Government Primary Health Care Research Articles

Out-of-pocket payments for under-five health care in rural southern Tanzania

Catastrophic payments and fairness in financial contributions for health care are becoming increasing concerns for many governments. Out-of-pocket financing for health care is common in many developing countries, including Tanzania. As part of the Multi-Country Evaluation of the Integrated Management of Childhood Illness (MCE-IMCI), the objective of this paper is to explore the determinants of variation and the level of out-of-pocket payments for child health care in rural Tanzania, with and without IMCI, using data from two household surveys conducted in 1999 and 2002. We analyzed data for 833 visits to health providers for 764 children who had been sick in the 2 weeks prior to the survey and who had sought care at a 'Western' or formal health care provider. We found evidence that IMCI was associated with lower out-of-pocket costs at government facilities (Tshs.3.5 compared with Tshs.6.9 without IMCI) and in NGOs (Tshs.95.1 compared with Tshs.267.3). Out-of-pocket payments were on average Tshs.110.1 when care was sought at government primary health care facilities running a cost-sharing scheme, about 15 times higher than in those not part of the scheme (p<0.0001). Those who visited NGO facilities paid about 30 times more than those seeking care at government facilities not operating the cost-sharing scheme (p<0.0001). In conclusion, there is no doubt that health care financing mechanisms and equitable access to government facilities have a major impact on household economic burden related to under-five illness. Increasing access to IMCI-based care, however, offers an additional opportunity to reduce out-of-pocket payments, mainly through more rational use of medicines. Increasing access to IMCI-based care would not only improve inequities in financial contributions, but also in health, an important consideration for its own sake.

Out-of-pocket payments and utilization of health care services in Albania: Evidence from three districts

Like most countries in Central and Southeastern Europe, Albania is currently considering a number of alternative health sector reform strategies to improve the availability, quality and use of primary health care services. However, in order to assess the likely success of such reforms, more needs to be known about the current levels, distribution and determinants of household out-of-pocket spending on health. The purpose of this paper is to use the 2002 Albania Baseline Health Survey, a survey of 2000 households in Berat, Kucova, and Fier, to understand the magnitude and distribution of out-of-pocket payments for health care services and to identify the factors that operate at the household- and provider-levels that determine whether individuals pay for health care and how much is paid within the month prior to the survey. Of particular interest in the study is examining the extent to which households incur out-of-pocket payments across a number of dimensions—including health insurance status, socio-economic status (SES), type of service, and type of facility. The findings suggest that out-of-pocket payments for care provided in government facilities are widespread, with marked differences in payment practices between inpatient and outpatient care. For outpatients using Primary Health Centers (PHCs), the type of facility that is the focus of the government's primary health care program, average payments appear to be nominal (0.6% of estimated total monthly household expenditure per capita). The multivariate findings indicate that insurance coverage significantly reduces the likelihood of paying for medicines to treat acute and chronic health problems, but not of paying for consultations. The policy implications of the findings on alternative health care financing reforms are briefly discussed.

Sick leave certification: an unwelcome administrative burden for the family doctor? The role of sickness certification in Maltese family practice

Introduction: In Malta, sickness certificates are needed from the first day of illness, and are issued by family doctors (FDs) either employed in the government primary healthcare system, or self-employed in private practice, or employed directly by an employer for this purpose alone. Patients visiting self-employed FDs pay directly, and are not reimbursed unless privately insured. We aimed to contribute to die discussion on die impact of sickness certification in family practice by studying the phenomenon using electronic data from an electronic patient record (EPR) used by self-employed FDs. We used this data to study the frequency of sickness certification and the relationship between the patient's reason for encounter, with or without a formal request for a certificate, and the doctor's diagnosis and certification practice.Methods: We used data collected by FDs in day-to-day private family practice using an episode-oriented EPR. The EPR database included all encounters in all episodes of care over a period of one year (1 January to 31 December 2001) documented by ten self-employed FDs, comprehensively coded with ICPC-2-E (Electronic Version of the International Classification of Primary Care, version 2).Results: The EPR database documented care for 7497 patients (45.4% male) over one year. During 15,781 encounters, sickness certificates were issued in 11.3% of 16,319 episodes of care. 5.7% of the reasons for encounter presented by the patient in new episodes were requests for administrative procedures, and this request was made in 8.2% of all new episodes of care.Conclusion: The distribution of morbidity seen by the FDs appeared to be very wide, with a dominance of acute respiratory, gastrointestinal and musculoskeletal symptoms and diagnoses, and the role of sickness certification was quite important. The frequency of sick leave certification in Malta is comparable with that in other European countries, but the average duration of episodes is shorter. Just over 11% of private FD encounters involve issuing a sickness certificate. The high proportion of reasons for encounter formulated as a request for a sickness certificate suggests that the active role of FDs in this form of social security in the Maltese population has supported the local development of family practice.

