Utilization of health services in developing countries—Tunisia

SOC.SC, & M&.

Vol. 8. pp. 287 to 304 Pergamon Press 1974. Printed in Great Britain

UTILIZATION DEVELOPING

OF HEALTH

SERVICES

IN

COUNTRIES-TUNISIA*

AMOK BENYOUSSEF World Health Organization, Geneva and ALBERTF. WESEN Brown University, Providence? Abstract-This paper is based on a WHO study on determinants of utilization of government health services in a province of Tunisia (Governorate of Nabeul). Seven study areas were selected which were considered typical both of different types of health facilities and of towns and rural settings in the province. In these study areas, an interview survey of a sample of households was undertaken and the data gathered from the survey were linked to available medical records for the 3808 members of the 678 households studied. The most striking finding of the study was the much greater use of ambulatory care services by urban than by the rural populations studied. It is argued that this rural/urban dijizrential is a result both ofdifirences among the populations and of differences in technical sophistication of and accessibility to rural and urban health centres. In general, utilization of health services by the study group was low when compared

with rates reported in most developed countries. Most persons used the health services only once or twice for a given episode of illness, and the great preponderance of diagnoses made were for acute illnesses, especially the common communicable diseases. It is also shown that when the population is grouped according to categories of respondents from highand low-user families, a number of contrasting demographic, socio-cultural and economic characteristics, and attitudes tend to differentiate these groups (in both urban and rural areas). Among characteristics more likely to be exhibited by respondents from high-user households are: indicators of literacy and language ability, use of mass media, socio-economic participation, type of occupation and employment status, and positive attitudes towards the health services including health personnel and towards disease prevention. The applicability of analyses of determinants of utilization in developed countries to the situation of developing countries such as Tunisia is discussed. On this basis, a framework for further study is developed which focuses upon modernization as the keypredictor of use of health services in developing countries. Some implications and related practical recommendations for better management of the health care delivery system in the studied area are also discussed.

1. INTRODUCTION It is generally agreed that among major obstacles facing health administrators and planners in the world, and especially in developing countries, is a lack of data on how and by whom health services are used. Administrators and planners tend to rely on such ruleof-thumb targets as x beds per 1000 population. However, a population does not behave entirely homogeneously. Differential usage of facilities can be expected. Administrators and planners should have this information in order to help assess whether their programmes are adequate to reach the population which is at risk. Generally speaking, two kinds of utilization study have commonly been undertaken. In one,

* Authors alone are responsible for views expressed in signed articles. t Until August 1971, World Health Organization, Geneva. S.S.M. 8/5--r

the unit of observation is the health-care facility. With this kind of study, various aspects of the performance of the facility may be examined, e.g. the diagnostic pattern, rate of output of services by facility staff, characteristics of utilizers, and so on. This type of study, since it observes only those who actually visit the healthcare facilities, cannot provide a good measure of the rate of utilization of health-care by the population generally. In the second kind of study, the population is the unit of observation and with proper sampling, good estimates of the level of utilization of population as a whole and of its sub-groups can be obtained [l]. Population’-based studies, in addition to describing the performance of the health-care sector, may also seek to explain that performance, e.g. discover the determinants of differences in utilization rates [2]. Generally speaking, utilization rates are the result of a complex interaction between the availability of services -including the terms on which they are available L-the health status of the population and the “health 287

288

Alrlo~ BENYOUSSEFand

habits”-i.e. propensity to seek care-of the population [3]. In some cases, one or another of these determinants might dominate [43. A very large literature on health service utilization and on its determinants has developed in the United States. Considerable literature of a similar type has developed in other developed countries [S], and there has been an increasing interest in making crossnational comparisons of utilization [6]. However, detailed information concerning the utilization of health services in developing countries is very rare and that information which is available is subject to substantially greater error than is the case with data from the more developed countries. General +amework We know, of course, that providing health services is much more problematic in developing than in developed countries. Resources are in short supply. Ratios of the numbers of doctors, nurses and other professionals to the population may be of the order of 10-100 times smaller than those pertaining in the more affluent societies. The availability of hospitals and of modern medical technology is perhaps even less equitably distributed among the nations of the world. Even within developed countries, moreover, the distribution of medical care facilities is highly skewed. However, tendency for both technological and manpower resources to concentrate themselves in urban centres, and particularly in the primate cities of the developing countries is even more pronounced. The result is that while in the urban areas of many developing countries substantial facilities may exist, frequently rural areas may have almost a complete dearth of manpower, facilities and modern technological resources for medical care. Moreover, facilities are frequently inadequately staffed, maintained and supplied. It is not uncommon, especially at the periphery, to find hospitals or dispensaries without even minimally adequate supplies or standing idle because there is no one to offer care. Problems of organization and administration combine with difficulties in transportation to aggravate this situation of acute scarcity. At the same time, among the rural populations which constitute the majority of the peoples of most developing countries, modern medicine is usually seen as no more than an ambiguous good. The theories and practices of Western Medicine often clash violently with the accepted maxims and values of the traditional society. Frequently, both the canons of folk practice and the existence of native practitioners seem to satisfy most of the medical needs of most of the people most of the time. When modern Western medicine, whether under governmental or private sponsorship, comes to the hinterland of developing countries it usually comes both as a strange and perhaps fearful innovation and as a competitor of established ways of obtaining help for the sick. On the other hand, the need for medical care is very

ALI~ERT F. WESSEN

high among the populations of developing countries, characterized as they are by high degrees of poverty, unchecked exposure to communicable diseases, and low life expectancy. These needs are particularly great among infants and young children, but it is probably fair to say that the level of need of populations in the typical developing countries is substantially greater than for those of the more affluent societies where medical services are more available. We may perhaps summarize the foregoing considerations by making three generalizations which, broadly speaking, may apply in most developing countries. 1. Availability of health services in developing countries tends to be sharply limited in terms of both facilities and manpower. 2. Although the distribution of services is often spotty, health facilities and manpower are least available to the rural populations which comprise the majority of most developing countries. 3. While their need for medical services is regularly high, numerous socio-cultural factors often act to inhibit the traditionalistic and rural populations of developing countries from utilizing those services which are available to them. It should be clear that the foregoing generalizations are very broad and that the degree to which they apply to various developing countries or to sub-populations within them is highly variable. In general, one would expect that the higher the gross national product, or other indicator of economic development, the less these generalizations would apply to a specific country. Similarly, developing countries vary greatly as to the degree to which a modern health service has been established in the various nations and in the extent to which it has been systematically brought to the rural populations. It is the purpose of this study to present data on the utilization of medical care in a province of Tunisia and thus to contribute to the literature on the use of health services in developing countries. We shall hope to specify more concretely some of the effects of the constraints on health service delivery outlined above on utilization behavior. And we shall demonstrate the utility of a methodology linking health service records and community surveys for health service utilization and management studies. 2. SETTING

AND DESIGN

OF THE TUNISIA

STUDY

Broadly speaking, Tunisia represents the situation of many developing countries which, despite limited resources and multiple problems of development, have developed health services which attempt to provide medical care for the whole population. Despite extensive programmes of industrialization and modernization, its population is still largely rural and engaged in agriculture, small scale industries, handicraft activities or trade. In planning this population-based utilization study, it was important to locate a study area which would

