African Population Studies
Union for African Population Studies
ISSN: 0850-5780
Vol. 9, Num. 1, 1994
African Population Studies/Etude de la Population Africaine, Vol. 9,
April/avril
1994
THE IMPACT
OF ACCESS TO HEALTH SERVICES ON
INFANT AND CHILD MORTALITY IN RURAL UGANDA
Charles
KATENDE
Code Number: ep94004
ABSTRACT
This
paper examines the impact of access to health facilities on infant and
child mortality in Uganda. Using the proportional hazard model, the paper
shows that access to health centers affects childhood mortality of rural
children; however, the effect is only substantial for children born to
non-educated mothers. This study was partly funded by the Rockefeller Foundation
through the Macro International Small Grants Program.
INTRODUCTION
Since
the Second World War, infant mortality has declined at an unprecedented
rate in many developing countries. The factors underlying this decline,
however, have been heatedly debated among researchers. Numerous studies
have presented persuasive evidence about the impact of biomedical and socioeconomic
factors, such as education, on this decline. But, surprisingly, less compelling
evidence is available with respect to the impact of health services. The
purpose of this study, therefore, is to examine the impact of access to
health facilities on infant and child mortality in rural Uganda. Uganda
provides an interesting case: owing to the predominance of small holdings
in the land-tenure system and the consequent scattered settlement pattern,
access to health facilities varies substantially among rural residents.
Households are located at diverse distances from health facilities. Further,
compared to the region as a whole, Uganda has very high infant mortality
levels (about 120 deaths per 1,000 live births, according to the preliminary
Uganda Population and Housing Census, 1991). This makes research in the
area a priority.
Previous
research on the impact of access
Although
availability of health services is expected to improve health status and
lower children's mortality levels, as a result of standard biological treatment
of diseases and injuries and immunization and vaccination of both pregnant
mothers and their children (Bimal 1991), available evidence in this regard
is mixed and inconclusive. Vernon (1993) and various other medical geography
studies offer evidence that access to services increases utilization and,
presumably, improves health status. But Malison et al. (1987) and Chaulagai
(1993) report no strong relationship between access and utilization of
services. Similar ambiguity arises with respect to evidence about the relationship
between access to services and infant mortality. Oruboloye and Caldwell
(1975), Al-Kabir (1984), and Hossain (1989) all report evidence of a significant
association between access to health services and child survival, but evidence
from Katende (1992), Rosenzweig and Schultz (1982), and Meer et al. (1991)
suggests that skepticism about this association is warranted.
One
particularly interesting finding relates to the way access to services
interacts with maternal education to influence child survival. Caldwell
(1979) finds this interaction to be significant and of a complementary
nature. In contrast, Rosenzweig and Schultz (1986) find this interaction
to be strong but of a substitution nature. After a comprehensive review
of the available evidence, Cleland and van Ginneken (1988) suggested that
the nature of this interaction is context-sensitive; its nature depends
mainly on the level of development of the health infrastructure.
In
general, the available evidence about the impact of access to services
on infant and child mortality and about the nature of the interaction between
access to services and maternal education is mixed, making further research
imperative. In response to this research demand, the current study tests
the following major hypotheses:
Access
to health facilities affects infant and child mortality differentials
in rural Uganda. Children residing near health facilities experience less
mortality than those far from the facilities.
The
effect of access to health facilities on child survival is expected
to depend on maternal education levels; it is likely to have less effect
on
the mortality of children born to educated parents than on the mortality
of children born to non-educated mothers.
