RESULTS

Demographic information

Type of house

The type of house is used as an indicator of economic status of the household. House types are divided into four categories (see Table 1). More than a third of the houses are constructed of mud bonded bricks and stones or wood with a straw or thatched roof (kachchi), while about a third are of cement bonded brick or stones with a tile or galvanized sheet roof (pakki), and about a quarter are a mixture between kachchi and pakki. A few are temporary huts or tents.

Table 1. Construction of houses

Type of construction

Number (%)

Kachchi (mud brick with straw/thatch roof)

7176 (39)

Pakki (cement brick with tile/sheet roof)

5903 (32)

Mixture of kachchi and pakki

5031 (27)

Hut / shelter / tent

437 (2)

The construction of houses was documented as part of the Nepal Living Standards Survey 1996 (NLSS)13. It is difficult to make direct comparisons between this cycle of the NMIS and the NLSS because in the NLSS the construction of the walls, roof and floor were noted separately. In the NLSS, 52% of the houses were recorded as having mud bonded brick or stone walls, 25% wood walls and 11% cement bonded stone or brick walls. Half had straw or thatched roofs, 28% had tile or slate roofs, and 11% galvanized sheet roofs. The results are probably compatible, depending upon the proportion of houses in the NLSS that were of 'mixed' construction.

Literacy of household head

Half (50% - 9306)of the household heads in NMIS cycle 6 were reported to be able to read and write. This is similar to the proportion found in other cycles of the NMIS. For example, in NMIS cycle 5 the proportion of household heads reported to be literate was 48%5.

The expected association between literacy of the household head and economic status of the household is found, taking the type of house construction as an index of economic status. In households living in pakki houses, the household head is three times more likely to be literate than in households living in houses of other types of construction. This is shown in Table 2.

Table 2. Type of house construction and literacy of household head

Type of house

Literacy of household head

Literate

Illiterate

Pakki (%)

4058 (69)

1840 (31)

Others (%)

5248 (41)

7423 (59)

Odds Ratio 3.12 (95% CI 2.92-3.33)

 

Health Services

Use of government health services

The number of household members reported to have used government health services in the last month is shown in Table 3.

Table 3. Number of household members reported to have used government health services in the last month

Number of members using services

Number of households(%)

0

16302 (88)

1

1892 (10)

2

306 (2)

>2

74 (0)

Total

19080

The percentage of households using government health services is remarkably low. It is much lower, for example, than in a recent similar survey in Uganda, East Africa8.

The proportion of households using government health services in the last month disaggregated by geographic area and by ethnicity is shown in Annex 5, Tables A5.1 and A5.2, and figure A5.1.

Factors affecting use of government health services

Area of residence

Households in urban areas are less likely to have used government health facilities in the last month than those in rural areas (Table 4). This probably reflects greater access to private clinics and other alternatives to government health services in urban areas.

Table 4. Area of residence and use of government health services in the last month

Area of residence

Used government health service

Yes

No

Urban (%)

258 (10)

2370 (90)

Rural (%)

2020 (13)

13932 (87)

Odds Ratio 0.75 (95% CI 0.65-0.86)

 

Economic status

The type of house is used as an index of the economic status of a household. Households of higher economic status (living in pakki houses) are less likely to have used government health services in the last month than those living in other types of houses (Table 5). This is true in both urban and rural areas. It may be because people who can afford to use private health services do so, rather than using government health services. It could perhaps also reflect better health status of people with higher economic status, although there is no direct evidence of this from this survey.

Table 5. Type of house construction and use of government health services in last month

Type of house

Used government health service

Yes

No

Pakki (%)

649(11)

5254 (89)

Others (%)

1627 (13)

11017 (87)

Odds Ratio 0.84 (95% CI 0.76-0.92)

 

Literacy of household head

Overall, those households with a literate head are more likely to have used government health services in the last month than those with an illiterate head (Table 6a). However, in urban areas, those households with a literate head are less likely to have used government health services in the last month (Table 6b). This seems to suggest that households with a literate head use the best available health services: in rural sites they may only have access to government facilities, but in urban sites they may choose available alternative services.

