SMCH/HCDS/01: Health Services in Developing Countries

Quadrant-I

Personal details

Role Name Affiliation

Principal Investigator Prof. CP Mishra Department of Community Medicine,
Institute of Medical Sciences, Banaras
Hindu University, Varanasi
Paper Coordinator Prof. Najam Khalique Department of Community Medicine,
J N Medical College, AMU, Aligarh
Content Writer Dr. Anees Ahmad Associate Professor
Department of Community Medicine,
J N Medical College, AMU, Aligarh
Content Reviewer Dr. M. Salman Shah Assistant Professor
Department of Community Medicine,
J N Medical College, AMU, Aligarh

Description of Module

Items Description of Module

Subject name Social Medicine & Community Health
Paper name Health Care Delivery System
Module name/Title Health Services in Developing Countries
Module Id SMCH/HCDS/01
Pre-requisites Understanding of health concerns in developing countries
Objectives To know about health services in developing countries
Health services, Developing countries, Dimensions of accessibility,
Keywords User charges.

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Introduction

Health care services can be considered the provision of all services that prevents disease and
preserves health. It extends from the provision of illness treatment and management to the
maintenance of the physical and mental well being of the individual. Health care is therefore
not merely medical care; it looks beyond the availability and affordability of medical care. As
commonly assumed health care provision does not commence or end with the health
insurance coverage availability. Theoretically, health care is multifaceted involving medical,
public health and social services. The social services working as primary promoter of health
comprise poverty reduction, housing adequacy, and environmental sanitation including the
provision of safe and wholesome water, adequate nutrition, education and employment1.
By necessity therefore health care embraces the factors that empower development:
economical welfare, political support, social services, infrastructure, agriculture, education
and individual accountability. It inculcates all the goods and services available in a country to
provide health, that includes “preventive, curative and palliative interventions, whether
directed to individuals or to populations.”2

Learning Outcomes

Upon completion of this module, the reader should be able to:

 Define the goals of the health services
 Enumerate the scope of health services
 Identify the dimensions of accessibility of health services
 Enumerate the reasons for non- utilization of effective interventions
 Identify the constraints on the demand for health care
 Enumerate the determinants of preferences for health care
 Enumerate the strategies for improving utilization of health services

Main Text

1. Goals of the health services

The goals have been defined in terms of mortality and morbidity reduction, increase in life
expectancy, decrease in growth rate of population, nutritional status improvements, providing
basic sanitation, required health manpower and resource development and various other
factors such as food production, literacy rate, reduced level of poverty, etc3.

2. Scope of health services

It is influenced by general and ever fluctuating national, state, and local health problems,
needs as well as the available assets to provide these services which includes four aspects4-
 Constructive services- which include environmental &nutritional measures, physical
society, etc.
 Personal protective services- which include immunization, periodic health
examinations, health education, etc.
 Curative services- which include the diagnosis and treatment of disease and injury.
 Restorative services- which include measures to help the individuals to return to full
working and living capacity.

3. Accessibility of health services

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Access to health care can be defined in different of ways ranging from its most narrow sense
to broader definition, in terms of geographic availability & the identifying four dimensions of
access respectively: availability, acceptability, accessibility, and affordability5.

3.1. Underutilization of effective interventions

There is plentiful evidence that access to effective health care is a major issue in the
developing countries. Millions of individuals suffer and die from conditions for which
effective interventions exists. A very large gap exists between the potential and actual
benefits of health care in the field of reproductive health& various communicable diseases
such as less than half of pregnant women get an antenatal check-up, and only 1/5th of births
are supervised by trained personnel in South Asia. In low- and middle- income countries
antiretroviral therapy coverage rates do not exceed 5%6.

The gross underutilization of effective health care, results in large unrealized health gains in
developing countries. Raising coverage rates to 99% from the current level of effective
prevention and treatment interventions & maternal health interventions may result in 63%
reduction of child deaths7& three-fourths reduction of maternal deaths6 respectively.

