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

Determinant factors behind changes in health-seeking behaviour before and after implementation of universal health coverage in Indonesia

Background

The health insurance system in Indonesia was transformed in 2014 to achieve universal health coverage (UHC). The effective implementation of essential primary health services through UHC has resulted in efficient healthcare utilisation, which is reflected in the health-seeking behaviour of the community. Our study aimed to examine the changes in health-seeking behaviour before and after the implementation of UHC in Indonesia and to identify what factors determine these changes.

Methods

We conducted a retrospective cohort study using the recall method and data collected through questionnaire-based interviews in Bandung, Indonesia. We used a two-step sampling technique—randomised sampling and purposive sampling, and a total of 579 respondents with acute or chronic episodes were recruited. \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\chi }^{2}$$\end{document}χ2 tests were used to identify the association between factors. Difference in difference model and a logistic regression model for binary outcomes were used to estimate the effect of the implementation of UHC on the health-seeking behaviour.

Results

Utilisation of public health facilities increased significantly after implementation of UHC, from 34.9% to 65.4% among the respondents with acute episodes and 33.7% to 65.8% among those with chronic episodes. The odds of respondents going to health facilities when they developed an acute episode increased after the implementation of UHC (OR = 1.22, p = 0.05; AOR = 1.42, p < 0.001). For respondents experiencing chronic episodes, the implementation of UHC increased the odds ratio (OR = 1.74, p < 0.001; AOR = 1.64, p < 0.001) that they would use health facilities. Five years after the implementation of UHC, we still found respondents who did not have health insurance (26 and 19 respondents among those with acute episode and chronic episode, respectively).

Conclusions

The effect of the implementation of UHC seemed greater for those experiencing chronic episodes than for those with an acute episode. Although the implementation of UHC has improved utilisation of public health facilities, the presence of people who are not covered by health insurance is a potential problem that could threaten future improvements in healthcare access and utilisation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13142-8.

Health versus other sectors: Multisectoral resource allocation preferences in Mukono district, Uganda

Objectives

To elicit citizen preferences for national budget resource allocation in Uganda, examine respondents’ preferences for health vis-à-vis other sectors, and compare these preferences with actual government budget allocations.

Methods

We surveyed 432 households in urban and rural areas of Mukono district in central Uganda.We elicited citizens’ preferences for resource allocation across all sectors using a best-worst scaling (BWS) survey. The BWS survey consisted of 16 sectors corresponding to the Uganda national budget line items. Respondents chose, from a subset of four sectors across 16 choice tasks, which sectors they thought were most and least important to allocate resources to. We utilized the relative best-minus-worst score method and a conditional logistic regression to obtain ranked preferences for resource allocation across sectors. We then compared the respondents’ preferences with actual government budget allocations.

Results

The health sector was the top ranked sector where 82% of respondents selected health as the most important sector for the government to fund, but it was ranked sixth in national budget allocation, encompassing 6.4% of the total budget. Beyond health, water and environment, agriculture, and social development sectors were largely underfunded compared to respondents’ preferences. Works and transport, education, security, and justice, law and order received a larger share of the national budget compared to respondents’ preferences.

Conclusions

Among respondents from Mukono district in Uganda, we found that citizens’ preferences for resource allocation across sectors, including for the health sector, were fundamentally misaligned with current government budget allocations. Evidence of respondents’ strong preferences for allocating resources to the health sector could help stakeholders make the case for increased health sector allocations. Greater investment in health is not only essential to satisfy citizens’ needs and preferences, but also to meet the government’s health goals to improve health, strengthen health systems, and achieve universal health coverage.

Determinants of healthcare seeking for childhood illnesses among caregivers of under-five children in urban slums in Malawi: a population-based cross-sectional study

BACKGROUND

There is considerable evidence that health systems, in so far as they ensure access to healthcare, promote population health even independent of other determinants. Access to child health services remains integral to improving child health outcomes. Cognisant that improvements in child health have been unevenly distributed, it is imperative that health services and research focus on the disadvantaged groups. Children residing in urban slums are known to face a health disadvantage that is masked by the common view of an urban health advantage. Granted increasing urbanisation rates and proliferation of urban slums resulting from urban poverty, the health of under-five children in slums remains a public health imperative in Malawi. We explored determinants of healthcare-seeking from a biomedical health provider for childhood symptoms of fever, cough with fast breathing and diarrhoea in three urban slums of Lilongwe, Malawi.

