Review of Literature and Theoretical Framework 2.1 Introduction Ilescilrch on thc ut~lrsation and determinants of health care services and related issues ha~c become an imponanl policy issue in the context of both developing and developed countries. The approaches of the governments towards health care provision and utilisation have heen different For Instance, in many advanced countries the role of the statc has bccn ~nstrumcntaland governments budgetary provisions and allocations have been si~bstanual Th~s con~ributed remarkably to overall improvements in the general hcalth status. uhlch is typically true in thc industrially advanced OECD countries (Gerdtliam and Junsson, 2002, Jonsson and Musgrove, 1997; Shieber and Maeda, 1997). In most developing countries. larger vacuum and deeper gap have been left out by the govcrnlnents as a pollcy inil~at~velalternat~ve to permit large scale private participation thcrchv encouraging out-of-pocket payment as the method of health care financing for both outpatient and inpatient care (Sanya1.1996. Selvaraju, 2003). The proportion of rcouric allocatloli for rercarch and development in general and health care research in particular has been much higher in developed market economies and has made slgniiicant contribution to the overall development of production and service sectors [Korllai and Ilgglcston. 1001). On the other hand, in most developing countries, the nature and cxtc111 ol'~n~er-sectoral co-ordination among the different departments such as watcr .;upply, irrtyation. sanitation, rural development, human resource developmenr. puhllc hc~lth. lam~ly wcliarc. tducatlon and housing have been very weak affecting the tlnct~onal efficiency and long run sustainability of various health care and related development programmes (GoI, 2002b). I)ctcrminants ol' population health are complex and the organisational structure of the health carc systcln bas~call)contributes to the operational efficiency or inefficiency of thc systcm, llealth care is a typical commodity bought and sold in a (partially) rcgulatcd or mostly tfcc markct system. Health is an invaluable asset and deterioration or decline in the health status require appropriate medical intervention. The technology induced health care has increased the medical expenditure and accentuated the miseries of thu common man on thu one side. and the changes in medical technology as an
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Review of Literature and Theoretical Framework
2.1 Introduction
Ilescilrch on thc ut~lrsation and determinants of health care services and related issues
h a ~ c become an imponanl policy issue in the context of both developing and developed
countries. The approaches of the governments towards health care provision and
utilisation have heen different For Instance, in many advanced countries the role of the
statc has bccn ~nstrumcntal and governments budgetary provisions and allocations have
been si~bstanual T h ~ s con~ributed remarkably to overall improvements in the general
hcalth status. uhlch is typically true in thc industrially advanced OECD countries
(Gerdtliam and Junsson, 2002, Jonsson and Musgrove, 1997; Shieber and Maeda, 1997).
In most developing countries. larger vacuum and deeper gap have been left out by the
govcrnlnents as a pollcy inil~at~velalternat~ve to permit large scale private participation
thcrchv encouraging out-of-pocket payment as the method of health care financing for
both outpatient and inpatient care (Sanya1.1996. Selvaraju, 2003). The proportion of
rcour ic allocatloli for rercarch and development in general and health care research in
particular has been much higher in developed market economies and has made
slgniiicant contribution to the overall development of production and service sectors
[Korllai and Ilgglcston. 1001) . On the other hand, in most developing countries, the
nature and cxtc111 ol'~n~er-sectoral co-ordination among the different departments such as
watcr .;upply, irrtyation. sanitation, rural development, human resource developmenr.
puhllc hc~l th . lam~ly wcliarc. tducatlon and housing have been very weak affecting the
tlnct~onal efficiency and long run sustainability of various health care and related
development programmes (GoI, 2002b).