Table 6a. Literacy of household head and use of government health services in the last month (all areas)

Literacy of household head

Used government health service

Yes

No

Literate (%)

1225 (13)

8081 (87)

Illiterate (%)

1053 (11)

8210 (89)

Odds Ratio 1.18 (95% CI 1.08-1.29)

Table 6b. Literacy of household head and use of government health services in the last month (urban areas)

Literacy of household head

Used government health service

Yes

No

Literate (%)

176 (9)

1703 (91)

Illiterate (%)

82 (11)

666 (89)

Odds Ratio 0.84 (95% CI 0.63-1.12)

Distance from government health facilities

The distance from the community (site) to the nearest government health facility was recorded as part of the institutional review of the facility. Households in communities where the nearest health facility is less than two hours journey away are somewhat more likely to have used government health services in the last month. (Table 7).

Table 7. Distance from nearest government health facility and use of government health services in the last month

Journey time to facility

Used government health service

Yes

No

Up to 2 hrs (%)

1927 (13)

13222 (87)

> 2 hrs (%)

92 (9)

882 (91)

Odds Ratio 1.40 (95% CI 1.11-1.76)

Use of other (non-government) health services

Almost a quarter of households (24% - 4428) reported using other, non-government, health services during the last month. This is twice as high as the proportion (12%) using government health services. The two figures are not mutually exclusive and a few households (774) used both government and non-government services in the same period.

The proportion of households using non-government health services in the last month by geographic area and ethnicity are shown in Annex 5, Tables A5.1 and A5.2 and Figure A5.2.

Among the people who used non-government health services, more than 9 out 10 used private clinics. Some people reported using more than one type of non-government health service. The most commonly used service after private clinics is traditional healers. The types of non-government health services used are shown in Table 8.

Table 8. Types of non-government health service used in the last month, among those who used any such service

Type of service

Number of households(%)

Private clinic

4003 (91)

Traditional healer

1584 (36)

NGO health facilities

155 (4)

Private practitioner

132 (3)

Self medication

46 (1)

Some people reported using more than one type of service

Focus groups in each site discussed the types of alternative to government health services used locally. The types of service mentioned are similar to those reported used in the last month by households, but with more emphasis on traditional healers and faith healers. The types of service mentioned are shown in Table 9.

Table 9. Types of non-government health service used locally, as mentioned in community focus groups

Type of service

Number of sites(%)

Traditional healer

124 (88)

Private clinic

98 (70)

Faith healer

54 (38)

Pharmacy/self medication

15 (11)

Friends & neighbours

11 (11)

NGO facility

7 (5)

Up to three responses were coded

 

Purpose of visiting government and non-government health services

For each reported visit to a government health service in the last month and for up to four visits to non-government health services in the last month, the purpose of the visit was asked. The reported reasons for visiting the service are similar for government and non-government services, as shown in Table 10.

Table 10. Reasons for visiting government and non-government health services during the last month

 Reason for visit

Govt. No. (%)

Non-govt. No. (%)

Acute illness (unspecified)

998 (36)

2380 (54)

Fever

658 (24)

1454 (33)

Acute respiratory infection

272 (10)

598 (14)

Chronic illness (unspecified)

144 (5)

384 (9)

Diarrhoea

127 (5)

272 (6)

Accident/injury

123 (4)

142 (3)

Immunisation

106 (4)

7 (0.2)

Pain in body

97 (4)

313 (7)

Delivery

58 (2)

46 (1)

Skin problem

43 (2)

77 (2)

Eye infection

42 (2)

100 (2)

Antenatal care

38 (1)

26 (0.5)

Tuberculosis

35 (1)

35 (1)

Other

30 (1)

73 (1)

As shown in Table 10, the main reasons for visiting health services are acute illnesses, including fever and acute respiratory illness. The pattern of reasons for using the government and non-government services is not markedly different. This suggests that the choice of one type of service over the other is not primarily based on the kind of problem but rather relates to issues of convenience, access, cost and quality. Government health services are apparently used more often then non-government services for immunisations (see Table 10).

