Publication: Bypassing Health Providers : The Quest for Better Price and Quality of Health Care in Chad
Loading...
Published
2008-01
ISSN
Date
2012-05-25
Author(s)
Editor(s)
Abstract
This paper investigates individuals' bypassing behavior in the health sector in Chad and the determinants of individuals' facility choice. The authors introduce a new way to measure bypassing using the patients' own knowledge of alternative health providers available to them instead of assuming that information as previously done. The authors analyze how perceived health care quality and prices impact patients' bypassing decisions. The analysis uses data from a Quantitative Service Delivery Survey in Chad's health sector carried out in 2004. The survey covers 281 primary health care centers and 1,801 patients. The matching of facility data and patient data allows the analysis to control for a wide range of important patient and facility characteristics, such as income, severity of illness, quality of health care, or price of services. The findings show that income inequalities translate into health service inequalities. There is evidence of two distinct types of bypassing activities in Chad: (1) patients from low-income households bypass high-quality facilities they cannot afford to go to low-quality facilities, and (2) rich individuals bypass low-quality facilities and aim for more expensive facilities that also offer a higher quality of care. These significant differences in patients' facility choices are observed across income groups as well as between rural and urban areas.
Link to Data Set
Citation
“Gauthier, Bernard; Wane, Waly. 2008. Bypassing Health Providers : The Quest for Better Price and Quality of Health Care in Chad. Policy Research Working Paper; No. 4462. © World Bank. http://hdl.handle.net/10986/6456 License: CC BY 3.0 IGO.”
Digital Object Identifier
Associated URLs
Associated content
Other publications in this report series
Publication Climate and Social Sustainability in Fragility, Conflict, and Violence Contexts(Washington, DC: World Bank, 2026-01-07)Climate change is widely recognized as a driver of violent conflict, but its broader social effects remain less understood. Ignoring these dimensions risks a vicious cycle where climate policies might undermine socially just adaptation. Evidence is still limited on how climate shocks influence political participation, trust, or migration. This paper helps fill that gap by examining links between climate change, conflict, and social sustainability, with a focus on inclusion, resilience, cohesion, and legitimacy. Using secondary data from 2019–24, the study applies simple correlation-based methods to test three hypotheses on the nature, severity, and composition of these associations. The analysis combines multiple climate impact measures, new conflict classifications, recent social sustainability frameworks, and controls for population and geography. The results reveal strong correlations—not causation—between climate events and contexts of fragility, conflict, and violence. Climate impacts are most pronounced in both national and subnational conflict settings. The study also finds robust links between fragility, conflict, and violence and low levels of social sustainability, reflecting its role as both a driver and consequence of conflict. Some dimensions—such as violent events and insecurity—appear weaker in areas most affected by climate shocks. Two of the hypotheses are supported, and one remains inconclusive.Publication The Macroeconomic Implications of Climate Change Impacts and Adaptation Options(Washington, DC: World Bank, 2025-05-29)Estimating the macroeconomic implications of climate change impacts and adaptation options is a topic of intense research. This paper presents a framework in the World Bank's macrostructural model to assess climate-related damages. This approach has been used in many Country Climate and Development Reports, a World Bank diagnostic that identifies priorities to ensure continued development in spite of climate change and climate policy objectives. The methodology captures a set of impact channels through which climate change affects the economy by (1) connecting a set of biophysical models to the macroeconomic model and (2) exploring a set of development and climate scenarios. The paper summarizes the results for five countries, highlighting the sources and magnitudes of their vulnerability --- with estimated gross domestic product losses in 2050 exceeding 10 percent of gross domestic product in some countries and scenarios, although only a small set of impact channels is included. The paper also presents estimates of the macroeconomic gains from sector-level adaptation interventions, considering their upfront costs and avoided climate