Using
a framework adapted from Mosley and Chen (1984), this study examines the
effects of access to health facilities on infant and child mortality by
identifying the following five mortality-proximate determinants:
maternal
risk factors (age, parity spacing)
environmental
contamination
nutritional
status
injury
personal
illness control
Access
to health facilities affects personal illness control by influencing both
choice and timing of the use of curative or preventive services, as opposed
to resorting to alternatives such as traditional therapy, self-treatment,
or taking no action at all. Mbulu (1978) suggested that in Africa, access
to health services affects child survival mainly through the non-use of
preventive services, implying that utilization of curative services is
minimally affected by the level of access. To test Mbulu's suggestion,
the separation of health services into preventive and curative services
will be given attention in this study's framework. Further, it is acknowledged
that factors such as education, socioeconomic status, maternal age, child
age, ethnicity, regional development differentials, and AIDS prevalence
can confound the association between access to health services and infant
and child mortality. These factors, therefore, are included in the analysis
using statistical controls.
DATA AND METHODOLOGY
The
1988 Uganda individual-level DHS and the community (cluster) level data
on service availability were combined to create a data set of children
for use in this study. However, the study was limited to rural areas since
proximity to health facilities is not a major issue in most urban areas
in Uganda. To obtain adequate sample size for analysis of such a rare event
as mortality, the reference period was extended to five years before the
survey, resulting into a sample size of 3,470 children.
The
hazard model used in this analysis is presented in the equation below.
It conveniently handles censoring and accounts for duration of exposure
to the mortality risk.
where:
hi(t;z)=the hazard of death at age t for child i with covariates
z
ho(t)=baseline
time function
Z/i=a
vector of the explanatory variables for child i
B=vector
of the coefficients of the explanatory variables
This
equation expresses the mortality hazard rate as a function of time and
independent variables. Using partial likelihood, the model's coefficients
can be estimated without specifying the shape of the time baseline function
(Cox 1972). This estimation method, however, presumes that the effect of
the explanatory variables does not vary over time, an assumption that is
necessarily adopted in this analysis. The estimated coefficients have to
be exponentiated in order to be interpreted as percent changes in the mortality
risk due to changes in an explanatory variable. The explanatory variables
were operationalized as follows:
Access
variables were measured by continuous natural log scale variables
that indicated the distance from a cluster to a hospital, health center,
or
private clinic.
Utilization
of health facilities was operationalized by information on whether
(a.) a mother received a tetanus shot, or (b.) prenatal care and delivery
assistance
were provided by trained personnel; or else by a continuous variable
indicating the percent cluster child immunization (BCG, DPT and POLIO1)
coverage.
Maternal
education was operationalized by a variable indicating whether the
child's mother had some education or none.
The
type of roof of the household's residence was used to indicate socioeconomic
status: papyrus or thatch roofs were considered to reflect low socioeconomic
status, while tiles, concrete, asbestos, corrugated, or iron sheets
were considered to reflect high socioeconomic status. Low socioeconomic
status
was specified as the reference category.
Type
of access road was used to reflect local transport infrastructure
and mode of transportation. Tarmac or graded murram, the designated reference
category,
reflect good infrastructure and access to motorized transportation;
other types of access roads reflect poor infrastructure.
Administrative
regions: Central, the reference category; East; West; South West;
and West Nile. These were used as dummy variables to reflect ethnicity
and other
regional differences.
A
district level index indicating HIV seroprevalence level was included
in the analysis as a continuous variable. The indices were estimated using
a model in which proximity to areas of high AIDS prevalence (Kampala,
Masaka,
Rakai) predicted the district seroprevalence rates. The estimation
was based on data from the Ministry of Health AIDS Surveillance Report
of December
1991, which reported on seroprevalence among various hospitals' prenatal
clinics attendants.
This
study faced the following limitations:
The
source of water was excluded due to lack of proper information.
Geographical
distance to a cluster is not a perfect proxy for access.
The
study is limited because of the cross-sectional nature of the data.
The
methodology used is vulnerable to various biases due to internal
migration, to the assumption that health facilities are randomly located,
and to the
assumption that siblings' mortality is independent.
The
criterion for locating government health facilities in Uganda is geographical
administrative units; hence this location is not expected to be associated
with area mortality differentials. A partial correlation test of siblings'
survival status was done and showed that there was no evidence of strong
correlations among siblings' mortality. Moreover, as argued by Guang (1993),
in high infant mortality populations it is unlikely that unobserved familial
effects (mostly genetic) constitute a strong influence on mortality levels.
