Skip to main content

Advertisement

SpringerLink
Log in

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

  • Published:
Maternal and Child Health Journal Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  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.

References

  1. Rodin, J., & de Ferranti, D. (2012). Universal health coverage: The third global health transition? Lancet, 380(9845), 861–862.

    Article  PubMed  Google Scholar 

  2. Ali, M., Asefaw, T., Byass, P., Beyene, H., & Pedersen, F. K. (2005). Helping northern Ethiopian communities reduce childhood mortality: Population-based intervention trial. Bulletin of the World Health Organization, 83(1), 27–33.

    PubMed Central  PubMed  Google Scholar 

  3. Ashwell, H. E., & Barclay, L. (2009). Outcome evaluation of community health promotion intervention within a donor funded project climate in Papua New Guinea. Rural and Remote Health, 9(4), 1219.

    CAS  PubMed  Google Scholar 

  4. Huber, D., Saeedi, N., & Samadi, A. K. (2010). Achieving success with family planning in rural Afghanistan. Bulletin of the World Health Organization, 88(3), 227–231.

    Article  PubMed Central  PubMed  Google Scholar 

  5. Dickerson, T., Crookston, B., Simonsen, S. E., Sheng, X., Samen, A., & Nkoy, F. (2010). Pregnancy and village outreach tibet: A descriptive report of a community- and home-based maternal-newborn outreach program in rural Tibet. The Journal of Perinatal & Neonatal Nursing, 24(2), 113–127.

    Article  Google Scholar 

  6. Hafeez, A., Mohamud, B. K., Shiekh, M. R., Shah, S. A. I., & Jooma, R. (2011). Lady health workers programme in Pakistan: Challenges, achievements and the way forward. The Journal of the Pakistan Medical Association, 61(3), 210–215.

    Google Scholar 

  7. Fort, M. P., Grembowski, D. E., Verdugo, J. C., Morales, L. C., Arriaga, C. A., Mercer, M. A., et al. (2011). Implementation and progress of an inclusive primary health care model in Guatemala: Coverage, quality, and utilization. Pan American Journal of Public Health, 30(3), 217–224.

    Article  PubMed  Google Scholar 

  8. Ministry of Health and Population Nepal, New ERA & ICF International Inc. (2012). Nepal Demographic and Health Survey 2011. Kathmandu, Nepal and Calverton, USA: Ministry of Health and Population, New ERA, and ICF International.

    Google Scholar 

  9. Baral, Y., Lyones, K., Skinner, J., & van Teijlingen, E. (2012). Maternal health services utilisation in Nepal: Progress in the new millennium? Health Science Journal, 6(4), 618–633.

    Google Scholar 

  10. Bhusal, C. L., Singh, S. P., Bc, R. K., Dhimal, M., Jha, B. K., Acharya, L., et al. (2011). Effectiveness and efficiency of Aama Surakshya Karyakram in terms of barriers in accessing maternal health services in Nepal. Journal of Nepal Health Research Council, 9(2), 129–137.

    CAS  PubMed  Google Scholar 

  11. New, E. R. A. (2011). Survey on coverage and compliance of chlorhexidine (Kawach) use and other components of community-based program in Banke, Jumla and Bajhang districts. Kathmandu, Nepal: NewERA, Nepal Family Health Program II.

    Google Scholar 

  12. Thomas, D., Messerschmidt, L., Mersserschmidt, D., & Devkota, B. (2004). Increasing access to essential obstetric care: A review of progress and process. Kathmandu: DFID, Options, Family Health Division of Nepal Ministry of Health.

    Google Scholar 

  13. Borghi, J., Ensor, T., Neupane, B. D., & Tiwari, S. (2006). Financial implications of skilled attendance at delivery in Nepal. Tropical Medicine & International Health, 11(2), 228–237.

    Article  Google Scholar 

  14. Nguyen, K.-H., Morgan, A., Morgan, C., Jimenez-Soto, E., & Hodge, A. (2013). How does progress towards the MDG 4 affect inequalities between different sub-populations? Evidence from Nepal. Journal of Epidemiology and Community Health, 76(4), 311–319. doi:10.1136/jech-2012-201503.

    Article  Google Scholar 

  15. Morrison, J., Jacoby, C., Ghimire, S. & Oyloe, P. (2012). What affects clean delivery kit utilization at birth in Nepal? A qualitative study. Asia-Pacific Journal of Public Health, 14, doi: 10.1177/1010539512458950.

  16. Samandari, G., Wolf, M., Basnett, I., Hyman, A., & Andersen, K. (2012). Implementation of legal abortion in Nepal: A model for rapid scale-up of high-quality care. Reproductive Health, 9, 7. doi:10.1186/742-4755-9-7.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Chhetry, D. B., Upreti, S. R., Dangal, G., Subedi, P. K., & Khanal, M. N. (2012). Impact evaluation of uterine prolapse surgery in Nepalese women. Journal of Nepal Health Research Council, 10(21), 167–171.

