Steven F. Koch

Utilization of focused antenatal care in Zambia: examining individual- and community-level factors using a multilevel analysis

OBJECTIVES We examine the individual- and community-level factors associated with the utilization of antenatal care, following the adoption of the focused antenatal care (FANC) approach in Zambia. METHODS Using the 2007 Zambia Demographic and Health Survey, linked with administrative and health facility census data, we specify two multilevel logistic models to assess the factors associated with (1) the inadequate use of antenatal care (ANC) (defined as three or fewer visits) and (2) the non-use of ANC in the first trimester of pregnancy. RESULTS Although all women in the selected sample had at least one ANC visit, 40% did not have the minimum number required (four), whereas more than 80% of the initial check-ups did not occur in the first trimester. At the individual level, the womans employment status, quality of ANC received and the husbands educational attainment are negatively associated, while parity, the household childcare burden and wealth are positively associated with inadequate utilization of ANC. Both individual- and community-level characteristics influence inadequate use and non-use of ANC in the first trimester; however, community-level factors are relatively stronger in rural areas. CONCLUSION The results suggest that improving the content of care during ANC visits may foster adequate use of ANC and encourage early initiation of ANC visits. Furthermore, health promotion programmes need to further encourage male involvement in pregnant womens decision to seek ANC to encourage adequate use of services.

On health insurance and household decisions: A treatment effect analysis☆

In developing countries, where health insurance is not a commonly purchased financial instrument, recent debates have revolved around extending health insurance coverage to a wider range of the population, primarily via compulsory insurance schemes. However, these debates rarely consider the competing demands placed on the family budget, which will influence the acceptability of the program by the populace. In this paper, we draw on data from the 2000 income and expenditure survey to examine treatment effects associated with household insurance status, providing a detailed examination of expenditure substitution patterns within South Africa. In agreement with economic theory, the expansion of health insurance coverage via compulsory schemes creates additional burdens for households, which households accommodate via expenditure substitution. The observed variation in the households ability to accommodate increased expenditure can and should be used in future to assess policy options and in the design of an optimal social health insurance program.

Did primary healthcare user fee abolition matter? Reconsidering South Africa's experience

South Africa waived user fees for primary healthcare in 1994 and, again, in 1996. The first waiver focused on young children, elderly adults, pregnant women and nursing mothers, while the 1996 reform waived fees for the remainder of the population, subject to means tests. We take advantage of household survey information to examine the impact of the policy on a subset of the reform-eligible population. Although it was expected that public healthcare facility usage would have increased post reform, no statistically significant evidence supported such a claim. Therefore, our results are consistent with some very recent research examining the 1994 reform, but are generally at odds with the general impression in the literature that user fee abolition matters when it comes to alleviating inequities in access to healthcare.

An assessment of the effect of user fee policy reform on facility-based deliveries in rural Zambia.

BackgroundImproving maternal health outcomes by reducing barriers to accessing maternal health services is a key goal for most developing countries. This paper analyses the effect of user fee removal, which was announced for rural areas of Zambia in April 2006, on the use of public health facilities for childbirth.MethodsData from the 2007 Zambia Demographic and Health Survey, including birth histories for the five years preceding the survey, is linked to administrative data and geo-referenced health facility census data. We exploit a difference-in-differences design, due to a differential change in user fees at the district level; fees were removed in 54 rural districts, but not in the 18 remaining urban districts. We use multilevel modelling to estimate the effect of this policy change, based on 4018 births from May 2002 to September 2007, covering a period before and after the policy announcement in April 2006.ResultsThe difference-in-difference estimates point to statistically insignificant changes in the proportion of women giving birth at home and in public facilities, but significant changes are found for deliveries in private (faith-based) facilities. Thus, the abolition of delivery fees is found to have some effect on where Zambian mothers choose to have their children born.ConclusionThe removal of user fees has not overcome barriers to the utilisation of delivery services at public facilities. User fee removal may also yield unintended consequences deterring the utilisation of delivery services. Therefore, abolishing user fees, alone, may not be sufficient to affect changes in utilisation; instead, other efforts, such as improving service quality, may have a greater impact.