Finally, it was assumed that within rural areas, internal migration occurred
randomly among populations and was therefore not significantly associated
with distance to health facilities.
Sample
Characteristics
As
expected, more children had access to health centers than to either hospitals
or private clinics (see Figure 1). The average distances to a health center,
a hospital, and a private clinic were 11, 19 and 15 kilometers respectively.
Of major concern is the 20% of the population that reported being more
than 10 kilometers away from any facility. It is also notable that 50%
of the population were at least 15 kilometers away from the nearest hospital;
this population bears substantial difficulties when faced with a medical
case that cannot be handled by health centers.
Out
of the 3,743 children born in the five years preceding the survey, 469
had died. Many of the deaths, 33%, occurred in the first month. Children
residing far from health facilities have higher death probabilities than
those residing near the facilities (as shown in Figures 2 through 5). The
difference in death probabilities increases with age; it is higher during
childhood years than during infancy. The sample distribution of other selected
variables and the correlation amongst them are shown in appendices I and
II respectively.
Multivariate
Analysis and Results
Multivariate
analysis was used to examine the net effect of access to health facilities
on child survival, after controlling for the other mortality correlates.
The analysis was done separately for neonatal, post-neonatal, and childhood
mortality. Access to health services had no significant effect on neonatal
or post-neonatal mortality, hence these results are not presented. Only
childhood mortality results are reported below.
Model
1 in Table 1 shows that access to health centers significantly affects
childhood mortality. For every percentage increase in distance to a health
center, the risk of childhood mortality increases by 19%. The effects of
access to hospitals and to private clinics on childhood mortality are not
significant. It is notable that the effect of access to private clinics
is opposite from the expected direction, indicating that proximity to a
clinic was associated with higher childhood mortality. Maternal age, as
shown by Model 2, was not significantly associated with childhood
mortality in rural Uganda, nor did controlling for it erode the significance
of the access to health centers. But controlling for the utilization variables
(Model 3) attenuated and turned the effect of access to health centers
insignificant. The effect of access to hospitals remained non-significant
but reversed the direction. The effect of access to private clinics also
remained negative and non-significant. The results from Model 3 do not
support the notion that utilization variables constitute a major mechanism
through which access to hospitals or to health centers affects childhood
mortality. It is surprising that none of the utilization variables was
significant. Nor did the combined effect of these variables contribute
significant explanatory power to the model.
Socioeconomic
factors and year of birth, introduced in Model 4 (Table 2), substantially
increase the models' explanatory power. But individually, only type of
area access road and year of births are shown to have a significant effect
on childhood mortality. However, controlling for these factors did not
have any notable effect on access to health centers or to private clinic.
The sign for access to hospital coefficient did change from positive to
negative, most likely because socioeconomic factors such as good roads
are highly correlated to access to hospitals.
Model
5 in Table 2 presents the results of the model with the interaction terms
between education and access to health facilities. This interaction is
also shown in Figure 6. The interaction is negative and significant, showing
that the effect on access to health centers depends on the level of maternal
education. Because non-educated mothers were equally as likely to be far
from a health center as educated mothers, these results cannot be attributed
to a distribution of educated mothers skewed by distance to health center.
The figure shows that the impact of access to a health center on the childhood
mortality experienced by educated mothers is very small, as indicated by
the almost horizontal line. In contrast, the impact on childhood mortality
of children born to non-educated mothers, shown by the line sloping downward
from left to right, is striking; it shows that proximity to health centers
substantially affects these children's survival.
Table
1
Table
2: Proportional hazard model estimaed coefficients for childhood mortality
in rural Uganda. Model 4 and 5 (DHS survey 1988)
Variable
(reference category
Model
4
Model
5
Coeff.
(SE)
RR
Coeff.
