Factors affecting decisions to seek treatment for sick children in Kerala, India

Caste and maternal health care service use among rural Hindu women in Maitha, Uttar Pradesh, India

The objective of this study was to examine the association between caste and maternal health care service use among rural Hindu women in India. We analyzed data from the Morbidity and Performance Assessment, a population-based cross-sectional study, for 482 Hindu women who were pregnant during January 1998 to January 1999 in Maitha, Uttar Pradesh, India. Maternal health care service use among both upper and lower caste women was very low. Upper caste women were almost three times more likely to use antenatal care (odds ratio [OR] = 2.72; 95% confidence interval [CI], 1.40-5.30), tetanus toxoid (OR = 2.50; 95% CI, 1.48-4.21), and contraceptives (OR = 2.66; 95% CI, 1.28-5.54) and almost five times (OR = 4.77; 95% CI, 1.81-12.54) more likely to have a trained birth attendant compared to the lower caste women. Caste was a significant determinant of tetanus toxoid use and trained birth attendant even after adjusting for sociodemographic factors. Besides caste, maternal literacy was the one sociodemographic factor that was significantly associated with the use of all maternal health care services. Information dissemination and awareness generation can improve the use of subsidized maternal health care services among women of all caste groups.

The effect of wealth status on care seeking and health expenditures in Afghanistan

This paper analyses the effect of wealth status on care-seeking patterns and health expenditures in Afghanistan, based on a national household survey conducted within public health facility catchment areas. We found high rates of reported care-seeking, with more than 90% of those ill seeking care. Sick individuals from all wealth quintiles had high rates of care-seeking, although those in the wealthiest quintile were more likely to seek care than those from the poorest (odds ratio 2.2; 95% CI 1.6, 3.0). The nearest clinic providing the government's Basic Package of Health Services (BPHS) was the most commonly sought first provider (53% overall), especially for relatively poor households (62% in poorest vs. 42% in least poor quintile, P < 0.0001). Sick individuals from wealthier quintiles used hospitals and for-profit private providers more than those in poorer quintiles. Multivariate analysis showed that wealth quintile was the strongest predictor of seeking care, and of going first to private providers. More than 90% of those seeking care paid money out-of-pocket. Mean (median) expenditures among those paying for care in the previous month were 873 Afghanis (200 Afghanis), equivalent to US$17.5 (US$4). Expenditures were lowest at BPHS clinics and highest at private providers. Financing care through borrowing money or selling assets/land ('any distress' financing) was reported in nearly 30% of cases and was almost twice as high among households in the poorest versus the least poor quintile (P < 0.0001). Financing care through selling assets/land ('severe distress' financing) was less common (10% overall) and did not differ by wealth status. These findings indicate that BPHS facilities are being used by the poor who live close to them, but further research is needed to assess utilization among populations in more remote areas. The high out-of-pocket health expenditures, particularly for private sector services, highlight the need to develop financial protection mechanisms in Afghanistan.

Information for decision making from imperfect national data: tracking major changes in health care use in Kenya using geostatistics

BACKGROUND

Most Ministries of Health across Africa invest substantial resources in some form of health management information system (HMIS) to coordinate the routine acquisition and compilation of monthly treatment and attendance records from health facilities nationwide. Despite the expense of these systems, poor data coverage means they are rarely, if ever, used to generate reliable evidence for decision makers. One critical weakness across Africa is the current lack of capacity to effectively monitor patterns of service use through time so that the impacts of changes in policy or service delivery can be evaluated. Here, we present a new approach that, for the first time, allows national changes in health service use during a time of major health policy change to be tracked reliably using imperfect data from a national HMIS.

METHODS

Monthly attendance records were obtained from the Kenyan HMIS for 1 271 government-run and 402 faith-based outpatient facilities nationwide between 1996 and 2004. A space-time geostatistical model was used to compensate for the large proportion of missing records caused by non-reporting health facilities, allowing robust estimation of monthly and annual use of services by outpatients during this period.

RESULTS

We were able to reconstruct robust time series of mean levels of outpatient utilisation of health facilities at the national level and for all six major provinces in Kenya. These plots revealed reliably for the first time a period of steady nationwide decline in the use of health facilities in Kenya between 1996 and 2002, followed by a dramatic increase from 2003. This pattern was consistent across different causes of attendance and was observed independently in each province.

CONCLUSION

The methodological approach presented can compensate for missing records in health information systems to provide robust estimates of national patterns of outpatient service use. This represents the first such use of HMIS data and contributes to the resurrection of these hugely expensive but underused systems as national monitoring tools. Applying this approach to Kenya has yielded output with immediate potential to enhance the capacity of decision makers in monitoring nationwide patterns of service use and assessing the impact of changes in health policy and service delivery.