impacts and finding significant net gross domestic product gains from adaptation opportunities identified in the Country Climate and Development Reports. Finally, the paper discusses the limits of current modeling approaches, and their complementarity with empirical approaches based on historical data series. The integrated modeling approach proposed in this paper can inform policymakers as they make proactive decisions on climate change adaptation and resilience.Publication Institutional Capacity for Policy Implementation: An Analytical Framework(Washington, DC: World Bank, 2026-01-07)State capacity is an important prerequisite for policy implementation, yet at the country level it is difficult to measure, assess, and reform. This paper proposes a focus on institutional capacity: the ability of public institutions to implement the specific policy mandates for which they are responsible. Based on a review of existing literature, the paper defines the different dimensions that compose institutional capacity and groups them into two cross-cutting categories: organizational dimensions (personnel, financial resources, information systems, and management practices) and governance dimensions (transparency, independence, and accountability). The paper proposes measures for organizational and governance dimensions using existing data, shows intra-institutional variation of these measures within countries, and discusses how new data could be collected for better measurement of these concepts. Finally, the paper illustrates how the framework can be used to diagnose the sources of common problems related to weak policy implementation.Publication South Africa’s Fragmented Cities: The Unequal Burden of Labor Market Frictions(Washington, DC: World Bank, 2026-01-08)Using high-resolution administrative, census, and satellite data, this paper shows that South African cities are characterized by spatial mismatches between where people live and where jobs are located, relative to 20 global peers. Areas within 5 kilometers of commercial centers have 9,300 fewer residents per square kilometer than expected, which is 60 percent below the global median. Poor, dense neighborhoods are most affected. In Johannesburg, a 10-percentile increase in distance from the nearest business hub corresponds to a 3.7-percentile drop in asset wealth (a proxy of household wellbeing) and 4.9-percentile drop in employment. In Cape Town, the declines are 4.0 and 3.7 percentiles, respectively. Employment is 87 percent lower in the poorest decile than the richest in Johannesburg and 61 percent lower in Cape Town. These findings suggest that South Africa’s spatial organization of people and economic activity constrains agglomeration and reinforces inequality. This methodology provides a scalable and standardized data-driven framework to analyze spatial accessibility and agglomeration frictions in complex, data-constrained urban systems.Publication Investment in Emerging and Developing Economies(Washington, DC: World Bank, 2026-01-07)The world faces a pressing challenge to meet key development objectives amid slowing growth and rising macroeconomic and geopolitical risks. With the number of job seekers rising rapidly, infrastructure shortfalls continuing to be large, and climate costs mounting, the case for a significant investment push has never been stronger. Yet the capacity to respond in many emerging markets and developing economies has eroded. Since the global financial crisis, investment growth has slowed to about half its pace in the 2000s, with both public and private investment weakening. Foreign direct investment inflows—a critical source of capital, technology, and managerial know-how—have also fallen sharply and become increasingly concentrated, leaving low-income countries with only a marginal share. The risks of further retrenchment are significant, as trade tensions, policy uncertainty, and elevated debt levels continue to weigh on investment. Reigniting momentum will require ambitious domestic reforms to strengthen institutions, rebuild macro-fiscal stability, and deepen trade and investment integration—the foundations of a supportive business climate. At the same time, international cooperation is indispensable. A renewed commitment to a predictable system of cross-border trade and investment flows, combined with scaled-up financial support and sustained technical assistance, is essential to help emerging markets and developing economies—especially low-income countries and economies in fragile and conflict situations—bridge financing gaps and implement the domestic reforms needed to restore investment as an engine of growth, jobs, and development.
Journal
Journal Volume
Journal Issue
Collections
Related items
Showing items related by metadata.