(SE)
RR
Accessibility
variables
Distance
(In) to hospital
Distance
(In) to health center
Distance
(In) to private clinic
-0.078
0.176
-0.087
(.120)
(.101)
(.074)
0.93
1.19
0.92
-0.089
0.415
-0.122
(.176)
(.145)
(.114)
0.91
1.52
0.89
Maternal
risk factors
Age
Age squared
-0.179
0.003
(.098)
(.002)
0.84
1.00
-0.176
0.003
(.098)
(.002)
0.84
1.00
Utilization
variables
Average
cluster immunization
Received
tetanus shot
Received
prenatal care
Delivery
by trained personnel
-0.003
-0.201
-0.328
0.061
(.005)
(.198)
(.247)
(.218)
0.99
0.82
0.72
1.06
-0.003
-0.172
-0.328
-0.090
(.006)
(.198)
(.246)
(.218)
0.99
0.84
0.72
1.09
Socio-economic
variables
Some maternal
education (none)
Socio-economic
status
Access
road (Tarmac/graded)
War region
East region
(Central)
West "
South
West "
West Nile "
District
HIV prevalence
-0.024
-0.047
0.619*
0.132
0.109
-0.293
-0.589
-0.978
-0.029
(.189)
(.199)
(.252)
(.398)
(.332)
(.574)
(.319)
(.671)
(.037)
0.689
0.025
0.605*
0.102
-0.024
-0.515
-0.651*
-1.122
-0.039
(.657)
(.199)
(.256)
(.399)
(.341)
(.589)
(.321)
(.676)
(.037)
1.99
1.03
1.83
1.11
0.98
0.60
0.52
0.33
0.96
Trend
by year of birth
1985 (1984/83)
1986
1987
1988
-0.789*
-1.170*
-0.974*
-1.863**
(.386)
(.401)
(.403)
(.517)
0.45
0.31
0.38
0.16
-0.825*
-.191**
-1.009*
-.908**
(.388)
(.402)
(.404)
(.519)
0.44
0.30
0.36
0.15
Interactions
of education with:
Distance
(In) to hospital
Distance
(In) to health center
Distance
(In) to private clinic
0.037
-0.445*
0.050
(.221)
(.191)
(.147)
1.04
0.64
1.06
-2Log
likelihood
Degrees
of freedom
P - value
Number
of cases
1931.45
22
.005
2321
1925.68
25
.003
2321
*
significant at .05 level. ** significant at .01 level.
DISCUSSION
This
study has found evidence that access to health centers affects childhood
mortality levels in rural Uganda. The effect is most evident with respect
to children born to non-educated mothers. Access to hospitals or to private
clinics was not significantly related to child survival. Furthermore, access
to health centers did not have a significant relationship with neonatal
or post-neonatal mortality.
It
is not surprising that the effect is found only with respect to childhood
mortality and access to health centers. Health centers are the principal
source of health services in rural areas, and health services are expected
to influence mainly childhood mortality levels. Hospitals, which serve
principally as referral units for complicated medical cases, only slightly
improve child survival because the complicated medical procedures are not
the major factor causing high childhood mortality levels. The finding that
access to private clinics is associated with lower child survival is surprising
and disturbing. One possible explanation for this finding is that these
clinics, to avoid competition from the free government service, locate
in areas that already have high mortality due to poor service. Moreover,
the presence of these clinics would not alleviate the area's mortality
problem because the clinics' services may be too expensive for the majority
of population.
The
effect of health centers, similar to what others have suggested (Da Vanzo
1984), is largest during childhood years because of differences in age-specific
mortality causes. Causes such as infectious diseases that can be controlled
by access to services are more pronounced during childhood years, hence
access factors are more important during this age.
According
to this study, the interaction between access to health facilities and
maternal education is of a substitution nature. Near a health center, access
to health facilities compensates for the lack of maternal education, closing
the infant and child mortality differential due to maternal education.
But far from a health center, maternal education compensates for lack of
access to services, widening the infant mortality differential due to maternal
education. This finding is similar to that of Rosenzweig and Schultz (1982).