    CAS  PubMed  Google Scholar 

  18. Department of Health Services Nepal.(2011) Department of Health Services Annual Report 2067/68 (2010/11). Kathmandu, Nepal: Government of Nepal, Ministry of Health and Population, Department of Health Services.

  19. Ensor, T., & Cooper, S. (2004). Overcoming barriers to health service access: Influencing the demand side. Health Policy Plan, 19, 69–79.

    Article  PubMed  Google Scholar 

  20. Jacobs, B., Ir, P., Bigdeli, M., Annear, P., & Van Damme, W. (2012). Addressing access barriers to health services: An analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan, 27(4), 288–300.

    Article  PubMed  Google Scholar 

  21. Oaxaca, R. (1973). Male-Female Wage Differentials in Urban Labor Markets. International Economic Review, 14(3), 693–709.

    Article  Google Scholar 

  22. Blinder, A. S. (1973). Wage discrimination: Reduced form and structural estimates. Journal of Human Resources, 8(4), 436–455.

    Article  Google Scholar 

  23. Bhalotra, S., Valente, C., & van Soest, A. (2010). The puzzle of muslim advantage in child survival in India. Journal of Health Economics, 29(2), 191–204.

    Article  PubMed  Google Scholar 

  24. Finks, J. F., Osborne, N. H., & Birkmeyer, J. D. (2011). Trends in hospital volume and operative mortality for high-risk surgery. New England Journal of Medicine, 364(22), 2128–2137. doi:10.1056/NEJMsa1010705.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  25. Hsiou, T. R., & Pylypchuk, Y. (2012). Comparing and decomposing differences in preventive and hospital care: USA versus Taiwan. Health Economics, 21(7), 778–795.

    Article  PubMed  Google Scholar 

  26. Lhila, A., & Long, S. (2012). What is driving the black-white difference in low birthweight in the US? Health Economics, 21(3), 301–315.

    Article  PubMed  Google Scholar 

  27. Fairlie, R. W. (1999). The absence of the African–American owned business: An analysis of the dynamics of self-employment. Journal of Labor Economics, 17(1), 80–108.

    Article  Google Scholar 

  28. Fairlie, R. W. (2005). An extension of the Blinder–Oaxaca decomposition technique to logit and probit models. Journal of Economic and Social Measurement, 30(4), 305–316.

    Google Scholar 

  29. Ministry of Health and Population Nepal. (2010). Nepal health sector program - Implementation plan II (NHSP IP II) 2010–2015. Kathmandu Nepal: Government of Nepal.

    Google Scholar 

  30. Darmstadt, G. L., Bhutta, Z. A., Cousens, S., Adam, T., Walker, N., de Bernis, L., et al. (2005). Evidence-based, cost-effective interventions: How many newborn babies can we save? Lancet, 365(9463), 977–988. doi:10.1016/S0140-6736(05)71088-6.

    Article  PubMed  Google Scholar 

  31. Lawn, J. E., Cousens, S., Zupan, J., & Steering, L. N. S. (2005). Neonatal survival 1–4 million neonatal deaths: When? Where? Why? Lancet, 365(9462), 891–900. doi:10.1016/S0140-6736(05)71048-5.

    Article  PubMed  Google Scholar 

  32. Gabrysch, S., & Campbell, O. M. R. (2009). Still too far to walk: Literature review of the determinants of delivery service use. Bmc Pregnancy Childb, 9, 34. doi:10.1186/1471-2393-9-34.

    Article  Google Scholar 

  33. Thapa, N., Chongsuvivatwong, V., Geater, A. F., & Ulstein, M. (2000). High-risk childbirth practices in remote Nepal and their determinants. Women and Health, 31(4), 83–97.

    Article  CAS  PubMed  Google Scholar 

  34. Morgan, A., Prasai, Y., Jimenez-Soto, E., Dettrick, Z., & Firth, S. (2011). Nepal: Developing an investment case for financing equitable progress towards MDGs 4 and 5 in the Asia Pacific region (Scale-up report). Brisbane, Australia: Nossal Institute for Global Health, University of Queensland, UNICEF Nepal.

    Google Scholar 

  35. New, E. R. A. (2007). Barriers and enabling factors influencing the use of a skilled birth attendant among marginalized populations in the Mid-Western region of Nepal. Kathmandu: Nepal Family Health Program II.

    Google Scholar 

  36. Thapa, S. (1996). Challenges to improving maternal health in rural Nepal. Lancet, 347(9010), 1244–1246. doi:10.1016/s0140-6736(96)90748-5.

    Article  CAS  PubMed  Google Scholar 

  37. Manandhar, M. (2000). Ethnographic perspectives on obstetric health issues in Nepal: A literature review. Kathmandu, Nepal: Department for International Development.

    Google Scholar 

  38. Agha, S., & Carton, T. W. (2011). Determinants of institutional delivery in rural Jhang. Pakistan. Int J Equity Health, 10, 31. doi:10.1186/1475-9276-10-31.

