality of care provided, accessibility to this care, and insurance available to the mother all had important effects on prenatal patterns. Large differences exist in the set of feasible policy options for improving prenatal care in urban and rural areas.

Breast-feeding patterns and determinants in Jordan.

PIP: The purpose of this paper is to analyze the patterns and determinants of the extent and duration of breastfeeding in Jordan. Data is from a national sample of women surveyed by the Government of Jordan in 1976 as part of the World Fertility Survey program. Women's level of education appears to have the expected negative impact on the decision to ever breastfeed the child or not. Having other children aged 4-6 in the home seems to reduce the probability of ever breastfeeding. In terms of short and long-diration breastfeeders, mother's education has the expected negative effect within both groups of women, but father's education has a significant impact only for the longer duration breastfeeders. Working away from home seems to interfere with breastfeeding only at the longer durations. The effects on breastfeeding of being an urban resident or in-migrant are generally negative. The child's being male increases the likelihood of its being breast-fed only at longer durations. The use of the pill or other contracetpives has a larger negative impact on the short duration decision, but no significant effect on the long duration choice. Having female children 7 to 12 in the home is found to increase the probability of breastfeeding beyond 4.5 months among the short duration group. Policy inplications focus on factors influencing the decisions of women to continue breastfeeding for short to moderate durations. The statistical techniques used in this paper are contained in a technical appendix.^ieng

Cluster analysis of food consumption patterns of older Americans.

This study uses data from the 1977-78 Nationwide Food Consumption Survey (NFCS) to develop a classification scheme for differentiating individuals into groups that have similar patterns of food consumption. The article examines the nutritional adequacy of those food patterns and identifies the socioeconomic factors associated with each pattern. Cluster analysis is used to identify the food consumption patterns of a nationally representative sample of persons aged 65 through 74 years. The results indicate that the food patterns of older persons can be well categorized as light eaters, heavy eaters, or consumers of large amounts of alcoholic beverages, salty snack products, animal fat products, legumes, or sweets and desserts. Following those different food patterns leads to noteworthy differences in nutrient intakes. Ethnic group membership and residence status are found to be the most important socioeconomic factors associated with differences in the food patterns followed.

The demand for adult outpatient services in the Bicol region of the Philippines.

The absence of demand analysis for primary health care services has hampered efforts to finance these services and to make them permanent parts of Third World medical systems. This paper introduces a demand model for adult outpatient services, describes the types of data required for estimating it, and presents the results of a preliminary estimation using data from a poor rural region of the Philippines. The results indicate that prices and distance are not nearly as important as determinants of demand in this sample as has usually been assumed by planners. There appears to be considerable room for full or partial financing of outpatient services from user fees.

Breast-feeding patterns in low-income countries.

Breast-feeding is important to infant nutrition, morbidity, and mortality, and to postpartum amenorrhea (hence to birth intervals). Evidence on breast-feeding patterns in low-income countries from nationally representative World Fertility Surveys and secondary sources shows that in all but a few such countries most children are breast-fed for at least a few months. The limited evidence available on trends seems to indicate a decline in the duration of breast-feeding, but in most of Asia and Africa breast-feeding is almost universal during at least the first 6 months. Earlier weaning is common in Latin America.