Care for perinatal illness in rural Nepal: a descriptive study with cross-sectional and qualitative components.

BackgroundMaternal, perinatal and neonatal mortality rates remain high in rural areas of developing countries. Most deliveries take place at home and care-seeking behaviour is often delayed. We report on a combined quantitative and qualitative study of care seeking obstacles and practices relating to perinatal illness in rural Makwanpur district, Nepal, with particular emphasis on consultation strategies.MethodsThe analysis included a survey of 8798 women who reported a birth in the previous two years [of whom 3557 reported illness in their pregnancy], on 30 case studies of perinatal morbidity and mortality, and on 43 focus group discussions with mothers, other family members and health workers.ResultsEarly pregnancy was often concealed, preparation for birth was minimal and trained attendance at birth was uncommon. Family members were favoured attendants, particularly mothers-in-law. The most common recalled maternal complications were prolonged labour, postpartum haemorrhage and retained placenta. Neonatal death, though less definable, was often associated with cessation of suckling and shortness of breath. Many home-based care practices for maternal and neonatal illness were described. Self-medication was common.There were delays in recognising and acting on danger signs, and in seeking care beyond the household, in which the cultural requirement for maternal seclusion, and the perceived expense of care, played a part. Of the 760 women who sought care at a government facility, 70% took more than 12 hours from the decision to seek help to actual consultation. Consultation was primarily with traditional healers, who were key actors in the ascription of causation. Use of the government primary health care system was limited: the most common source of allopathic care was the district hospital.ConclusionsMajor obstacles to seeking care were: a limited capacity to recognise danger signs; the need to watch and wait; and an overwhelming preference to treat illness within the community. Safer motherhood and newborn care programmes in rural communities, must address both community and health facility care to have an impact on morbidity and mortality. The roles of community actors such as mothers-in-law, husbands, local healers and pharmacies, and increased access to properly trained birth attendants need to be addressed if delays in reaching health facilities are to be shortened.

Sick leave certification: a unique perspective on frequency and duration of episodes - a complete record of sickness certification in a defined population of employees in Malta.

BackgroundIn Malta, sickness certificates are needed from the first day of illness, and are issued by family physicians (FPs) either employed by the government primary health care system, self-employed in private practice, or employed by an employer for this purpose alone. The latter system, when applied by the employer, is compulsory. In order to contribute to the debate on the role of the FP in this context, electronic data collected by a group of company-employed FPs was used to study the phenomenon of sickness certification. This database is a complete record of the selected employees' sick leave certification during the study period.MethodsData collected by company-employed FPs from a defined population was used: all employees of selected Maltese companies served by a group of FPs. The database included episode-based data from home visits over three years (01/01/1997 – 31/12/1999), by 9 company-appointed FPs regarding 421 employees of five companies.Results3015 episodes of sickness absenteeism, with an average duration of 2.9 days, were documented. Employees who did intensive manual work had relatively higher rates. Furthermore, a relatively higher incidence of work injury, sprains and strains, anxiety and depression and low back pain as found in manual workers, and in male workers. This trend was shown to be statistically significant.ConclusionsThe frequency of sick-leave certification in Malta is comparable to that in other European countries, but the average duration of certificates is much less than reported in other studies that generally did not include data on short-term illness and certification. This has important implications on future research in the field. A number of common disorders were found to be significantly more prevalent causes of sickness certification in manual workers, amongst them anxiety and depression.