Publication Leakage of Public Resources in the Health Sector : An Empirical Investigation of Chad(2007-09)In the public sector in developing countries, leakage of public resources could prove detrimental to users and affect the well-being of the population. This paper empirically examines the importance of leakage of government resources in the health sector in Chad, and its effects on the prices of drugs. The analysis uses data collected in Chad as part of a Health Facilities Survey organized by the World Bank in 2004. The survey covered 281 primary health care centers and contained information on the provision of medical material, financial resources, and medicines allocated by the Ministry of Health to the regional administration and primary health centers. Although the regional administration is officially allocated 60 percent of the ministry's non-wage recurrent expenditures, the share of the resources that actually reach the regions is estimated to be only 18 percent. The health centers, which are the frontline providers and the entry point for the population, receive less than 1 percent of the ministry's non-wage recurrent expenditures. Accounting for the endogeneity of the level of competition among health centers, the leakage of government resources has a significant and negative impact on the price mark-up that health centers charge patients for drugs.Publication Delivering Service Indicators in Education and Health in Africa : A Proposal(2010-06-01)The Delivering Service Indicators seek to provide a set of indices for benchmarking service delivery performance in education and health in Africa in order to track progress in and across countries over time. It seeks to enhance effective and active monitoring of service delivery systems and to become an instrument of public accountability and good governance in Africa. The main perspective adopted by the Delivering Service Indicators index is one of citizens accessing services and facing potential shortcomings in those services available to them. The index is thus presented as a Service Delivery Report Card on education and health. However, unlike traditional citizen report cards, it assembles objective information from micro level surveys of service delivery units.Publication The Contribution of Traditional Herbal Medicine Practitioners to Kenyan Health Care Delivery : Results from Community Health-seeking Behavior Vignettes and a Traditional Herbal Medicine Practitioner Survey(World Bank, Washington, DC, 2011-09)This study examines the role that Traditional Herbal Medicine Practitioners (THMPs) play in Kenya in the context of its human resources for health crisis. Two surveys were carried out to obtain evidence. The first documented the choices and perceptions of households in 36 communities on seeking medical assistance for eight common illnesses. The second survey asked 258 THMPs in five provinces to identify their knowledge sources, training, common illnesses treated, forms of payment, challenges, and concerns. Community-derived data show that households make reasonable decisions when faced with difficult circumstances: they prefer hospitals when these are affordable and seek care at clinics and health centers when hospitals are too far away. There is significant self-care and use of pharmacies, although THMPs are preferred for worms and lower respiratory problems. In general, THMPs provide an important though diminishing role in the provision of health care; they are not sought out in situations when inadequate care is dangerous, specifically infant diarrhoea and potential TB. Whilst Human Resources for Health (HRH) policies are urgently required to strengthen the conventional health workforce and increase their accessibility for the poor, policies should not ignore the findings from this study: many of the rural poor currently receive services from a traditional health workforce not linked to, or regulated by, the national government. This paper argues that formal recognition of their role by the government and by the conventional medical associations, and a targeted strategy to strengthen and build on the positive qualities evident in many traditional medicine practices may be beneficial to safeguarding the well-being of the poor.Publication The Comparative Nature of Faith-Inspired Health Care Provision in Sub-Saharan Africa : Strengthening the Evidence for Faith-inspired Health Engagement in Africa, Volume 2(World Bank, Washington, DC, 2012-11-01)This role of faith-inspired health care providers in sub-saharan Africa and public-private partnerships is comprised of a three volume series on strengthening the evidence for faith inspired engagement in health in sub-Saharan Africa. An increasing level of interest in the role of faith in development has generated much debate and dialogue at the international and national levels over the last decade. Despite difficulties in communication and differences in cultures within such debates, there has been a continued reaffirmation of the potential benefits that faith-inspired communities can bring towards efforts to achieve the millennium development goals (MDGs), especially in the areas of health. This series focuses on assessing the role and market share of faith-inspired providers and on assessing the extent to which they are involved in and benefit from public-private partnerships. The purpose of this series of three HNP discussion papers is to round up various analytical