1. The document discusses health services in developing countries, outlining goals of reducing mortality and morbidity, increasing life expectancy, and improving access. 2. It notes that while effective interventions exist, there is widespread underutilization, especially among the poor. Barriers include inadequate resources, poor allocation to primary care, and low quality of services. 3. Both supply- and demand-side factors constrain access. On the demand side, low income, user fees, and other costs limit utilization. Cultural preferences, lack of knowledge, and poor perceived quality also reduce demand.

1. 1
SMCH/HCDS/01: Health Services in Developing Countries
Quadrant-I
Personal details
Role Name Affiliation
Principal Investigator Prof. CP Mishra Department of Community Medicine,
Institute of Medical Sciences, Banaras
Hindu University, Varanasi
Paper Coordinator Prof. Najam Khalique Department of Community Medicine,
J N Medical College, AMU, Aligarh
Content Writer Dr. Anees Ahmad Associate Professor
Department of Community Medicine,
J N Medical College, AMU, Aligarh
Content Reviewer Dr. M. Salman Shah Assistant Professor
Department of Community Medicine,
J N Medical College, AMU, Aligarh
Description of Module
Items Description of Module
Subject name Social Medicine & Community Health
Paper name Health Care Delivery System
Module name/Title Health Services in Developing Countries
Module Id SMCH/HCDS/01
Pre-requisites Understanding of health concerns in developing countries
Objectives To know about health services in developing countries
Keywords
Health services, Developing countries, Dimensions of accessibility,
User charges.

2. 2
Introduction
Health care services can be considered the provision of all services that prevents disease and
preserves health. It extends from the provision of illness treatment and management to the
maintenance of the physical and mental well being of the individual. Health care is therefore
not merely medical care; it looks beyond the availability and affordability of medical care. As
commonly assumed health care provision does not commence or end with the health
insurance coverage availability. Theoretically, health care is multifaceted involving medical,
public health and social services. The social services working as primary promoter of health
comprise poverty reduction, housing adequacy, and environmental sanitation including the
provision of safe and wholesome water, adequate nutrition, education and employment1
.
By necessity therefore health care embraces the factors that empower development:
economical welfare, political support, social services, infrastructure, agriculture, education
and individual accountability. It inculcates all the goods and services available in a country to
provide health, that includes “preventive, curative and palliative interventions, whether
directed to individuals or to populations.”2
Learning Outcomes
Upon completion of this module, the reader should be able to:
 Define the goals of the health services
 Enumerate the scope of health services
 Identify the dimensions of accessibility of health services
 Enumerate the reasons for non- utilization of effective interventions
 Identify the constraints on the demand for health care
 Enumerate the determinants of preferences for health care
 Enumerate the strategies for improving utilization of health services
Main Text
1. Goals of the health services
The goals have been defined in terms of mortality and morbidity reduction, increase in life
expectancy, decrease in growth rate of population, nutritional status improvements, providing
basic sanitation, required health manpower and resource development and various other
factors such as food production, literacy rate, reduced level of poverty, etc3
.
2. Scope of health services
It is influenced by general and ever fluctuating national, state, and local health problems,
needs as well as the available assets to provide these services which includes four aspects4
-
 Constructive services- which include environmental &nutritional measures, physical
society, etc.
 Personal protective services- which include immunization, periodic health
examinations, health education, etc.
 Curative services- which include the diagnosis and treatment of disease and injury.
 Restorative services- which include measures to help the individuals to return to full
working and living capacity.
3. Accessibility of health services