I)ctcrminants ol' population health are complex and the organisational structure of
the health carc systcln bas~call) contributes to the operational efficiency or inefficiency
of thc systcm, llealth care is a typical commodity bought and sold in a (partially)
rcgulatcd or mostly tfcc markct system. Health is an invaluable asset and deterioration or
decline in the health status require appropriate medical intervention. The technology
induced health care has increased the medical expenditure and accentuated the miseries
of thu common man on thu one side. and the changes in medical technology as an
important instrument of the market have thoroughly transformed the profile and pattern
of secondary and tcniary hcalth carc (Kornai and Eggleston, 2001). In general, the
developing countries experience many problems and constraints in the provision of
health care like inadequate essential drugs, lack of qualified medical and para-medical
personnel particularly In rural and tribal areas. insufficient community health care visits,
poor transport and lack of material for dressing and treatment. These constitute the major
suppl! constraints. which rrsrrlcr the utll~sation of the health care services (Ross Mary
McMnhan. 1986. flergwali. et.al, 1973) Thus, in the rural areas of most developing
countrles, supply factors In the form of infrastructural constraints restrict the utilisation
of thc essential health care services On the other hand, the physician parameter act as a
proxy Sor the patient i i i malters relating to the nature and type of diagnostic or
therapeutic procedures and the quantity and quality of (specialised) medical services for
both outpatient and inpatlent care(fuchs. 1972) However, medical science cannot claim
thu hll crcdit kir the impr{~velnents in thc health status. For instance, the American
Medical Association states: "Med~cal Sclence does not seek major credit for the
Improvements In the health level during the past 25 years. Certainly our standards of
living and li~glicr education level have contributed substantially to the betterment of
healtll ievcls" (Quoted In Fuchs. 1972; see also Illich, 1976)
I lealth carc cconomlcs. an Important branch of normative economics deals with, in
general. the production ~ii'llcalrh and consumption of health care services. Health care is
treated as a commodity just like any other commodity in the market and in this process
the iit~lisation of qualiiy hcalth care services has become a serious problem for the
\'ulncrable secuons, marginal cornmunlrles and the rural poor. In the present world of
technology re~olution. health care pricing is generally more skewed and the ability to
pi^? 11I'thc people is a constraint on the utilisation of quality health care services. Thus,
inalntaining individual and community health IS a serlous concern and promoting health
surveillance. achlev~ng equity through proper allocation and redistribution of health care
rcsourccs are important policy issues. At the theoretical and empirical levels, the
determinants ol' product1011 or supply of health and consumption or demand for health
care are crucial in the analysis of the utilisation of medical care services and in the whole
licld t~l'research in health care economics(Wagstaff.1989;Fielder,l981).The determinants
of health owe much to the nature and pattern of the health care provision, medical
infrastructure, the socio-economic status and the cultural aspirations of the people. The
singlc lnost important factor influencing the individual or family health status is the
quality o f life. which would be basically Influenced by the socio-economic and
demopraphic ractors At the policy level. there should be reconciliation between these
micro and macro economic health issues, which are crucial when health status variable(s)
act as a determinant o f labour productivity and economic efficiency (see fig.2.3). In the
long run, cross sectional houseliold health surveys, particularly at the policy level, should
contrihutc fbr sustaining thc health status by improving the overall socio-economic status
and in part~cular the nu t r~ t~ona l standards 1'11~1s. Improving the level o f income through
e~nploymen! yuar;lntcc programtne and. of course, eradication o f poverty and deprivation
act as important detrrinlnants of health status sustainability in the long run (Rothman,
et.al 1998; Sen. 2005)
I:rom a polirical cconom) vie\vpoint, demand for health care and its sustainability
depcnds much on the nature and character uf resource al locat~on in the health sector,
quantity and qualit) of incdlcal car t ser\icea and equity considerations in health care
prov~.;ion. hcalth care ~ n h t r u c t u r e . the a\,ailabil~ty and cost of medical technology.
medical expenditure and the socio-economic status of the patient or the household. Thus.