Integration of mental health care into primary care. Demonstration cost-outcome study in India and Pakistan.

Targeting resources on cost-effective care strategies is important for the global mental health burden. To demonstrate cost-outcome methods in the evaluation of mental health care programmes in low-income countries. Four rural populations were screened for psychiatric morbidity. Individuals with a diagnosed common mental disorder were invited to seek treatment, and assessed prospectively on symptoms, disability, quality of life and resource use. Between 12% and 39% of the four screened populations had a diagnosable common mental disorder. In three of the four localities there were improvements over time in symptoms, disability and quality of life, while total economic costs were reduced. Economic analysis of mental health care in low-income countries is feasible and practicable. Our assessment of the cost-effectiveness of integrating mental health into primary care was confounded by the naturalistic study design and the low proportion of subjects using government primary health care services.

Does use of a government service depend on distance from the health facility?

To reduce mortality from common childhood illnesses such as diarrhoea and upper respiratory infections, it is important that health services are available and used appropriately. Physical accessibility to a health facility may influence its use, particularly in rural areas. We assessed whether use of government services for treatment of the three most common acute childhood illnesses (fever, diarrhoea and upper respiratory infections) was influenced by the physical accessibility of the government primary health care centres. We analyzed data from a household survey which was collected between November 1992 and January 1993, from 139 randomly selected villages located around 14 government facilities in Thatta, a rural district of Pakistan. There were 691 children under 5 years of age who suffered from the three acute illnesses; 85% of these children used either a government or a private service. Children living at less than 4 km from a government facility made 22% less use of that facility than those living 4 km or more away. After controlling for the effects of distance from a private facility and treatment cost in a multiple logistic regression model, children living less than 4 km from a government facility were no more likely to use the facility than those living 4 km or more away (Adjusted Odds Ratio: 1.01, 95% Confidence Interval: 0.68-1.50). These results suggest that factors other than distance are the primary determinants of use of government services for treating children in the Thatta district. To increase the use of government health services, policymakers should assess carefully the factors determining the use of existing facilities, before they plan the building of more health facilities. Further studies are needed to examine the management of health facilities and the clients' perception of health-care providers.

Home Visiting of Varying Frequency and Child Development

Two studies were made of home visiting and psychosocial stimulation with deprived urban children in Jamaica. The aim was to determine the relative effectiveness of different frequencies of visiting on the children's developmental levels and the feasibility of integrating the model into government primary health care services. Health paraprofessionals supervised by a nurse from a local health center conducted the intervention. In the first study, 152 children aged 6 to 30 months were assigned to groups visited biweekly, monthly, or not at all by area of residence. The biweekly group showed small but significant increases in scores on the Griffiths Mental Development Scales (developmental quotient) and performance subscale compared with the monthly and control groups, whereas no benefit was shown in the Griffiths scores of the monthly group. In the second study, 58 children aged 16 to 30 months from the same neighborhoods were randomly assigned to weekly visited and control groups. The group visited weekly showed marked improvements in the performance and hearing and speech subscales as well as the developmental quotient scores. The results indicate that as the frequency of visiting increases from none through monthly and biweekly to weekly, the benefits increase as well.

The Mandwa experiment, an alternative strategy.

