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Maternal and Child Health Journal
Published in: Maternal and Child Health Journal 3/2015

01-03-2015

Utilisation of Health Services and Geography: Deconstructing Regional Differences in Barriers to Facility-Based Delivery in Nepal

Authors: Andrew Hodge, Abbey Byrne, Alison Morgan, Eliana Jimenez-Soto

Published in: Maternal and Child Health Journal | Issue 3/2015

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Abstract

While established that geographical inaccessibility is a key barrier to the utilisation of health services, it remains unknown whether disparities are driven only by limited access to these services, or are also attributable to health behaviour. Significant disparities exist in health outcomes and the coverage of many critical health services between the mountains region of Nepal and the rest of the country, yet the principal factors driving these regional disparities are not well understood. Using national representative data from the 2011 Nepal Demographic and Health Survey, we examine the extent to which observable factors explain the overall differences in the utilisation of maternal health services. We apply nonlinear Blinder–Oaxaca-type decomposition methods to quantify the effect that differences in measurable characteristics have on the regional coverage gap in facility-based delivery. The mean coverage of facility-based deliveries was 18.6 and 36.3 % in the mountains region and the rest of Nepal, respectively. Between 54.8 and 74.1 % of the regional coverage gap was explained by differences in observed characteristics. Factors influencing health behaviours (proxied by mothers’ education, TV viewership and tobacco use, and household wealth) and subjective distance to the health facility were the major factors, contributing between 52.9 and 62.5 % of the disparity. Mothers’ birth history was also noteworthy. Policies simultaneously addressing access and health behaviours appear necessary to achieve greater coverage and better health outcomes for women and children in isolated areas.
Appendix
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Footnotes
1
One could elect to employ a probit instead of a logit model. However, the decomposition holds exactly for a logit model and only very closely for a probit model (see Farilie [28]).
 
2
One difficulty in interpreting the “unexplained” portion of the decomposition is that in the presence of categorical variables the separate contributions of sets of dummy variables to this portion are not invariant with respect to the choice of reference groups. If one is interested in decomposing the residual portion, Yun [46, 47] provides a solution which involves normalising the categorical variables’ coefficients prior to the decomposition.
 
3
We also estimated the decomposition between the Mountains and Hill regions and the Mountain and Terai regions separately. While the observed differences were greater between the Mountains-Terai samples, the results (available upon request) are similar. We also re-ran the model using a linear probability model and the results are again similar.
 
4
While many health information messages are broadcasted on TV, we speculate that one-to-one counselling is more effective than any mass communication in achieving behavioural change. Unfortunately, questions on visits from female community health volunteers or participation in mothers’ groups are not available. Health education is also delivered through radio messages. Thus, we estimated the decomposition model replacing weekly television viewership with combined weekly use of radio and/or TV. The results (not shown) are similar and the conclusions drawn are identical to conclusions based on the main results. The key difference is that the combined measure plays a smaller role in explaining the regional gap, while the contribution of wealth is somewhat larger, indicating some likely correlation between these variables.
 
5
Ideally we would like to employ some type of instrumental variable estimation. However, finding appropriate instruments is a monumental task. While ignoring this bias makes the problem tractable, our results may only be interpreted as suggestive.
 
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Metadata
Title
Utilisation of Health Services and Geography: Deconstructing Regional Differences in Barriers to Facility-Based Delivery in Nepal
Authors
Andrew Hodge
Abbey Byrne
Alison Morgan
Eliana Jimenez-Soto
Publication date
01-03-2015
Publisher
Springer US
Published in
Maternal and Child Health Journal / Issue 3/2015
Print ISSN: 1092-7875
Electronic ISSN: 1573-6628
DOI
https://doi.org/10.1007/s10995-014-1540-x

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