a broad framework for a scientific understanding and evaluation o f health care requires at
lcast a i'our lilld cl;rbs~licat~on and analysis of the medical care functions viz, preventive
carelmcdicine ( cp ~ncrcascd birth spacing, reduction in family size, communicable and
Fig 2.3: A Schematic V ~ e w o f Health Economies -- X I a t i . t l r ~ r ~ R . m U h , 1
U -. . 1Oo7n ho H.4* i"h T&.,.. ",*"h, ~ ,h , . '1 j I~lq.""".l h ~ . d . C a n m p & o n l,.\'nb,*
! F e + - , ,,:,, , , A , 5 o , b,du, ,,, ,!u, ~ . -. -i p ~ ' * ~ ' d u c ' ' D n ~ l m m ~ "'
i d.,,. mu.,,: ..,,,I.,, , .,I. ,a!,\. , ( - , / r. llr,. ,.. i," I
i i
Fig: 2.4 A Syslerns Analysis of Hea l th C a r e
individual object~ves:
party ~npui," (influenced by
Objectives Income, Le~sure
Hospital
Objecl~res Those ol 'ch~ef phlrtc~ans
Cap~ral Iechnology
Source Z w r ~ f c l and Breyer (1997)
Fig: 2.5s: Determinants 01 Health Level
Basic Determinants
* Pupulatlon * Env~ronrnent * Genome ( B ~ o l o g ~ c a l Rlsks) t Social Orpan~zat~on (Economic structure, political
mst~tut\oor. science and Technology, culture and ~dealog))
bucietsl 1 1 Structural Determinants I L i.e\el o l h e a l t h L Occupational btructure L Social stralifical~on
Redistribut>ve mrchan~srns-Taxes and Subsldles
4 P r e r i m r l r Dere rm~nsn t r
Household
L \+or l lng cond~rlons (Occupar~onal rtsks) L I l i l ne sond~lions (soc~al rjsks)
S l ' u h l ~ i l > it,nfcrred ent~tlements + kducmlon, roc~a l securlt)
+Vdrket baaed entirlemenls Food and Houslng L L ~ f e rr)le (Behav~oural r ~ s k s l + Health care s)stem
I)~,ca\c agcnc) [ l l ~ ~ i l a g ~ c d l / He.. \ D~agnos~s and
C'helnicdl. Treatment
Ph>r~cal. status Env~ronrnental
- Uctcr~n~na l~on ... ...--.b Health act~ons
Source Irenk n al (1'491)
Fig: 2.5b Determinants 01 Population Health: Evans-Stoddart Model
Fig 2 . 5 ~ Dcterm~nants 01 llealth
Individual !
Fig: 2.6 hludel o f the Pathways b! whlch SES influences health
-. - SES Exposure IO I I-
Constra~nls cnrctnogens and * E\tsrnal palhogens
en\ lronrnent * 5oc1al Health
stir lronment * a n d Performrnce of * Resources health-relevant Illness
behaviours
Psyrhuluy~cal ~nflucncrr
CNS and Endocrine
t Cognition * Immune and cardiovascular
Source Adlrr and Ortrove (IP99)
Fig: 2.7 Kroegers Model of llealth Seeking Behaviour
I a b l c : ? . I ~ ( j r n c r ~ ~ ~ ~ b l i c Heslth Studies , -
91. Stud) Focus 8 Major Findings
?"' : -~ ! i I Perce~ved susceptibil~ty, ser~ousnesr, perce~ved j
I , Rosens~och Behavoural benefits and barr~ers to tak~ng the decision are
Solon el a1 ' I (1067)
L-. I _ .