Insular pathways to health care in the city: a multilevel analysis of access to hospital care in urban Kerala, India

OBJECTIVES

To identify individual and urban unit characteristics associated with access to inpatient care in public and private sectors in urban Kerala, and to discuss policy implications of inequalities in access.

METHODS

We analysed the NSSO survey (1995-1996) for urban Kerala with regard to source and trajectories of hospitalization. Multinomial multilevel regression models were built for 695 cases nested in 24 urban units.

RESULTS

Private sector accounts for 62% of hospitalizations. Only 31% of hospitalizations are in free wards and 20% of public hospitalizations involve payment. Hospitalization pathways suggest a segmentation of public and private health markets. Members of poor and casual worker households have lower propensity of hospitalization in paying public wards or private hospitals. There were important variations between cities, with higher odds of private hospitalization in towns with fewer hospital beds overall and in districts with high private-public bed ratios. Cities from districts with better economic indicators and dominance of private services have higher proportion of private hospitalizations.

CONCLUSIONS

The private sector is the predominant source of inpatient care in urban Kerala. The public sector has an important role in providing access to care for the poor. Investing in the quality of public services is essential to ensure equity in access.

Affording what's free and paying for choice: comparing the cost of public and private hospitalizations in urban Kerala

OBJECTIVE

To assess the cost of public and private hospitalizations in urban Kerala and discuss policy implications of social disparities in the economic burden of hospital care.

METHODS

The NSSO survey on health care (1995-1996) for urban Kerala was analysed with regards to expenditure incurred by hospital episodes. Multilevel linear models were built to assess factors associated with levels of health expenditure.

FINDINGS

Hospital care involves paying admission fees in 68% of cases of hospitalizations (98% in private and 20% in public sector) in urban Kerala. Poor households and those headed by casual workers show significantly lower levels of health expenditure and a higher proportion of health-related loss of income than other social groups. Although there is significant expenditure in both sectors for these groups, hospitalization on free public wards is associated with lower expenditure than other options. Factors linked with higher expenditure are: duration of stay; hospitalizations on paying public wards and in the private sector; hospitalizations for above poverty line households and hospitalizations for chronic illnesses. Expenditure for services bought from outside the hospital is important in the public sector.

CONCLUSION

Hospitalization incurs significant expenditure in urban Kerala. Greater availability of free medical services in the public sector and financial protection against the cost of hospitalization are warranted.

Childhood diarrhoea management practices in Bangladesh: private sector dominance and continued inequities in care

BACKGROUND

Monitoring for disparities in health and services received based upon gender, income, and geography should continue as renewed efforts to reduce under-five mortality are made in response to millennium development goal #4. The purpose of this survey was to provide a nationally representative description of current childhood diarrhoea management practices and disparities in Bangladesh.

METHODS

A nationally representative, cross-sectional, cluster-sample survey was carried out in randomly selected rural and urban populations across Bangladesh. The survey was completed over an 8 month period between November 2003 and June 2004.

RESULTS

A total of 7308 children with a prevalent diarrhoeal illness episode within 560 clusters were identified and enrolled in the survey. In 61% of the cases help was sought from a health care provider, with over 90% practicing in the private sector. Caretaker practice disparities favouring males and higher income households were identified. Significant trends (P < 0.001) favouring higher income households were found for having sought help from any provider or a licensed doctor and for treating their child with oral rehydration solution or an antibiotic. Female children in urban households were less likely to be seen by a licensed allopath, adj OR 0.73 (95% CI 0.57, 0.94). Among rural households gender disparities were limited to females being less likely to receive an antibiotic, adj OR 0.74 (95% CI 0.65, 0.86).

CONCLUSION

Households seeking help from a health provider overwhelmingly utilize the private sector in Bangladesh. Gender inequities in the utilization of licensed providers and purchase of antibiotics, favouring males were identified. Findings suggest that higher income, urban households tend to practice greater gender discrimination. In order to better understand health dynamics in urban populations, in particular slum-dwellers, there is a need to disaggregate survey data by household location.

Care seeking behaviour for childhood illness--a questionnaire survey in western Nepal

BACKGROUND

The World Health Organization estimates that seeking prompt and appropriate care could reduce child deaths due to acute respiratory infections by 20%. The purpose of our study was to assess care seeking behaviour of the mothers during childhood illness and to determine the predictors of mother's care seeking behaviour.

METHODS

A cross-sectional survey was conducted in the immunization clinics of Pokhara city, Kaski district, western Nepal. A trained health worker interviewed the mothers of children suffering from illness during the preceding 15 days.