On the demand side, cultural and educational factors may hinder disease recognition and
health care potential benefits, whereas economic factors may suppress utilization. It is
estimated that deficient care seeking leads to 6-70% of child deaths. The median study
concludes that 23% of fatally ill children doesn’t take any treatment8.

On the supply side, suitable interventions may not be provided at all, maybe due to scanty
resources. The significant gaps that exist between the actual health spending and the spending
required for provision of essential health services package suggest lack of availability as the
root of the problem among many poor countries9. Many effective interventions are not
excessively expensive, even for the poorest of countries. For instance, interventions applied at
home delivery may avoid one half of child deaths in sub-Saharan Africa6.

Despite of health care availability, sometimes due to poor quality effectiveness fall short of its
potential efficacy. A review shows mixed evidence of impact of primary care clinics on
population health, although the primary health care interventions has high efficacy10.

In practice, supply and demand are intermingled, availability of poor quality health care
results in little demand for it. Evidence shows that demand is quality driven11. A survey in a
rural area of India shows very low utilization of public health facilities, although freely
available12. The reason is very poor quality care, though the quality of the alternatives in the
form of private sector is also doubtful. The demand and supply sides interventions should
progress in accordance.

3.2. Least usage of effective interventions by the poor

The lowest utilization of effective interventions causes concern from perspectives of

efficiency and equity resulting in the poor to be the least healthy and probability to benefit
most from the health care. The maximum health gains could be achieved through focused
meager resources for the treatment of poor through prioritization of programs towards the
health care needs of the underprivileged in the form of primary care and maternal and child
health packages. But, the evidence shows in theses programs also there exists bias in the
benefits delivery13.

The Demographic Health Surveys (DHS) provides the strongest evidence for the distribution
of the interventions related to reproductive and child and health 14,15. Households are ranked
by an index of assets possessed e.g., refrigerator, sanitary latrines, safe drinking water, etc.

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The surveys conducted in the mid-1990s in forty countries showed that in the poorest 20% of
households 56% of childhood diarrhea cases were treated with oral rehydration whereas in the
richest fifth of households 71% of cases were treated with oral rehydration14. Coverage is
highest in sub-Saharan Africa, but inequality in coverage is also highest. The differences in
immunization rates are even more than the other interventions. On average (42 countries), the
full coverage rate of immunization is 66% in the richest household quintile than the poorest
quintile in which coverage rate is only 38.5%16.

Approximately 1/3rd of children in the better off households are not immunized is beyond
acceptance & to make it worse approx. 60% of the poor children are deprived of such
immunity. Latin America and the Caribbean have the lowest immunization rates but the
difference in rich-poor immunization rates are lower as compared to Africa and South Asia.
On an average, the country having higher overall coverage rate also have greater rich- poor
difference in immunization rates suggesting that if there is marginal improvement in
immunization rates, better off will be the first to contract benefit21.

The variances in socioeconomic status for the reproductive health services utilization are still
larger. On an average, there is 5.2 times more medically supervised in the richest quintile
women than the poorest 1/5th of women15. The lowest coverage is seen in South Asia and
parts of sub- Saharan Africa whereas the socioeconomic dissimilarity in utilization are high in
most regions except Central Asia and Eastern Europe. Similar magnitude of inequality is seen
in the contraceptives use with 4.6 times more utilization among woman in the richest 1/5th
than the woman in the poorest 1/5th15.

The results of DHS between 1990s & after 3-5 years showed improved coverage & reduced
rich- poor difference for example Egypt, Kazakhstan& Nepal. Improved coverage rates &
reduced inequality for the deliveries attended by trained professional is also seen, for example
Egypt, India & Turkey etc. Unluckily, countries like Nepal, Bangladesh & Haiti showed little
or no improvement in terms of coverage & inequalities where there is 1- 2% increase in
delivery attended by trained professional among the poorest 1/5th. However, in countries like
Cameroon, Malawi etc. for the poorest 20% the rate of coverage for births supervised by
medical personnel actually went down. The non- DHS surveys between 1986-1987 & 1995-
1996 showed increased inequalities in health care access in India17.

