If You Build It Nearby and Keep the Price Low, Will They Come? Large‐Scale Evidence on the Relative Roles of Access and Quality in Use of Healthcare in Low‐and Middle‐Income Countries

• DOI: http://doi.org/10.1111/saje.12244
• Published date: 01 March 2020
• Date: 01 March 2020
• Author: Nicholas Wilson

South African Journal of Economics Vol. 88:1 March 2020

doi: 10.1111/saje.12244

3

© 2020 Economic Society of South Africa

IF YOU BUILD IT NEARBY AND KEEP THE PRICE LOW, WILL

THEY COME? LARGE-SCALE EVIDENCE ON THE RELATIVE

ROLES OF ACCESS AND QUALITY IN USE OF HEALTHCARE

IN LOW-AND MIDDLE-INCOME COUNTRIES

NICHOLAS WILSON†,*

Abstract

Health policy reform often emphasises improving access to healthcare. Recent studies highlight

the role healthcare quality plays in determining which health providers individuals use and health

outcomes. Yet, there is little standardised large-scale evidence on the importance of quality of care

relative to access in determining healthcare use. This paper examines the relative roles of access

and quality in whether individuals seek healthcare and how these vary with socioeconomic status

in a sample of over 250,000 national household survey respondents from low- and middle-income

countries. My results suggest that quality is as large a barrier as access. Among quality barriers,

drug availability is as large a barrier as provider availability. Analyses of the barriers-socioeconomic

status gradients indicate that the quality-SES gradient is much less steep than the access-SES

gradient, highlighting that increasing incomes may not be sufficient to address quality barriers and

that supply-side interventions may be necessary.

JEL Classification: I11, I12, I15, O12

Keywords: Access, health behaviour, healthcare, quality

1. INTRODUCTION

Health policy reform, particularly in low- and middle-income countries, often empha-

sises improving access to healthcare, including reducing the price of healthcare or ad-

dressing distance barriers to using healthcare. For example, the most recent World Bank

Development Report on health states, “access to free or low-cost care can produce large

increases in [the poor’s] consumption of health care” (World Bank, 1993). A new set

of studies highlights the role of healthcare quality, including dimensions such as pro-

vider effort (e.g. Das and Hammer, 2005; Leonard, 2007; Leonard et al., 2007; Das

et al., 2008; Leonard, 2008; Leonard and Masatu, 2010; Das et al., 2016) and provider

absence (e.g. Chaudhury et al., 2006; Das et al., 2008; Goldstein et al., 2013), in deter-

mining which health-providers individuals use and health outcomes. Building on this

literature, researchers and policymakers have begun exploring mechanisms for addressing

the “know-do gap” (e.g. The Economist, 2017), a measure of quality of care relative to

* Corresponding author: Department of Economics, Reed College, 3203 SE Woodstock Blvd,

Portland, OR 97202, USA. E-mail: nwilson@reed.edu

† Department of Economics, Reed College

South African Journal

of Economics

4South African Journal of Economics Vol. 88:1 March 2020

© 2020 Economic Society of South Africa

provider ability and performance-based financing to improve quality of care (e.g. Basinga

et al., 2011; Miller and Babiarz, 2013; De Walque et al., 2015; Donato et al., 2017).

Yet, there is little standardised large-scale evidence on the importance of quality of care

in determining demand for healthcare in low- and middle-income countries. This paper

examines the relative roles of quality and access in whether individuals seek healthcare

and how these relative roles vary with socioeconomic status in a sample of over 250,000

national household survey respondents from low- and middle-income countries.

Low median income, limited government support for healthcare and large rural pop-

ulations suggest that access would be the predominant barrier to healthcare use in low-

and middle-income countries. Shortcomings on the intensive (i.e. quality) margin on the

supply side may also be a large barrier, particularly with recent increases in income, pop-

ulation densities and international donor support for healthcare. Large-scale empirical ev-

idence on whether access or quality is a bigger barrier, and which dimensions thereof are

the most important, will inform policymakers’ efforts to increase healthcare use and help

promote cost-effective reforms. Whether and how fast these barriers decline with socio-

economic status will yield suggestive evidence on the likelihood that economic develop-

ment will reduce these barriers and the importance of other mechanisms such as quality

performance-based financing (e.g. Eggleston, 2005; Glazer et al., 2007; Robinson et al.,

2009; Mullen et al., 2010; Basinga et al., 2011; Maynard, 2012; De Walque et al., 2015;

Christensen, 2016; Konetzka et al., 2018; Miller et al., 2013; Sherry et al., 2017) and

publicly provided quality ratings (e.g. Mukamel et al., 2004; Glazer et al., 2007; Glazer

et al., 2008; Varkevisser et al., 2012; McCullough et al., 2015; Ryskina et al., 2018).

I examine the relative roles of access and quality as barriers to healthcare seek-

ing behaviour and how the relative importance varies with socioeconomic status. The

Demographic and Health Surveys (DHS) from several countries ask female respondents

about healthcare seeking behaviour when they are sick or need medical advice and what

barriers, if any, led them to choose not to seek healthcare. These barriers include ac-

cess barriers such as distance, transportation, money, concerned about going alone and

permission. These barriers also include quality barriers such as drug shortages, provider

absence, absence of a female provider and (in a small set of countries) provider rude-

ness. I pool DHS from the 14 countries with detailed data on specific barriers, resulting

in a sample of over 250,000 respondents. I examine the distribution of specific barri-

ers and use semi-parametric and parametric regression methods to estimate the associa-

tions between barriers to using healthcare and two key measures of socioeconomic status

(i.e. total consumer durables and years of schooling). These gradients may be interpreted

as conditional likelihoods of these specific barriers. To provide evidence on the relevance

of barriers for wellbeing and not just healthcare use, I examine the association between

barriers as reported by adult respondents and the health outcomes of their young children.

My results suggest that, in low- and middle-income settings, quality of health-

care is as large a barrier as access in determining whether individuals use healthcare.

About 52% of respondents report quality as a barrier and 50%report access as a barrier.

Approximately 40% of respondents reported that they did not seek healthcare because

they were concerned about drug shortages and a similar proportion reported that they did

not seek healthcare because they were concerned that a provider would not be available.

Approximately 30% of respondents reported distance, transportation and money were

barriers. Regression analyses indicate that the quality-socioeconomic status gradient is