On the performance of fractional multinomial response models for estimating Engel curves

ABSTRACT Engel curves are often estimated within a linear, or at least approximately linear, system of equations. However, Engel curves are required to lie on or within the unit interval, while summing to unity. These restrictions are not easily accommodated within a linear system. Therefore, we apply the fractional multinomial logit model in our estimation of expenditure shares, because it more readily accommodates these theoretical restrictions. Within our estimation subsample from the South African Income and Expenditure Survey, we find that accounting for these restrictions within the fractional multinomial logit model provides a better fit to the data than does the standard linear system.

Quasi-experimental evidence on tobacco tax regressivity

Tobacco taxes are known to reduce tobacco consumption and to be regressive, such that tobacco control policy may have the perverse effect of further harming the poor. However, if tobacco consumption falls faster amongst the poor than the rich, tobacco control policy can actually be progressive. We take advantage of persistent and committed tobacco control activities in South Africa to examine the household tobacco expenditure burden. For the analysis, we make use of two South African Income and Expenditure Surveys (2005/06 and 2010/11) that span a series of such tax increases and have been matched across the years, yielding 7806 matched pairs of tobacco consuming households and 4909 matched pairs of cigarette consuming households. By matching households across the surveys, we are able to examine both the regressivity of the household tobacco burden, and any change in that regressivity, and since tobacco taxes have been a consistent component of tobacco prices, our results also relate to the regressivity of tobacco taxes. Like previous research into cigarette and tobacco expenditures, we find that the tobacco burden is regressive; thus, so are tobacco taxes. However, we find that over the five-year period considered, the tobacco burden has decreased, and, most importantly, falls less heavily on the poor. Thus, the tobacco burden and the tobacco tax is less regressive in 2010/11 than in 2005/06. Thus, increased tobacco taxes can, in at least some circumstances, reduce the financial burden that tobacco places on households.

Catastrophic health payments: does the equivalence scale matter?

We present a revised method for estimating equivalence scales. Such scales are used to adjust household welfare to account for the size of the household, and are used extensively in the application of the World Health Organizations (WHO) methodology for the evaluation of catastrophic health payments. Applications of the WHO method are underpinned by early estimates that do not control for household income, and, therefore, are likely to overstate equivalence. Thus, in addition to revising the method, we update the scale estimates for one country, South Africa, using more recent data. South Africa is considered, because the end of Apartheid has led to extensive social and economic changes that have influenced household structure and, presumably, equivalence. We also present information on the possible degree to which earlier estimates are overstated, as well as the effect that has on other components of the WHO method, especially the determinants of out-of-pocket expenditures and catastrophic health payments. We find that, in the worst case, initial estimates could be overstated by as much 46%, leading to the understatement of poverty lines by as much as 17%. Despite these large differences, the average incidence of catastrophe in health expenditure was largely unaffected. Instead, differences in scales affect conclusions related to the determinants of out-of-pocket payments and catastrophic health expenditures, as well as the distribution of catastrophe across household size. Given that South Africa has low levels of catastrophic health expenditure, the effect could be even larger in other countries, and, therefore, we recommend that researchers consider a range of scales, when examining catastrophic health expenditures.

Assessing regional variations in the effect of the removal of user fees on facility-based deliveries in rural Zambia

Background Maternal health remains a concern in sub-Saharan Africa, where maternal mortality averages 680 per 100,000 live births and almost 50% of the approximately 350,000 annual maternal deaths occur. Improving access to skilled birth assistance is paramount to reducing this average, and user fee reductions could help. Objective The aim of this research was to analyse the effect of user fee removal in rural areas of Zambia on the use of health facilities for childbirth. The analysis incorporates supply-side factors, including quantitative measures of service quality in the assessment. Method The analysis uses quarterly longitudinal data covering 2003 (q1)-2008 (q4) and controls for unobserved heterogeneity, spatial dependence and quantitative supply-side factors within an Interrupted Time Series design. Results User fee removal was found to initially increase aggregate facility-based deliveries. Drug availability, the presence of traditional birth attendants, social factors and cultural factors also influenced facility-based deliveries at the national level. Conclusion Although user fees matter, to a degree, service quality is a relatively more important contributor to the promotion of facility-based deliveries. Thus, in the short-term, strengthening and improving community-based interventions could lead to further increases in facility-based deliveries.