Utilization of health services in developing countries be broadly typical of facilities and communities to be encountered throughout the country. On the advice of the WHO representative in Tunisia and the Tunisian authorities, it was decided to select the Governorate of Nabeul as the study area. This Governorate (Province), one of the 13 provinces of the Republic, has a population of about 316,000 persons (1966 census). It is located on the Cap Bon peninsula and includes a diversified farming area with many vineyards and orchards, extensive beach areas, some of which are virgin, an almost inaccessible interior mountain area, isolated fishing villages, and the capital city of Nabeul (23,000 inhabitants). Although very accessible to Tunis (Nabeul is about a 1 hr drive), the province as a whole is not unduly influenced by this metropolitan centre. It is, however, somewhat more developed economically than many parts of the country and accordingly represents a province which is somewhat above average with respect to its health facilities and health status. The health services of the Governorate are similar in plan to those of the nation as a whole. Medical care is provided free by government health services to those who are judged unable to pay-between 80 and 90 per cent of the populationas well as to those who are covered under the Social Security system. Private medicine exists for those few who can afford it. At the time of the study there were very few private practitioners in Nabeul Governorate. Prosperous people frequently travelled to Tunis for medical care. Paying patients are also welcome at the government health services. Each person who is covered under the Social Security system, or who is indigent, is issued a numbered identification card qualifying him (or her) for free care. It is expected that patients will utilize the service nearest to their house unless referred elsewhere for specialist care. Health records in the various centres are filled numerically and the file number is listed for each family member upon the family identification card. It should be noted that the health centres in Tunisia are expected to keep detailed medical records of all visitors to the centre, except for paying patients. Families with incomes below a certain level are entitled to obtain a “Carte de Soins” from the health authorities and these cards enable the family members to use the health facilities with only a token payment. For practical purposes, the health facilities can be assumed to be free for such people. A small proportion of the population of the study area is covered by national social security insurance by virtue of their occupation. They possess “Cartes Nationales de Se’curite’Sociale” or CNSS (Social Security National Cards), cards which entitle them and the members of their families to obtain free medical care. Both types of cards specify the health centre for which they are valid. Although there is some flow of patients from a geographic rej$on to the health centres belonging to the adjacent regions, the magnitude of such flow is relatively small. There is a hierarchical system of health services through which services in each Governorate (Province)

289

are regionalized. The following types of care settings are found: (a) Regional hospitaLwith 150/200 beds, a full range of specialist services and with out-patients clinics serving the local population’s ambulatory care needs. This is the basic centre which receives referrals from satellite service centres, and is usually found in the provincial capital. (b) Auxiliary hospital-usually found in market towns (of about 10,000 persons) which are trade areas for areas of about 40 km. Usually these hospitals have from 50 to 100 beds, provide general medical, surgical and obstetrical care as well as outpatient facilities for the local area and are staffed by one or two full-time physicians. (c) Dispensaries with obstetrical service-usually found in smaller towns and large villages. Full-time physician service for general ambulatory care; limited beds for overnight medical care; obstetrical beds for normal deliveries; full-time midwifery services and maternal and child health clinics. (d) Dispensaries withfull-time medical care-like (c), but without any provision for regular obstetrical services. (e) Rural dispensarieewith a full-time injrmier (nurse) and first-aid service and periodic clinics (two or three times a week) held by a visiting physician. Found in most villages. Each dispensary with a physician in residence as well as each hospital will have one or more satellite rural dispensaries for which it is responsible. It was desired to study utilization patterns both with reference to type of health services and to sociodemographic and economic characteristics of community (urban/rural) [7]. In order to cover the full range of settings, seven study areas were chosen and accordingly separate samples were defined for each of the study areas[8]. As it has been indicated, there are two approaches to utilization studies, i.e. health services based and population based. In the Tunisia study both approaches were used. The community-based household survey of utilization This approach involved the preparation of household sample frames in the seven study areas, the development and pre-testing of a questionnaire designed to be answered by heads of household, training of interviewers and implementation of the survey. The purpose of community interviewing was to search out those factors which differentiate a population into “high” and “low” utilizers of the health services. While a good deal is known about the factors affecting utilization in poulations of developed countries, there is little information about whether or not these same variables would account for differential demand on the health services in the situation of a developing country. In the Tunisia Study, the assumption was that they would, at least to some degree.

290

AMOR BENYOUSSEFand ALBERT F. WESSEN

Population samples Within each of the three d&gations (Districts) chosen for study (Korba, Menzel Temime and Nabeul), it was planned to interview households representative both of the major township and of selected rural areas. However, the time and resources available did not permit the completion of the full programme and as a result only the urban area of Nabeul was sampled. Accordingly, four rural ureas (from Korba and Menzel Temime Delegations) were studied. In order to develop a sample frame in these areas it was necessary to utilize current listings of house units developed by the Malaria Eradication Programme. From these lists a simple cluster sample was developed. In the urban areas no listings of households were available and the team was, therefore, required to develop a sampling frame. Housing units were selected at random from the frame and all heads of households residing in a selected house were to be interviewed. The number of housing units samples and households interviewed are summarized in Table 1. Altogether 18 houses among those selected did not yield interviews, ten in the rural areas because the houses were not inhabited, and eight in the urban areas because the inhabitants were absent or refused co-operation. It has been decided to make the household the unit of interviewing and the sampling plan had been developed accordingly. For reasons of economy of time, it was not possible to interview all adult members of households. It was decided, therefore, to use the head of the household as the interviewee whenever he was available, and in his absence to interview his spouse. In practice, not infrequently, joint interviews with these informants were held. A word of explanation may be in order about why the head of household was selected as the primary interviewee; given the strong patriarchal orientation of the Tunisian culture, especially among the rural population of the study area, it was felt that it might be necessary to approach the head of household to gain any information whatsoever, particularly as the interviewers were to be predominantly male. While the team suspected that the head of household might be less familiar than some other members of the household concerning the actual health status and utilization behaviour of all family members--especially young children-we thought information concerning his attitudes and sociodemographic and economic characteristics would be particularly important in determining family patterns of utilization. Table 1. Number

No. No. No. No.

of of of of

of housing

houses identified houses sampled households interviewed* individuals studied

* A small proportion

The household questionnaire covered the following informational areas: (a) identification data including number of Carte de Soins (CS), or of Carte Nationale de Se&rite’ Sociale (CNSS); (b) socio-demographic data on family; (c) perceived need for treatment and reported utilization of services; (d) attitudes toward health care, health personnel and health services, including levels of satisfaction; (e) self-treatment and “folk medicine”; (I) socio-economic data on the family (mainly on the head of household). On the basis of initial pre-testing of the questionnaire, the instrument was redrafted and translated from French into Arabic and used as the basis for the training of interviewers, followed by closely supervised field practice in interviewing. This practice-done in communities outside the study area-also served as the basis for a further revision of the questionnaire before it was put into use in the first study area (Korba). On the basis of this experience and others [9], it was decided that the household questionnaire method was yielding consistent and interesting responses and that, after minor revisions in questionnaire format and wording, the questionnaire should be applied in the other areas of the study. Linkage of interviews with medical records The population interview method has built in limitations as a means of assessing utilization of health services. One must rely on informants’ memories for data, and even for short periods (e.g. 1 month) reporting errors may be substantial. Similarly, valid diagnostic data are hard to obtain because patients either do not know how, or cannot correctly report, their medical findings. Such data are available in the medical records of hospitals and ambulatory case centres. On the other hand these records almost never provide enough socio-demographic and economic data to allow serious analysis of the behavioural determinants of utilization. Ideally, therefore, it would be desirable to match or link interview data with medical records on given respondents-something which is usually not feasible in utilization studies. However, community-based because of the Tunisian system or records the linkage method proved feasible in this study. Since each family (except for paying patients) holds a numbered identification card on which is listed the medical record numbers of each family member, it was possible to record their numbers and thus match interviews directly with the records. Estimates of utilization

units sampled

and households

interviewed

Urban

Rural

Total

8616 381 446 2489

4847 198 232 1319

13513 519 678 3808

of houses were multi-family

dwellings.

