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WP2 - Rapid methods for monitoring the utilization of healthcare facilities by the poor: Findings from a pilot project in rural Bangladesh

Future Health Systems

There has been growing concern about the inequities in the utilization of health care services by the socially disadvantaged in any setting. Health programme personnel always aim to increase the level of utilization of the services they provide to people from all segments of society. Despite all-out efforts, the utilization rates are quite often inversely correlated with the socioeconomic status or any other marker of disadvantageousness that identify a population group. Focused attention given to the disadvantaged groups can be of help in improving the situation. A prerequisite for focusing attention is monitoring of the service utilization by the disadvantaged group with a known degree of reliability. Commonly, data from surveillance and cross sectional surveys are used to assess the level of utilization of the services by populations from various socioeconomic groups, and especially by the most disadvantaged among them. Surveillance, being very resource intensive is not quite practical for this purpose. Cross sectional surveys, especially the thirty cluster sampling (Henderson & Sundaresan, 1982) scheme, with 210 respondents are considered to be reasonably practical and has been in use for monitoring the coverage of EPI services for quite some time. In fact, the task of covering 210 respondents from the targeted socioeconomic group per catchment area of a service facility is not so small a task when a large number of service facilities are to be monitored. In addition the task of data analysis and their interpretation also becomes technical, requiring expertise beyond the domain of programme management.

The other method which has recently been discussed is the use of the benefit incident ratio technique in monitoring the utilization of services by the poor or any other disadvantaged group in the society. The method is simple to some extent, but nevertheless, involves complex statistical manipulation. In this respect, there is a clear need for innovations in monitoring service utilization by the most disadvantaged sections of society.

Other than the abovementioned methods, there has not been any simple and less resource demanding method which can be practically used by the programme managers at the facility level. Some of the methods which are used in the industrial sectors for quality control, has the potential for adoption in monitoring service utilization in general and by the most disadvantaged in particular. Such techniques include lot quality assurance sampling (LQAS) and sequential sampling techniques. The LQAS method is more rapid, simple and time efficient (Jutand & Salamon, 2000), and may be less costly than many others (Singh, Jain, Sharma, & Verghese, 1996), for it is based on a much smaller sample size. LQAS is also found to be effective in improving public health services like immunization coverage by identifying low performing areas (Lanata, Stroh, Jr.Black, & Gonzales, 1990; Tawfik, Hoque, & Siddiqi, 2001). The sequential sampling method is quite similar to LQAS, needing a smaller sample size than cross sectional or fixed sample schemes.

Keeping the above in mind, the present exercise applied benefit incidence, LQAS and sequential sampling methods in monitoring the utilization of health services by the poorest section of the population in two upazilas in Bangladesh. The practical challenges in adopting the methods and the consistency in the conclusions made by using the three methods have been examined and their possible use has been discussed.