David R. Hotchkiss

The socio-economic determinants of maternal health care utilization in Turkey.

The purpose of this study is to investigate the individual-, household- and community-level factors that affect womens use of maternal health care services in Turkey. The data used for the study come from the 1993 Turkey Demographic and Health Survey (TDHS), a nationally representative survey of ever married women 15 to 49 years of age. In order to assess the impact of socio-economic factors on maternal health care utilization, we use logistical regression techniques to estimate models of the prenatal care use and birth delivery assistance among women who have had at least one birth in the three years prior to the survey. Separate models are also estimated for urban and rural women. The results indicate that educational attainment, parity level, health insurance coverage, ethnicity, household wealth and geographic region are statistically significant factors that affect the use of health care services thought essential to reduce infant and child mortality rates. The results of the model are used to provide insights for both micro- and macro-level planning of maternal health service delivery.

Referral revisited: community financing schemes and emergency transport in rural Africa.

Referral between first and second levels of care in rural African health systems is an extremely complex problem. Problems that have plagued the process of referral include poor service quality, low availability of trained personnel, inadequate supplies of drugs and medical diagnostic equipment and inadequate communication infrastructure. In this paper, the authors analyse the role of transport costs in the utilization of referral and how community health insurance schemes can help reduce the economic burden of transport costs, thereby improving referral utilization and health outcomes. Following the introduction, the authors provide a conceptual framework of the individual-, household- and community-level factors that affect referral in the rural African context, with particular emphasis on the role of the time and monetary costs of transport and the potential role of community risk-sharing schemes. The paper then presents a detailed case study from Kenya where a community has been experimenting with a health insurance scheme which provides emergency transport for emergency referral. Data from the past eight years of experience in northern Kenya suggests that support for the insurance scheme has depended on the reliability of the health system, as well as the seasons and various external problems, such as political interference, drought and insecurity. Conclusions drawn support the idea of community financing schemes for transport, not merely as a life-saving strategy in remote and resource-poor health infrastructures, but also as a means to help build trust in the health system itself and thus improve sustainability through local institutional support.

Expansion of rural health care and the use of maternal services in Nepal

In order to improve living standards among the rural poor, the government of Nepal has invested heavily in improving the provision of health care services in rural areas. The purpose of this paper is to assess the impact of this investment on the use of maternal health care services. A bivariate probit model is used to estimate the effect of physical access to government health care services, along with individual-, household-, and other location-specific characteristics, on the use of prenatal care and birth delivery care. The results of the estimation are used to carry out policy simulations that assess the magnitude of the impact of improvements in health care availability on service utilization. The results indicate that physical access to a health care facility, as it is currently structured in rural areas, has a statistically significant but modest impact on the use of maternal services.

Do Service Providers in Tanzania Unnecessarily Restrict Clients' Access to Contraceptive Methods?

Data from the 1996 Tanzania Service Availability Survey are used to analyze the prevalence of medical barriers by type of provider by type of facility and by urban-rural location. Relatively high proportions of providers restrict eligibility by age particularly for oral contraceptives the most widely used method among Tanzanian women. Between 79% and 81% of medical aides trained midwives maternal and child health aides and auxiliary staff (the most common types of family planning service providers in rural Tanzania) impose age restrictions for the pill. Among all providers 10-13% report that there is at least one modern method they would never recommend and 13% report having sent a client home until her next menses an inappropriate process hurdle for the provision of most hormonal methods. In the aggregate these restrictions severely limit access to contraceptives for certain groups of women. For example young unmarried women who are not menstruating at the time of their visit would encounter one or more barriers or process hurdles at more than 70% of urban facilities and at 80% of rural facilities. If pre-service and in-service training and supervisory visits placed greater emphasis on compliance with the Tanzanian National Family Planning Programs service guidelines and standards providers unnecessary restrictions on contraceptive use might be reduced and ultimately eliminated. (authors)

Association Between Child Marriage and Reproductive Health Outcomes and Service Utilization: A Multi-Country Study From South Asia