RESULTS

A total of 292 mothers were interviewed. Pharmacies (46.2%) were the most common facilities where care was sought followed by allopathic medical practitioners (26.4%). No care was sought for 8 (2.7%) children and 26 (8.9%) children received traditional/home remedies. 'Appropriate', 'prompt' and 'appropriate and prompt' care was sought by 77 (26.4%), 166 (56.8%) and 33 (11.3%) mothers respectively. The mothers were aware of fever (51%), child becoming sicker (45.2%) and drinking poorly (42.5%) as the danger signs of childhood illness. By multiple logistic regression analysis total family income, number of symptoms, mothers' education and perceived severity of illness were the predictors of care seeking behaviour.

CONCLUSION

The results of the present study show that the mothers were more likely to seek care when they perceived the illness as 'serious'. Poor maternal knowledge of danger signs of childhood illness warrants the need for a complementary introduction of community-based Integrated Management of Childhood Illness programmes to improve family's care seeking behaviour and their ability to recognize danger signs of childhood illness. Socioeconomic development of the urban poor may overcome their financial constraints to seek 'appropriate' and 'prompt' care during the childhood illness.

Scaling up health interventions in resource-poor countries: what role does research in stated-preference framework play?

Despite improved supply of health care services in low-income countries in the recent past, their uptake continues to be lower than anticipated. This has made it difficult to scale-up those interventions which are not only cost-effective from supply perspectives but that might have substantial impacts on improving the health status of these countries. Understanding demand-side barriers is therefore critically important. With the help of a case study from Nepal, this commentary argues that more research on demand-side barriers needs to be carried out and that the stated-preference (SP) approach to such research might be helpful. Since SP techniques place service users' preferences at the centre of the analysis, and because preferences reflect individual or social welfare, SP techniques are likely to be helpful in devising policies to increase social welfare (e.g. improved service coverage). Moreover, the SP data are collected in a controlled environment which allows straightforward identification of effects (e.g. that of process attributes of care) and large quantities of relevant data can be collected at moderate cost. In addition to providing insights into current preferences, SP data also provide insights into how preferences are likely to respond to a proposed change in resource allocation (e.g. changing service delivery strategy). Finally, the SP-based techniques have been used widely in resource-rich countries and their experience can be valuable in conducting scaling-up research in low-income countries.

Understanding the relationship of maternal health behavior change and intervention strategies in a Nicaraguan NGO network

Few studies of community interventions examine independent effects of investments in: (1) capital (i.e., physical, human and social capital), and (2) management systems (e.g., monitoring and evaluation systems (M&E)) on maternal and child health behavior change. This paper does this in the context of an inter-organizational network. In Nicaragua, international non-governmental organizations (NGOs) and local NGOs formed the NicaSalud Federation. Using Lot Quality Assurance Sampling (LQAS), 14 member organizations took baselines measures of maternal safe motherhood and child health behavior indicators during November 1999 and August 2000, respectively, and final evaluation measures in December 2001. In April 2002, retrospective interviews were conducted with supervisors and managers in the 14 organizations to explore changes made to community health strategies, factors associated with the changes, and impacts they attributed to participating in NicaSalud. Physical capital (density of health huts), human capital (density and variety of paramedical personnel) and social capital (density of health committees) were associated with pregnant women attending antenatal care (ANC) 3+ times, and/or retaining ANC cards. The variety of paramedic personnel was also associated with women making post-partum visits to clinics. Physical capital (density of health huts) and social capital (density of health committees and mothers' clubs) were associated with child diarrhea case management indicators. One safe motherhood indicator (delivery of babies by a clinician) was not associated with intervention strategies. At the management level, NicaSalud's training of members to use LQAS for M&E was associated with the number of strategic and tactical changes they subsequently made to interventions (organizational learning). Organizational learning was related to changes in maternal and child health behaviors of the women (including changes in the proportion using post-partum care). As the latter result would not have occurred without NicaSalud, we conclude that this inter-organizational network provided added value by instigating organizational learning.

Gender role and child health care utilization in Nepal

OBJECTIVE

To study the gender role in child health care utilization in Nepal.

METHODS

We analysed 8112 individual observations of age </=15 years from 2847 households in 274 communities, obtained from the 1996 Nepal Living Standard Survey. Four steps of a health seeking action, namely illness reporting, choosing an external care, choosing a specific health care provider, and spending money to treat the sick child, were examined using discrete/continuous choice models.