1 Anderson & Nrwma1rn(IV73)
, 1 - 1 6 ' Kroeyer I
( IqSja) I t I s i
. . b e t w ~ n rural and urban.
k { - T & T - -%k hnks cn publ~c ' K d e q u t c inst~tutlonal capacli and the severity 1 1 , , . 1 LZo?! , 1 Ieallh care system / of market failures
Murray CJL(1996)
Mehrotra and Javren (2002) --i
. - . . .. --- - Morb~d l r y T Differences between sel f ~e rce l ved and observed I
~ o n c e p t u a l l s ~ t i o n Health service
. . * ~ . - Comprehcns~ve health surve)
In India
Household is the most Important producer and
Us 142 60 per illness episode in urban area. Rs 1 15 1.81 per eplsode in the rural areas. with wlde
to the road and rervlce centre, are positlvcly l lcdthcare related to the use o f health care. Age o f the
srrvlce utillsation respondents and household size negatively associated w ~ t h health care use. Caste IS
.~ ! unlmpottant 1 Coclo-cultural factors and governmental suppon
Mor,allt) ; programs In the field of health and education 1 reduced monal i ty low Income countrlcs lncludlng /
~
4 h e lndlan state o f Kerala
( IU78 i d ~ s i r ! b u ! ! c ~ a, ,)avlF , 121,01, 1 50 i1a l valueand
Heath care ---. . Murra) a C'hen
. . f l l - - ~ ~ ~ - . + . -. Morbid't) cllnlcal d~agnos~s
. , . nd utllisatlon o f medlcal services
I Soc~al values crucial In determlnlng the dellvery and dlstributlon o f health care resources.
1 Self- perce~ved symptoms are a key Input to
I uchr L. , lq,?l Pti)sic!ansand lr,edlcrl care
Mcdlcai care decis~ons are physlclan induced ...~, .
I,drker , 1 4 8 2 , l l i ) ~ i \ eho ld health P rov~de i a standard methodology for sample
. . s u r ~ r ) ' household health survey uslng a two-week recall L.. --
In d e m o c r a t ~ ~ socletles to Improve population 1 1 I I l 'npul~ l lnn hcalth liedlth, resource reallocation f rom health care to
astlvltles that more dlrectly prevent illness ~ --
Lcadrr,hlp challenSe Lack o f political will of the modern governments \I r l t on et a1 I 14'471 In care , prefer market orlented solutions to complex health
. . *- . .~ . -. - care probiems -- ~III<:ILL;V~C I el r l lr i lcprrted rural Integration-cllnlcal. functional. physician system
l IVY7) , lic,~!ili _ ~mindcial
2 4 Yoder R I I Y ~ Y ! I
I,r rr idre Soc~o.econom~c characteristics quallty o f care arc
-- I the -- Dctermlnants ofdemand -----I The nature o f cholces and health seeklng I
Kur,i i hedlth I hehavlour In cruclal for rural health planning and 1
lo0. uhbch ind~cater that peoples abll ity to pa) l mas the c ruc~a l determinant o f health care
1 and I I and 17 days for urban IPS. , 7 , 8 --?----. Basic determ~nants basic, structural. proximate, at ,
;'> I TenL J e l AI I 1 0 0 \ ~ "::::::;" system!c, soc~etbl, m l~ tu l lona i , hou~eho.' and
I ' .- 1 ~ n d ~ v ~ d u a l levels ! , U.rsrldn ,, , , O x O , : HeJllh cconij,neir,cs I-~rovldes an analytical survey of British applied I
osltlve health econometrtcs stud~es. . ldenttfies the role of vub l~c health (indirectly) and 1
processors in medical care Health determinants include: biological, socio-economic, racial-ethnic, psychological. env~ronmental, bio-medical rlsk
general model o f he-lth status
C tnrintunity approach '' 119q8) I" hcalth research
I
: ; 2 ' t i umhu~ I IOU71 M n r h d ~ f ) hurden
clmlcal medlclne(d~;ectl~)ln lmprovlng health status In splre of enormous investments In the health sector, panlcularly cancer, the relation between health care spending and health o f populations remalns weak. The rate o f hospital~sation per I000 populatlon differs across provinces In Canada For ~naance. it IS 75 In Winnipeg, 110 In non- Wtnn~peg and 90 in Manltoba Argues for
populatlon hcalth lnformat~on system __ It lncludes the panerns of utilisat~on by age and sex as well as economic, organisatlonal and cultural delermlnants o f and access to utlllsat~on of health care Community based approach include the need ' demand for care, co-morbtdlty and use o f health rervices, relation o f natural history of disease to Ihe use o f health serv~ces . -
urban centres. The reported annual rates o f hospitai~sat~on for males exceeded those for males in rural and urban Ind~a. The rate ofhospital~sation rhowed a rlse with MPCE Average duratlon of
I able: 2.2 Soc~u-Kcynutnnr Slnlic: and Demand for Medical Care ..-._---._7
I ~ l . n o I Study Focus. . ' Ma 'o r findin s 1 , , l)eai<,ll i2(,(,2, pol,c> .