perspectives and emerging research on faith engagement in health in Africa from a range of researchers and practitioners from the north as well as the south. The series is structured into three volumes: a first volume on the role and market share of faith-inspired providers and public-private partnerships, a second on satisfaction and the comparative nature of faith-inspired health provision, and the third on mapping of faith inspired provision and the extent to which faith-inspired providers reach to the poor.Publication Universal Maternal Health Coverage? Assessing the Readiness of Public Health Facilities to Provide Maternal Health Care in Indonesia(World Bank, Jakarta, 2014-07)Over the period 2011-2013, Indonesia had universal maternal health coverage for its population. Facility-based deliveries, however, remain relatively low: only about 63 percent of all deliveries occurred at a health facility in Indonesia. Recent progress notwithstanding, and despite the relatively high utilization rates for most key maternal health services, the level of maternal mortality remains high in Indonesia, especially in provinces such as West Papua, North Maluku, Papua, Gorontalo, West Sulawesi, Maluku, and South Kalimantan. This policy paper assesses the supply-side readiness of Indonesia s public health facilities in providing key maternal health services such as antenatal care (ANC) as well as basic and comprehensive emergency obstetric care. The focus in the paper is on assessing to what extent Indonesia's universal maternal health coverage is real. Ensuring the supply-side readiness of Indonesia's health system, incorporating lessons from the past experiences of implementing universal maternal health coverage under the different social health insurance programs, will be one key factor in ensuring that implementation of universal health coverage (UHC) results in improvements in health outcomes, including for maternal health. The policy paper is structured as follows: the section maternal health in Indonesia provides background on maternal health in Indonesia and on intended reforms to attain UHC by 2019. Assessing universal maternal health coverage in Indonesia provides information on maternal health benefits under existing social health insurance programs. Public facility supply-side service readiness for maternal health outlines the supply-side implications of maternal health coverage using national guidelines as well as the World Health Organization's (WHO's) service availability and readiness assessment (SARA) framework, focusing specifically on ANC as well as basic and emergency obstetric care services and presents an assessment of service readiness using facility-level data. The report concludes with policy implications in the final section, policy implications and conclusions.
Users also downloaded
Showing related downloaded files
Publication Antidumping Mechanisms and Safeguards in Peru(World Bank, Washington, DC, 2005-07)Peru's experience in the application of antidumping and safeguard measures is characterized by a radical change in the philosophy and procedures of trade at the beginning of the 1990s, and by an increasing use of these mechanisms. Trade liberalization was accompanied by the liberalization of foreign currency transactions and of financial and labor markets. Also, the internal revenue administration was modernized, institutions for regulation and competition defense were created, and state enterprises were transferred to private owners or concessionaires. New laws and institutions were created to regulate markets, including INDECOPI, a novel government agency charged with antimonopoly regulation and consumer defense, and which houses the Antidumping and Subsidies Commission. This highly autonomous and technical Commission became the central player in the implementation of WTO rules and procedures for fair trade. Since the reform was launched, a total of 81 trade protection cases have been presented, of which 57 were followed by a dumping investigation. The application of antidumping duties was approved for 29 of the cases investigated. Only two cases of safeguard investigations were recorded, one of which (Chinese textile clothing articles) is still in the negotiation phase. This paper reviews that case experience in detail, concluding that Peru has clearly differentiated between unfair competition and dumping on the one hand, and damage and safeguards on the other, and has applied strict technical criteria to the former and broader political considerations to the latter. Despite recent indications of a partial retreat from those principles, the decade-old reform is expected to last.Publication 1 World Manga : Passage 1. Poverty - A Ray of Light(San Francisco: VIZ Media and World Bank, 2006)The first World Manga series offers a premise where the hero must grapple with social problems of a global magnitude that are set in the real world. Fifteen year-old orphan Rei survives by his wits and guts on the mean streets of the world. His fortunes take a strange turn when he meets a trainer wielding some powerful transformational magic who offers to coach him to achieve his dream of becoming the greatest marital artist in the world! But it seems Rei's trainer is more interested in developing his mind, spirit and ugh! Heart than his thrashing, raging, and fighting moves! The stakes get higher when Rei meets a young woman fighting just to survive! Can Rei meets vanquish the