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doi:10.1093/pubmed/fdh207 Advance Access Publication 8 December 2004
Abstract there is tension between the public and the private health sector.
The private health sector tends to serve the affluent; thus the
There is a growing literature on health seeking behaviours
and the determinants of health services utilization especially public sector resources should be freed for the poor. A dynamic
in the context of developing countries. However, very few cooperation, either formal or informal, between the two sectors
The Author 2005, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.
50 JOURNAL OF PUBLIC HEALTH
rural part of the country,15 poverty coupled with illiteracy, the Given the complex nature of the health care delivery system
low status of women and inadequate water and sanitation facil- in Pakistan and the limited resources available to the health
ities have had a deep impact on health indicators.16 Beside lim- care sector, it is essential for the various sectors to plan and
ited knowledge of illness and wellness, cultural prescriptions,17 work together to improve the health of Pakistanis. Thus it is
perceptions of a health service and provider and social barriers, important to understand the health seeking behaviour of the
cost has been a major barrier to the provision of an effective population and the factors driving this behaviour.
health service.18 This has affected the physical and financial
accessibility of the health services.
The health care system in Pakistan comprises the public as Factors affecting health seeking behaviour
well as private health facilities. In the public sector, under the
A variety of factors have been identified as the leading causes of
Devolution Plan of the Government of Pakistan in 2000,19 the
poor utilization of primary health care services: including poor
districts have been given comprehensive administrative as well
socio-economic status, lack of physical accessibility, cultural
as financial autonomy in almost all sectors, including health.
beliefs and perceptions, low literacy level of the mothers and large
The districts are now responsible for developing their own
family size. Review of the global literature suggests that these fac-
strategies, programmes and interventions based on their locally
tors can be classified as cultural beliefs, socio-demographic status,
generated data and needs identified. Following the principles of
womens autonomy, economic conditions, physical and financial
Alma Alta, the public health care system is primary care
accessibility, and disease pattern and health service issues.26
focused. At the community level, the Lady Health Worker
Each group of factors is considered separately in the follow-
status of women prevents them from recognizing and voicing with the dearth of transportation and with poor roads, which
their concerns about health needs. Women are usually not contributes towards increase costs of visits.22,56,57 Availability
allowed to visit a health facility or health care provider alone or of the transport, physical distance of the facility and time taken
to make the decision to spend money on health care. Thus to reach the facility undoubtedly influence the health seeking
women generally cannot access health care in emergency situa- behaviour and health services utilization.4,6,18,27,58 The distance
tions.35 This certainly has severe repercussions on health in separating patients and clients from the nearest health facility
particular and self-respect in general of the women and their has been remarked as an important barrier to use, particularly
children. Despite the fact that women are often the primary in rural areas.59 The long distance has even been a disincentive
care givers in the family, they have been deprived of the basic to seek care especially in case of women who would need some-
health information and holistic health services.44 In Pakistan, body to accompany. As a result, the factor of distance gets
having a subjugated position in the family, women and children strongly adhered to other factors such as availability of transport,
need to seek the permission of head of the household or the total cost of one round trip and womens restricted mobility.
men in the family to go to health services.4,43,46 Women are
socially dependent on men and lack of economic control rein- Health services and disease pattern
forces her dependency.17 The community and the family as The under-utilization of the health services in public sector has
institutions have always undermined her prestige and recogni- been almost a universal phenomenon in developing countries.
tion in the household care. The prevailing system of values pre- On the other hand, the private sector has flourished everywhere
serves the segregation of sexes and confinement of the women because it focuses mainly on public health goods such as ante-
and patient satisfaction with the treatment play a role in health providers seem imperative.71,77 A comprehensive health care
seeking behaviour.6,9-11 system has to focus on the 66 per cent of rural people who are
the poorest of the poor and who become visible only when pro-
grammes are signed with international donors. A more coordi-
Conclusion nated effort in designing behavioural health promotion
To develop rational policy to provide efficient, effective, accept- campaigns through inter-sectoral collaboration78 focusing more
able, cost-effective, affordable and accessible services, we need on disadvantaged segments of the population (i.e. women, chil-
to understand the drivers of health seeking behaviour of the popu- dren and elderly would be step towards improvement). If a
lation in an increasingly pluralistic health care system. This health service is to work, it must start from what users need.
relates both to public as well as private sectors. This paper has described the general situation vis--vis
Raising the socio-economic status through multi-sectoral health seeking behaviour and health service utilization in devel-
development activities such as womens micro-credit, life-skill oping countries, presenting a special accent on Pakistan. With
training and non-formal education have been shown to have a the advent of decentralization in Pakistan,19 policy is formu-
positive impact on health seeking behaviour, morbidity and lated at the district level. Therefore, policy makers must under-
mortality besides the overall empowerment of women popula- stand health behaviours and health care use at the district level,
tion.72,73 Gender sensitive strategies and programmes need to be and give enough credence to these facts so that policies could be
developed. Health providers also need to be sensitized more designed appropriately. In-depth research is imperative to visu-
towards the needs of the clients especially the women to alize the real picture of the habits and practices of the people of
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