FRIEDRICH-EBERT-STIFTUNG – A majority working in the shadows 2 USE OF MEDICAL CARE: HOW PEOPLE IN INFORMAL EMPLOYMENT RATE ACCESS TO HEALTH SERVICES Rudolf Traub-Merz and Manfred Öhm 2.1 INTRODUCTION Health protection is a key pillar of social protection. Access to health care is a fundamental human need, and having access to health services when needed is – as we show in this chap­ter – of paramount importance. The informally employed, representing the large majority of employers, employees and own-account workers in all six surveyed countries, expect their governments to improve access to health care systems, citing it as their top priority among improvements in state services. The central concern of government health policies should be to establish a system of medical care that is accessible to all who are sick and need treatment. Accessibility to medi­cal services is determined by supply and demand. Without going into detail, access to health 1 is a multidimensional concept and can be measured along three main dimensions: (a) availability of medical services: services should exist in sufficient quality and quantity where they are needed;(b) affordability: the extent to which people are able to pay for medical care – if health care is provided for a fee and charges are above what poorer segments in society can afford, med­ical care may be materially available but remain financially inaccessible;(c) acceptability: measures the extent to which a medical service meets a community’s cultural needs and expectations. Within this framework, access combines the availability of health care with the capacity to pay for it and culturally accepted health norms. Some aspects of access are supply factors, while others reflect the societal conditions of demand. This chapter looks at the use of medical care by the infor­mally employed. In this chapter we do not assess how satis­fied patients are with the services they receive when visiting medical facilities. Instead, we inquire how important it is for people to have access to good health services and how often they go for medical care. We begin with an assessment of the extent to which medical care is available when needed. The views of respondents are examined in terms of location, income, age and gender. A picture is established concerning the extent to which the use of medical care is determined by 1»Access to health« is a term that goes beyond access to health ser­vices, and also includes the availability of clean water and healthy food. socio-economic disparities. The study then looks at respond­ents’ needs hierarchies. By asking respondents to prioritize from a list of state services we are able to build up a ranking according to urgency. From there we are able to show how respondents adjust their needs hierarchies in relation to the intensity with which they use medical care. While no detailed analysis is provided on the availability of medical services, some supply indicators are nevertheless considered which show that the demand for better health services is inversely related to the availability of medical care. 2.2 USE OF MEDICAL CARE To assess the openness of a health care system and obtain an understanding of the barriers that may prevent resort to medical treatment, we asked interviewees about the fre­quency with which they were able to access medical care. 2 The question was phrased as follows:»Over the past year, how often, if ever, have you or anyone in your family gone without medicine or medical treatment?« 3 4 The question referred not to the respondent alone but in­cluded all members of their family. The question does not ask about the frequency of illness or the number of visits or non-visits to medical facilities. Instead, it asked interviewees to weight the incidence of their need for treatment and whether they in fact received treatment. We thus obtain testimony of the respondent’s impression of whether medical care was available when needed. Respondents could voice their opinion on the actual number of cases of treatment or just articulate a gut feeling. Either way, the question casts light on their perceptions: do people believe that they are able to use health services when needed? 2 We limit our analysis here to only one aspect in evaluating the use of medical services. A more detailed paper that looks at the assessment of quality of services and compares public with private health facilities will be published at a later stage. 3 This question is part of a five-sequence question that includes food, clean water, cooking fuel and cash income and is used to construct an index for lived poverty. We follow here the AfroBarometer(AB) ap­proach and acknowledge the work of AB in this area. 4 In our data analysis, we include only households that in response to another question reported cases of sickness over the past 12 months. The answers from households with no cases of sickness were ignored. See Appendix Table 2 for cases. 8