    Article  Google Scholar 

  39. Kesterton, A. J., Cleland, J., Sloggett, A., & Ronsmans, C. (2010). Institutional delivery in rural India: The relative importance of accessibility and economic status. Bmc Pregnancy Childb, 10, 30. doi:10.1186/1475-9276-10-31.

    Article  Google Scholar 

  40. Ndao-Brumblay, S. K., Mbaruku, G., & Kruk, M. E. (2012). Parity and institutional delivery in rural Tanzania: A multilevel analysis and policy implications. Health Policy Plan,. doi:10.1093/heapol/czs104.

    PubMed Central  PubMed  Google Scholar 

  41. Filmer, D., & Pritchett, L. H. (2001). Estimating wealth effects without expenditure data—or tears: An application to educational enrollments in states of India. Demography, 38(1), 115–132. doi:10.2307/3088292.

    CAS  PubMed  Google Scholar 

  42. Bhurtyal, A., Poudyal, A. K., Maskey, M. K., Adhikari, D., Sharma, D. R., & Bhurtyal, K. (2011). Changes in utilisation of health services after removal of user fees: Observations in rural Nepal. Journal of Epidemiology and Community Health, 65(1 Supp), A177. doi:10.1136/jech.2011.142976f.88.

    Article  Google Scholar 

  43. Powell-Jackson, T., Neupane, B. D., Tiwai, S., Morrison, J., & Costello, A. (2008). Evaluation of the safe delivery incentive programme - Final report of the evaluation. Kathmandu, Nepal: SSMP Nepal.

    Google Scholar 

  44. Witter, S., Khadka, S., Nath, H., & Tiwari, S. (2011). The national free delivery policy in Nepal: Early evidence of its effects on health facilities. Health Policy Plan, 26, ii84–ii91. doi:10.1093/heapol/czr066.

    Article  PubMed  Google Scholar 

  45. Oaxaca, R. L., & Ransom, M. R. (1999). Identification in detailed wage decompositions. Review of Economics and Statistics, 81(1), 154–157.

    Article  Google Scholar 

  46. Yun, M.-S. (2004). Decomposing differences in the first moment. Economics Letters, 82(2), 275–280.

    Article  Google Scholar 

  47. Yun, M.-S. (2005). A simple solution to the identification problem in detailed wage decompositions. Economic Inquiry, 43(4), 766–772.

    Article  Google Scholar 

  48. Byrne, A., Hodge, A., Jimenez-Soto, E. & Morgan, A. (2013). Looking Beyond Supply: A Systematic Literature Review of Demand-Side Barriers to Health Service Utilization in the Mountains of Nepal. Asia-Pacific Journal of Public Health, forthcoming.

  49. Foundation, Nepal Public Health. (2012). Overcoming barriers to scaling skilled birth attendants utilization in improving maternal, newborn and child health in Nepal. Nepal: Kathmandu.

    Google Scholar 

  50. Heydon, S. (2011). Mountains and medicines: History and medicines use in rural Nepal. Southern Med Review, 4(1), 4–8. doi:10.5655/smr.v4i1.77.

    Article  Google Scholar 

  51. Davis, W. (2003). Voices from the mountain: Oral testimonies from Nepal. London, United Kingdom: The Panos Institute.

    Google Scholar 

Download references

Acknowledgments

The research described in this study is made possible through funding from the Australian Department of Foreign Affairs and Trade, Grant ID 47734. The funder of the study had no role in the study design, data collection, the analysis or the interpretation of the results, or the writing of this paper.

Conflict of interest

The authors declare that they have no competing interests.

Author information

Authors and Affiliations

  1. School of Population Health, The University of Queensland, Public Health Building, Herston Road, Herston, QLD, 4006, Australia

    Andrew Hodge & Eliana Jimenez-Soto

  2. The Nossal Institute for Global Health, The University of Melbourne, Alan Gilbert Building, 161 Barry Street, Carlton, VIC, 3010, Australia

    Abbey Byrne & Alison Morgan

Authors
  1. Andrew Hodge
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Abbey Byrne
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alison Morgan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eliana Jimenez-Soto
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andrew Hodge.

Appendix

Appendix

See Tables 3, 4, 5, 6.

Table 3 Logit regressions for facility-based delivery
Full size table
Table 4 Non-linear decomposition of the difference in facility-based delivery between the Mountains and the other regions of Nepal, pooled sample benchmark
Full size table
Table 5 Non-linear decomposition of the difference in facility-based delivery between the Mountains and the other regions of Nepal, without wealth
Full size table
Table 6 Variable descriptions
Full size table

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hodge, A., Byrne, A., Morgan, A. et al. Utilisation of Health Services and Geography: Deconstructing Regional Differences in Barriers to Facility-Based Delivery in Nepal. Matern Child Health J 19, 566–577 (2015). https://doi.org/10.1007/s10995-014-1540-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10995-014-1540-x

Keywords

Search

Navigation