METHODS

This was a population-based cross-sectional study involving 543 caregivers of under-five children. Data on childhood morbidity and healthcare seeking in three months period were collected using face-to-face interviews guided by a validated questionnaire. Data were entered in CS-Pro 5.0 and analysed in SPSS version 20 using descriptive statistics and logistic regression analyses.

RESULTS

61% of caregivers sought healthcare albeit 53% of them sought healthcare late. Public health facilities constituted the most frequently used health providers. Healthcare was more likely to be sought: for younger than older under-five children (AOR = 0.54; 95% CI: 0.30-0.99); when illness was perceived to be severe (AOR = 2.40; 95% CI: 1.34-4.30); when the presenting symptom was fever (AOR = 1.77; 95% CI: 1.10-2.86). Home management of childhood illness was negatively associated with care-seeking (AOR = 0.54; 95% CI: 0.36-0.81) and timely care-seeking (AOR = 0.44; 95% CI: 0.2-0.74). Caregivers with good knowledge of child danger signs were less likely to seek care timely (AOR = 0.57; 95% CI: 0.33-0.99).

CONCLUSIONS

Even in the context of geographical proximity to healthcare services, caregivers in urban slums may not seek healthcare or when they do so the majority may not undertake timely healthcare care seeking. Factors related to the child, the type of illness, and the caregiver are central to the healthcare decision making dynamics. Improving access to under-five child health services therefore requires considering multiple factors.

What influences where they seek care? Caregivers' preferences for under-five child healthcare services in urban slums of Malawi: A discrete choice experiment

Access to and utilisation of quality healthcare promotes positive child health outcomes. However, to be optimally utilised, the healthcare system needs to be responsive to the expectations of the population it serves. Health systems in many sub-Saharan African countries, including Malawi, have historically focused on promoting access to health services by the rural poor. However, in the context of increasing urbanisation and consequent proliferation of urban slums, promoting health of children under five years of age in these settings is a public health imperative. We conducted a discrete choice experiment to determine the relative importance of health facility factors in seeking healthcare for childhood illnesses in urban slums of Malawi. Caregivers of children under five years of age were presented with choice cards that depicted two hypothetical health facilities using six health facility attributes: availability of medicines and supplies, thoroughness of physical examination of the child, attitude of health workers, cost, distance, and waiting time. Caregivers were asked to indicate the health facility they would prefer to use. A mixed logit model was used to estimate the relative importance of and willingness to pay (WTP) for health facility attributes. Attributes with greatest influence on choice were: availability of medicines and supplies (β = 0.842, p<0.001) and thorough examination of the child (β = 0.479, p <0.001) with WTP of MK3698.32 ($11) (95% CI: $8–$13) and MK2049.13 ($6) (95% CI: $3–$9) respectively. Respondents were willing to pay 1.8 and 2.4 times more for medicine availability over thorough examination and positive attitude of health workers respectively. Therefore, strengthening health service delivery system through investment in sustained availability of essential medicines and supplies, sufficient and competent health workforce with positive attitude and clinical discipline to undertake thorough examination, and reductions in waiting times have the potential to improve child healthcare utilization in the urban slums.

Econometric analysis to evaluate the effect of community-based health insurance on reducing informal self-care in Burkina Faso

OBJECTIVE

This study examines the role of community-based health insurance (CBHI) in influencing health-seeking behaviour in Burkina Faso, West Africa. Community-based health insurance was introduced in Nouna district, Burkina Faso, in 2004 with the goal to improve access to contracted providers based at primary- and secondary-level facilities. The paper specifically examines the effect of CBHI enrolment on reducing the prevalence of seeking modern and traditional methods of self-treatment as the first choice in care among the insured population.