In the early 1970s a study was set up to examine the health problems of a rural community in Maharashtra (India) state and explore ways in which the available medical technology could be applied. The study area which comprised 30000 people living in 30 villages in the Raigad district of Maharashtra state was chosen as roughly representative of the Indian population 3/4 of whom live in rural areas. The project known as the Mandwa experiment operated from 1973 to mid-1983. This article describes how it was set up what was achieved and the problems that were encountered. The first 2 years were spent looking at the structure of the community and the health problems of the people and ascertaining how the existing public and private health services worked. The most common health problem was malnutrition which with the poor water supply standard of hygiene and the strain of having to survive took a heavy toll on a population who viewed chronic illness as normal. The government primary health care service consisted of 2 subcenters and a dispensary with 10 beds. These units were understaffed and the doctors and nurses were primarily concerned with providing curative services for the leaders and rich members of the community. The only government health program that was implemented with any success was family planning and the measures used to publicize the program were resented. Most of the health problems were related to maternal and child health. The project established a small health center with 10 beds which was used chiefly for obstetric care and emergency treatment. It took about 3 years to establish the project. Appreciably increased immunization rates were achieved but this was only after the village health workers had replaced the auxiliary nurse midwives. This with better hygiene at deliveries resulted in the total elimination of tetanus the 2nd largest cause of death in India. The number of cases of leprosy detected before the project was 63 over 12 years; at the end of the project this had increased to 161 in the same population and the village health workers ability to screen for leprosy was similar to that of the trained leprosy technicians. The rate of early detection of tuberculosis was high and by visiting the patients regularly at home the village health workers ensured that treatment with streptomycin was given once the doctor had confirmed the diagnosis. Deaths from dehydration were virtually eliminated by explaining to mothers how to use oral rehydration using a homemade salt and sugar solution. For malaria the village health workers took blood smears from patients with fever and then presumptively treated them with chloroquine. Definitive treatment was provided for patients who yielded positive results on smear testing. The experience from the Mandwa project suggests that semiliterate and even illiterate villagers can be taught to prevent disease and to recognize and treat it effectively.

Field Guide for the Study of Health-Seeking Behaviour at the Household LEVEL

In 1983 the United Nations University and the United Nations Childrens Fund (UNICEF) developed a program to involve anthropologists and others using anthropological methodologies in examining the extent to which the nutritional and health practices of families are affected by programs of primary health care that include nutrition activities. Projects were initiated in 11 countries. This guide is valuable to researchers and others interested in undertaking similar studies of the impact of programs on household behavior. The major goal of the research guided by this manual is to analyze the impact of existing government primary health care programs on the perceptions beliefs knowledge and health-seeking behavior of representative households in populations served by these programs. Assessing the health and nutrition knowledge beliefs and practices of the selected households; is the factors affecting peoples perception of the primary health care program; and the extent to which the various available health resources particularly the primary health care system have affected understanding of health and illness and health-seeking behavior is described. Information from observations and interviews provides a general description of the study community. This description includes geographical location demographic distribution of the population and socioeconomic characteristics of the community. Household level data are collected from surveys or growth monitoring. The core of the study methodology consists of a series of in-depth interviews with members of selected families to find out their perceptions of the effect of primary health care programs. 10 specific interview guides have been developed. These cover definitions of health and illness; common illness in children and possible solutions; diet of mothers and children; diet of sick children; morbidity history of all household members; morbidity history of the children; inventory of remedies in the house; history of last/present pregnancy and delivery; use of health resources; and use and experience with official health resources. Ethnographic methods are described as well as selection training and supervision of field workers and data analysis methods.

Need Assessment for Undergraduate Medical Curriculum of Bangladesh Through Exploring The Views of Government Primary Health Care Doctors

Objective: To identify the relevancy of contents of undergraduate medical curriculum of Bangladesh for providing service at primary health care (PHC) level through exploring the views of government PHC doctors. Methods: This descriptive study was conducted upon the government doctors who were working at primary health care level of Bangladesh. A total of 545 doctors of 176 upozilas of 62 districts of the country participated in this study by filling mailed self administered semi-structured questionnaires Result: It was found that majority of doctors were satisfied on their skill and knowledge that they acquired at undergraduate level. Their opinions indicated that clinical subjects of MBBS course need more emphasis than basic subjects. On the basis of their opinion a total of 129 health problems are prioritized according to the load of the health problems at the working place of PHC doctors. Conclusion: Curriculum of undergraduate medical education should be reviewed and more emphasis should be given on skills especially on the clinical subjects keeping in mind common health problem of Bangladesh Key words: Need Assessment Medical Curriculum; Medical Education Bangladesh; Undergraduate Curriculum Bangladesh; Health Needs Bangladesh; Curriculum Development Bangladesh.