Utilization

of health services in developing

below are thus based upon data extracted from the medical records of the study population. These data can be analyzed both by a number of visits and episodes, and by the type of diagnosis. For purposes of this analysis episodes include two or more consecutive visits by an individual for the same diagnosis. Diagnoses were recorded according to the World Health Organization’s International Classification of Diseases, 1965 Edition. Since the diagnostic or general complaint entered on the records did not always correspond to these diagnoses, a judgment was necessary in many cases to make a reasonable diagnostic classification. Many common illnesses are sometimes diagnosed in different ways. For example, an episode which in one place may be diagnosed as diarrhoea, may in another place be diagnosed a? dysentery, etc. Accordingly, substantial caution must be used in interpreting the diagnostic data to be given below. The study areas provided us with the opportunity to study utilization patterns in each of the types of case setting discussed above. Thus we have data from the clinics at the regional hospital at Nabeul, the auxiliary hospitalatMenzelTemime, the dispensarywith osbstetrical service at Korba, and from four rural dispensaries in the rural areas studies. reported

3. FINDINGS

The summary results of any study of utilization of medical care may be conveyed by one figure: the mean number of visits per hundred persons per year. This summary figure, while explaining little in itself about the dynamics of medical care behaviour, provides a measure of the intensity of contact between the health services and the populations. It allows, therefore, for a comparison in this direction among nations or other defined areas of study. Measuring

utilization

In the Tunisia Study the estimates of utilization rates provided are based upon 5 years’ experience (1964/1968) of those members of the sampled popula-

tion for which it was possible to retrieve medical records. All persons, of course, did not utilize the health services for the entire time period because of death, migration, etc. Therefore, we developed our utilization rates on the basis of the mean length of time during which members of our study population were registered as patients in the sampled clinics. Table 2 shows the distribution of the sample population for whom registration cards were identified and for whom medical records (Fiche Mitdicale-FM) were ascertained. As Table 2 shows, the linking method as applied in this study involves four operations, in each of which loss of data may occur. Moreover, in three of the four operations, differences in the numbers of persons accounted for can theoretically also be explained by real behaviour on the part of the population. Unfortunately, it is impossible to assess the extent to which the progressive decrements in population sizes shown in Table 2 are the result of imperfect date or reflect actual population behaviour. As indicated above, all heads of households receiving free care (either as indigents or as members of the national social security system) are issued a registration card entitling them and their families to use government health services. 78.6 per cent of the persons found in this study belong to a household where the head was reported as holding a registration card; there was no difference between urban and rural sub-samples. This figure corresponds well with the belief of health service officials that the public health services are reaching 8c-90 per cent of the Tunisian population. The remainder of the population presumably either utilize private practice or have not been reached by any modern medical services. When a member of a household to which a registration card has been issued presents himself at dispensary or hospital for care, he is issued a record, the number of which (FM) is recorded on the family registration card (CS or CNSS). Most of those households holding a registration card had at least one member for whom a medical record number was listed. Again, differences betwen urban and rural sub-samples were minimal.

Table 2. Number of persons in the studied population Operations 1 2

3

4 5

Categories No. of persons in households sampled No. of persons in households in which the head holds registration cards (CS or CNSS) No. of persons in households where at least one member holds a medical record (FM) No. of persons having evidence of a medical record (FM) number No. of persons for whom medical records (FM) were retrieved

291

countries

for whom medical

records

were retrieved

Urban

Rural

Total

2489

1319

3808

1931

1054

2985

1826

963

2789

1399

566

1965

1085

382

1467

AMOR BENYOUSSEFand ALBERT F. WESSEN

292

Major decrements appear when one ascertains the total number of household members for whom a medical record number was listed. For the study group, only about half (51.5 per cent) of the total population of households samples was reported as having a medical record. Of all the members of households in which at least.one member utilized government health services, onl) 70 per cent were themselves listed as having a medical record number. Obviously, not all family members of utilizing families use health services. But the proportion attending is substantially higher in the urban sub-sample (76.6 per cent) than in the rural group (605 per cent). Finally, there was the clerical task of retrieving the medical records for members of the study population for whom record numbers had been established. We were successful in locating 74.7 per cent of these records. This “retrieval rate” was higher for the urban sample, the larger proportion of whom (Nabeul and Menzel Temime sub-samples) attended hospital outpatient departments, than for the rural sample which utilizes peripheral health centres-77.6 vs 67.5 per cent. Utilization rates can be computed for that proportion of the population whose medical records were retrieved. As Table 2 shows, there are 1467 persons in this category, or 38.5 per cent of all the persons identified in the household survey. The differences between rural and urban groups is again striking: we have utilization data for 28.9 per cent of the rural population identified and for 43.6 per cent of the urban population. Obviously, the differences between the number of medical records retrieved and the number for whom record numbers were established must be a function of imperfections in the data, mainly missing records. (Errors in transcription of record numbers either on the family registration card or in our data collection probably amount for only a small part of this data loss.) Since injirmiers (nurses) and other medical personnel are expected to keep the file records in addition to their heavy loads of patient care, it is not surprising that record files were frequently in imperfect order. As indicated, this was more likely to be the case in rural dispensaries than in the larger centres. We think it likely that other clerical sources of data loss are also greater in rural than in urban areas. However, since

health centres are required to keep a daily log of attendance listing registration numbers of each patient (in addition to use of the medical record), we believe that the major contribution of clerical error to the decrements of population figures shown in Table 2 lay in loss or misfiling of records. When one considers the differences between categories 2, 3 and 4 of Table 2, it is likely that real differences in health behaviour among households are prominent in accounting for observed differences (although imperfections in the data are certainly still present). Thus it is likely that it is true that a smaller proportion of rural household-members actually have used health services to which they are entitled than in the case of urban household-members. Thqfact that (as reported below) the utilization rate for the rural population whose records were retrieved is substantially lower than for the urban population tends to give some credence to this interpretation. We believe, therefore, that while approximately equal proportions of rural and urban households have utilized government health services, a larger proportion of urban household members have used medical facilities at least once than did their rural counterparts. Since it was possible to compute utilization rates only for that proportion of the population for whom the medical records were retrieved, the estimation of the overall utilization rate in the study area must be approached indirectly. We shall first present data on the population for whom medical records were available and then extrapolate these data to the entire study population.

Utilization by rural and urban population groups Table 3 presents the overall utilization data for approximately 40 per cent of the sample for whom medical records were found. Since all of the members of the sample for whom medical records were found did not attend the health sevices in each of the 5 yr studied, we have accordingly computed the average number of years for which each person had a utilization entered in his record. For the entire studied group this mean was 2.74 and, as might be expected, was somewhat lower for the rural than for the urban population. (2.49 versus 2.83.)

Table 3. Number of visits by population whose medical records (FM) were retrieved: 1964-1968

Residence

No. of

status

persons

Rural Urban Total

382 1085 1467

No. of visits 1964-1968 882 4801 5683

Annual visiting rate per 100 persons 92.7 156.4 141.4

Average no. of years

Mean % of retrieved population

covered by records

visiting each year

249 2.83 2.74

46.2 88.5 17.4

Utilization

Annual visiting rates were computed by dividing the mean annual number of visits per person during the 5yr period for which data were collected by the number of persons having records retrieved. The results show that 141.4 persons per 100 persons per year visited the health services. Even allowing for some probable under-estimation, these results are substantially lower than those found in developed countries. Moreover, there is a major difference in rates between rural and urban populations, the former having a rate of only slightly more than half that of the urban areas (i.e. 92.7 versus 156.4). These are indeed large differences in the degree of utilization considering that everyone in the population base, by definition, has utilized health services at some time. Table 4 presents our best estimates of the utilization rates for the entire study population. While the study population does not represent a random sample either of the “Governorate” of Nabeul or of Tunisia as a whole, it was selected in such a way as to include typical rural and urban areas and also the full range of health services. We believe, therefore, that the following estimates may be indicative of the situation in many rural areas, small towns and provincial capitals in Tunisia. Table 3 was based only on that part of the population which had given some evidence of some utilization of health services by indicating the number of their medical records (Fiche Medical+FM), but also had records which were accessible and could be transcribed. To use the rate of utilization derived from this table as a basis for extrapolating directly to the total study population would certainly result in an underestimate. Is there any evidence for believing that the amount of utilization reported on the non-retrieved records (25.3 per cent of all those persons known to have utilized health services at least once) would be significantly different from that recorded on those records which were retrieved? We can see no persuasive ground for thinking that this might be so. It seems as likely that rarely-used records might disappear through disuse and that frequently-used records might be lost or displaced in the rush of daily work. Therefore, we tentatively assumed that any error introduced by incomplete retrieval of record is random. Such an assumption would allow us to apply the utilization rates found in Table 3 to that portion of the study Table 4. Estimates

