Abstract
This paper investigates individuals’ bypassing behavior in the health sector in Chad and the determinants of individuals’ facility choice. We introduce a new way for measuring bypassing which uses the patients’ own knowledge of alternative health providers available to them, instead of assuming perfect information as previously done. We analyze how objective and perceived health care quality and prices impact patients’ bypassing decisions. The analysis uses data from a health sector survey carried out in 2004 covering 281 primary health care centers and 1801 patients. We observe that income inequalities translate into health service inequalities. We find evidence of two distinct types of bypassing activities in Chad: (1) patients from low-income households bypass high quality facilities they cannot afford and go to low-quality facilities, and (2) rich individuals bypass low-quality facilities and aim for more expensive facilities which also offer a higher quality of care. These significant differences in patients’ facility choices are observed across income groups as well as between rural and urban areas.
Highlights
In most Sub-Saharan African countries, weak competition in the health sector creates a situation where the population is often faced with local primary health providers which are monopolies
Some individuals choose to be treated in health centers farther away from their homes, and incur greater time and transport costs in order to obtain services perceived as better adapted to their needs
Because the quality of health care provided by a health center is likely to influence its demand and the likelihood that it is bypassed it is among the main variables of interest in the paper
Summary
In most Sub-Saharan African countries, weak competition in the health sector creates a situation where the population is often faced with local primary health providers which are monopolies. Some individuals choose to be treated in health centers farther away from their homes, and incur greater time and transport costs in order to obtain services perceived as better adapted to their needs Such bypassing of health centers has been shown by Akin and Hutchinson (1999) as being an important phenomenon in Sri Lanka. We make use of data collected in Chad as part of a Health Facility Survey organized by the World Bank in 2004 to examine empirically how bypassing decisions are influenced by differences in service quality, level of competition, and patients’ socio-economic characteristics. Informal providers in Chad represent an important part of the health sector in rural and urban areas Accounting for these providers allows a better understanding of individual choices with respect to health services.
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