Policymakers need to be aware of how changes in government policy will affect demand for health services.  In Uganda, the health sector is projected to have the fastest growing share of government expenditure over the next few years. Recent policy changes on user fees raise the question of whether income and user fees are the main factors that influencing health care demand.   

Using data from the Ugandan National Household Survey, researchers from the Institute of Development Policy and Management at the University of Manchester, UK attempted to discover how important income and other factors are in determining demand for private, government and pharmacy-based health care for adults and children.  The data is analysed for differences based on gender and age.

There is currently limited evidence concerning the impact of user costs on the determinants of health care-seeking behaviour both globally and for sub-Saharan Africa.  Furthermore, much of this work does not go substantially beyond including the direct costs to clients of health care and does not differentiate by age and gender - factors that are often important in varying demand.

The analysis revealed a number of significant findings:

• Higher income levels significantly increase demand for health care, particularly among women.  As income increases, traditional health care is used less and demand for private health care grows.
• Demand for health care increases steadily with educational level for both men and women, whilst the level of demand for children's health care – particularly girls not yet attending school - increases with the mother’s education level. 
• Women with secondary level education and men with university level education are considerably less likely to use government hospital facilities and more likely to favour private clinics.
• For women at lower income levels, increases in income lead to increased demand for government health care, whilst they are more likely to reduce their demand for health care where consultation fees are charged.
• Being close to a health centre is strongly associated with increased demand.
• Gender differences exist in demand for cheaper government provided hospitals. Women are more likely to seek such treatment and at an earlier age than men.

By analysing the factors influencing health seeking behaviour, the study helps to move the health policy debate in Uganda beyond user fees.  Policy lessons include the following:

• The importance of distance suggests that the use of more local clinics may be a good alternative to centralised urban units catering for large numbers of people. Future policies aimed at reducing travel costs would also bring substantial benefits.
• The existence of a user fee was significant in reducing women's demand only. Reduction or abolition of user fees can be expected to generate increased demand for health care by women.
• For both men and women higher educational levels are associated with a preference for private health care, suggesting that government services are of inferior quality. The quality of care at government facilities, particularly with a projected increase in investment, should be assessed further and improved.
• Significant gender differences in health seeking behaviour warrant further investigation. It is possible that control of income expenditure within a household may have an effect.

While user fees and income level are significant, they are not the only important determinants of demand for health care.  Distance, educational level and gender are also associated with differences in demand.

Source(s):
‘Determinants of health seeking behaviour in Uganda – is it just income and user fees that are important?’ IDPM working paper six, by D. Lawson, 2004 Full document.
'The demand for primary health care in the Bicol region of The Phillipines', Economic Development and Cultural Change 34(4): 755-782 by J.S. Akin, 1986
'The demand for medical care: evidence from urban areas in Bolivia', World Bank Living Standards Measurement Study Paper No. 123 by M. Li, Masako, 1996

id21 Research Highlight: 11 January 2005

Further Information:
David Lawson
Institute of Development Policy and Managment
University of Manchester
Manchester M13 9QH
UK

Tel: +44 (0) 773 667 6124
Fax: +44 (0)161 273 8829
Contact the contributor: david.lawson@manchester.ac.uk

IDPM, University of Manchester, UK

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