293

of health services in developing countries

of utilization

group known to have utilized health services at least once. The resultant estimated total care load thus formed the numerator for the estimate provided in Table 4. If we assume that those persons not known to have a medical record (FM) were indeed non-users, we can use the total sample size as the denominator. The estimated utilization rates are, of course, substantially lower than the rates for known utilizers reported in Table 3. The weight of large numbers of persons for whom we have na evidence of utilization bears especially hard upon the rural group which had declined by 57 per cent. The estimated rate for the urban group by contrast has declined by 44 per cent. Moreover, applying the average number of visits per visiting person per year derived from Table 3 to these estimated utilization rates, one may estimate the proportion of the total population study who used health services in the course of a given year. It may be said from this estimate that about 50 per cent of the population are reached by the health services in a given year, the figure for the urban group being about 56 per cent and that for the rural group about 43 per cent. Interestingly enough the lower utilization rates for rural and urban people seem less likely to reflect gross inaccessibility of health services than a behavioral tendency for urban people to use them more often than rural people. At least for the areas studied it would appear that coverage of population attained by health services is about the same -for townsmen as for countrymen. One may speculate, however, that something about the contact of rural people with the peripheral health centre leads them to return less often than do town-dwellers to their more complex and better equipped health centres. Figure 1 shows that the rural/urban differential discussed above prevails for almost all sex and age groupings. The typical J-shaped curve relating age to utilization rate appears clearly among urban males and females in somewhat attenuated form among rural respondents, especially males. As in most other countries, women show higher rates of utilization than do men in almost all age groups and in both rural and urban areas. Utilization by diagnostic episode Table 5 gives information

rates of total studied

Residence status

No. of persons

Estimated annual care load of population sample

Rural Urban Total

1319 2489 3808

525 2188 2713

_

population:

Estimated utilization rate/100 persons 39.8 87.9 71.2

on the number of visits for

1964-1968 Estimated proportion of population using health services per year (%) 42.9 56.3 50.5

294

AMOR BENYOUSEF and ALBERT F. WESSI:N

01o-4’

I 5-9

I IO-14

I I 15-24 25-34 Age

Fig.

1. Utilization

rates

I 35-44

I 45-54

I 55-64

I 65f

group

by age group and sex for total urban and rural samples: period 196468.

the same diagnostic episode made by persons in the study sample during the period 1964-1968. It is notable that the vast majority of persons (85 per cent of the total sample) are reported as having visited the dispensary only once for the same episode during this period. This is to say that in 85 per cent of the cases there was only one visit registered for a given diagnosis before another intervening diagnosis appeared on the clinic record. It should also be noted that the number of persons making more than three visits for the same diagnostic episode is extremely small-only 8 per cent of all the episodes reported. Thus the dispensaries are largely utilized as one-time services. This pattern is found in all seven of the study centres and varies hardly at all between rural and urban dispensaries. Thus, the mean number of consecutive visits per episode varies between 1.17 and 1.29 among the seven dispensaries that are studied, and the proportion of one-visit episodes varies between 82.4 and 88.4 per cent. In this respect at least, the overall pattern of patient management appears to be similar in all study areas. Moreover, the popular pattern of utilization seems rarely to involve the demand for repeated visits Table 5. Relation

No. of episodes reported Total no. of visits made No. of consecutive visits per episode y0 One-visit episodes

for the same diagnostic episode. Apparently, patients are either satisfied with the attention and advice given at the first visit or do not return for further treatment for other reasons. Because follow-up visits are rarely made, it appears that health services personnel see their function as providing for the immediate needs of individuals rather than offering continuing care. Table 6 carries the analysis forward a little further. It shows that while the number of visits per diagnostic episode does not vary between urban and rural subsamples, the number of visits per visiting person per year shows a substantial excess--of the order of about two times morein urban dispensaries than in rural centres. This means that the number of episodes of illness per year which result in visits to the dispensaries by the private population is substantially greater in urban areas than in rural areas. It should immediately be added that this should not be interpreted as indicating that the urban population is necessarily more often sick than is the rural population, but merely that they tend to go to the health services more frequently when ill than do rural people. And we may also conclude that the difference in annual visiting rates between

of health service visits to diagnostic

“episodes”

Urban

Rural

Total

3855 4801

721 882

4516 5683

I ,24 84.6

1.22 86.8

1.24 85.0

Utilization

of health services in developing countries

295

Table 6. Visiting pattern by episodes* and annual visiting rate? for urban- and ruralpopulation samples: period 1964-1968

Visits per visiting person per year

Residence status

1.25 0.67 1.13

1.24

I.55 0.82 1.41

Urban Rural Total

No. of episodes per year resulting in visits

Visits per diagnostic episode

1.22 1.24

* Episode: number of consecutive visits for the same diagnoses. t Annual visiting rate: visits per 100 persons per year. urban and rural persons is likely to be either a difference of behaviour among the population or an artifact of administrative patterns of medical care in the health services. An analysis of the diagnoses made shows that the various clinics have seen and treated a wide variety of medical conditions. The number of different diagnoses made in the various clinics is in large part a function of the sample size. But the range of diagnoses made is much greater in the three urban centres-which report between 124 and 184 different diagnoses. Obviously, given the small sample size, a large number of the diagnoses were reported only once or twice within the five years of study. Table 7 presents the major groups of diagnoses made on the linked data during the period 1964-1968 according to the breakdown between urban dispenTable 7. Groups

ofdiagnoses

saries and rural health centres. This table was prepared by abstracting the total number of visits for every diagnosis in which at least five cases were noted in any one of the seven centres studied. This led to some 86 different diagnoses being entered into this table; some which were closely related have been grouped in order to improve the analysis. The major diagnoses have also been grouped according to type of diagnosis. These 86 different diagnoses account for 89 per cent of all visits made to the urban dispensaries. Four diagnostic categories account respectively for 5 per cent or more of the total visits made. Acute bronchitis (group 1) accounts for 10.6 per cent of all visits made in the urban clinics and for 13.8 per cent of those made in rural clinics. Influenza (group 1) accounts for 5.9 per cent of visits made to urban clinics, and 3.4 per cent of those made to rural health services. Diarrhoea

by percentage of total visits for total urban ples: period 19641968

All diagnoses

Groups 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

of diagnoses

All major* respiratory diseases All major gastro-intestinal diagnoses Major skin diseases Major eye disorders Injuries and abscesses (major diagnoses) Muscular, skeletal and neuromuscular disorders Major genito-urinary diagnoses Major gynecological diagnoses Dental conditions Major diagnoses affecting the liver Major disorders affecting the ears Major diagnoses affecting the circulatory system (or blood) Nutritional disorders General and childhood infectious diseases Symptoms and ill-defined conditions Diagnostic and preventive activities All other diagnoses (less than five in any health centre)

* “Major” diagnoses service studied.