There is evidence that suggests that the share of public health expenditures to the poor is
lesser than the rich in developing countries18,19,20. The poorest fifth receive their share of
public health spending in few countries viz. Columbia, Argentina, Costa Rica, Sri Lanka,
Malaysia, Thailand. The poor get<10% of the public health subsidy in countries like Nepal,
Guinea etc. whereas in the remaining countries the poorest 20% receive 10-15% of the public
health expending. In primary care public health expending also there exists pro-rich bias in
most of the countries21.

Inclusion of regional variations & quality difference in public health spending will strengthen
the evidence of rich getting proportionately higher primary care. The Asian incidence study in
provides practical support for this opinion20. The marginal increase in proportion of public
health spending for the poor will have a greater impact in terms of utilization than the rich
population22. This theory is coherent with support that public health spending has a positive
impact though marginal on the poor population health whereas there is no significant effect
on rich population health23,24,25.

4. Non- utilization of effective interventions

There are many factors which are responsible for the effective health care underutilization in
the developing countries in which economic factor is one of the important factor in health
care underutilization9. The WHO Commission on Macro- economic and Health recommends

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increase in health care expenditure. The other factors includes improper resource allocation,
rural- urban & poor- rich disparity. The hospital- based care uses majority of public health
expending whose accessibility to poor rural populations is least6,18. However, the shift in
resources to primary care may not necessarily provide the desired effect on population health
distribution and level10,22,26. The quality of primary care have major deficiencies in most of
the developing countries10,27.

Inadequate resources, inappropriate allocation, and lack of quality are major obstructions to
the effective health care delivery for the poor population. The problem of access cannot be
resolved without taking care of each of the above deficits. Suppression of demand is
influenced by two main sets of factors viz. those limiting consuming ability& those with
lesser eagerness. The health care demand also have certain constraints e.g. household income,
health care charges, and travelling cost & preferences which are determined by culture, health
care benefits knowledge& the service quality21.

5. Health care demand constraints

5.1.Household income

There are evidences strong positive correlation of household income with health care
utilization after taking care of other demand related determinants e.g. women belonging to
high household income group have higher probability of receiving antenatal care & delivery
by trained medical personnel28,29,30,31,32. Likewise, multivariate analyses reveals that there
exists positive association between household income and immunization rate33,34.

The out of pocket expenditure strengthens the income & health care utilization relationship.
Pooling of risks, subsidization through pre- payment options, can interrupt the reliance of
health care utilization on household income. Out of pocket expenditure & poor access makes
the household income a constraint for health care utilization21.

5.2. User Charges

The out of pocket expenditure make pricing a significant factor of constraint on demand e.g.
in Vietnam the hospital visit cost is 22% of per capita annual household income net of food
expenditure for the poorest 20%35. The evidence endorses that the health care charges hinders
demand11. Most of the studies in developing countries suggests price inflexible nature of
health care i.e. demand decreases less than proportionally to price36,37,38,39,40. Some of the
studies suggests price flexible nature of health care41,42.

Health care usage charge sensitivity is more for poor than the rich i.e. if the usage charge
increases the health care consumption share will increase for rich11,40,43,44. Unluckily, the
experience of fee waiving, especially in Africa, is non- promising45. The usage charges
deprives majority of poor population from basic services that are essential User fees often
effectively exclude the poor from essential services, whereas only a small proportion of cost
is recovered46. Increased utilization of health services by the poor in Uganda occurred as a
result of usage charge elimination however, no increase in utilization for child & maternal
health was seen after removal of usage charge in Africa47. Quality improvement can balance
the influence of increase in price11. Evidence showed that increased usage charge, travel time
reduction, quality improvement if combined together can increase utilization, even from
Africa that if increased user charges are combined with reductions in travel time and
improvements in quality, utilization can increase, even for the poor43.

The public system of health care are extensively affected by the unofficial payment especially
in countries like Eastern Bloc and Soviet Union which often exceeds the existing official
charges48.

