Health-care facility choice and the phenomenon of bypassing

Health policy-makers in developing countries are often disturbed and to a d egree surprised by the phenomenon of the ill travelling past a free or subs idized local public clinic (or other public facility) to get to an alternat ive source of care at which they often pay a considerable amount for health care. That a person bypasses a facility is almost certainly indicative eit her of significant problems with the quality of care at the bypassed facili ty or of significantly better ca re at the alternative source of care chose n. When it is a poor person choosing to bypass a free public facility and p ay for care further away, such action is especially bothersome to public po licy-makers. This paper uses a unique data set, with a health facility survey in which a ll health facilities are identified, surveyed, and located geographically; and a household survey in which a sample of households from the same health district is also both surveyed and located geographically. The data are an alyzed to examine patterns of health care choice related to the characteris tics and locations of both the facilities and actual and potential clients. Rather than using the distance travelled or some other general choice of t ype of care variable as the dependent variable, we are able actually to ana lyze which specific facilities are bypassed and which chosen. The findings are instructive. That bypassing behaviour is not very differen t across income groups is certainly noteworthy, as is the fact that the mor e severely ill tend to bypass and to travel further for care than do the le ss severely ill. In multivariate analysis almost all characteristics of bot h providers and facilities are found to have the a priori expected relation ships 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 qual ity ca re relative to the money charged (if any), as other, often further a way, providers.