include

and rural sam-

Urban Total visits 4805

Rural Total visits 881

% Of total visits

% Of total visits

24.3 16.8 5.7 2.9 3.2 22 4.6 2.2 2.1 1.2 26

25.0 21.5 7.2 1.2 4.1 2,o 2.6 0.9 1.2 1.5 3.0

3.3 0.6 0.7 5.6 105

5.6 0.1 0.1 8.6 4.3

10.8

8.5

those where there were at least five cases in any health

296

AWORBENYOLJSSEFand ALBERT F. WESSEN

(group 2) accounts for 7.7 per cent of visits made in urban clinics, and 9.5 per cent of those made in rural clinics. Finally, vaccinations or inoculations (group 16) accounts for 7 per cent of visits made in urban dispensaries, but for only 3.2 per cent of those made in the rural dispensaries. Collectively, these four diagnostic categories account for about 30 per cent of the total workload of the health centres studies in Nabeul Governorate. Almost half of the illnesses seen in these dispensaries are for three major disease groups-respiratory diseases, gastrointestinal disorders and skin diseases. In addition, 5.6 per cent of visits made in the urban dispensaries and 8.6 per cent of those at rural centres we diagnosed only as symptoms or ill-defined conditions. Particularly in the urban health services a significant proportion of the workload is directed to preventive or diagnostic activities (10.5 per cent of all visits in urban health services as against 4.3 per cent of those in rural ones). One is struck with the fact that most of the conditions diagnosed are acute conditions. Among the chronic conditions the only diagnoses which account for more than 1 per cent of all of the visits made are tuberculosis, rheumatism and syphilis. The more serious medical diagnoses, for example bronchopneumonia, heart disease, etc. are also rarely encountered. The primary load seems to consist of the infectious diseases which are most often in themselves not serious. It is particularly surprising that so few injuries are reported. Similarly, there are relatively very few gynaecological diagnoses made. The latter omission can be explained by the fact that pre- and post-natal visits reported in Table 7 were by those patients who came to the dispensary rather than to the maternal and child health centre for help. The overall impression, therefore, is that the population uses the health service primarily for symptomatic relief connected with the ordinary illnesses which beset them, and that they use the dispensary most often only once for each episode of these conditions. Although physicians do see a wide range of medical conditions, they rarely see surgical problems and are seldom called upon to deal with seriously ill patients who need hospital referral, with diagnostic problems, or with chronic conditions such as diabetes or heart disease which need prolonged followup. It is also important to note that there are few major differences in the diagnostic pattern between the urban and the rural dispensaries. Rural dispensaries do tend to see a somewhat higher proportion of gastrointestinal disorders (21.5 per cent of total load vs 16.8 per cent) and have in general a smaller range of diagnoses. Moreover, a few conditions are largely confined to the rural areas, for example, malaria, prurigo, rheumatic fever. There is also a substantially higher proportion of visits for unknown causes in the rural dispensaries than in the urban ones, as well as a larger proportion of visits where the diagnosis is missing. Overall, however, the impression is that the diagnostic pattern of visits to the primary health centres does not vary sub-

stantially between the urban and the rural populations. What does vary is the extent to which these people use the health services for the conditions with which they present themselves. One is also struck by the relatively small range of the average visiting rates by diagnosis. For example, given an overall rate of 1.24 visits per episode, the range among the 86 diagnoses grouped in Table 7 was between 1.00 and 3.44. These diagnoses for which there was an average of more than two visits per episode were the following: tuberculosis (urban and rural health services); chronic bronchitis (urban health services); diseases of hair and hair follicle (rural health services), arthritis (urban health services); syphilis (urban health services); nervousness (urban health services) and vaccinations and inoculations (both urban and rural health services). High and low utilization categories For the purpose of relating socio-cultural, economic and attitudinal characteristics of the population to the level of utilization, four utilization categories were developed. Because it was not feasible to compute specific utilization rates by household, we used the proportion of family members who had been registered at the health services as a basis for developing utilization categories. Our category of “high-user households” comprises those households in which 90 per cent or more of the members reported a medical record number. Similarly, the “low-user households” consisted of those in which fewer than half of the members reported a medical record number. Table 8 shows the numbers of individuals from high and low-user households by residence status. Strikingly, 73 per cent of urban residents who were in one of the two categories mentioned were from high-user households, conversely only 304 per cent of the rural residents were from low-user households. Population characteristics

and utilization category

Three groups of population characteristics-sociocultural, economic and attitudinal will be considered. (a) Socio-cultural characteristics indicative of modernization and high social participation Table 9 presents the distribution of rural and urban residents who manifest five behaviour patterns indicaTable

8. High

Utilization category High-user households Low-user households Total

and

low utilizers residence Urban all members No. (%)

by

urban

and

rural

Rural all members No. (%I

589

70.0

126

30.4

221

30.0

288

69.6

810

100.0

414

loo.0

Utilization of health services in developing Table 9. Selected socio-cultural characteristics population by residence status

297

countries

of the studied

Proportion of population having a given trait Rural Urban A Literacy and language ability

1 Read and write 2 Read Arabic newspaper 3 Speak French B Socio-cultural participation 1 Watch television 2 Participate in social and economic meetings 3 Read Arabic newspaper

tive of participation in modern life. Three of these are related toliteracy and language ability as well, three of them measure participation or involvement in Tunisian social life. In every case higher proportions of the urban population manifest a given trait than do rural dwellers. Rural people are especially likely not to watch television or to be able to speak French--obvious signs of the failure of the accoutrements of European society to penetrate into some rural areas. Urban people are also almost twice as likely to claim literacy than are rural dwellers. Insofar as these socio-cultural characteristics of respondents influence them toward utilization of health services, their greater frequency among urban dwellers may help to explain the higher utilization rates shown by this group. Table 10 provides some evidence on this point. In every case, since the ratios are all greater than one, a higher percentage of members of the high utilization category showed these selected traits than did members of the low utilization category. The degree to which this is so may be represented by the ratio of the proportions of high and low utilizers who manifest selected socio-cultural traits. Thus, Table 10 shows that rural dwellers who speak French were 2.79 times more likely to be higher utilizers than are those who do not. At the other extreme, participation of rural

Table those

31.4 18.3 17.4

17.9 12.2 5.1

57.5

15.4

51.2 18.3

32.1 12.2

dwellers in socio-economic meetings is only 1.16 times as likely to place them in high utilization group than non-participation. In every comparison but one (participation in socio-economic meetings) possession of one of the traits listed in Table 10 is more likely to be associated with high utilization on the part of rural dwellers. Rural dwellers are particularly likely to comcially in rural areas, those traits having to do with literacy and language ability are more often associated with utilization than are the more diffuse traits having to do with socio-cultural participation. (b) Attitudes towards prrsonul hvulth nnd health utilization catqor) In the community survey, questions on a number of attitudes towards personal health and health services were asked. It was hoped that some of these would help predict high and low utilization. The results of 20 of these questions are presented in Table 11. For 10 of these, there seem to be consistent and suggestive differences in utilization categories among both rural and urban respondents. Differences of more than 20 per cent are found for both urban and rural residents in the following cases: members of high-user families more often reported that their doctor speaks enough with the patient, that there was a satisfactory understanding between doctors and patients, that the

10. Ratio of individuals from “high-user households” to from “low-user households” by selected socio-cultural characteristics and residence status Urban

Rural

1.36 1.65 1.72

2.04 2.74 2.79

1.32

1.37

1.26 1.65

1.16 2.74

A Literacy

and language ability 1 Read and write 2 Read Arabic newspaper 3 Speak French B Socio-cultural participation 1 Watch TV 2 Participate in social and economic meetings 3 Read Arabic newspaper

AMOR BENYOUSSEF and ALBERTF. WESSEN

298

staff in the health services is adequate, and that they did not experience an excessive waiting time at their last visit. A general attitude differentiating both rural and urban respondents was that members of high-user households agreed more frequently than those from low-user households that it is possible to prevent noncommunicable diseases. In the urban sub-sample, moreover, substantially more respondents from highuse families thought that doctors were capable of preventing illness among adults and among aged persons. There seems thus to be some indication that an awareness of the potentiality of disease prevention is associated with high-user households. Finally, we note that what little evidence we were able to elicit concerning the population’s use or liking for traditional medicine seems to be associated with low-user households, especially in rural areas (items 7 and 8). We expected folk medical practices to account for a major proportion of low utilization of health services, particularly among the rural population. The highest proportion of respondents admitting this is found among low-user households in rural areas, but Table

-

only 19.4 per cent of this group indicated that they used “old recipes” to cure their symptoms. From our own casual observations in the study area we believe that the actual usage of traditional medicine is much higher than this. Perhaps the explanation is that respondents were unwilling to report their use of traditional medical methods, given the intensive pressures towards modernization which affect all the population. Table 11 sheds further light on rural-urban differences in utilization behaviour in four respects: members of both high- and low-user households in rural areas had much more difficulty with transportation to the health centres than did the urban dwellers; on the other hand, rural respondents from high- and low-user families more frequently indicated that they had a need for treatment than did urban dwellers. Rurai dwellers are particularly likely to complain about the doctor-patient relationship; this is especially noticeable among members of low-user households. These urban-rural differences are perhaps well summed up by observing that rural dwellers, especially low utilizers, less often feel that their medical care is satisfactory (item 20) than do urban dwellers.