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5.3. Other Costs (excluding user charges)

In the developing world additional charges like cost of travel and earning loss are important
factor in health care consumption. The time, energy & cost incurred to reach health care
facilities may play a significant role in utilization. The expected deleterious impact of extra
costs on the utilization of health care services is confirmed by the evidence28,49,50,51. In Ghana
the rate of health care utilization was doubled by reduction in distance to public health
facilities to half52.

6. Determinants of preferences for health care

6.1. Culture and gender issues

The deep-seated roots reflecting social & cultural patterns results in lessen demand for
modern-day health care system &preference of traditional system over modern system. The
adherence to social & cultural patterns is not firm as improved knowledge & income results
more use of modern therapy21.

The roles & attitudes of gender acts as an important determinant of behaviour related to
health care seeking such as access to reproductive, maternal & child interventions. The social
factors are not fully separated from the economic factors with the evidence from Indonesia
that increase in control of women over household expenses results in improved prenatal care
utilization53. The causality of association is a debatable point. Women in Africa, in the richest
group utilizes more public health services as opposite to women in the poorest group18.

6.2. Knowledge and education

The utilization rates are affected by knowledge & education. The immunization rate in India
is very poor in spite of being free reason being the lack of awareness of benefits reported by
one third of mothers, approx. one third not knowing the place to go for immunization 54. Poor
knowledge results in decreased demand for health care as demonstrated by a detailed study
from a village of North India55.

The socioeconomic factors affects the knowledge related to illness for which there are
considerable evidence from the developing world e.g. higher illness reporting are found
among the rich as compared to the poor18,56,57. The households from higher socioeconomic
group have more probability of illness sign recognition in child from rural Tanzania58.

6.3. Poor quality demand response

The demand of the health services is also driven by the quality of the health services. Poor
quality includes irregular services, poor availability of health care personnel, bad behaviour of
the staff, drugs availability, improper prescription etc.

The health services poor quality is leading problem in most of developing countries6,10.
Irregular opening of health facilities12; higher rates of absenteeism of health care
personnel12,59,60,61; inappropriate staff behaviour62; wrong diagnosis is common6;
unavailability of medicines, occasionally pilferage6,63; and inappropriate prescription and
treatment6are some of the quality related factors. 40% reduction in utilization was seen due to
deterioration of quality within 5 years in Ghana52.

The nearest facility is bypassed due to low quality resulting in care seeking at higher facility
of public health care or the private facility10,64. The likelihood of bypassing the public primary
care is more if the quality is poor in Sri Lanka65. Similar findings are also reported from
countries like Indonesia, Pakistan, and El Salvador10,64.

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7. Strategies for raising effective interventions utilization

Improving the effective health care utilization needs additional wealth for health services in
the developing world. This necessitates that health care spending is concentrated to the most
effective programs and interventions and avoidance of geographic mismatch. It demands
regulatory, management, and political reforms for delivering health care at good quality21.

7.1. Extension of health insurance cover

Pre-payment and credit schemes reduce the burden on household income for health care
seeking. Repetitive appeals have been made to reduce out of pocket financing reliance in
developing world9,66. According to Organization for Economic Cooperation and
Development/World Health Organization (OECD/WHO) DAC guidelines66, “the
development of equitable financing through increasing pre-payment and risk pooling is one of
four priorities for the development of a pro- poor health system delivering quality, accessible
health services to the poor”66.

7.2. Price subsides for pro-poor

The health insurance coverage extension is a goal to be achieved at long-term. At current

levels out-of-pocket financing can be provided to poor’s group only21. Identification of the
poor &appropriate incentives provision to providersis the major challenge21.

The criteria for out of pocket exemptions must be defined. Other groups under exemption
may include poorest fifth, indigenous people, adolescents,migrants, refugees etc66.

7.3. Use of cash incentives for raising utilization

Besides the economic factors, other non- economic factors also play a role in health care
utilization such as cultural and knowledge factors that can be overcome by cash incentives.
This approach can be practical for preventive interventions viz. growth monitoring,
immunization & ANC care6.

The cash incentives should target poor especially poor women either directly or indirectly.
Similar result can be seen through micro-credit schemes; however, evidence for this is
unclear67.

