The Role of User Charges and Structural Attributes of Quality On the Use of Maternal Health Services in Morocco
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Author(s): Hotchkiss D R, Krasovec K, El-Idrissi M D Z, Eckert E, Karim A M
This study examines the role of household out-of-pocket costs and structural attributes of quality on the use of maternity care in Morocco using empirical data collected from both households and health care facilities. The study uses a nested mixed multinomial logit model to estimate the effects of structural attributes of quality, price, distance, and individual characteristics of women on the utilization of skilled and unskilled delivery assistance. The availability of a special DHS supplement on household out-of-pocket health care expenditures, as well as individual-, household-, and facility-specific information, makes this the first study of the demand for maternity care based on DHS data. The Moroccan setting provides substantial variation in the types of assistance available to women, ranging from home delivery aided only by friends and relatives at one extreme, to modern private hospitals at the other end of the spectrum. The reduced-form model specifications contains price, travel time, and different combinations of structural attributes of quality, including the availability of medical equipment, drugs, and infrastructure, the numbers and types of practitioners in the facility, and the availability various types of maternity services, and the interaction of these variables with individual characteristics of Moroccan women. The coefficient estimates are used to carry out policy simulations of the impact of changes in the level of out-of-pocket fees on utilization patterns for maternity care in Morocco. As of 1995, the majority of Moroccan women still gave birth at home, without the assistance of a skilled birth attendant (55.9 percent). Rural women were five times as likely as urban women to have home births without skilled assistance (78.7 percent vs. 18.8 percent). All forms of maternity care were more economically and geographically accessible to urban compared to rural women. The public sector was the most common source of facility based care (34 percent), as well as a more important source of care for urban (58 percent) than rural (19 percent) women. Rural women from richer households were considerably more likely than poor women to use public providers; while in urban areas, where there is better availability of private practitioners, wealthier women were slightly less likely to use public providers. Facility-based private health care providers assisted 16 percent of urban deliveries, but fewer than one percent of rural deliveries. On the whole, quality of care measures, such as the availability of drugs, equipment and infrastructure, were not substantially better in private facilities than in public facilities. Our policy simulations showed that increases in out-of-pocket costs for public facilities would be expected to have very little impact on women living in better-off households, but would have a substantial and detrimental effect on the poor. Health reform strategies that involve increases in out-of-pocket payments in the form of co-payments could be implemented without untoward effects on appropriate use of maternity care for better-off women, but would be contra-indicated for poorer and rural households. Among wealthier households, the positive effect of quality improvements was greater than the dampening effect of user fee increases, even if out-of-pocket costs of using public facilities were to be doubled. However, among the poor, the net effect of any strategy that involved increases of more than ten percent in out-of-pocket costs would have a detrimental influence on utilization rates, regardless of quality improvements. Our findings suggest that in Morocco, unlike countries with stronger traditions of skilled and mobile midwifery services, maternity continues to be a risky proposition, particularly for poor and rural women. The Moroccan government's emphasis on expanding social health insurance to improve financial access to public sector maternity services for the poor and for rural populations is clearly an urgent priority.
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