Evidence
from this paper shows that preventive service utilization is not the major
mechanism through which access to health facilities affects infant and
child mortality in rural Uganda. This suggests that the main mechanism
may be through non-utilization of curative services. Although the result
may have been affected by the poor measurement of preventive services such
as immunization, this evidence is consistent with the fact that a non-immunizable
disease, malaria, is the leading cause of infant and child mortality in
Uganda (Ministry of Health 1992). Curative services are the major solution
to malaria and to other non-immunizable diseases that may be rampant in
Uganda.
CONCLUSION AND RECOMMENDATIONS
With
regard to the finding that the effect of access to health service is much
more evident than that of access to hospitals, it is concluded and recommended
that efforts to reduce childhood mortality should emphasize access to health
centers rather than to hospitals; the latter requires much more resources
but yields relatively fewer health returns. It is also recommended that
the observed relationship between access to private clinics and higher
childhood mortality draw monitoring attention to ensure that this association
is not at all causal through poor practices or other service deficiencies.
Further, private clinic should be involved in national child survival programs.
It
has been shown that the effect of access to health centers is more pronounced
for mothers with less education. Since the proportion of mothers with no
education is substantial and efforts to expand health services are subject
to resource constraints, an approach that balances strategies between increased
female-education participation and increased health-service access is recommended.
In
addition to the strong preventive health care campaign already in place,
another campaign to increase availability and utilization of curative services
should be initiated in rural Uganda. The results here suggested that curative
services may be a major mechanism through which inaccess to services was
influencing childhood mortality.
Uganda's
new policy of government health service user fees, meant to improve health-service
financing and lead to better services, should be put into perspective with
other objectives such as improvement of the childhood mortality situation.
The latter calls for increasing access to health services in rural areas.
Efforts should be made to ensure that this new policy does not result in
decreased access to health services that could lead to higher childhood
mortality levels.
Finally,
many people -- including health policy makers in Uganda -- may hold the
view that the country's infant and child mortality poor performance is
wholly attributable to the AIDS epidemic. This study shows that access
to health facilities is significantly associated with childhood mortality.
Although the contribution of AIDS may not have been controlled for adequately,
there is no reason to suspect that the AIDS component was a confounding
factor in the association observed, inasmuch as this disease has nothing
to do with access to health centers. It is therefore suggested that as
we blame the AIDS epidemic for many of the mortality problems in Uganda,
we should not forget that some of this mortality may be due to factors
such as access to health facilities. The latter can be addressed to improve
the situation.
Appendix
i: Selected sample characteristics
Rural
Uganda, 1988 DHS
Table
i
Variable
Mean
Std
dev.
No.
Distance
to health centers
11.1
11.9
3449
Distance
to hospitals
19.1
13.6
3473
Distance
to private clinic
14.8
12.3
3314
Cluster
percent of children immunized
42.1
20.5
125 (Clusters)
District
seroprevalence (prenatal clinic clients)
12.1
3.6
17 (Districts)
Table
ii
Variable
Percent
of children (N=3743)
Variable
(cntd)
Health
Utilization
Child
age
Mother
received tetanus
Mother
received prenatal care
Delivery
assistance by trained personnel
52%
84%
29%
0-11
months
29%
21%
18%
Socio-economic
characteristics
Mother
had some education
High socioeconomic
status household
53%
37%
36-47
months
48-59
months
17%
15%
Community
characteristics
Locality
with good access road
Central
region
East region
West region
South West region
Nest Nile
region
24%
5%
21%
24%
6%
45%
4%
Appendix
ii
Figures
1 2 3
Figures
4 5 6
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S. (1989) "Effect of public programs on family size and child education
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C. (1992) The effect of accessibility to clinics on infant and child mortality:
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F.; M. Smith; and T. Sharpe. (1978) "The determinants of Health
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K.; R. Bergman and J. Kusner. (1993) "Socio-cultural determinants
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Oruboloye,
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Roseinzweig,
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Appendix
ii: Table of correlations among explanatory variables
Acc
HC
Hosp
PC
Imm
Tet
Pren
DA
Road
War
Educ
SES
Centr
East
West
WN
SW
HIV
Age
Acces
HC
Hosp
PC
Imm
Tet
Pren
D.A.