7.4. Lowering the distance barrier

Transport system improvement lowers the distance barrier through reduction of cost of
reaching health care and raising the facilities to catchment area population ratio6. In Africa,
financed and community administered funds provide emergency interest free loans to cover
the cost& help in emergency obstetric caretravel68,69.

Summary

Health services includes not only medical services but also environmental, nutrition, others
services. Developing countries face major challenges in the form of double burden of
communicable & non- communicable diseases with overburdened health system, aggravated
by the poor accessibility, affordability, inequitable distribution & poor utilization of existing
resources. The various measures for improving this is better political commitment, insurance
based health services & equitable distribution of health services that are accessible,
acceptable and affordable.

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References

1. Michael C. Belcon, Nasar U. Ahmed, Mustafa Z. Younis, Moye Bongyu. Analysis of

national healthcare systems: searching for a model for developing countries -
Trinidad and Tobago as a test case. Public Administration & Management Volume
13, Number 3, 40-74.
2. WHO, 2000. Why do health systems matter?
3. K. Park. Text Book of Preventive and Social Medicine, 23rded.
4. World Health Organization. Planning of Public Health Services. Technical Report
Series No. 215. WHO, 1961.
5. Penchansky R, Thomas JW. The concept of access: definition and relationship to
consumer satisfaction. Med Care 1981; 19:127-40.
6. World Bank. The millennium development goals for health: rising to the challenges.
Washington DC: World Bank; 2004. 

7. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris
SS; Bellagio Child Survival
Study Group. How many
child deaths can we prevent this year? Lancet
2003;362:65-71.
8. Hill Z, Kirkwood B, Edmond K. Family and community practices that promote child
survival, growth and development. London: Public Health Intervention Research
Unit, Department of Epidemiology and Population Health, London School of
Hygiene; 2003.
9. Commission on Macroeconomics and Health. Macroeconomics and Health: investing
in health for economic development. Geneva: World Health Organization; 2001.
10. Filmer D, Hammer J, Pritchett L. Weak links in the chain: a diagnosis of health
policy in poor countries. World Bank Res Obs 2000; 15:199-224.
11. Alderman H, Lavy V. Household responses to public health services: cost and quality
tradeoff. World Bank Res Obs 1996; 11:3-22. 

12. Banerjee A, Deaton A, Duflo E. Health care delivery in rural Rajasthan. Econ Polit
Wkly 2004; 39:944-9. 

13. Gwatkin DR. Overcoming the inverse care law: designing health care programs to
serve disadvantaged population groups in developing countries. Washington DC:
World Bank; 2001.
14. Gwatkin DR, Rustein S, Johnson K, Pande RP, Wagstaff A. Socioeconomic
differences in health, nutrition and population. Washington DC: World Bank, Health,
Population and Nutrition Group; 2000.
15. Gwatkin DR, Rustein S, Johnson K, Pande RP, Wagstaff A. Initial country-level
information about socioeconomic differentials in health, nutrition and population.
Washington DC: World Bank, Health, Population and Nutrition Group; 2003. 

16. Gwatkin DR, Devishwar-Bahl G. Immunization coverage inequalities: an overview
of socioeconomic and gender differentials in developing countries. Washington DC:
World Bank; 2001.
17. Sen G, Aditi I, Asha G. Structural reforms and health equity: a comparison of the
NSS Surveys, 1986-87 and 1995-96. Econ Polit Wkly 2002; 37:1342-52.
18. Castro-Leal F, Dayton J, Demery L, Mehra K. Public spending on health care in
Africa: do the poor benefit? Bull World Health Organ 2000; 78:66-74. 