i ~ c ~ i e ' i ; i y d z ~ o n seiarately p:otective o f health SES 1 . .. . . - - and health negalively related
1 1 - i d l e r rnc ' Labour market Inequality and inequality In SES defined in
SES and health terms of educat~on. ~ncome, occupation detcnorates the gaps between the hcalth "haves" and "have nots"
, stay varied between 13 and 18 days for rural IPS /
I i "";;c,:; r r rv lcES.- . l O f ~ d
h s n i v e correlation between SES and use o f med~cal care 1 1 SCrvICes
I - - - - -- - V i i a " i i a ; b for health services IS hlghly skewed. Costs and 1 I. 1 Fuchs(l996) 1. health care 1 benefits of care different across SES, age, sex, and social
eeoeraohv
1 Adler and 8 Ostrovr
I I O Q ~ I S i S and hcalth 1 Breast cancer and mal~gnant melanoma rates hlgher among
upper SES group .,,., ' i a v l n . ~ I Soc~al ralue and / Sochal values determining the delivery and distributhon o f
, _ 1 ~ - - *0_1 . + -&?!thhcare , health care resources
l u Fond. Anne Pr~rnar) health 1 Consumer's socio-economhc characteristics, qualhry o f care (1995) iarc the r n a ~ d c t e r m i n a n u ofcare.
, , Wade and 1 Rural lhealth .Thenlure ofchotces and the health seekhna behavlour cruchal " 1 B ~ ~ k s I 1979) m;dna$rmet_ 1 for rural health plannrnp and management.
( T u o types health benefits (a) consumption benefits o f health
!: M u u r ~ n c ~ i J M 1 Dcmand for In the form o f increased utllhty and (b) investment benefits o f
I (19821 health j health in the form of healthv time available for activ~ties such i I , as consumption, working and hnvestment In health
I ! Hakkincn.l! I Demand for j A s~gnificant ponion o f health care utilisatton depends on 11991 1 1 _ health 1 doctors' declshons and is generated by pauent-doctor contacts ,
Murra) FI dl Anributes o f health variat~ons across individuals lnclude I
1191)91 I iedhh~nrqual~t ! chance. genes. physical and soc~al environment a n d ! ' lnteractlon between enes and the envhronment I *'derrnan dnd I O,,i;h t i ~ u ~ i n l l o w R o m e households are w i l l ~ n g to pay for '
l.a\) I 19461 a ~ s ~ l ~ s e r \ i c e s provlded by the government _J
'Table 2.3 Heal th Care Financing /Expenditure ~ . . . -. -. - . . .. .-- Sl.no Stud! I Focu, j M a j o r Findings
. .. .- . . .. --- - Private sector crucial In the provision o f health care servlces in \'~e!nom An average household spends $9 1 a month on health 1 care or $1 12 annually I The households spend a larger share o f thew Income on health (around 3 4 percent) as compared to 1 09 percent of the state
i o n ~ r m m e n t r tn 1901.9d k-z- . . .- . . . . , . - ' . I Uugal dnd k,i ' The percapita annual household medtcal expenditure worked
2 , Am,n (1989, 1 "u!-F,Rsj82 49, w h ~ c h was 7.64% o f the total consumptlon
I'""", !&an ba~reerelathon to rural areas
~ l i , l d d i , d --[; SOchaI tnsurancc contr~butions, prtvate lnsuranc]
(2001 1 tinarlclng , prrmiums, communtty Ananclng, out- of-pocket payments are 1 r ~ s o u r c e s o f health finance
Rural The Chlnese study revealed that high medical expenditure, the
7 LIU et a1 (1995) prhmary cause of poverty panicularly after the global~sation
+ -. a enda Averaee medical exoend~ture oer eohsode was Rs.850. Rs 1065
Medical / for IP-care in rural bnd urbanare; respeclively and Rs 70 and / expend~ture Rs 97 for OP care In rural and urban areas In 1993.