Road
War
Educ
SES
Centr
East
West
SWest
WNile
HIV*
Age
1
.58
1
.42
.29
1
.43
.06
.27
1
-.25
-.12
-.29
.02
1
-.04
-.05
-.18
.03
.07
1
-.07
-.08
-.06
-.01
.002
.34
1
-.08
-.01
-12
-.09
-.07
.20
.24
1
.05
-.10
.14
-.03
.07
-.14
-.09
-.24
1
.26
.41
.16
.03
-.06
-.02
-.00
-.02
-.08
1
-.02
.05
-.02
-.10
-.04
.09
.13
.21
-.14
.08
1
-.09
.02
-.07
-.12
.05
.08
.12
.23
-.16
.05
.19
1
.22
.30
.18
.04
-.23
-.07
.05
.18
-.15
.45
.17
.21
1
-.10
-.20
-.15
-.11
-.29
.19
.16
.21
-.39
-.13
.02
.02
-.28
1
-.10
.06
-.07
-.02
.17
.002
-.14
-.04
-.09
-.06
.02
-.01
-.13
-.14
1
-.00
-.00
-.07
.08
.07
.03
-.11
-.05
.13
-.05
-.13
-.15
-.12
-.13
-.06
1
-.09
-.10
.04
.03
.33
-.01
-.06
-.28
.44
-.21
-.11
-.12
-.47
-.50
-.22
-.21
1
.13
.12
.28
-.04
-.34
-.16
.03
.11
-.05
.06
.15
.13
.48
-.07
-.36
-.37
.01
1
.00
-.04
-.01
-.01
.02
-.04
-.05
-.10
.09
-.02
-.19
.10
-.04
-.38
-.03
.03
.06
-.03
1
Source: 1988 Uganda DHS, rural sample.
* Estimated from MOH AIDS surveillance reports data
Access - Accessibility to any health facility
HC - Health center
Hosp - Hospital
PC - Private clinic
Imm - Cluster children immunization coverage
Tet - Tetanus shot during pregnancy
Pren - Prenatal care
DA - Delivery assistance by trained personnel
Road - Type of access road
War - Region experienced war
Educ - Maternal education
SES - Socio-economic status
SWest - South west region
WNile - West Nile region
Centr - Central region
Table 2: Proportional hazard model estimated coefficients
for childhood in rural Uganda. Model 1, 2 and 3 (DHS survey, 1988)
Variables (Ref. category)
Model 1
Model 2
Model 3
Coeff.
(SE)
RR
Coeff.
(SE)
RR
Coeff.
(SE)
RR
Accessibility variables
Access to hospital
Access to health center
Access to private clinic
0.021
0.179*
-0.093
(.105)
(.089)
.-(.069
1.02
1.19
0.91
0.018
0.176*
-0.093
(.104)
(.088)
(.069)
1.02
1.19
0.91
-0.049
0.152
-0.082
(.111)
(.089)
(.070)
0.95
1.16
0.92
Maternal risk factors
Age
Age squared
-0.147
0.002
(.094)
(.002)
0.86
1.00
-0.144
0.002
(.096)
(.002)
0.87
1.00
Health utilization
Average immunization
Received tetanus
Delivery by trained personnel
Received prenatal care
-0.007**
-0.212
-0.266
0.138
(.005)
(.193)
(.237)
(.237)
0.99
0.81
0.77
1.15
-2 Log likelihood
Degrees of freedom
P value
Number of cases
2374.8
3
0.05
3290
1965.12
5
0.097
2321
1959.46
9
0.092
2321
* significant at .05 level. ** significant at
.01 level.
Copyright 1994 - Union for African Population Studies.