PURPOSE Despite the pervasiveness of child marriage and its potentially adverse consequences on reproductive health outcomes, there is relatively little empirical evidence available on this issue, which has hindered efforts to improve the targeting of adolescent health programs. The purpose of this study was to assess the association of child marriage with fertility, fertility control, and maternal health care use outcomes in four South Asian countries: India, Bangladesh, Nepal, and Pakistan. METHODS Data for the study come from the most recent Demographic and Health Surveys conducted in the study countries; we used a subsample of women aged 20-24 years. Child marriage, defined as first marriage before 18 years of age, is categorized into two groups: first married at ages 15-17 years and first married at age ≤14 years. We used multivariate logistic regression models. RESULTS The results of the study suggest that child marriage is significantly associated with a history of rapid repeat childbirth, current modern contraceptive use, female sterilization, not using contraception before first childbirth, pregnancy termination, unintended pregnancy, and inadequate use of maternal health services, although the associations are not always consistent across countries. Furthermore, women who married in early adolescence or childhood show a higher propensity toward most of the negative outcomes, compared with women who married in middle adolescence. CONCLUSIONS Child marriage adds a layer of vulnerability to women that leads to poor fertility control and fertility-related outcomes, and low maternal health care use.

The Impact of Medical Insurance for the Poor in Georgia: A Regression Discontinuity Approach

Improving access to health care and financial protection of the poor is a key concern for policymakers in low- and middle-income countries, but there have been few rigorous program evaluations. The Medical Insurance Program for the Poor in the republic of Georgia provides a free and extensive benefit package and operates through a publicly funded voucher program, enabling beneficiaries to choose their own private insurance company. Eligibility is determined by a proxy means test administered to applicant households. The objective of this study is to evaluate the programs impact on key outcomes including utilization, financial risk protection, and health behavior and management. A dedicated survey of approximately 3500 households around the thresholds was designed to minimize unobserved heterogeneity by sampling clusters with both beneficiary and non-beneficiary households. The research design exploits the sharp discontinuities at two regional eligibility thresholds to estimate local average treatment effects. Results suggest that the program did not affect utilization of health services but decreased mean out-of-pocket expenditures for some groups and reduced the risk of high inpatient expenditures. There are no systematic impacts on health behavior, management of chronic illnesses, and patient satisfaction.

Evaluation of the Performance of Routine Information System Management (PRISM) framework: evidence from Uganda

BackgroundSound policy, resource allocation and day-to-day management decisions in the health sector require timely information from routine health information systems (RHIS). In most low- and middle-income countries, the RHIS is viewed as being inadequate in providing quality data and continuous information that can be used to help improve health system performance. In addition, there is limited evidence on the effectiveness of RHIS strengthening interventions in improving data quality and use. The purpose of this study is to evaluate the usefulness of the newly developed Performance of Routine Information System Management (PRISM) framework, which consists of a conceptual framework and associated data collection and analysis tools to assess, design, strengthen and evaluate RHIS. The specific objectives of the study are: a) to assess the reliability and validity of the PRISM instruments and b) to assess the validity of the PRISM conceptual framework.MethodsFacility- and worker-level data were collected from 110 health care facilities in twelve districts in Uganda in 2004 and 2007 using records reviews, structured interviews and self-administered questionnaires. The analysis procedures include Cronbachs alpha to assess internal consistency of selected instruments, test-retest analysis to assess the reliability and sensitivity of the instruments, and bivariate and multivariate statistical techniques to assess validity of the PRISM instruments and conceptual framework.ResultsCronbachs alpha analysis suggests high reliability (0.7 or greater) for the indices measuring a promotion of a culture of information, RHIS tasks self-efficacy and motivation. The study results also suggest that a promotion of a culture of information influences RHIS tasks self-efficacy, RHIS tasks competence and motivation, and that self-efficacy and the presence of RHIS staff have a direct influence on the use of RHIS information, a key aspect of RHIS performance.ConclusionsThe study results provide some empirical support for the reliability and validity of the PRISM instruments and the validity of the PRISM conceptual framework, suggesting that the PRISM approach can be effectively used by RHIS policy makers and practitioners to assess the RHIS and evaluate RHIS strengthening interventions. However, additional studies with larger sample sizes are needed to further investigate the value of the PRISM instruments in exploring the linkages between RHIS data quality and use, and health systems performance.

