4.1 Theoretical Framework
4.1.2 Theoretical Framework for Determinants of Health Care Utilization
4.1.2.1 The Modified Grossman (1972) Demand for Health Care
Following Grossman (1972) and its extensions, the demand for maternal and child health care is a derived demand to enhance the stock of good health of women and children. The quantity of health care demanded is related to its own shadow price and the price of other goods as well as other maternal characteristics. Maternal characteristics affect taste and health productive efficiency of the woman and child.
These characteristics include; wealth status, education, marital status, health insurance status, area of residence, age, religion, employment status and region. For instance, the more wealthy and educated a woman is, the more she is able to afford the health care needed to improve the efficiency of her health and that of her child. Also, the utilization of maternal and child health care by women and children promotes good health which in turn improves utility.
Assume that the ith woman and her child's have a utility function U where Ui U
Hi,Zi,Xi
... (7)Hi is the stock of health for the mother and child at age t, Z is a vector of all other goods consumed, and Xi is a vector of characteristics of the ith woman and child that influence preferences for maternal and child health care.
0& Z 0. U H
U
The health of the ith woman and child is produced via a health production technology (T) such that
Hi T
Ci,Mi,Yi
... (8) 0, 0.i
i M
T C
T
Ci stands for maternal and child health care while Mi is a vector of other complementary health inputs, Yi is a vector of characteristics of the ith woman and child that determine the efficiency of their own health production.
Equations 7 and 8 form a composite utility function which is stated as;
Uyi U
T
Ci,Mi,Yi
,Zi;Xi
...(9) Equation 9 is differentiated with respect to Y to obtain equation 10
, , ,
........................(10),
i i i i i i
Y X Z M C Y U
U
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If Zi* is define as a vector consisting of Zi and Mi, equation 10 is reduced to
, * , ,
...........................(11),
i i i i
i U C Z X Y
U
Equation 11 is maximised subject to the budget constraint in equation 12.
Ii PcCi Pz.Zi...........................(12) Where Ii is income of the ith woman, Pc is the price of health care, while Pz is the vector of prices of other goods. The optimisation process yields a demand or utilisation function specified in equation 13
Di DC,
PC,PZ,IiXi,Yi
...,,,(13) Equation 13 is estimated as the maternal and child health care utilisation model. The D1 is the demand/utilisation of maternal and child health care services, Pc is the price of health care, Pz is the price of other goods, I is the wealth/income of the ith woman, X is the vector of characteristics of ith woman which influences her health care consumption, Y is a vector of characteristics that determine the efficiency of health production such as education.4.1.2.2 Andersen (1968) and Andersen and Newman (1995) health care utilisation model
Following Andersen (1968) as well as Andersen and Newman (1995) the determinants of health care utilszation are categorized into three; the predisposing factors, the enabling factors and the need based factors. The predisposing factors consists of sociocultural and demographic characteristics of the individual; these include, education, occupation/employment status, ethnicity, age, gender social networks and interaction such as religion, beliefs of health care benefits and knowledge that people have concerning the health care system.
The second determinant of health care utilisation is the enabling factor; which consists of determinants such as individual/family resources and community resources.
Family resources are made up of economic status and location of residence; these include income, health insurance cover, travel capacity and quality of relationships.
The community resources incorporate access to health facilities and availability of persons for assistance such as health personnel. The third is the need factor. Health care is demanded because of societal or clinically evaluated need for health care; such needs comes about due to functional or health problems that necessitates health care
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utilisation. Andersen (1995) incorporated health care system into the model as another determinant of health care utilisation; health system includes health policy, health resources and organization as well as their changes over time. Health resources includes; health care providers and their level of education while the health system organisation reflects how the health system manages it resources and this affects access and structure of health care. The volume of health personnel and their quality as well as how health care resources are distributed affects health care utilisation. The 1995 model also included the issue of consumer satisfaction which has to do with convenience, quality financing and provider characteristics.
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Figure 4.1 modified Andersen (1968) model of determinants of health care utilisation Health care utilisation Need based
factors
Perceived needs, clinically evaluated needs Family resources
Community resources
Needs due to functional disability or health problems Income/wealth,
health insurance, travel to health facility,
availability of health facilities and health personnel.
Education, occupation/empl oyment status Ethnicity, age, gender, social networks and interaction such as religion.
Predisposing factors Demographic Sociocultural Health beliefs
Enabling factors
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Applying this model to maternal and child health care utilisation, we can say that the determinants of maternal and child health care utilisation are education, employment status, ethnicity, age, religion, wealth/income, insurance, distance to health facility and availability of health care providers. The need factors are based on the fact that every pregnant woman is perceived to be in need of antenatal care and skilled delivery care;
while every under-five child is also said to be in need of immunisation and bed nets.
The theoretical model by Andersen (1968) as well as Andersen and Newman (1995) have similar features with the modified Grossman (1972) health care demand model. The similarity lies in the derived demand model in equation 13. Some of the determinants of health care demand in equation 13 are similar to the determinants of health care utilisation in Andersen's model of health care utilisation. Table 4.1 presents information on the description of variables for each of the theoretical models for objectives one and two in equations 6 and 13.
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Table 4.1: Description of Variables for the Theoretical Models for Objectives One and Two
Variable Description
Objective 1: the welfare model for inequity analysis: equation 6 is estimated
yi Dependent variable which stands for maternal and child health care utilisation
Z Health care utilisation due to need variable C Access cost
X Health care utilisation due to non-need variables such as socioeconomic and demographic factors
P Variables representing the role of responsibility in determining inequity in health care utilisation such as religion, culture, preferences.
Objective 2 : the model of demand for health care utilisation: equation 13 is estimated D Demand/utilisation of maternal and child health care
pc Price of health care pz Price of other goods
I Income/wealth of individual
X A vector of characteristics of the ith woman and child that influence preferences for health care..
Y A vector of characteristics of the ith woman and child that determined the efficiency of the health production.
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