Health Policy and Planning, Vol 14, 135-151, Copyright © 1999 by Oxford University Press
J Akin and P Hutchinson
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.
ARTICLES
Health-care facility choice and the phenomenon of bypassing
The World Bank, Uganda Resident Mission, and The University of North Carolina at Chapel Hill, USA
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