3. 3
Access to health care can be defined in different of ways ranging from its most narrow sense
to broader definition, in terms of geographic availability & the identifying four dimensions of
access respectively: availability, acceptability, accessibility, and affordability5
.
3.1. Underutilization of effective interventions
There is plentiful evidence that access to effective health care is a major issue in the
developing countries. Millions of individuals suffer and die from conditions for which
effective interventions exists. A very large gap exists between the potential and actual
benefits of health care in the field of reproductive health& various communicable diseases
such as less than half of pregnant women get an antenatal check-up, and only 1/5th
of births
are supervised by trained personnel in South Asia. In low- and middle- income countries
antiretroviral therapy coverage rates do not exceed 5%6
.
The gross underutilization of effective health care, results in large unrealized health gains in
developing countries. Raising coverage rates to 99% from the current level of effective
prevention and treatment interventions & maternal health interventions may result in 63%
reduction of child deaths7
& three-fourths reduction of maternal deaths6
respectively.
On the demand side, cultural and educational factors may hinder disease recognition and
health care potential benefits, whereas economic factors may suppress utilization. It is
estimated that deficient care seeking leads to 6-70% of child deaths. The median study
concludes that 23% of fatally ill children doesn’t take any treatment8
.
On the supply side, suitable interventions may not be provided at all, maybe due to scanty
resources. The significant gaps that exist between the actual health spending and the spending
required for provision of essential health services package suggest lack of availability as the
root of the problem among many poor countries9
. Many effective interventions are not
excessively expensive, even for the poorest of countries. For instance, interventions applied at
home delivery may avoid one half of child deaths in sub-Saharan Africa6
.
Despite of health care availability, sometimes due to poor quality effectiveness fall short of its
potential efficacy. A review shows mixed evidence of impact of primary care clinics on
population health, although the primary health care interventions has high efficacy10
.
In practice, supply and demand are intermingled, availability of poor quality health care
results in little demand for it. Evidence shows that demand is quality driven11
. A survey in a
rural area of India shows very low utilization of public health facilities, although freely
available12
. The reason is very poor quality care, though the quality of the alternatives in the
form of private sector is also doubtful. The demand and supply sides interventions should
progress in accordance.
3.2. Least usage of effective interventions by the poor
The lowest utilization of effective interventions causes concern from perspectives of
efficiency and equity resulting in the poor to be the least healthy and probability to benefit
most from the health care. The maximum health gains could be achieved through focused
meager resources for the treatment of poor through prioritization of programs towards the
health care needs of the underprivileged in the form of primary care and maternal and child
health packages. But, the evidence shows in theses programs also there exists bias in the
benefits delivery13
.
The Demographic Health Surveys (DHS) provides the strongest evidence for the distribution
of the interventions related to reproductive and child and health 14,15
. Households are ranked
by an index of assets possessed e.g., refrigerator, sanitary latrines, safe drinking water, etc.

4. 4
The surveys conducted in the mid-1990s in forty countries showed that in the poorest 20% of
households 56% of childhood diarrhea cases were treated with oral rehydration whereas in the
richest fifth of households 71% of cases were treated with oral rehydration14
. Coverage is
highest in sub-Saharan Africa, but inequality in coverage is also highest. The differences in
immunization rates are even more than the other interventions. On average (42 countries), the
full coverage rate of immunization is 66% in the richest household quintile than the poorest
quintile in which coverage rate is only 38.5%16
.
Approximately 1/3rd
of children in the better off households are not immunized is beyond
acceptance & to make it worse approx. 60% of the poor children are deprived of such
immunity. Latin America and the Caribbean have the lowest immunization rates but the
difference in rich-poor immunization rates are lower as compared to Africa and South Asia.
On an average, the country having higher overall coverage rate also have greater rich- poor
difference in immunization rates suggesting that if there is marginal improvement in
immunization rates, better off will be the first to contract benefit21
.
The variances in socioeconomic status for the reproductive health services utilization are still
larger. On an average, there is 5.2 times more medically supervised in the richest quintile
women than the poorest 1/5th
of women15
. The lowest coverage is seen in South Asia and
parts of sub- Saharan Africa whereas the socioeconomic dissimilarity in utilization are high in
most regions except Central Asia and Eastern Europe. Similar magnitude of inequality is seen
in the contraceptives use with 4.6 times more utilization among woman in the richest 1/5th
than the woman in the poorest 1/5th15
.
The results of DHS between 1990s & after 3-5 years showed improved coverage & reduced
rich- poor difference for example Egypt, Kazakhstan& Nepal. Improved coverage rates &
reduced inequality for the deliveries attended by trained professional is also seen, for example
Egypt, India & Turkey etc. Unluckily, countries like Nepal, Bangladesh & Haiti showed little
or no improvement in terms of coverage & inequalities where there is 1- 2% increase in
delivery attended by trained professional among the poorest 1/5th
. However, in countries like
Cameroon, Malawi etc. for the poorest 20% the rate of coverage for births supervised by
medical personnel actually went down. The non- DHS surveys between 1986-1987 & 1995-
1996 showed increased inequalities in health care access in India17
.
There is evidence that suggests that the share of public health expenditures to the poor is
lesser than the rich in developing countries18,19,20
. The poorest fifth receive their share of
public health spending in few countries viz. Columbia, Argentina, Costa Rica, Sri Lanka,
Malaysia, Thailand. The poor get<10% of the public health subsidy in countries like Nepal,
Guinea etc. whereas in the remaining countries the poorest 20% receive 10-15% of the public
health expending. In primary care public health expending also there exists pro-rich bias in
most of the countries21
.
Inclusion of regional variations & quality difference in public health spending will strengthen
the evidence of rich getting proportionately higher primary care. The Asian incidence study in
provides practical support for this opinion20
. The marginal increase in proportion of public
health spending for the poor will have a greater impact in terms of utilization than the rich
population22
. This theory is coherent with support that public health spending has a positive
impact though marginal on the poor population health whereas there is no significant effect
on rich population health23,24,25
.
4. Non- utilization of effective interventions
There are many factors which are responsible for the effective health care underutilization in
the developing countries in which economic factor is one of the important factor in health
care underutilization9
. The WHO Commission on Macro- economic and Health recommends

