John S. Akin

The Demand for Primary Health Care Services in the Bicol Region of the Philippines

Mortality is assumed to be strongly reduced by medical care however the effects of medical services on health are often underestimated because some of the same factors which lead to an increased demand for primary health care (PHC) services are also associated with increased morbidity and mortality. Consequently understanding the determinants of the demand for medical services is important for evaluating health outcomes. This paper estimates the parameters of a simple model of the demand for health services using data from the Bicol Multipurpose Survey data from the Philippines. The parameters of the demand for key components of PHC--outpatient prenatal delivery well-child and infant immunizations--are estimated. Findings suggest that the quality of the care may be very important but that economic factors as deterrents to using medical care--inaccessibility cash costs and lack of income--may not be of paramount importance. Finally it is shown that the provision of free services in rural areas may not insure that the services reach the poorest people. (authors modified)

Cohort Profile: The Cebu Longitudinal Health and Nutrition Survey

The Cebu Longitudinal Health and Nutrition Survey (CLHNS) was originally conceptualized as an interdisciplinary study of infant-feeding patterns, particularly the overall sequencing of feeding events (milks and complementary foods), the factors affecting feeding decisions and how feeding patterns affect the infant, mother and household. The idea was to study these topics within as natural a setting as possible and to analyse how infant-feeding decisions interacted with social, economic and environmental factors to affect health, nutritional, demographic and economic outcomes. The study was subsequently expanded to cover a wide range of maternal and child health and demographic issues that could be well studied using a prospective, community-based sample. The study was initially the product of collaboration among researchers at the Carolina Population Center at the University of North Carolina at Chapel Hill (led by B.M.P. with J.S.A. and D.K.G.), The Office of Population Studies Foundation at the University of San Carlos in Cebu, Philippines (led by the late Director Wilhelm Fleiger) and the Nutrition Center of the Philippines (led by Florentino Solon). L.S.A. took the lead for follow-up surveys beginning in 1990. Later, the study team was expanded to include researchers presently at the Northwestern University (C.W.K. and T.M.D.) and Johns Hopkins University (M.J.H.). The study was initiated with cooperation and approval from the Cebu Department of Health. The CLHNS website includes a full list of investigators and their affiliations. The CLHNS was one of the first large-scale, population-based surveys designed with a conceptual framework in mind. The guiding framework was adapted from Mosley and Chen’s health determinants model, which posits that underlying community-, householdand individual-level variables affect a set of proximate health behaviours which, in turn, influence health outcomes such as growth and infectious disease morbidity and mortality. The study was designed by a highly interdisciplinary group of economists, sociologists, nutritionists, demographers and physicians. The CLHNS has been funded by a large number of government and non-government organizations (listed in the Funding section).

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.

Decentralisation and Government Provision of Public Goods: The Public Health Sector in Uganda

While many developing countries have devolved health care responsibilities to local governments in recent years, no study has examined whether decentralisation actually leads to greater health sector allocative efficiency. This paper approaches this question by modeling local government budgeting decisions under decentralisation. The model leads to conclusions not all favourable to decentralisation and produces several testable hypotheses concerning local government spending choices. For a brief empirical test of the model we look at data from Uganda. The data are of a type seldom available to researchers–actual local government budgets for the health sector in a developing country. The health budgets are disaggregated into specific types of activities based on a subjective characterisation of each activitys ‘publicness’. The empirical results provide preliminary evidence that local government health planners are allocating declining proportions of their budgets to public goods activities.

Distribution of medical insurance in China

This paper investigates factors related to the distribution of medical insurance coverage in China, using information from an eight-province household survey of almost 16,000 individuals, conducted in 1989. Results of bivariate analyses show that medical insurance coverage, defined very broadly, varies considerably by individual and regional characteristics. Age, gender, education, occupation, employment sector, urbanization, level of industrial and commercial development, and province are all related to being insured or not. In addition, we find that the type of insurance program available to people varies by these same factors, and that the benefits provided by the seemingly uniform public and worker programs also vary, especially by province and degree of urban development. When the individual and regional variables are considered together in logistic regression analyses, the factors most strongly statistically related to the likelihood of being insured are where one works and where one lives. The distribution of insurance benefits in China appears to result in a pattern in which the rural and the poor, who are often at great risk of illness, are less likely to have medical insurance.

Equity and the utilization of health services: Report of an eight-province survey in China

This paper investigates equity with respect to one component of welfare in China--the provision and use of health services. Based upon a large-scale survey of almost 16,000 individuals in eight provinces in China, we examine a sub-sample of working-age adults who have identified themselves as injured or ill during the four weeks prior to being interviewed. We found that, beyond the level of severity of the reported condition, very few individual-level factors are related to the use of services when ill or injured. Only gender (female) and employment in state-run enterprises are associated with higher patterns of use. These results suggest that China has achieved a very wide distribution of clinics and other services at the local level, and that they are widely used by those who identify need for them. It is rare to be over half an hour away by bike from some form of care and the majority of care appears to be reasonably inexpensive. This broad availability of services contrasts with recent reports from China stressing declining accessibility, and paints a picture of relatively equal access to health care.

Did the distribution of health insurance in China continue to grow less equitable in the nineties? Results from a longitudinal survey

This paper examines changes in the distribution of health insurance across socioeconomic groups in China over the 1989-1997 period. The analysis is based on the China Health and Nutrition Survey (CHNS), a unique micro-level longitudinal survey of households in eight Chinese provinces. Findings indicate that while aggregate insurance coverage rates in the sample changed little over this period, certain previously noted differences in coverage rates across socioeconomic groups narrowed significantly. These findings bring into question the presumption that continued market-oriented reform would lead to increased differences in coverage across those groups. The results, in fact, suggest exactly the opposite, that as the market oriented changes have occurred important disparities in health insurance coverage have been reduced. If these reductions are occurring there are important implications for policy. The groups normally targeted for equity reasons seem to be making progress over time but continued improvements are needed for these groups to reach the levels of coverage enjoyed by more fortunate subgroups.

Prenatal care and pregnancy outcome in Cebu, Philippines☆

Abstract This paper examines the direct and indirect effects of patterns of prenatal care usage on birth weight and gestational age for a randomly selected sample of 3,080 rural and urban women. We analyze indirect effects of prenatal care on intermediate maternal factors (nutritional, stress, smoking, and drinking), then the impacts of these factors along with prenatal care on pregnancy outcome. The simultaneous equations statistical approach corrects for endogeneity of prenatal care and the intermediate maternal factors. Results of simulations of the effects of changes in the number of prenatal visits on intermediate and health outcome factors have important policy implications.

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.

THE DETERMINANTS OF BREAST-FEEDING IN SRI LANKA

Breast-feeding is the focus of rapidly growing interest. Research on the determinants of breast-feeding is only beginning. The research in this paper is based on World Fertility Survey data for Sri Lanka. We develop what we believe to be an appropriate probit model and find that there are significant socioeconomic factors that influence breast-feeding, in addition to the demographic factors focused upon in the literature. Moreover, some of them have clear policy implications, which are elaborated herein with respect to labor force, education, family planning and internal migration policies. In the course of the paper we also address a number of generally neglected statistical issues that should be considered in analyzing the determinants of breastfeeding, including problems resulting from digit preference or age heaping, the need to use dichotomous dependent variables, unavoidable truncation biases in the basic data, and structural shifts in the determinants of breastfeeding at different durations.