Disparities in use of healthcare services between rural and urban areas have been empirically attributed to several factors. This study explores the existence of this disparity and its implication for planning and managing healthcare delivery systems.
The objectives determine the relative importance of the various predisposing, enabling, need and health services factors on utilization of health services; similarity between rural and urban areas; and major explanatory variables for utilization
A four-stage model of service utilization was constructed with 31 variables under appropriate model components. Data is collected using cross-sectional sample survey of 1086 potential health services consumers in selected health facilities and resident milieu via questionnaire. Data is analyzed using factor analysis and cross tabulation.
The 4-stage model is validated for the aggregate data and data for the rural areas with 3-stage model for urban areas. The order of importance of the factors is need, enabling, predisposing and health services. 11 variables are found to be powerful predictors of utilization.
Planning of different categories of health care facilities in different locations should be based on utilization rates while proper management of established facilities should aim to improve health seeking behavior of people.
Differences in health status, based on indices such as infant mortality, young and child mortality and maternal mortality, between developed countries and developing countries have witnessed historical documentation1. Within the developing countries, the phenomenon has shown aggravation as we move from urban to rural areas. Unfortunately, the causes of this disturbing reality are illnesses that can be treated and deaths that can be prevented by simple interventions but for which inappropriate structures have constituted a stumbling block. In order to justify the amount of money spent on health and the number of workers employed, serious attention is required in improving quality of healthcare services while containing costs and also in planning of health care activities and carrying out effective management functions relating to health care delivery systems (HCDS).
This cannot be done outside the imperatives of utilization. This is because utilization is the most activity-related problem, being consumer-oriented with diverse dimensions in needs, perceptions and knowledge. To the extent that utilization entails the cooperation and invitation of people outside the health system crystallizes the magnitude of the problem. Indeed, utilization as a major factor in planning any health care delivery system is validated by past and contemporary situations around the world. At the inception of HFA/2000, WHO2 had warned that its goals, support activities, management and implementation may be irrelevant if they are not tuned towards maximum utilization. In the United States of America, hospitals and related health facilities require formal utilization review procedures as condition for participation under health plans and some kind of utilization review process in each institution seeking accreditation. In the United Kingdom, the comprehensive National Health Scheme (NHS) is structured to ensure equity and encourage all constituents to seek the use of services. Even in the “apartheid era” in South Africa, the health sector enjoyed desegregation by reconstructing health services along the principles of accessibility, affordability, acceptability, equity and efficacy. In developing countries, attempts have been directed towards promoting utilization particularly among the rural populations but success has been limited. Free medical services as a means of improving utilization through the elimination of financial barriers has formed a major issue of political activism. Success in this direction has been limited due to inappropriate structures that result from not tuning planning and management activities towards utilization, a situation compounded by other existing problems including3,4,
- Rapid population growth
- Increasing demand for health services against dwindling resources
- Faulty allocation of limited resources
- Internal inefficiency of government health care programs and health services.
- Poor quality of private health care services
- Inadequate support infrastructural facilities like water, electricity and good roads.
These problems have resulted in inappropriate structures, faulty allocation of resources and incongruent staff scheduling6 which would not have arisen if potential utilization had formed the bases upon which the establishment of the facilities were initially hinged. This situation is a call to restructuring which can only be facilitated by x-raying the relationship between distribution of resources, health problems and patterns of utilization whereby identified determinants would reveal the services to be provided for the growing population as well as their magnitude.
Utilization of service is the actual coverage and it is categorized into ambulatory medical care services (outpatient and home); inpatient services (hospital); and preventive services7. To achieve optimal levels of utilization, all the three categories must enlist the cooperation and initiative of the population as well as those of the health service providers. Hitherto, the assumption has been that the Health Ministry and other providers of health services knew the demand on their resources, upon which planning was based, by the number of people that demand services. There is at present increasing evidence, especially in the developing world, that many more who attempt to obtain such services are not getting them for a number of reasons. In Nigeria, particularly in Kwara State, the discrepancy between what the levels of health care utilization are and what they ought to be is easily discernible. This underlines current efforts in relating utilization to resources as well as to past and present planning efforts. It has been said that there is need to review planning efforts and their appropriateness, especially when viewed from the context of utilization of health care services8.