Utilization of health services in developing countries—Tunisia

This paper is based on a WHO study on determinants of utilization of government health services in a province of Tunisia (Governorate of Nabeul). Seven study areas were selected which were considered typical both of different types of health facilities and of towns and rural settings in the province. In these study areas, an interview survey of a sample of households was undertaken and the data gathered from the survey were linked to available medical records for the 3808 members of the 678 households studied. The most striking finding of the study was the much greater use of ambulatory care services by urban than by the rural populations studied. It is argued that this rural/urban differential is a result both of differences among the populations and of differences in technical sophistication of and accessibility to rural and urban health centres. In general, utilization of health services by the study group was low when compared with rates reported in most developed countries. Most persons used the health services only once or twice for a given episode of illness, and the great preponderance of diagnoses made were for acute illnesses, especially the common communicable diseases. It is also shown that when the population is grouped according to categories of respondents from high- and low-user families, a number of contrasting demographic, socio-cultural and economic characteristics, and attitudes tend to differentiate these groups (in both urban and rural areas). Among characteristics more likely to be exhibited by respondents from high-user households are: indicators of literacy and language ability, use of mass media, socio-economic participation, type of occupation and employment status, and positive attitudes towards the health services including health personnel and towards disease prevention. The applicability of analyses of determinants of utilization in developed countries to the situation of developing countries such as Tunisia is discussed. On this basis, a framework for further study is developed which focuses upon modernization as the key predictor of use of health services in developing countries. Some implications and related practical recommendations for better management of the health care delivery system in the studied area are also discussed.