METHODS

Three stages of analysis were adopted to measure this effect. First, propensity score matching was used to minimize the observed baseline differences between the insured and uninsured populations. Second, through matching the average treatment effect on the treated, the effect of insurance enrolment on health-seeking behaviour was estimated. Finally, multinomial logistic regression was applied to model demand for available health care options, including no treatment, traditional self-treatment, modern self-treatment, traditional healers and facility-based care.

RESULTS

For the first choice in care sought, there was no significant difference in the prevalence of self-treatment among the insured and uninsured populations, reaching over 55% for each group. When comparing the alternative option of no treatment, CBHI played no significant role in reducing the demand for self-care (either traditional or modern) or utilization of traditional healers, while it did significantly increase consumption of facility-based care. The average treatment effect on the treated was insignificant for traditional self-care, modern self-care and traditional healer, but was significant with a positive effect for use of facility care.

DISCUSSION

While CBHI does have a positive impact on facility care utilization, its effect on reducing the prevalence of self-care is limited. The policy recommendations for improving the CBHI scheme's responsiveness to population health care demand should incorporate community-based initiatives that offer attractive and appropriate alternatives to self-care.

How to do (or not to do) ... Designing a discrete choice experiment for application in a low-income country

Understanding the preferences of patients and health professionals is useful for health policy and planning. Discrete choice experiments (DCEs) are a quantitative technique for eliciting preferences that can be used in the absence of revealed preference data. The method involves asking individuals to state their preference over hypothetical alternative scenarios, goods or services. Each alternative is described by several attributes and the responses are used to determine whether preferences are significantly influenced by the attributes and also their relative importance. DCEs are widely used in high-income contexts and are increasingly being applied in low- and middle-income countries to consider a range of policy concerns. This paper aims to provide an introduction to DCEs for policy-makers and researchers with little knowledge of the technique. We outline the stages involved in undertaking a DCE, with an emphasis on the design considerations applicable in a low-income setting.

Implementing Intermittent Preventive Treatment for Malaria in Pregnancy: Review of Prospects, Achievements, Challenges and Agenda for Research

INTRODUCTION: Implementing Intermittent Preventive Treatment for malaria in Pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) through antenatal care (ANC) clinics is recommended for malaria endemic countries. Vast biomedical literature on malaria prevention focuses more on the epidemiological and cost-effectiveness analyses of the randomised controlled trials carried out in selected geographical settings. Such studies fail to elucidate the economic, psychosocial, managerial, organization and other contextual systemic factors influencing the operational effectiveness, compliance and coverage of the recommended interventions. OBJECTIVE: To review literature on policy advances, achievements, constraints and challenges to malaria IPTp implementation, emphasising on its operational feasibility in the context of health-care financing, provision and uptake, resource constraints and psychosocial factors in Africa. RESULTS: The importance of IPTp in preventing unnecessary anaemia, morbidity and mortality in pregnancy and improving childbirth outcomes is highly acknowledged, although the following factors appear to be the main constraints to IPTp service delivery and uptake: cost of accessing ANC; myths and other discriminatory socio-cultural values on pregnancy; target users, perceptions and attitudes towards SP, malaria, and quality of ANC; supply and cost of SP at health facilities; understaffing and demoralised staff; ambiguity and impracticability of user-fee exemption policy guidelines on essential ANC services; implementing IPTp, bednets, HIV and syphilis screening programmes in the same clinic settings; and reports on increasing parasite resistant to SP. However, the noted increase in the coverage of the delivery of IPTp doses in several countries justify that IPTp implementation is possible and better than not. CONCLUSION: IPTp for malaria is implemented in constrained conditions in Africa. This is a challenge for higher coverage of at least two doses and attainment of the Abuja targets. Yet, there are opportunities for addressing the existing challenges, and one of the useful options is the evaluation of the acceptability and viability of the existing intervention guidelines.

