Public Perception on Access to Health Services in Nepal 

Paper to be presented at the Panel: “The relationship between service delivery and state-building in fragile and conflict-affected situations: evidence from the first round of an original panel survey” in the THE DEVELOPMENT

STUDIES ASSOCIATION ANNUAL CONFERENCE 2013 16th November 2013

THE MEDICAL SCHOOL, UNIVERSITY OF BIRMINGHAM, EDGBASTON CAMPUS

Bishnu Raj Upreti, PhD, Director, Sony KC, Researcher

Nepal Centre for Contemporary Research, (NCCR)G.P.O. 910, Kathmandu, NepalWebsite: www.nccr.org.np

Tel. 0097715000053 e-mail: bupreti@nccr.wlink.com.np

sony@nccr.org.np

Outline of presentation

1. The context

2. Methodological note

3. Findings on public perception on health service delivery

4. Conclusions

1. The context of ehealth services in Nepal

• This paper is an outcome of ongoing research in Nepal under the SLRC

• Decade of armed conflict and political transition• Severe disturbance in delivery of services • Emergence and growth of private helth service after

1990 and huge investment • Maoist objection to private health services and

demanded for state responsibility of helath service . • Nationalization v/s privatization of health service

debate at policy and political levels posed several operational complications

• Service providing units of government were targeted – Recruitment, donation, – Killing, torture, abduction – Health posts as training camps and venue of

meetings

2. Methodological note• Survey of 3175 households of Rolpa (717 HH), Bardiya

(1213 HH) and Ilam (1246 HH) districts between September and November, 2012.

• The areas were selected on the basis of the degree of impacts of the conflict

• Purposive sample used to capture geographic variation in conflict, physical accessibility and access to services.

• Data are not representative at the district level but representative at the village level (as Wards within the VDCs were randomly selected using the 2011 voters list)

• 9th of the eleven components contained in the survey instrument was related to the perception on health service delivery.

• The survey instrument on perception on health services was designed using three main indicators: a) Access to health services/time required, b) Frequency of taking the health services and c) Satisfaction of the respondents on the available health services.

3. Findings: public percetion on health service delivery

Average time taken to reach the health postBy rural urban context

Time in minutes

By district Time in Minutes

Urban 31.28 Rolpa 61.53

Rural 44.6 Bardiya 20.93

Ilam 46.75

Total 40.22 Total 40.22

Average time taken to reach the nearest health post

Source: Field Survey, 2012

3. Findings on health service delivery-2

Districts   

When did you or other household members last use this service?In past 7 days

In past 30 days

In past 6 months

In past year

More than one year ago

Total

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Rolpa 133 18.6

260 36.3

212 29.6

44 6.1 67 9.4 716

Bardiya

235 19.4

612 50.5

251 20.7

46 3.8 68 5.6 1212

Ilam 208 16.7

487 39.1

362 29.1

80 6.4 108 8.7 1245

Total 576 18.2

1359

42.8

825 26 170 5.4 243 7.7 3173

Access to health services by district

3. Findings -3

Context   

When did you or other household members last use this service?In past 7 days

In past 30 days

In past 6 months

In past year

More than one year ago

Total

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Urban

188 18.0

447

42.9

267

25.6

59 5.7 82 7.9 1043

Rural

388 18.2

912

42.8

558

26.2

111 5.2 161

7.6 2130

Total

576 18.2

1359

42.8

825

26.0

170 5.4 243

7.7 3173

Use of health service by urban-rural context

3. Findings -4

Age group  

When did you or other household members last use this service?In past 7 days

In past 30 days

In past 6 months

In past year

More than one year ago

Total

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

< 25 226

19.9 512

45.0 276

24.3 55 4.8 68 6.0

1137

25 to 50 316

17.6 750

41.8 481

26.8 99 5.5 150 8.4

1796

50 or > 34

14.2 97

40.4 68

28.3 16 6.7 25

10.4 240

Total 576

18.2

1359

42.8 825

26.0 170 5.4 243 7.7

3173

Access to health service by age group of average age of household

3. Findings -5

 Ethnicity

When did you or other household members last use this serviceIn past 7 days

In past 30 days

In past 6 months

In past year

More than one year ago

Total

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Brahmin / Chhetri

200 19 441 41.9

286 27.2

47 4.5 78 7.4 1052

Janjati / indigenous group

264 17.6

628 41.8

390 25.9

99 6.6 122 8.1 1503

Dalit 50 20.2

114 46.2

62 25.1

9 3.6 12 4.9 247

Madhesi

33 16.3

92 45.5

49 24.3

5 2.5 23 11.4

202

Muslim 8 8.2 52 53.6

29 29.9

4 4.1 4 4.1 97

Other 21 29.2

32 44.4

9 12.5

6 8.3 4 5.6 72

Total 576 18.2

1359

42.8

825 26 170 5.4 243 7.7 3173

Access to Health service by ethnicity

3. Findings -6

3. Findings -7

3. Findings -8

Age group of respondents

Very satisfied

Fairly satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

Total

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Row %

less than 25 48

11.7 264

64.4 73

17.8 21 5.1 4 1.0

410

25 to 50

202

11.0

1142

61.9 386

20.9 89 4.8 25 1.4

1844

50 or above 95

10.6 552

61.7 194

21.7 42 4.7 11 1.2

894

Total345

11.0

1958

62.2 653

20.7 152 4.8 40 1.3

3148

Satisfaction level of health service by age group of respondents

3. Findings -9

Gender of respondent 

Overall satisfaction with the quality of the service on most recent use of the facility

Very satisfied

Fairly satisfied

Neither satisfied, nor dissatisfied

Dissatisfied

Very dissatisfied

Total

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Row %

Count

Male 15010.

982

159.

6 31522.

9 71 5.2 21 1.51378

Female 195 111137

64.2 338

19.1 81 4.6 19 1.1

1770

Total 345 111958

62.2 653

20.7

152 4.8 40 1.3

3148

Satisfaction level of health service by gender

4. Conclusions•  Though the decentralized health service delivery systems

was affected by civil war and governance weaknesses and caused poor performance in general, this study found that people are not so negative as presented in the media and public discourse.

• Access to health services is largely determined by gender, age group, livelihood activities, household size, number of children, roof type, wall type, religion, ethnic group and district

• Health posts of terai areas are most accessible and accessed by more people compared to health posts of the hill areas.

•  People in rural areas tend to take services from the health posts more often than the people in the urban areas since there are fewer options in the rural areas than that in the urban areas.

• People's willingness and need to visit the health posts was determined by the occurrence of diseases. For example, as people are more suffered from the diseases they have higher priority to visit the health posts.

4. Conclusions-2• While developing the future health service

policies and strategies the actors in health sector have to consider the main reasons of dissatisfaction of the respondents by geography (ensuring health services to the people of geographically isolated and or remote, inaccessible areas), ethnicity (Muslim, Madeshi and Bramin-Chhetri), gender (female), rural urban context (providing more numbers of health services to the rural areas) and political .

Thank you