19. Filmer D. The incidence of public expenditures on health and education. Background
note for the World Development Report 2004: making services work for the poor.
Washington DC: World Bank; 2003.
20. O'Donnell O, van Doorslaer E, Rannan-Eliya RP, Somanathan A, Adhikari SR,
Harbianto D, et al. The incidence of public spending on healthcare: comparative
evidence from Asia. World Bank Econ Rev 2007; 21:93-123.
21. O'Donnell O. Access to health care in developing countries: breaking down demand
side barriers.Cad Saude Publica 2007, 23:2820-2834.
22. Filmer D, Hammer J, Pritchett L. Weak links in the chain II: a prescription for health

8
 policy in poor countries. World Bank Res Obs 2002; 17:47-66.
23. Bidani B, Ravallion M. Decomposing social indicators using distributional data. J
Econ 1997; 77:125-40.
24. Gupta S, Verhoeven M, Tiongson ER. Public spending on health care and the poor.
Health Econ 2003; 12:685-96.
25. Wagstaff A. Child health on a dollar a day: some tentative cross-country
comparisons. Soc Sci Med 2003; 57:1529-38.
26. Filmer D, Pritchett L. The impact of public spending on health: does money matter?
Soc Sci Med 1999; 49:1309-23.
27. World Health Organization. World Health Report 2000. Geneva: World Health
Organization; 2000.
28. Wong EL, Popkin BM, Guilkey DK, Aking JS. Accessibility, quality of care and
prenatal care use in the Philippines. Soc Sci Med 1987; 24:927-44.
29. Schwartz J, Akin J, Popkin B. Price and income elasticities of demand for modern
health care: the case of infant delivery in the Philippines. World Bank Econ Rev
1988; 2:49-76.
30. Panis C, Lillard L. Health inputs and child mortality. J Health Econ 1994; 13:455-89.
31. Guilkey DK, Riphan R. The determinants of child mortality in the Philippines:
estimation of a structural model. J Dev Econ 1998; 56:281-305.
32. Barbhuiya MA, Hossain S, Hakim MM, Rahman SM. Prevalence of home deliveries
and antenatal care coverage in some selected villages. Bangladesh Med Res Counc
Bull 2001; 27:19-22.
33. Steele F, Diamond I, Amin S. Immunization uptake in rural Bangladesh: a multilevel
analysis. J R Stat Soc Ser A Stat Soc 1996; 159:289-99.
34. Gage AJ, Sommerfelt AE, Piani AL. Household structure and childhood
immunization in Niger and Nigeria. Demography 1997; 34:295-309.
35. World Bank. Growing healthy? A review of Vietnam’s health sector. Hanoi: World
Bank; 2001.

36. Heller P. A model of the demand for medical and health services in Peninsular
Malaysia. Soc Sci Med 1982; 16:267-84.

37. Akin J, Griffin CC, Guilkey DK, Popkin B. The demand for primary health care
services in the Bicol region of the Philippines. Economic Development and Cultural
Change 1986; 34:755-82.
38. Gertler P, Locay L, Sanderson W. Are user fees regressive? The welfare implications
of health care financing proposals in Peru. J Econ 1987; 36:67-88.

39. Sauerbron R, Nougtara A, Latimer E. The elasticity of demand for health care in
Burkina Faso: differences across age and income groups. Health Policy Plan 1994;
9:186-92.

40. Mocan HN, Tekin E, Zax JS. The demand for medical care in urban China. World
Development 2004; 32:289-304. 


41. Chernichovsky D, Meesook O. Utilization of health services in Indonesia. Soc Sci

Med 1986; 23:611-20. 


42. De Bethune X, Alfani S, Lahaye JP. The influence 
of abrupt price increases on
health service utilization: evidence from Zaire. Health Policy Plan 1989; 4:76-81. 


43. Gertler P, van der Gaag J. The willingness to pay for medical care: evidence from
two developing countries. Baltimore: John Hopkins University Press; 1990. 


44. Litvack J, Bodart C. User fees plus quality equals improved access to health care:
results of a field experiment in Cameroon. Soc Sci Med 1993; 37:369-83. 


9
45. Gilson L. The lessons of user fee experience in Africa. Health Policy Plan 1997;
12:273-85. 


46. Ahrin-Tenkorang D. Mobilizing resources for health: the case for user fees revisited.
Geneva: Commission on Macroeconomics and Health; 2000. (CMH Working Paper
Series, WG3:6). 


47. Schneider H, Gilson L. The impact of free maternal health care in South Africa. In:
Berer M, TK Sundari R, editors. Safe motherhood initiatives: critical issues. Oxford:
Blackwell Science; 1999. p. 93-101. 


