In a previous news blog  we argued that many poor people in cities within low- and middle-income countries (LMICs) bypass local facilities in slums and proceed directly to outpatient departments at local hospitals. They are clearly prepared to trade convenience and time to obtain what they perceive as a superior service. Now it turns out that poor people are, at least in some places, heavier users of health services than rich people. This is because they are less healthy than richer people, do I hear you say? Well, it would appear not. In their outstanding study in New Delhi, Das and Sánchez-Páramo  found that poor people consult more frequently for time-limited single episode diseases than richer people. And they do so despite out-of-pocket payments. What is going on here? Their behaviour is contrary to economic theory, whereby the marginal utility of a service should be less attractive to people with smaller disposable incomes, and this should be particularly the case when utility gain is small. This counter-intuitive finding reminds me of the observation that very poor people will pay for radios or television even while they are still hungry, in direct contradiction of Maslow’s hierarchy of needs.
The authors speculate the reasons for high consulting rates for short duration conditions. They consider the possibility that many short duration conditions are really manifestations of chronic diseases causing short-term complications; boils and thrush in patients with diabetes, etc. This seems unlikely because the gradient in consultation rates between rich and poor people is the same among young and old people, despite the steep gradient in prevalence of chronic disease by age. The authors think the most likely explanation lies in information asymmetry – the poor are less likely to buy their own medicines and this could reflect lower knowledge levels. I have another explanation – that low income and high consultation rates reflect the same latent variable. Some people, according to this theory, have generally less resilient personalities, find it harder to obtain and retain jobs, and are more likely to seek solace in consultation. This is a hard hypothesis to test in cross-sectional studies, but it could be studied in longitudinal studies or possibly using Mendelian randomisation. No-one should interpret any confirmatory findings as victim-bashing – rather the reverse; it provides society an opportunity to demonstrate its caring attitude.
— Richard Lilford, CLAHRC WM Director
- Lilford RJ. A Heretical Suggestion. NIHR CLAHRC West Midlands News Blog. 9 February 2018.
- Das J & Sánchez-Páramo C. Short but not Sweet: New Evidence on Short Duration Morbidities from India. Policy Research Working Paper 2971. Washington, D.C.; World Bank Development Research Group. 2003.