5. 5
increase in health care expenditure. The other factors includes improper resource allocation,
rural- urban & poor- rich disparity. The hospital- based care uses majority of public health
expending whose accessibility to poor rural populations is least6,18
. However, the shift in
resources to primary care may not necessarily provide the desired effect on population health
distribution and level10,22,26
. The quality of primary care have major deficiencies in most of
the developing countries10,27
.
Inadequate resources, inappropriate allocation, and lack of quality are major obstructions to
the effective health care delivery for the poor population. The problem of access cannot be
resolved without taking care of each of the above deficits. Suppression of demand is
influenced by two main sets of factors viz. those limiting consuming ability& those with
lesser eagerness. The health care demand also have certain constraints e.g. household income,
health care charges, and travelling cost & preferences which are determined by culture, health
care benefits knowledge& the service quality21
.
5. Health care demand constraints
5.1.Household income
There are evidences strong positive correlation of household income with health care
utilization after taking care of other demand related determinants e.g. women belonging to
high household income group have higher probability of receiving antenatal care & delivery
by trained medical personnel28,29,30,31,32
. Likewise, multivariate analyses reveals that there
exists positive association between household income and immunization rate33,34
.
The out of pocket expenditure strengthens the income & health care utilization relationship.
Pooling of risks, subsidization through pre- payment options, can interrupt the reliance of
health care utilization on household income. Out of pocket expenditure & poor access makes
the household income a constraint for health care utilization21
.
5.2. User Charges
The out of pocket expenditure make pricing a significant factor of constraint on demand e.g.
in Vietnam the hospital visit cost is 22% of per capita annual household income net of food
expenditure for the poorest 20%35
. The evidence endorses that the health care charges hinders
demand11
. Most of the studies in developing countries suggests price inflexible nature of
health care i.e. demand decreases less than proportionally to price36,37,38,39,40
. Some of the
studies suggests price flexible nature of health care41,42
.
Health care usage charge sensitivity is more for poor than the rich i.e. if the usage charge
increases the health care consumption share will increase for rich11,40,43,44
. Unluckily, the
experience of fee waiving, especially in Africa, is non- promising45
. The usage charges
deprives majority of poor population from basic services that are essential User fees often
effectively exclude the poor from essential services, whereas only a small proportion of cost
is recovered46
. Increased utilization of health services by the poor in Uganda occurred as a
result of usage charge elimination however, no increase in utilization for child & maternal
health was seen after removal of usage charge in Africa47
. Quality improvement can balance
the influence of increase in price11
. Evidence showed that increased usage charge, travel time
reduction, quality improvement if combined together can increase utilization, even from
Africa that if increased user charges are combined with reductions in travel time and
improvements in quality, utilization can increase, even for the poor43
.
The public system of health care are extensively affected by the unofficial payment especially
in countries like Eastern Bloc and Soviet Union which often exceeds the existing official
charges48
.