RESULTS

There was no statistically significant difference between boys and girls by demographic, socio-economic and geographical status in the sample. However, gender was associated with all four utilization decision steps. While the net effect of being a boy was modest in illness reporting (p<0.10), it appeared stronger in the choice of external care, in the choice of public provider and in the choice of expenditure with the private provider (p<0.05).

CONCLUSION

Gender role not only affects illness reporting but also affects the decision to choose a health care provider and how much to spend on the sick child, i.e. it affects the entire steps of a health seeking action.

Determinants of health care seeking for childhood illnesses in Nairobi slums

The practice of appropriate health seeking has a great potential to reduce the occurrence of severe and life-threatening child illnesses. We assessed the influence of socio-demographic, economic and disease-related factors in health care seeking for child illnesses among slum dwellers of Nairobi, Kenya. A survey round of the Nairobi Urban Demographic Surveillance System (NUDSS) generated information on 2-week child morbidity, illness symptoms, perceived illness severity and use of modern health services. During this round of data collection, interviewers visited a total of 15,174 households, where 3015 children younger than 5 years lived. Of the 999 (33.1%) children who were reported to have been sick, medical care of some sort was sought for 604 (60.5%). Lack of finances (49.6%) and a perception that the illness was not serious (28.1%) were the main reasons given for failure to seek health care outside the home. Health care seeking was most common for sick children in the youngest age group (0-11 months). Caretakers sought medical care more frequently for diarrhoea symptoms than for coughing and even more so when the diarrhoea was associated with fever. Perception of illness severity was strongly associated with health care seeking. Household income was significantly associated with health care seeking up to certain threshold levels, above which its effects stabilized. Improving caretaker skills to recognize danger signs in child illnesses may enhance health-seeking behaviour. Integrated Management of Child Illnesses (IMCI) programmes must be accessible free of charge to the urban poor in order to increase health care seeking and bring about improvements in child survival.

The effect of maternal education on gender bias in care-seeking for common childhood illnesses

This paper assessed gender bias within hospitalisation rates to ascertain whether differential care-seeking practices significantly contribute to excess female mortality. It then examined the impact of socio-economic factors, particularly maternal education and economic status, on gender bias. The results find both the clear and significant impact of gender on hospitalisation rates, as well as the simultaneous inability of rising education and economic status to alleviate this bias. A secondary analysis was conducted within a uniquely large and ongoing randomised control trial that sought to measure the impact of Zinc supplementation on hospitalisations and deaths in low-income communities in New Delhi, India. During the course of the study, 85,633 children were enrolled and monitored over one year of follow-up. Of the 430 deaths that occurred, 230 were female (0.57% of total females), while 200 were male (0.43% of all males). Despite this higher mortality amongst females (p<0.02), girls were hospitalised far less frequently than boys. Of the 4418 children who were hospitalised at least once, 2854 (64.6%) were males and only 1564 (35.4%) were females, indicating a significantly lower rate of care-seeking for females (p<0.00). Curiously, our results show that gender bias is highest amongst highly educated mothers, and decreases steadily for children of mothers with a middle school education, a primary school education, and is lowest amongst mothers with no formal education. Put differently, female children of mothers with no formal education were significantly more likely to be hospitalised than children of mothers with several years of formal education, even after adjusting for all other factors. Economic status was not found to affect the association of gender and hospitalisation, though overall odds of hospitalisation rose with increasing economic status. Paternal education was found not to be significantly related to hospitalisation.

Gender inequality, family planning, and maternal and child care in a rural Chinese county

This study examines the determinants of prenatal and obstetric care utilization within the context of recent social and economic changes in contemporary rural China. The aim of this study is to test the general hypothesis that gender inequality (women's status and son preference) and the state's family planning policy have a significant influence on maternal and childcare utilization. Both qualitative and quantitative data from a field survey in 1994 in rural Yunnan were used in the study. The findings lend support to this hypothesis. For example, the extent to which the husband shares housework and childcare, as an important marker of rural Chinese women's position within the family, is positively associated with the likelihood that a woman receives prenatal examinations, stops heavy physical work before birth, and gives birth under aseptic conditions. Also, a woman's exposure to the larger world beyond the village increases her chances of giving birth with the assistance of a doctor or health worker. Son preference is an impeding factor for maternal and child health care utilization. Already having a son in the family reduces the chances that the mother will stop heavy physical work before birth for a subsequent pregnancy. Female infants with older sisters are the least likely to receive immunizations. Women with "outside the plan" pregnancies are less likely than those with "approved" pregnancies to receive prenatal examinations, to stop strenuous work before birth, and to deliver under aseptic conditions. Thus, the study provides further evidence that the family planning policy has a negative impact on women and their families, whose fertility and son preferences conflict with the birth control policy.