Focus group discussions shed more light on the types of alternative health services used and the reasons for their use. It seems that traditional healers are favoured for certain kinds of illnesses, while private clinics are used (by those who can afford them) because of convenience and quality. People also report trying several different services until they get satisfactory treatment for their problem.

 

Experience of government health services

Additional information was sought about visits by any member of a household to government health services during the last month.

Characteristics of service users

Among the people who used the government health services during the month prior to the survey, 47% are males and 53% are females. Their mean age is 25 years (median 21 years).

Government facilities visited

The type of government health facility visited is shown in Table 11. Nearly half the reported visits were to health posts.

Table 11. Type of government health facility visited during the last month(among those who visited any)

Type of facility

Number (%)

Health post

1326 (48)

Sub health post

689 (25)

District hospital

620 (22)

Other hospital

67 (2)

Primary health care centre

60 (2)

Mobile clinic

5(0)

Availability of health workers and medicine

For nearly all visits (93% - 2584) to government health facilities it was reported that a health worker was available. The variation in this figure by geographic area and by ethnicity is shown in Annex 5, Tables A5.1 and A5.2 and Figure A5.5.

However, the situation was much less good for availability of the medicines needed. In less than a third of reported visits were all the medicines required available. The reported availability of medicines is shown in table 12.

Table 12. Reported availability of required medicines in visits to government health facilities

Availability of medicines

No. (%) of visits

All available

844 (30)

Some available

1103 (40)

None available

821 (30)

The variation in availability of medicines by geographic area and by ethnicity of the respondent is shown in Annex 5, Tables A5.1 and A5.2 and Figure A5.4

Alternative sources of medicines

Since most patients do not receive all the medicines needed for their treatment from the government health facilities, many patients have to get the required medicines from other sources. The alternative sources used for getting medicines not available in government health facilities are shown in table 13.

Table 13. Sources of medicines not available from government health facilities

Source

Number (%)

Drug shop

1409 (80)

Private clinic

203 (11)

Pharmacy

124 (7)

Neighbours/friends

46 (3)

Waiting time

Most (83%) people visiting a government health facility report waiting one hour or less before seeing a health worker. Only 7% report waiting 2 hours or more. This probably reflects local knowledge of when there is likely to be a health worker available, so that people time their visits to coincide with the presence of a health worker. It probably also underestimates the number of abortive visits, where there is no health worker present and a second or third visit is needed before being seen. And it does not reflect the fact that many people choose to use other services rather than government health services, perhaps because they have had bad reports of the government service.

 

Payment for government health services

People who used government health facilities during the month prior to the survey were asked how much they had to pay for different items. Almost every body has to pay the fixed fee for registration. However, most people, (83%) do not pay anything extra for medicines. This is perhaps not surprising in view of the low availability of medicines in government health facilities. The payments made are summarised in table 14.

Table 14. Mean payment for different items to government health facilities and proportion of people paying for these items

Item

Mean (NRs)

Median (NRS)

No. (%) who paid

Fixed fee

4

2

1805 (100)

Medicines

38

0

315 (17)

Total payment

58

2

1835 (100)

Views about government health services

All households were asked what they thought about government health services, what they thought the main problems with the service were and how they thought the services could be improved.

Overall opinion of services

Only one out of thirteen households (8%) consider the health services provided by the government are good. A third of them think the services are bad, and nearly 60% of them think the services are neither good nor bad. The opinions about government health services are shown in Table 15.

Table 15. Opinions about government health services

Perception of service

Number (%)

Good

1355 (8)

Neither good nor bad

10631 (59)

Bad

5920 (33)

The proportion of households rating government health services as 'good' in different geographic areas and among different ethnic groups is shown in Annex 5, Tables A5.1 and A5.2 and Figure A5.3.

Perceived problems with government health services

The most common problems complained of by household respondents are lack of medicine, bad attitude of workers and poor physical condition of facilities.