11. Proportion of rural (R) and urban (U) sample respondents giving positive sponses to questions on attitudes by utilization category

Items

A General attitudes 1 Need for treatment 2 Action to be taken in case of felt need 3 Knowledge of means of preventing non-communicable diseases 4 Doctor capable of treating illnesses 5 Doctor capable of assuring prevention for adults 6 Doctor capable of assuring prevention for aged 7 Doctor’s treatment better than old recipes 8 Preference given to old recipes B Specific attitudes uis-b-ois health services and staff 9 Health services are sufficient 10 Waiting time (at last visit) no longer than hoped for 11 No difficulty with transportation 12 No difficulty with waiting time hours are convenient 13 Consultation 14 Staff is adeauate 15 Services are-well organized 16 Staff behaviour is good 17 Staff is capable 18 Doctor speaks enough with patient understanding is 19 Doctor-patient satisfactory 20 Medical care is satisfactory

R

Percentage responses High U

-

of affirmative by utilization Low R

U

-

76.1

65.6

13.2

66.7

86.7

85.6

80.3

72.1

73.3

79.2

58.5

667

93.3

88.0

85.4

87.9

93.3

94.4

85.4

69.1

60.0

85.6

61.0

69.1

96.7 3.3

95.2 6.4

90.2 19.5

90.9 9-1

43.9

48.5

20.0 33.3 20.0 80.0 16.7 93.3 70.0 90.0 56.7

26.4 72.8 25.6 91.2 61.2 89.6 71.2 84.8 61.6

41.5 24.4 14.6 13.2 48.8 15.6 65.9 85.4 22.0

48.5 667 15.2 87.9 45.5 78.8 63.6 84.8 39.4

56.7 161

568 80.8

22.0 63.4

364 84.8

re-

Utilization

of health services in developing

299

countries

Table 12. Selected occupational and economic characteristics by residence status Proportion of population having a given characteristic Rural Urban A Occupational category 1 Farmers 2 Craftsmen 3 Merchants 4 Government employees B Wage and employment status 1 Non-agricultural day workers 2 Paid by salary 3 Have permanent job

(c) Economic characteristics Table 12 presents the distribution of urban and rural residents according to seven economic characteristics. Four of these are related to occupational category and three to wage and employment status of the head of households with registration cards as would be expected, in every occupational category except farmers there are higher proportions living in urban areas. Similarly, more people in the urban sample are paid by salary than in the rural sample (58.4 vs 42.9), but in both populations almost the same proportions have a permanent job (56.5 vs 5X3); for those who claimed to be agricultural day workers, the difference between the urban and rural sample is small (26.4 vs 21.2). We shall now examine the impact of occupational categories and conditions of employment on utilization. Both Tables 13 and 14 present ratios of respondents from high- and low-user households using the same method developed above.

Table 13. Ratio of respondents from high’ and low-user households by selected

occupation category sample only)

Farmers Craftsmen Merchants Government

employees

Table 14. Ratio of respondents households by wage-employment status

Paid by salary Have permanent Non-agricultural

job day workers

(urban

152 1.18 0.70 0.50

from high and low-user status and residence

Urban

Rural

1.56 1.36 1.52

1.20 1.15 0.68

264 174 6.8 6.5

68.6 0.0 1.9 1.9

26.4 58.4 56.5

21.2 42.9 55.8

Since the occupational patterns are so different among rural and urban populations, we shall limit ourselves only to the comparison of different occupational groups of urban dwellers. On the other hand. the distributions of the population by mode of employment, whether rural or urban, is roughly similar (Table 12). This permits us to compare the influence of the mode of employment on the utilization of health services for the urban and rural groups. An examination of the ratios of utilization within the urban sample (as presented in Table 13) reveals that farmers who reside in towns are very high utilizers in comparison with all the other occupational categories, particularly the government employees. Indeed, urban farmers utilize health services more than three times as frequently as government employees, 1.3 times as often as craftsmen, and twice as frequently as merchants. These differences, we assume, are due to the fact that the urban farmers have little cash available and little knowledge regarding health services, and therefore resort to government health services more often. We assume, on the other hand, that the better-off and more sophisticated merchants and government employees have recourse to private medical care. Since in the rural sample we only have farmers, we can only compare the utilization ratios of urban and rural farmers. We find that the latter use governmental health services one-third less than their urban counterparts. We assume that the differential is due both to socio-cultural differences and to the fact that urbanites enjoy greater accessibility (in objective terms) to the betterequipped health facilities in these settings. Table 14 tests the impact of mode of employment on the utilization of health services by place of residence. In each one of these modes the ratio of respondents from high- to low-user households in the urban setting is higher than the corresponding category in the rural setting, but the difference is most marked among nonagricultural day workers. Thus, non-agricultural day workers in the urban setting come from high-user households almost three times as often as their rural colleagues. Differences in ratios for the other two

AMOR BENYOUSSEF and ALBERTF. WESSEN

300

modes are certainly less marked (1.3 times for those paid by salary, 1.2 times for those who have permanent jobs), but they all point in the same direction. This seems to confirm the trend noted earlier that urban populations have better knowledge, more acceptance and therefore use available public health services more than their rural counterparts. It seems that the degree of “modernity” as reflected by literacy, language ability and socio-cultural participation (see Table lo), also has a different impact on utilization in urban than in rural settings. In urban areas, the higher socio-economic classes apparently utilize private health services which are available, which they can afford and which they prefer, to a higher degree than those of the lower classes. In the rural settings, on the other hand, those who are more “modern” utilize the public health services more often than those who are less modern, perhaps because they cannot afford or obtain access to private medical care. Finally, we would like to point out that the different characteristics which we separated for analytical reasons form a total set of factors, inseparable one from the other. An examination of the data suggests that all these factors together influence the differential patterns of utilization of health services. 4. DISCUSSION

There are two main lines of explanation of utilization of health services in developing countries. They concern, respectively, the health facilities and characteristics ofthe population. We assume that actual utilization rates will be dependent upon a complex of factors relating to the interaction between individuals who perceive a need for service and the specific practitioners or facilities which are available to them [lo]. The following arguments will therefore be complementary. 1. Healthfacilities In general, it may be suggested that the greater the expertise and sophistication, the more effective are the results of modern medical care. This has led, especially in developed countries, to an increasing tendency toward specialization on the part of physicians and other health workers and towards concentration of services in hospitals or other complex facilities where multiple technologies are available for the treatment of the ill. And in developed countries, such as the United States, there is evidence that the utilizing public increasingly is taking advantage of the more sophisticated facilities both in terms of the locus of care which they select and of the type of practitioner which they visit. In all countries a rough regionalization of services is apparent. This gives rise to a hierarchy of medical services, ranging from the complete hospital medical centre, through district or community hospitals and group practice clinics to the place of practice of the general practitioner or other provider of primary care. This full range of services is differentially available

according to the degree of urbanization of a given area. Well-defined regionalization schemes are found in those countries where rational planning has guided the provision of services of a national government. In those countries where sophisticated medical services cannot be made available to all the population, it has typically been assumed that all areas should at least have dispensaries or first-aid post attended by paramedical personnel available to them. The hierarchy of health services in the Tunisian province as described above is a good example of this kind of organization. As the population becomes knowledgeable about these different levels of sophistication of medical services, it may be reasonable to make two hypotheses about utilization of services in the various types of medical facilities: (1) that the productivity rate (i.e. the number of cases seen per professional worker, or other similar measure), will be greater in facilities having a greater range of services and technical sophistication available than in those providing fewer services; (2) that populations will tend differentially to choose, where possible, to attend the facility where the highest degree of sophistication of services is available to them. Some medical care planners, believing that these hypotheses will be borne out by the evidence, have argued that the whole notion of providing unsophisticated “minimal” service centres to remote rural populations need to be rethought. This argument takes on increased cogency as education and experience provide these populations with greater discernment about the possibilities of modern medicine and as modern transportation makes travel’ increasingly less difficult. In the present study, it was found that rural persons did not frequently “jump the queue” and present themselves directly at urban hospitals. But the strong evidence presented above showing that they tended to use the unsophisticated dispensaries sparingly-and to evaluate these services somewhat negatively argues that many rural people are not satisfied with the minimal services that peripheral health services now provide. When only these are available, they seem to use them as little as possible. 2. Concerning the characteristics of the populafion of developing countries One may expect that the same demographic and social factors which differentially affect the utilization of health services in developed countries will operate, but often with increased force. Studies on utilization of health service in the developed countries have repeatedly suggested that the rates of utilization vary according to such parameters as socio-economic status, eduoation, urban/rural differences and according to a number of culturally determined attitudes. In all of the ensuing discussion it is assumed that factors of need and availability are controlled with respect to the individual “predisposing” or “enabling” factors discussed below. (a) Socio-economic .statu.s.In industrial countries it

