Explaining the Low Use of Health Services by the Poor: Costs, Attitudes, or Delivery Systems?

Empirical evidence that such explanations do not fully account for income trends in preventive and symptomatic use is provided, and results suggest that neither financial access nor health education, without accompanying improvements in delivery systems, will eliminate income differentials in use.

Abstract

The poor, especially children, continue to receivefewer health services relative to need than the affluent. Explanations have traditionally focused on cost constraints or on cultural differences. This paper provides empirical evidence that such explanations do not fully account for income trends in preventive and symptomatic use. A third explanation, based on inadequacies in delivery systems used by the poor, is required. Factors representing each explanation are added sequentially to a multivariate model in order to shed light on their role in the income-use relationships. Particularly instructive are changes in estimates when types of delivery systems are added, since system differences have been ignored in much previous research. The importance of factors promoting use among the poorly. e.g., public assistance, is underestimated, while the role of individual characteristics, e.g., attitudes, is overestimated. Results suggest that neither financial access nor health education, without accompanying improvements in delivery systems, will eliminate income differentials in use.