The tradeoff between price and quality of services in the Philippines.

This paper examines the tradeoff that consumers make between price and quality in the demand for health care. The analysis is based on data collected from both households and health care facilities in Cebu, Philippines. The availability of both types of data makes this one of only a handful of demand for health care studies that includes detailed information on both individual characteristics and facility attributes of all relevant alternatives. The developing country setting provides substantial variation in the type of facility chosen, ranging from home delivery aided only by friends and relatives at one extreme to modern private hospitals at the other end of the spectrum. The alternatives vary greatly in quality and price, making this an ideal context for examining the role of these variables in facility choice. The nested logit model specifications that are estimated contain price, travel time, and different combinations of quality measures, including the availability of medical supplies, practitioner training, service availability, facility size and crowdedness, and their interaction with individual characteristics. In addition, the sensitivity of the results to different choice-set definitions is analyzed. In particular, models that use conventional choice-set definitions that are based only on nominal status are compared with models that attempt to classify facilities into relatively homogeneous groups based on price and quality. The estimation results, which correct for the two-stage design of the household survey, indicate that facility crowding and practitioner training are significant determinants of consumer choice. The results also indicate that individual characteristics such as education of the woman interact in important ways with quality in influencing choice. For example, the availability of drugs is a significant determinant of facility choice for women with high levels of education, but not for others. In addition, the results support the hypothesis that price is a significant determinant for poor households, but not for other households. The model is used to conduct policy simulations designed to be informative to public officials interested in the effect of cost recovery schemes on utilization patterns. The simulations indicate that, when public facilities simultaneously increase user fees and the aspects of quality over which policy makers can exercise control in the short-run, the mean probability of using public facilities increases for both poor and non-poor households.

Relationships between antenatal and postnatal care and post-partum modern contraceptive use: evidence from population surveys in Kenya and Zambia

BackgroundIt is often assumed, with little supportive, empirical evidence, that women who use maternal health care are more likely than those who do not to use modern contraceptives. This study aims to add to the existing literature on associations between the use of antenatal (ANC) and post-natal care (PNC) and post-partum modern contraceptives.MethodsData come from the most recent Demographic and Health Surveys (DHS) in Kenya (2008–09) and Zambia (2007). Study samples include women who had a live birth within five years before the survey (3,667 in Kenya and 3,587 in Zambia). Multivariate proportional hazard models were used to examine the associations between the intensity of ANC and PNC service use and a woman’s adoption of modern contraceptives after a recent live birth.ResultsTests of exogeneity confirmed that the intensity of ANC and PNC service use and post-partum modern contraceptive practice were not influenced by common unobserved factors. Cox proportional hazard models showed significant associations between the service intensity of ANC and PNC and post-partum modern contraceptive use in both countries. This relationship is largely due to ANC services; no significant associations were observed between PNC service intensity and post-partum FP practice.ConclusionsWhile the lack of associations between PNC and post-partum FP use may be due to the limited measure of PNC service intensity, the study highlights a window of opportunity to promote the use of modern contraceptives after childbirth through ANC service delivery. Depending on the availability of data, further research should take into account community- and facility-level factors that may influence modern contraceptive use in examining associations between ANC and PNC use and post-partum FP practice.

THE EFFECTS OF MATERNAL–CHILD HEALTH SERVICE UTILIZATION ON SUBSEQUENT CONTRACEPTIVE USE IN MOROCCO

There are a number of reasons for anticipating that contact by women in developing country settings with modern maternal-child health (MCH) services will lead to increased use of family planning services. Indeed, the expectation of such a relationship underlies the integrated service delivery strategy that has been adopted on a more or less global basis. However, the available empirical evidence in support of this proposition is inconclusive. This study re-examines this issue in Morocco. Household survey data and data on the supply environment for health and family planning services gathered in 1992 are analysed in the study. A full-information maximum likelihood estimator is used to control for the possible endogeneity of health care and contraceptive choices. The findings indicate a substantial and apparently causal relationship between the intensity of MCH service use and subsequent contraceptive use. Policy simulations indicate that sizeable increases in contraceptive prevalence might be realized by increasing the coverage and intensity of use of MCH services.