In the developing world, those
in poverty underutilise the health care that is available to them, and
furthermore spend income on ineffective solutions. Much of the effective health
care available is cheap and readily available, with high levels of marginal
benefit, particularly for the poor. These effective solutions are largely preventative
and have low associated costs. Measures include vaccination programmes,
improved sanitation and increased usage of mosquito nets. There are numerous
reasons why there is underutilisation. On the supply side the barriers revolve
around access and the quality of healthcare provided: resource allocation is
insufficient leading to substandard quality healthcare and a lack of essential
services that leads users not to bother, furthermore resource allocation is
inefficient as it is focused for example on providing services in urban areas
where they fail to benefit the rural poor who could benefit much more. In
conjunction with this there are barriers that stifles the demand for healthcare,
economic constraints restrict their ability to consume and their preferences
and behaviour affect their desire to utilise the available healthcare. By
nature, supply and demand behave cyclically and supply goes hand in hand with
demand and it is problematic to attempt to extricate fully one from the other.

Going forward, I will set out the evidence of underutilisation focus on the
factors that repress demand and some of the behaviours that result in effective
solutions being underutilised, and then give some solutions that can improve up
these problems.

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One prevalent example of underutilisation is found in a study in
Bolivia, only 4.1% of children who died were hospitalised before the fatal
episode and 61.7% of children whose illness led to death were not seen by
medical experts, whether that be a hospital, public health centre or private
practitioner. (Aguilar AM, Alvarado R, Cordero D, Kelly P, Zamora A,
Salgado R. Mortality survey in Bolivia: the final report. Investigating and
identifying the causes of death for children under five. Arlington: Basic
Support for Institutionalizing Child Survival; 1998. (Technical Report). Furthermore,
on child mortality, another paper finds that 63% of global child deaths are
avoidable. (Child Survival Study Group.

How many child deaths can we prevent this year?). Immunisation rates are
lower among poorer families than richer ones, and these disparities between the
richest quintile and poorest quintile carry over into receiving the correct
treatment for diarrhoea and utilisation of reproductive health services. (Initial country­level information about
socioeconomic differentials in health, nutrition and population. Washington DC:
World Bank, Health, Population and Nutrition Group; 2003). This shows that
the poor in developing countries seek healthcare less than the richer citizens
in the same countries. One seemingly
obvious solution would be to redress some of the supply side issues and see how
the demand reacts. However, even why supply side issues are improved it does
not always correspond to a matched increase in demand for services. Seva Mandir
found that even when they ran efficient monthly immunisation camps in Udaipur
that up to 80% of children were left unvaccinated. (improving immunisation coverage in rural India/p62). This suggests
that remedying supply side issues alone is not enough in order to increase
demand and that the constraints and preferences of the poor are key in
determining the demand for healthcare in developing countries.


(Argument put forward by Bannerjee and Dufflo: going to need psychological
references?) With the case of Seva Mandir and its vaccination programmes, there
are several behavioural reasons that result in the potential beneficiaries not
wanting to complete the vaccination programmes. There is a dynamic inconsistency
issue engrained within the behaviour of the poor, which leads them to
hyperbolically discount the potential rewards in the future of taking a certain
action. Here, the action is to vaccinate children, immunising them from
measles. The costs are the efforts and opportunity cost that taking a child to
a camp are all in the present where as humans we are ruled by impulse and
emotion. We value our time in the present far more highly than we do our time
in the future. The potential benefits of such preventative medicine lie in the future
and are often difficult to understand to uneducated parents. Their child may
get sick anyway and they may end up questioning the value of the immunisation,
not understanding what the immunisation process was designed to protect
against. Time inconsistency leads to the procrastination of worthwhile actions;
why do today what can wait until tomorrow? This valuation system determines the
preferences of the poor when making decisions with regards to vaccination and
leads the poor to ignore available healthcare solutions.

A societies tradition and culture can further determine the very poor
value various different treatments. Many developing societies place high value
on spiritual and cultural beliefs, and these means the poor prefer use traditional
healing methods over and above modern medicine. In Bolivia, many of the parents
used traditional medicine at least in equal measure with modern medicine
(Bolivia paper). In Udaipur, Banerjee and Duflo found that “experts argued it
would be exceedingly difficult to convince villagers to immunise their children
without first changing their beliefs” (62). Traditional beliefs about gender
can also determine demand for maternal care and fertility treatment. Many patriarchal
societies restrict access for women to these services. Thus, gender issues and
traditions can suppress demand for health care.


Education, and the lack thereof, and a lack of required knowledge helps
underpin this decision making process of failing to immunise and more generally
to seek more appropriate healthcare. It is clear that many of the poorest do
not have the levels of knowledge required to recognise various illnesses and do
not understand the extensive potential benefits of preventative medicines. Surely,
if those parents in Bolivia had known that their children may be fatally ill
they would have made more of an effort to seek medical attention at the
critical moment? A study found that in India, a third of mothers stated that
they did not vaccinate their children because they didn’t understand the
benefits (What’s in a country
average? Wealth, gender, and regional inequalities in immunization in India).

In Delhi, the poor match the rich in their spending on minor illnesses,
however, for more chronic illnesses, the rich outspend the poor. (Short But Not Sweet: New Evidence on Short Duration
Morbidities from India). This may be because the poor cannot afford to spend
the increased amounts to deal with more serious ailments, but sometimes also is
due not being able to recognise when symptoms are more serious and require more
serious attention. The poor further misunderstand often the type of medication
they need (the millennium goals for health: rising to challenges), and misspend
their resources on antibiotics and further believe that remedies cannot be
effective unless they directed straight into the blood stream. Due to this lack
of comprehension of modern medicine it is hard for customers build trust; when
a doctor prescribes nothing and symptoms disappear, it is hard for people to
understand the causality behind it. (Bannerjee& Dufflo 61). Evidence
overwhelmingly suggests that socioeconomic background influences perception of
illness and that the rich report illnesses more (references 16, 54, 55 in paper).

This could be because as (paper suggests) that when a large portion of the
population of the poor are in a persistent state of poor health, this state
becomes the normal and it becomes harder to recognise illnesses when they come
about. A more educated, or at least more knowledgeable poor, would more readily
recognise the benefits of the preventative healthcare that they currently show
weak demand for.


There are also income and cost
constraints on the demands of the poor. It has been shown that there is a positive
association with levels of child immunisation and family income (31,32).

(whatcha paper) argues that “the nature of health financing in the developing
world, with heavy reliance on out-of-pocket payments, strengthens the relationship
between health care utilisation and income”. The poor are also more cost
sensitive. As mentioned, much of health care financing comes out-of-pocket