. - 1 I
.- - . - .-
Study [ Focus - I.-.- M a j o r Findings
(1995) i data bas"' ma~n iy urban biased.
Jackson i 2000 ) Ger~atr~c care and! Causal llnk between ageing and medical expenditure
*"-*,.A;,,,.*
o f expendtture on child btrIh In rural Kerala ~arabana I 0ne.seventh o f the households in Kerala spend more than 20% j2001) 1 ACLe'b I o f the~r annual ~ncome on med~cal ex endihre.
I ulasldhrr tkpendlture-? E G i a t D r y resource alloc:ion and cxpendlture , ,,,,,., , cumpress~on & 1 compresston In the soctal sector badly affected the educattonal ,,",,I 8
healrh sector and hector In lnd~a - - - - - -- J Table 2.4 Political Economy and Equity
-r.s.tu.d~ ;..- -.. -1 , Fucu! _+-. - , M a j o r findings
sd,,ldnd,P \uc~aI LOW SES Increases the rtsk o f poor health Strong assoclatlon between soc~ai class (low Income) and low 1 ZZ:h ~ service ul t l~sat~on ,
Mechdn~i D 114th , Development strategies to Improve populauon health I t?Uo?) ; 1nequd11!\ : m2lncrease health tnequalttles
,
I Access IS equitable when the use of health servlces 1s
(20021 1 Hrs l lh rqulty 1 determtned by demographic factors and need and not ' I b) soctal character~sttcs or the abillty to pay
I : Underddeelopmcnr 1s due to hlghly skewed or Yd$,+rru.\ '
Table: 2.5 Rural Health
' . L3roor1 1?79 , p:ldL:%fi~ . -2r.i +@r r,ra healtr plann~ng and mana"gcmen1 I , f luao- C. m n J I ! 51ya- 1) ofrne pat.ents sobgnt medtcal lreatmenl
health wry~ey_lxreaees the ut~l isat~on o f med~cal care services
l'able: 2.6 Other Related Studies I 1 M a j o r findings
Will~amson tnv~ronmentai / Environment. the basis for aublic health and 1 1 (1996) 1 health / soclal medicine.
Protecting workers' Interests, betterment o f
2 fn~~ronmentaland worklng condlt~ons Inside the industry and Muk1'I' iYv7' ' I c ~ c ~ p d l ~ o n a l health env~ronmental protect~on out slde poses X ~ I O U S
- c- . . . - - j threat lo occuparlonal health 4 srare of successful menral functtonlng, resulting
. . ( 1996)
..
Health plannlnp i transponatlon , communlcatlon and environment) ' an Important determinant o f utilisation and non-
+-~-- util isat~on o f health care facilit~es.
Wade and Brooka The nature o f choices and health seeking
(1979) , behaviour is cruc~al for health plannlng and
mana ement I ,. .! . 'Mar~dn.~ and Health car; :Three dimensions o f health care decenrral~sation-
Law plays an tmponant role in regulating the Marun.K and
I ,ohn,on~, hw and 1 ~nteraction between factors external to publ~c 1
health, through the regulation o f activ~t~es and
i 13 Bhat. Rdlncsh
+.- Abu-Zetd and
I S ' Da_nr (1985) . j. ,.. . . . - . - .
