The Well-Being of the Elderly in Asia: A Four-Country Comparative Study

10. Patterns of Health Care Utilization

Chapter 10 PATTERNS OF HEALTH CARE UTILIZATION Mary Beth Ofstedaf andJosejina N Natividad A s detailed in Chapter 2 and noted elsewhere throughout this volume, all the countries under study have experienced tremendous reductions in both mortality and fertility in recent decades. These changes have led to new challenges for these countries, primarily resulting from a rapidly aging population . Because older persons have high per capita health care needs (Binstock, 1997), growth in this segment of the population will increase demand for both acute and long-term care services (Soldo and Manton, 1985). The impending growth in both the number and proportion of older persons in Asia thus has policymakers concerned (Hermalin, 2000; Interministerial Committee on the Ageing Population, 1999; Ogawa and Retherford, 1997). To complicate matters, until recently the health infrastructures in the study countries have been primarily oriented toward problems of infectious diseases and maternal and child health (see Chapter 3). In order to plan for and implement health services for the older population, it is important to gain a better understanding ofthe determinants ofhealth and health care utilization in later life in each of these countries. 413 414 The Well-Being ofthe Elderly in Asia The major objective ofthis chapter is to examine the levels and determinants of health care utilization both within and across countries. The surveys contain information on the use of a variety of health care services, ranging from preventive care and routine outpatient care, to hospitalization and specialized community services for the elderly. For within-country comparisons we will focus on variation in service use across subgroups defined by selected sociodemographic, economic, and health characteristics. We also examine cross-country variation to assess the extent to which differences in economic development and health care programs are reflected in differential levels and patterns ofhealth service utilization. The theoretical framework that we draw on for this analysis is a behavioral model originally developed by Andersen (1968) and since modified byAndersen and his colleagues (e.g., see Aday andAndersen, 1974;Andersen and Newman, 1973). It is the most commonly used model for research on health services utilization (Wan, 1989), and has been used in many studies in the United States (Wolinsky and Johnson, 1991; Wan, 1989). This behavioral model postulates three basic sets of factors influencing the use of health services: need, predisposing factors, and enabling factors . The need component hypothesizes that people seek services when they are ill or perceive themselves to be at risk of illness. Need is typically measured by indicators of health status, including presence of chronic diseases, functional limitation, and self-perceived health. The predisposing component asserts that some individuals have a higher propensity to use health services than others, based largely on their health beliefs and degree offamiliarity with and trust in the medical system. Predisposition is often operationalized in terms of demographic characteristics (e.g., gender and age), characteristics representing position in the social structure (e.g., ethnicity and education), and level of social connectedness (presence of spouse and children), as well as measures of health beliefs (not available in these surveys). Predisposing characteristics are thought to be more salient to the use of outpatient care than to in-patient hospitalization, the latter ofwhich is often associated with a life-threatening health event and, as such, is more a matter of necessity than choice (Wan, 1989). Finally, the enabling component argues that the likelihood ofutilization among individuals who have the need and predisposition to use health services is influenced by their ability to access the services. Enabling factors may take the form of individual or family-level characteristics such as the availability of health insurance or financial resources, or knowledge of and connnections to service providers, as well as community-level factors such as the availability and accessibility of health care facilities and personnel. Patterns of Health Care Utilization 415 Figure 10.1. Determinants of Health Services Utilization NEED OR 1I1..NESS LEVEL Self-perceived health Life-threatening conditions Debilitating conditions ADL limitations PREDISPOSING CHARACTERISTICS Age Gender Education Social support from spouse, children UTILIZATION OUTCOMES Preventive services Outpatient care from traditional practitioners Outpatient care from Western medical doctors Hospitalization Unmet need for services ENABUNG CHARACTERISTICS Income Employment Urbanicity Health system Figure 10.1 presents the conceptual framework for our analysis of health care utilization and identifies how we operationalize determinants and outcomes. Although we classify the characteristics into distinct dimensions along the lines of previous work (e...