specter of poverty? This publication includes some of the following headings: poverty - a ray of light; HIV/AIDS - first love; child soldiers of boys and men; global warming - the lagoon of the vanishing fish; girl's education - life lessons; corruption - broken trust; and interview with the author of the first World Bank Manga (passage one to passage six).Publication Case Study 2 - Andhra Pradesh, India : Participation in Macroeconomic Policy Making and Reform(Washington, DC, 2003-03)For the past six years, the State of Andhra Pradesh in India has been at the vanguard of efforts to modernize the economy and the state while pursuing policies to improve the lives of the poorest. The Chief Minister and head of the ruling Telugu Desam Party (TDP), Mr. Chandra Babu Naidu, is known by some as the "Laptop Minister" for his modernizing initiatives. He has reached out to international organizations and investors but has also maintained his base of support at home, in part through expanded programs in education, health, and rural development. "I have initiated so many things," Naidu said. "They are going on and will pay off after some time. But people need something today." The challenges facing the government are daunting. Andhra Pradesh (AP) is one of the largest and poorest states in India. Its population of almost 80 million approaches that of the Philippines, the 13th most populous country in the world. Even as its high-tech industries develop rapidly, AP's overall literacy rate remains a modest 44% and one-third of the population lives in poverty.Publication Accessing Economic and Political Impacts of Hydrological Variability on Treaties : Case Studies on the Zambezi and Mekong Basins(2012-03-01)International river basins will likely face higher hydrologic variability due to climate change. Increased floods and droughts would have economic and political consequences. Riparians of transboundary basins governed by water treaties could experience non-compliance and inter-state tensions if flow falls below levels presumed in a treaty. Flow information is essential to cope with these challenges through water storage, allocation, and use. This paper demonstrates a simple yet robust method, which measures gauge station runoff with wetness values derived from satellite data (1988-2010), for expanding sub-basin stream flow information to the entire river basin where natural flow information is limited. It demonstrates the approach with flow level data that provide estimates of monthly runoff in near real time in two international river basins: Zambezi and Mekong. The paper includes an economic framework incorporating information on existing institutions to assess potential economic and political impacts and to inform policy on conflict and cooperation between riparians. The authors conclude that satellite data modeled with gauge station runoff reduce the uncertainty inherent in negotiating an international water agreement under increased hydrological variability, and thus can assist policy makers to devise more efficient institutional apparatus.Publication Digital Africa(Washington, DC: World Bank, 2023-03-13)All African countries need better and more jobs for their growing populations. "Digital Africa: Technological Transformation for Jobs" shows that broader use of productivity-enhancing, digital technologies by enterprises and households is imperative to generate such jobs, including for lower-skilled people. At the same time, it can support not only countries’ short-term objective of postpandemic economic recovery but also their vision of economic transformation with more inclusive growth. These outcomes are not automatic, however. Mobile internet availability has increased throughout the continent in recent years, but Africa’s uptake gap is the highest in the world. Areas with at least 3G mobile internet service now cover 84 percent of Africa’s population, but only 22 percent uses such services. And the average African business lags in the use of smartphones and computers as well as more sophisticated digital technologies that catalyze further productivity gains. Two issues explain the usage gap: affordability of these new technologies and willingness to use them. For the 40 percent of Africans below the extreme poverty line, mobile data plans alone would cost one-third of their incomes—in addition to the price of access devices, apps, and electricity. Data plans for small- and medium-size businesses are also more expensive than in other regions. Moreover, shortcomings in the quality of internet services—and in the supply of attractive, skills-appropriate apps that promote entrepreneurship and raise earnings—dampen people’s willingness to use them. For those countries already using these technologies, the development payoffs are significant. New empirical studies for this report add to the rapidly growing evidence that mobile internet availability directly raises enterprise productivity, increases jobs, and reduces poverty throughout Africa. To realize these and other benefits more widely, Africa’s countries must implement complementary and mutually reinforcing policies to strengthen both consumers’ ability to pay and willingness to use digital technologies. These interventions must prioritize productive use to generate large numbers of inclusive jobs in a region poised to benefit from a massive, youthful workforce—one projected to become the world’s largest by the end of this century.