RFI: Effectiveness of Patient's Referral Channels (3)
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Dear Frank,
Your query reminded me of a useful paper from a study in Sri
Lanka about the phenomenon of bypassing in relation to referral
(see abstract below). There are also several articles that might
be relevant in the October 2005 issue of Social Science and
Medicine, including: Paula Tibandebage and Maureen Mackintosh
"The market shaping of charges, trust and abuse: health care
transactions in Tanzania." Soc Sci Med. 2005 Oct;61(7):1385 -
1395 (abstract below).
Hope these are helpful to you.
Best wishes,
Wendy Holmes MB BS MSc
Deputy Director Technical Programs
Centre for International Health
Macfarlane Burnet Institute for Medical Research and Public
Health
Alfred Medical Research & Education Precinct (AMREP)
Commercial Road, Melbourne 3004
GPO Box 2284, Melbourne, Australia 3001
Tel: +61-3-9282-2145 (office)
Fax: +61-3-9282-2144
Home phone: +61-3-9689-2363
Time zone: 10 hours ahead of GMT
mailto:holmes@burnet.edu.au
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Akin JS, Hutchinson P. Health-care facility choice and the phe-
nomenon of bypassing. Health Policy Plan. 1999 Jun;14(2):135-51.
World Bank, Uganda Resident Mission
Health policy-makers in developing countries are often disturbed
and to a degree surprised by the phenomenon of the ill travel-
ling past a free or subsidized local public clinic (or other
public facility) to get to an alternative source of care at
which they often pay a considerable amount for health care. That
a person bypasses a facility is almost certainly indicative ei-
ther of significant problems with the quality of care at the by-
passed facility or of significantly better care at the alterna-
tive source of care chosen. When it is a poor person choosing to
bypass a free public facility and pay for care further away,
such action is especially bothersome to public policy-makers.
This paper uses a unique data set, with a health facility survey
in which all health facilities are identified, surveyed, and lo-
cated geographically; and a household survey in which a sample
of households from the same health district is also both sur-
veyed and located geographically. The data are analyzed to exam-
ine patterns of health care choice related to the characteris-
tics and locations of both the facilities and actual and poten-
tial clients. Rather than using the distance travelled or some
other general choice of type of care variable as the dependent
variable, we are able actually to analyze which specific facili-
ties are bypassed and which chosen. The findings are instruc-
tive. That bypassing behaviour is not very different across in-
come groups is certainly noteworthy, as is the fact that the
more severely ill tend to bypass and to travel further for care
than do the less severely ill. In multivariate analysis almost
all characteristics of both providers and facilities are found
to have the a priori expected relationships to facility choice.
Prices tend to deter use, and improved quality of services to
increase the likelihood of a facility being chosen. The answer
to the bypassing dilemma seems to be for providers to provide as
good quality care relative to the money charged (if any), as
other, often further away, providers.
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Paula Tibandebage and Maureen Mackintosh The market shaping of
charges, trust and abuse: health care transactions in Tanzania.
Soc Sci Med. 2005 Oct;61(7):1385 - 1395
Abstract:
Effective health care is a relational activity, that is, it re-
quires social relationships of trust and mutual understanding
between providers and those needing and seeking care. The break-
down of these relationships is therefore impoverishing, cutting
people off from a basic human capability, that of accessing of
decent health care in time of need. In Tanzania as in much of
Africa, health care relationships are generally also market
transactions requiring out of- pocket payment. This paper analy-
ses the active constitution and destruction of trust within Tan-
zanian health care transactions, demonstrating systematic pat-
terns both of exclusion and abuse and also of inclusion and mer-
ited trust. We triangulate evidence on charges paid and payment
methods with perceptions of the trustworthiness of providers and
with the socio-economic status of patients and household inter-
viewees, distinguishing calculative, value based and personal-
ised forms of trust. We draw on this interpretative analysis to
argue that policy can support the construction of decent inclu-
sive health care by constraining perverse market incentives that
users understand to be a source of merited distrust; by assist-
ing reputation-building and enlarging professional, managerial
and public scrutiny; and by reinforcing value-based sources of
trust.