There is plenty of survey evidence of low quality in the process of care. This relates both to clinical (clinical knowledge, adherence to diagnostic and treatment protocols, etc.) and non-clinical (inter-personal relations) aspects of the process. There is, however, less evidence on he effect of different aspects of the process of care on health outcomes and behavior. An exception in this regard is Peabody, Gertler, and Liebowitz (1998), who use the LSMS Jamaica data to study the relationship between quality and birth weight. While none of the structural measures of quality had a statistically significant effect, they found that women who had access to complete examination (process) had infants that weighed an average of 128g more at birth.

# **Quality and health seeking behavior**

One of the conduits through which health care quality affects health outcomes is client behavior, including both care seeking behavior (utilization of health services) and adherence behavior (i.e., compliance with treatment regimes, follow-up visits and referTals). However, concern with quality was limited in early studies of health care demand. 56 To the extent that health care quality was considered at all, it was treated as an unobserved variable, pertaining to the provider type rather than the individual provider (e.g., Gertler, Locay, and Sanderson 1987; Gertler and van der Gaag 1990). More recently, there have been studies that have used cross-sectional data to examine the effect of a series of structural quality variables on healthseeking behavior.<sup>57</sup> In some of these studies, multicollinearity across quality characteristics and service type prevented the examination of independent impact of each characteristic. Generally, the studies demonstrate a significant and sometimes large statistical correlation between quality and utilization. However, as Gertler and Hammer (1997) note, with the exception of the experimental study by Litvack and Bodart (1993), this may reflect the effect of utilization on pricing and quality policy rather than the other way around.

Researchers have also used facility and household data to study the phenomenon of bypassing - i.e., when patients reject a closer facility in favor of a more distant health care provider. There is only a limited literature on this issue, mostly focusing on the case where households bypass public facilities in favor of the private sector (Akin and Hutchinson 1999; Leonard, Mliga, and Mariam 2000). In large part, this reflects the complexity of the data required to analyze this aspect of health seeking behavior. In general, studies have found that bypassing is associated with facility quality (e.g., number of doctors, drug availability,

> **56** Several contributors (e.g., Akin, et al. 1984; 1986; Litvack and Bodart 1993) have noted that excluding quality from

> the purview of analysis is problematic on methodological grounds. Higher price may simply reflect higher quality, and, insofar as clients are willing to pay for quality, the failure to control for it in estimation of health care demand will result in

> underestimation of the price effect.

> **57** Mwabu and Ainsworth (1993) consider drug availability and staffing; Lavy and Germain (1994) measure the quality of various provider types through drug availability, staffing, infrastructure, and service range; Akin et al. (1995) use operational cost per capita as reported by facility as the preferred proxy for quality, but also consider measures relating to the

> physical conditions of facilities and availability of drugs (percentage of year) to control for differences in efficiency. Litvack

> and Bodart (1993) focus on drugs as the primary component of quality. Although the scope of the study is narrow, **its**

> methodological strength is due to the experimental design.

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