6. 6
5.3. Other Costs (excluding user charges)
In the developing world additional charges like cost of travel and earning loss are important
factor in health care consumption. The time, energy & cost incurred to reach health care
facilities may play a significant role in utilization. The expected deleterious impact of extra
costs on the utilization of health care services is confirmed by the evidence28,49,50,51
. In Ghana
the rate of health care utilization was doubled by reduction in distance to public health
facilities to half52
.
6. Determinants of preferences for health care
6.1. Culture and gender issues
The deep-seated roots reflecting social & cultural patterns results in lessen demand for
modern-day health care system &preference of traditional system over modern system. The
adherence to social & cultural patterns is not firm as improved knowledge & income results
more use of modern therapy21
.
The roles & attitudes of gender acts as an important determinant of behaviour related to
health care seeking such as access to reproductive, maternal & child interventions. The social
factors are not fully separated from the economic factors with the evidence from Indonesia
that increase in control of women over household expenses results in improved prenatal care
utilization53
. The causality of association is a debatable point. Women in Africa, in the richest
group utilizes more public health services as opposite to women in the poorest group18
.
6.2. Knowledge and education
The utilization rates are affected by knowledge & education. The immunization rate in India
is very poor in spite of being free reason being the lack of awareness of benefits reported by
one third of mothers, approx. one third not knowing the place to go for immunization54
. Poor
knowledge results in decreased demand for health care as demonstrated by a detailed study
from a village of North India55
.
The socioeconomic factors affects the knowledge related to illness for which there are
considerable evidence from the developing world e.g. higher illness reporting are found
among the rich as compared to the poor18,56,57
. The households from higher socioeconomic
group have more probability of illness sign recognition in child from rural Tanzania58
.
6.3. Poor quality demand response
The demand of the health services is also driven by the quality of the health services. Poor
quality includes irregular services, poor availability of health care personnel, bad behaviour of
the staff, drugs availability, improper prescription etc.
The health services poor quality is leading problem in most of developing countries6,10
.
Irregular opening of health facilities12
; higher rates of absenteeism of health care
personnel12,59,60,61
; inappropriate staff behaviour62
; wrong diagnosis is common6
;
unavailability of medicines, occasionally pilferage6,63
; and inappropriate prescription and
treatment6
are some of the quality related factors. 40% reduction in utilization was seen due to
deterioration of quality within 5 years in Ghana52
.
The nearest facility is bypassed due to low quality resulting in care seeking at higher facility
of public health care or the private facility10,64
. The likelihood of bypassing the public primary
care is more if the quality is poor in Sri Lanka65
. Similar findings are also reported from
countries like Indonesia, Pakistan, and El Salvador10,64
.

7. 7
7. Strategies for raising effective interventions utilization
Improving the effective health care utilization needs additional wealth for health services in
the developing world. This necessitates that health care spending is concentrated to the most
effective programs and interventions and avoidance of geographic mismatch. It demands
regulatory, management, and political reforms for delivering health care at good quality21
.
7.1. Extension of health insurance cover
Pre-payment and credit schemes reduce the burden on household income for health care
seeking. Repetitive appeals have been made to reduce out of pocket financing reliance in
developing world9,66
. According to Organization for Economic Cooperation and
Development/World Health Organization (OECD/WHO) DAC guidelines66
, “the
development of equitable financing through increasing pre-payment and risk pooling is one of
four priorities for the development of a pro- poor health system delivering quality, accessible
health services to the poor”66
.
7.2. Price subsides for pro-poor
The health insurance coverage extension is a goal to be achieved at long-term. At current
levels out-of-pocket financing can be provided to poor’s group only21
. Identification of the
poor &appropriate incentives provision to providersis the major challenge21
.
The criteria for out of pocket exemptions must be defined. Other groups under exemption
may include poorest fifth, indigenous people, adolescents,migrants, refugees etc66
.
7.3. Use of cash incentives for raising utilization
Besides the economic factors, other non- economic factors also play a role in health care
utilization such as cultural and knowledge factors that can be overcome by cash incentives.
This approach can be practical for preventive interventions viz. growth monitoring,
immunization & ANC care6
.
The cash incentives should target poor especially poor women either directly or indirectly.
Similar result can be seen through micro-credit schemes; however, evidence for this is
unclear67
.
7.4. Lowering the distance barrier
Transport system improvement lowers the distance barrier through reduction of cost of
reaching health care and raising the facilities to catchment area population ratio6
. In Africa,
financed and community administered funds provide emergency interest free loans to cover
the cost& help in emergency obstetric caretravel68,69
.
Summary
Health services includes not only medical services but also environmental, nutrition, others
services. Developing countries face major challenges in the form of double burden of
communicable & non- communicable diseases with overburdened health system, aggravated
by the poor accessibility, affordability, inequitable distribution & poor utilization of existing
resources. The various measures for improving this is better political commitment, insurance
based health services & equitable distribution of health services that are accessible,
acceptable and affordable.

8. 8
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