Utilization of health services in developing countries has been known for many years that socio-economic status is associated with differences in the degree of utilization of physicians and other health services. This is thought to reflect both the problems of economic barriers to service and differential demand among population sub-groups for such services. In recent years in the United States the inverse relationship between degree of poverty and utilization of medical services has decreased or even been reversed and presently there seem to be few gross differences among various socio-economic categories as to their rate of utilization of medical services. These changes are usually interpreted as having been brought about by the recent increase in third party payments for medical care for the poor. At the same time, it is almost certainly still true that relative to the level of need and more poverty stricken groups in the American population utilize less services than do the more affluent, and there has been data from the United Kingdom suggesting that under the conditions of the National Health Services, lower-class users of medical care indulge in it less frequently in relation to need than do those of higher status. Poverty appears to inhibit the use of health services in at leastfour ways. We contend that these effects are likely to be more marked in developing than in developed countries because of the greater relative differences in affluence between the poor and those who are well-off and because of the relative scarcity of health resources. Economic, social and logistic barriers. When health care is a commodity, economic barriers are obviously of tremendous importance. This is so particularly when health insurance coverage is largely unavailable to the poverty-stricken population. In developing countries, the reality of the economic barriers associated with poverty are greatly magnified, and even minimal charges may make the use of health care prohibitive for poor families. Hence, in most developing countries medical services are offered free by the government to most of the population. But for the very poor, the problem of obtaining medical care may often conflict with the need to work in order to support a family. On balance, economic barriers per se probably are less of a hindrance to obtaining medical care on the part of the population in most developing countries than they have historically been in “free enterprise” countries such as the United States. In most countries of the world, Platos observation that there are two kinds of medicine, one for the rich and one for the poor, has generally held. Where medicine is controlled by the mechanisms of the marketplace, these differences are reflected in differential quality of care available. Where economic barriers are removed through charity or the provision of public medical care, the wealthy have often felt, correctly or not, that they could purchase better care and associated amenities through private medical practice. In any case, public or charity clinics have often had social characteristics which have deterred many of the poor from making full use of their facilities. The bureauc-

301

racy, impersonality, unpleasant facilities and long waiting time characteristic of hospital outpatient departments have often been commented upon as a deterrent to use of medical care. When ethnic and other cultural differences are involved, the social distance between providers of care and recipients has sometimes become so marked as to make medical encounters aversive to those in need. Documentation of the problems of medical care for the poor in the developed countries is extensive and needs no recitation here. Moreover, the poor usually have greater difficulty in gaining access to medical care facilities than do the wealthy because of unavailability of transportation, length of time required to obtain care, conflict between appointment times and work or family obligations, and similar logistic factors. These problems, of course, bear most heavily upon the rural poor who often reside miles from the nearest centre of available care. We suggest that these social and logistical barriers regularly operated with a high degree of forCe upon the populations of developing countries. It is clear that in many developing countries the sheer factor of distance becomes a major predictor of who will or will not be able to utilize health services, and gradients relating distance from the health centre to the utilization of service have been drawn for a number of countries. Physicians and other health service workers in developing countries usually represent the advantaged, if not the elite, classes of society; by virtue of their education and training they may find it difficult to communicate with uneducated groups. As Table 11 above showed, substantial numbers of respondents, especially from high low-user households voiced dissatisfaction with their relationship and degree of communications with the doctor. In traditional societies social status and the associated phenomena of social distance are more important determinants of behaviour than in more urbanized societies. And when medical care is offered by outsiders the factors of social distance are maximized. We would therefore expect that the social and logistic barriers to medical care associated with poverty will tend to act with greater force in developing than developed countries. Attitudinalfactors. Among the psychological manifestations of poverty are a number of attitudes which themselves inhibit the utilization of medical care. These include lack of sophistication and understanding about need for care, and appreciation of modern medicine. Above all, the poor, no strangers to problems of all sorts, may come to have a higher threshold for dealing with the vicissitudes of health; apathy often comes to be a presenting symptom of poverty. We believe that these psychological concomitants of poverty will be more pronounced the greater the degree of poverty. Hence we would expect to find their effect maximal in those countries where the average level of poverty is such that the “poverty level” in developed countries would be defined as representing those of high income/

302

AMOR BENYOUSSEFand ALBERT F. WESSEN

Generally speaking, it is the poor who are most often illiterate and lack access to mass communications and social participation in the large society. Tables 9 and 10 above have shown how these traits were concentrated in the economically depressed rural areas and how they are associated with low utilization of health services. In sum, we would expect that in developing countries socio-economic status would have even a larger effect upon the utilization of medical care services than in developed countries even in the face of the common provision of public medical services for the great bulk of the population which cannot pay for their medical care. (b) Urban/rural status and “modernizing” characteristics. In developed countries the level of use of medical services has historically tended to be higher for urban residents than for those in rural areas. This has been explained as a result both of the relative unavailability of medical services to rural people and of factors associated with the rural way of life. Apparently, the demand for medical care in relation to need among rural dwellers is often lower than it is among urban people. This may reflect the results of poverty (so often a rural phenomenon), educational differences, or differential perceptions of the adequacy of available medical care facilities. In developed countries differences between rural and urban areas have become increasingly less marked over the last 50 yr. In most developing countries they are still very pronounced, and the differences apply both to the differential availability of services and to the characteristics of population. One would expect, therefore, a much more marked difference in the level of utilization of health services between rural and urban people in developing countries than in developed countries. Indeed, perhaps the most striking finding of the Tunisia Study is the marked difference in utilization rates between rural and urban populations. This is especially impressive when it is realized that the “urban” population as defined in this study is in no sense metropolitan, residing as they do in regional towns of 25,000 (Nabeul) and less (see Fig. 1 and Tables 3, 4, 8 and 10). As we argued above, there is evidence that these differences in Tunisia are related both to differential access to the more sophisticated health services and to differential characteristics of the rural and urban populations. American data have shown some tendency toward higher utilization of health services on the part of better educated groups in the population. This has been particularly true with reference to the use of dental services and, in general, of preventive services. Education provides not only increasing sophistication with respect to health needs and to the methods of modern medicine, but in general allows an individual to develop a more cosmopolitan view of his world than otherwise might have been possible. Suchman suggested that in a New York population, utilization varied according to the degree to which populations

demonstrated “cosmopolitan” as opposed to “parochial” attitudes. In particular, these attitudes affected their use of the medical care system as well as their confidence in it. What seems to have been true for the United States is likely to be even more true in developing countries where education, even of a primary level, is a major force in breaking down reliance upon traditionalistic world views and folk practices. An important function of education is to help individuals cope with their needs by making intelligent use of available social and health services. In countries where tradition%1 health attitudes have been strong and have been thought by the government to hinder development, educational systems have made special efforts to overcome such attitudes as fatalism or reliance upon folk methods of treatment. Here the aim has been not only to improve the health of the public, but also to motivate a population for participation in a developing economy. Moreover, education may-also serve as a surrogate for a variety of cultural influences, all of which are transmitting modernizing ideas. The mass media, especially radio, are becoming pervasive even in remote areas of developing countries. Those who by inclination and interest are exposed to the mass media may be likely to overcome cultural inhibitations to the use of medical care services. In countries where the use of a European language is widespread, knowledge of and regular contact with these languages may be an indicator of modern attitudes. As modernizing attitudes are an integral part of the development process, and as these are mediated through education, we would expect them to be major predictors of “modern” behaviour and it is our assumption that the use of modern health facilities is an example of such modern behaviour. That such forces affect utilization behaviour in the Tunisian Study was shown in Table 10. The preceding discussion may be summarized in terms of a general hypothesis, namely that the utilization and the auailability of medical care services in deve/aping countries is a function of the relative modernization of the population. We are arguing that when, as in most developing countries, Western medicine is a scarce commodity which is culturally only partially assimilated and which must compete with other forms of care, those who utilize services will be primarily those who in other ways are most attuned to the transformations which we label “modernization”. The foregoing hypothesis may be confirmed both with respect to cross-national comparisons and to intra-national comparisons. The higher the level of development of a country-the more modernized it is, the more urbanized, the higher the level of affluence, the greater the average rate of utilization of health services should be. In general, available data show that this is so. Of course, facilities are more available in terms of relationship to the population in the developed countries. Moreover, utilization in the most highly industrialized nations such as the United States, Canada or the United Kingdom is substantially higher

