Understanding spatial variation in the utilization of health services: does quality matter?

Utilization of health services are an important policy concern in most developing countries, reflecting both efforts to improve health outcomes and to meet international obligations to make health services broadly accessible. Although many policy and research initiatives have focused on the need to improve physical access, not enough is understood about what factors affect health care choices, and why low levels of utilization persists among certain socioeconomic groups or geographic regions despite improved physical access. Reflecting these concerns, this paper focuses on the role of health care quality in understanding spatial variation in the utilization of both curative and preventive health services in Mozambique. The analysis is based on matched household and facility data, where the sample of household was drawn from the catchment area of each facility. The findings show that health care quality is a significant and important factor in women.s choice of delivery location. In particular, both the presence of maternity staff and a broader service range make it more likely that women choose a facility-based delivery. Conversely, the analysis suggests that quality is not a significant determinant in decisions about outpatient visits, while physical access, education, and economic variables are important. The findings hence suggest that the impact of quality may be service specific, and that although certain dimensions of quality may have little or no impact on outpatient visits, they may be important determinants of the use of other health services. As developing countries to continue to face difficult trade-offs between quality and physical access in the allocation of resources, it will be important to deepen our understanding of how individuals make health care choices. The results presented in this paper are a step in that direction.