48. Lewis M. Who is paying for health care in Europe and Central Asia? Washington
DC: World Bank; 2000. 


49. Mwabu G, Ainsworth N, Nyamete A. Quality of medical care and choice of medical
treatment in Kenya: an empirical analysis. J Hum Resour 1993; 28:838-62. 


50. Lavy V, Strauss J, Thomas D, de Vreyer P. Quality of care, survival and health. J
Health Econ 1996; 15:333-57. 


51. Thomas D, Lavy V, Strauss J. Public policy and anthropometric outcomes in Cote
d’Ivoire. J Public Econ 1996; 61:155-92. 


52. Lavy V, Germain J-M. Quality and cost in health care choice in developing countries.
Washington DC: World Bank; 1994. (Lsms Working Paper, 105). 


53. Beegle K, Frakenburg E, Thomas D. Bargaining power within couples and the use of
prenatal and delivery care in Indonesia. Stud Fam Plann 2001; 32:130-46. 


54. Pande R, Yazbeck A. What’s in a country average? Wealth, gender, and regional
inequalities in immunization in India. Soc Sci Med 2003; 57:2075-88. 


55. Das J, Das S. Trust, learning and vaccination: a case study of a North Indian village.
Soc Sci Med 2003; 57:97-112. 


56. Strauss J, Thomas D. Health, nutrition and economic development. J Econ Lit 1998;
36:766-817. 


57. Sadana R, Tandon A, Murray CJL, Serdobova I, Cao Y, Xie WJ, et al. Describing
population health in six domains: comparable results from 66 household surveys.
Geneva: World Health Organization; 2002. (Global Programme on Evidence for
Health Policy Discussion Paper, 43).

58. Schellenberg JA, Victora CG, Mushi A, de Savigny D, Schellenberg D, Mshinda H,

et al. Inequities among the very poor: health care for children in rural southern
Tanzania. Lancet 2003; 361:561-6.

59. Chaudhury N, Hammer J, Kremer M, Muralidharan K, Rogers H. Teachers and

health care providers absenteeism: a multi-country study. Washington DC: World
Bank Development Research Group; 2003.

60. Chaudhury N, Hammer J. Ghost doctors: absenteeism in Bangladeshi health facilities.

Washington DC: World Bank Development Research Group; 2003.

61. World Bank. World Development Report 2004: making services work for the poor.
Washington DC: World Bank; 2004.

10
62. Dodd R, Munck L. Dying for change: poor people’s experience of health and ill-
health. Geneva: World Health Organization/Washington DC: World Bank; 2001.

63. McPake B, Asiimwe D, Mwesiqye F, Ofumbi M, Ortenblad L, Streefland P, et al.

Informal economic activities of public health workers in Uganda: implications for
quality and accessibility of care. Soc Sci Med 1999; 49:849-65.

64. Akin J, Hutchinson P. Health-care facility choice and the phenomenon of bypassing.
Health Policy Plan 1999; 14:135-51.

65. Samrasinghe D, Akin J. Health strategy and financing study: final report. Colombo:
Ministry of Health and Women’s Affairs; 1994.

66. Organization for Economic Cooperation and Development/World Health

Organization. DAC guidelines and reference series – poverty and health. Paris:
Organization for Economic Cooperation and Development/World Health
Organization; 2003.

67. Pitt MM, Khandker SR, McKernan SM, Abdul Latif M. Credit programs for the poor
and reproductive behavior in low-income countries: are the reported causal
relationships the result of heterogeneity bias? Demography 1999; 36:1-21.
68. Samai O, Sengeh P. Facilitating emergency obstetric care through transportation and
communication, Bo, Sierra Leone. The Bo PMM Team. Int J Gynaecol Obstet 1997;
59 Suppl 2:S157-64.
69. Eissen E, Effene D, Sabitu K. Community loan funds and transport services for
obstetric emergencies in Northern Nigeria. Int J Gynaecol Obstet 1997; 59 Suppl
2:S48.

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