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Utilization of health services in developing countries than in those European and South American countries which are generally thought of as developed, but which have not yet achieved comparable rates of urbanization or of economic development, e.g. Yugoslavia, Poland, Argentina. In the few situations in which data are available, it is clear that the least developed countries uniformly show low rates of utilization of care. Taylor et al. have noted, for example, that the productivity of the physician in both public and private medical care in Turkey is very low, only a few patients receiving his services during the course of a day. Taylor and his group also have pointed out that in a Punjabi village which they studied, only a quarter of the population living within walking distance of dispensary services utilize them. We expect, therefore, that the overall rate of utilization of health services will depend upon the degree of economic development of the various countries of the world. Moreover, within each country we would expect that levels of utilization would vary, both according to degree of urbanization of various regions, between cities and rural areas, and among population groups which have been more or less exposed to the social and psychological processes of modernization. We have presented evidence from Tunisia that this tends to be so within our study population.

5. CONCLUSION It should be emphasized that both the factors having to do with the distribution and type of facilities in various regions of developing countries and the demographic and socio-economic factors characterizing their populations interact to determine actual levels of utilization of health services (Tables 10, 12 and 13). Thus, in rural areas in most countries health services will be relatively unavailable and will consist of a minimum of sophisticated services. At the same time, the rural population is likely to make relatively little use of these services because of its relative poverty, because of social and logistic barriers, and because of its attitudes, values and ideologies. These effects may interact to produce very low rate of utilization of services in rural areas. The opposite results may be expected in urban settings where economic opportunities, educational facilities and the whole process of modernization have progressed farther and where the fullest range of sophisticated medical services are available. To the extent that the population studied in Tunisia is representative of developing countries, the data support these general conclusions. We demonstrated that in the Tunisian study areas: (1) Utilization of health services is low in comparison to that which has been observed in more developed countries. Ambulatory health services are used most often for treatment of the common communicable diseases, and 85 per cent of all patients are seen only once per episode of illness.

(2) Although some health services were available and accessible freely to all the population studied (including rural residents), we estimated that 505 per cent of the population utilize health services in a given year. (3) Utilization rates are strikingly higher among urban than rural residents. We have argued that this reflects both the lesser sophistication of rural health centres and differences between the populations. (4) Respondents from high-user households were especially likely to have the following characteristics: urban residents who were literate had cultural traits such as reading Arabic newspaper, speaking French, watching television and participating in social and economic meetings. They tended also less often to admit being influenced by traditional medical practices, believed in the capabilities of modern medicine to prevent as well as treat illness, and were satisfied with the health services. We suggest that these findings reflect the fact that high utilizers are disproportionately found among the most “modernized” segments of the population. Much work remains to be done in the study of health care systems and their use by the people of developing countries. This paper, based partly on a WHO study in Tunisia, has developed a framework which we hope may prove useful in further studies. It emphasized the importance of modernization, both of health facilities and socio-cultural characteristics of the population, as the major factor in promoting increased use of health services. Looked at another way, we may perhaps suggest that the degree qfcot!erugr und utilization of the health services is a good indicator of the level of modernization of a region or country. Acknow/r~~e,nrntsThanks to the assistance of the Ministrv of Public Health of Tunisia and the co-oueration of the population and different national research’ institutions (Centre d’Etudes et de Recherches Economiques et Sociales-CERES, and Institut National de la Statistique-INS), this study was undertaken by a multidisciplinary WHO team of which A. Benyoussef, A. F. Wessen, R. Chical, H. Christensen, S. Litsios, P. Roz6 and T. Phan-Tan were members. In the Final Technical Report of the Study, the learn benefited from suggestions and comments by the Minister of Public Health of Tunisia and by his close collaborators, in particular, Dr. M. Bahri. Dr. 0. Sfar, Dr. T. Hachicha, Dr. Slim, Mr. Tahar B. Youssef and Mr. Boubaker Bellai’d (Public Health Administrator, Nabeul Regional Hospital). as well as from Prof. M. Seklani, Director CERES and IN& Mr. C. Tarifa, INS, Dr. K. W. Newell and Dr. M. Torfs of WHO. We are especially grateful to our late colleague, H. Christensen, whose contribution to the team’s effort was indispensable. REFERENCES 1.

WHO, Etude Pilote en Tunisie sur l’utilisation des services de sant& externes dans le Gouvernorat de Nabeul, Final Report by A. Benyoussef, H. Christensen and A.

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F. Wessen, RECS/72. 1, 139 pages. Abridged version in English, RECS/72.1, 35 pages, 1972. Bite T. W. and White K. L. Factors related to the use of health services: an international comparative study. Med. Care 7, 124, 1969. Rosenstock I. M. Why people use health services. Milbank Memorial Fund Quarterly, XLIV, 94, 1966. Kalimo E. and Sievers K. The need for medical care: estimation on the basis of interview data. Med. Care 6, 1, 1968. Broyelle J., Brams L., Fagnani F., Tabah L. Recherches sur les besoins de Sante dune population. Bulletin de PINSERM T. 24, 613, 1969. Fiilop J. Enquetes tpidtmiologiques complexes: Population rurale de la Hongrie. La Santh Publique, Revue internationale, Bucarest, 10, 2 (French-Russian), 1969. WHO/International Collaborative Study of Medical Care Utilization, 1970. It may be said that the Tunisia Study has had three major objectives. These were: (a) to determine appropriate research methodology for ascertaining patterns of utilization of health services in a developing country. Emphasis was placed on the desirability of finding inexpensive and quick methods if possible; (b) to analyze the principal factors likely to influence the use of health services by the study population. The WHO team sought four factors-demographic, socio-cultural, economic attitudinal and organizational-which would account for different degrees of utilization; (c) to provide a report to the Tunisian Public Health Ministry upon the results of the Study. In addition to the description and

analysis of utilization patterns, the report was to discuss methodological findings and make recommendation concerning such matters as the better management of health care delivery, the medical records in use in outpatient services, the improvement of relationships between the health services and the community, the type of further research in this area, etc. 8. Description of the seven study areas: (a),Nabeul-small urban centre (23,000 inhabitants); capital of the Governorate; regional hospital with a full range of specialized services; (b) Menzel Temime-market town of about 15000, some 80 km. from Nabeul; auxiliary hospital with surgical and obstetrical care as well as outpatient facilities; (c) Korba-market town of about 13,000, some 20 km. from Nabeul; dispensary with obstetrical service; (d) Korba Rural-Rural areas extending outside Korba town for l&15 km: medical care available in Korba town dispensary; (e) Bir Drassen-rural area with rural dispensary, some 16 km. inland from Korba; (f) Menzel Horr and Rai’nine-rural areas with good accessibility to Menzel Temime hospital; small rural dispensaries available. 9 For example, an experimental “one day ad hoc census” of health centres users, in which on the spot interviewes of attendants at health services was undertaken also afforded the opportunity to test alternative “shortform” approaches of getting utilization data. 10 For a thorough review of the literature on use of health services, see: MC Kinley J. B. Some approaches and problems in the study of the use of services-an overview. J: N/t/t. sot. Behuv. 13, 1 15, 1972.