Determinants of parental reports of children's illnesses: empirical evidence from Nepal

Household surveys from the developing world consistently record a generally low level of illness reporting, but the evidence that substantial differences exist in illness reporting between income groups is scanty. In contrast, a huge gap in illness reporting exists between rich and poor countries. Medical anthropologists have highlighted the differential illness perception across income groups but little is known as to what extent economic variables do determine one's illness decision. In this paper, discrete choice theory is used to explain why some parents choose to report their children's illnesses more often than others in Nepal. An empirical model is developed that depicts illness-reporting decisions as a function of inter alia, price and income. Data are drawn from Phase I of the Nepal Living Standards Survey. The results suggest that income as well as the price that parents expect to pay on treatment of their children's non-chronic ailments determine their decision to report an illness, when controlling for other variables (price responsiveness =-1.16; income responsiveness=0.23; p-value=0.00). This behaviour is theoretically consistent as parents weigh the opportunity costs of their decision (here, choosing to report an illness). Its implications are broader and raise other questions, e.g., Can we explain the difference in illness-perception rates between rich and poor countries that have different mechanisms to finance health care?

Progress towards early detection services for infants with hearing loss in developing countries

BACKGROUND

Early detection of infants with permanent hearing loss through infant hearing screening is recognised and routinely offered as a vital component of early childhood care in developed countries. This article investigates the initiatives and progress towards early detection of infants with hearing loss in developing countries against the backdrop of the dearth of epidemiological data from this region.

METHODS

A cross-sectional, descriptive study based on responses to a structured questionnaire eliciting information on the nature and scope of early hearing detection services; strategies for financing services; parental and professional attitudes towards screening; and the performance of screening programmes. Responses were complemented with relevant data from the internet and PubMed/Medline.

RESULTS

Pilot projects using objective screening tests are on-going in a growing number of countries. Screening services are provided at public/private hospitals and/or community health centres and at no charge only in a few countries. Attitudes amongst parents and health care workers are typically positive towards such programmes. Screening efficiency, as measured by referral rate at discharge, was generally found to be lower than desired but several programmes achieved other international benchmarks. Coverage is generally above 90% but poor follow-up rates remain a challenge in some countries. The mean age of diagnosis is usually less than six months, even for community-based programmes.

CONCLUSION

Lack of adequate resources by many governments may limit rapid nationwide introduction of services for early hearing detection and intervention, but may not deter such services altogether. Parents may be required to pay for services in some settings in line with the existing practice where healthcare services are predominantly financed by out-of-pocket spending rather than public funding. However, governments and their international development partners need to complement current voluntary initiatives through systematic scaling-up of public awareness and requisite manpower development towards sustainable service capacities at all levels of healthcare delivery.

Building health research systems to achieve better health

Health research systems can link knowledge generation with practical concerns to improve health and health equity. Interest in health research, and in how health research systems should best be organised, is moving up the agenda of bodies such as the World Health Organisation. Pioneering health research systems, for example those in Canada and the UK, show that progress is possible. However, radical steps are required to achieve this. Such steps should be based on evidence not anecdotes. Health Research Policy and Systems (HARPS) provides a vehicle for the publication of research, and informed opinion, on a range of topics related to the organisation of health research systems and the enormous benefits that can be achieved. Following the Mexico ministerial summit on health research, WHO has been identifying ways in which it could itself improve the use of research evidence. The results from this activity are soon to be published as a series of articles in HARPS. This editorial provides an account of some of these recent key developments in health research systems but places them in the context of a distinguished tradition of debate about the role of science in society. It also identifies some of the main issues on which 'research on health research' has already been conducted and published, in some cases in HARPS. Finding and retaining adequate financial and human resources to conduct health research is a major problem, especially in low and middle income countries where the need is often greatest. Research ethics and agenda-setting that responds to the demands of the public are issues of growing concern. Innovative and collaborative ways are being found to organise the conduct and utilisation of research so as to inform policy, and improve health and health equity. This is crucial, not least to achieve the health-related Millennium Development Goals. But much more progress is needed. The editorial ends by listing a wide range of topics related to the above priorities on which we hope to feature further articles in HARPS and thus contribute to an informed debate on how best to achieve such progress.