1 ~ ~ ~ ~ a n d j c c e: a1 l199U)
I ' 7 hhSUI lY** !
behaviours. Increase Investment in technology and proper
Ptivate Sector management of health care resources Regulate the rlvate secror throu h a ro riate le tslatlons I
Gender .=I-JJ=+ and health Higher female morbidiry
,,ssrna, flea ,n I Lo* antenatal care dur~ng pregnanc) in sp re o f
. . ---- tnc ava11ab.l.t) o f s ~ c h fa;~ t es In :he PHCr Uomen's educartoi Income fam, \ strJ;rJrc and ktnsh~p stgn~ficant determtnants and occuparton. ~ santtatlon factlltles lnslgntficant derermlnants of ~ health care service uttlisatton . . . . -- -
, Inpartent rate 23 per1000 during 365 d F s T h e ' Morbtdlty and ( monthly prevalence rate for routlne illnesses was
utll~satmn 64 per I000 m rural and only I 1 per IOW ~ I populatton In urban arcas
burden / The reported annual rates o f hosp~tal~sat~on for
~ &- . males exceeded males In rural and urban lndla - i i Hosp~tal cost variations are due to differences in
1 9 o luu i~hu ie , l lu\p~tal lcngth o f ' average length of stay Increased ut~llsation o f OP
I 1978 I s~d\ ! care factlit~es wll l reduce the leneth of 1
2 4 1 Udllc! i?0!l21 _ u i & s ~ i n lof health care servlces among the rural elderly I Access. resources. distance. transDortatton tlme. 1
1 - _. _ _ - I
has ttai~satton
: ?,, ~ I h b 1 5 ,,IIC! Uusscl RIs& cost o f IP hospiu care has increased the
, (1'172 1 1 OP and IP carc ; use o f OP hospltal care and the substttur~on of ,
8 hos ital OP care for IP care. < -
1 !I ~ ~ ~ n ; ; dlld -- ' k%Zand OP and 0u;atlent vlrtts and ~npatlcnt admtss~ons decline :
. , office hours are the supply stde factors and age. 1
2 5 sex, family stze. social structure. race, educatton. / ~~~~~a t t on .~~ l t u re .~ncome .~nsu rance and need are !
Benth>t!l!l (1982) IP care
I laynci and Ue!~:h.~m! 1'1821
Ahu-leid and Ildnn ( 1981
I ll) I (1992) .~ . ..> - - .--
Bhatt~a and Cleland (1995)
with decreasin accessib~li 2 2 4 Hard[, C et a1 1 facllon ; a s ,$ton in p?bllc OP health care .
I 1 t2004l , . - -. Access and monthlv DercaDlta consumer !
. - 1 - - 1 sources of health care more than at later partty 1 I Women's education. Income, fam~ly structure. )
I
/ health and ktnsh~p slgn~ficant determinants and women's 1 / occuparton, sanltatlon facllitles were not /
- - - I Access and OP and I IP carc use
? -
h,aternal health . . . . - -
1 1 Insignificant I
Outpatlent vtslrs and Inpatlent adm~sslons decline I wtth decreasing accesslblltty LOW antenatal care durlng pregnancb In splte of : the ava~lability ofsuch services in the PHCs 1 -
Ilealrh Pos~ttve cffect of maternal schooling o the usc of prenatal and delivery care services. Educarlonal level, economlc status, and rcltgton
Maternal health are signtficant predictors o f maternal servlce
1 Maternal health That is. mother's at first partty consult modern
,8u!uuejd qijeaq put? (~ilod q11e.y 01 aur(apln4 e apl\old
pue aseqoiep am qileaq [euo!9al aqi a~oldur! plnw slt[.l sarpnis ~I~JP-LII pi111 J!II.>:,~s
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