A number of the problems with government health services mentioned by households are mirrored in the views of health workers interviewed in the health facilities. Table 16 summarises the problems mentioned by the households and health workers.

 

Table 16. Perceived problems with government health services

Problem

Households No. (%)

H workers No. (%)

Lack of medicines

9339 (59)

108 (84)

Poor condition of facilities

6402 (40)

78 (61)

Bad attitude of staff

5622 (35)

-

Lack of staff

1777 (11)

82 (64)

Facility too far away

1447 (9)

-

Lack of equipment

895 (6)

-

Too expensive

659 (4)

-

No female staff

315 (2)

-

Lack of community support

-

17 (13)

No problems

1045 (7)

-

Up to 3 answers were allowed

It is not surprising that health workers did not mention some of the problems important to households, such as 'bad attitude of staff'. However, in the institutional review, about two thirds (65%) of health workers said that they had received complaints about the service of their facility from the community.

Suggestions for improving government health services

The suggestions from households about how to improve government health services are shown in Table 17. Most suggestions are about providing 'more' of various items, with more medicines being top of this list. The suggestions are basically for what would be a better service from the point of view of the user. They do not address what would need to be done to achieve these changes (mainly increases) in service.

 

Table 17. Suggestions from households for improving government health services

Suggestion

Number (%)

Provide more medicines

8901 (57)

Provide more equipment

5409 (35)

Improve staff attitudes

4322 (28)

Provide more doctors

4279 (27)

Provide free service

2882 (18)

Provide more health posts

1342 (9)

Provide more health workers

817 (5)

Provide female staff

603 (4)

Provide health education

80 (1)

As well as the household respondents, focus groups discussed their ideas for improving government health services. Like households, they expressed a desire for more medicines and facilities. They wanted doctors to treat rich and poor patients alike. They also wanted clarity about what services can be expected from government clinics (along the lines of Patient Charters being introduced in a number of countries) and more community involvement of health care workers. And the issue of providing health education was raised more frequently than by the individual households. The proportions of focus groups raising different themes are shown in Annex 3.

Willingness to pay for improved health services

Respondents were asked if they would be willing to pay

for improved government health services. More than two thirds (69% - 12,596) are willing to pay more for an improved service.

Among those who are willing to pay more, on average they are willing to pay 10 Rupees for each visit to a health facility. The urban population are willing to pay more compared with the rural population. The amounts people are willing to pay in different geographic areas and in different ethnic groups are shown in Annex 5, Tables A5.1 and A5.2 and Figure A5.6.

It seems likely that an official policy of cost sharing, probably as a fixed fee for attendance at a health facility, would find favor with many people in Nepal. However, this would only be widely acceptable if the level of the fee is modest and if the payments led to some tangible improvements in the service the people received. Setting user fees too high and not accompanying them with efforts to improve the service delivered would probably lead to even more people using alternative sources of health service and failure to collect fees.

Households who reported using Government health service in the last month are one and a half times more likely to say they are willing to pay for improved health services than households who have not used Government health services in the last month (Table 18). This is still true when literacy of the household head is taken into account.

Table 18. Willingness to pay for improved government health services and use of services in the last month

Used govt health service in last month

Willing to pay for improved service

Yes

No

Yes (%)

1717 (76)

537 (24)

No (%)

10879 (68)

5159 (32)

Odds Ratio 1.52 (95% CI 1.37-1.68)

Sources of health information

Focus groups were asked what sort of information people like them would like about staying healthy and what source would be best to get the information from. Table 19 shows the sources of information mentioned by the focus groups. The most popular were radio, health facilities and female health workers.

 

Table 19. Preferred sources of health information mentioned by focus groups

Source of information

Number (%)

Radio (and TV)

93 (67)

Health facilities

73 (53)

Female health workers

73 (53)

Other individuals

57 (41)

Community leaders

36 (26)

Newspapers

31 (22)

Trained health workers

27 (19)

Local government

20 (14)

Family members

19 (14)

Self

16 (12)

Traditional healer

1 (1)

Up to 3 answers were coded

 


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