Treatment choices for fevers in children under-five years in a rural Ghanaian district

<p>Abstract</p> <p>Background</p> <p>Health care demand studies help to examine the behaviour of individuals and households during illnesses. Few of existing health care demand studies examine the choice of treatment services for childhood illnesses. Besides, in their analyses, many of the existing studies compare alternative treatment options to a single option, usually self-medication. This study aims at examining the factors that influence the choices that caregivers of children under-five years make regarding treatment of fevers due to malaria and pneumonia in a rural setting. The study also examines how the choice of alternative treatment options compare with each other.</p> <p>Methods</p> <p>The study uses data from a 2006 household socio-economic survey and health and demographic surveillance covering caregivers of 529 children under-five years of age in the Dangme West District and applies a multinomial probit technique to model the choice of treatment services for fevers in under-fives in rural Ghana. Four health care options are considered: self-medication, over-the-counter providers, public providers and private providers.</p> <p>Results</p> <p>The findings indicate that longer travel, waiting and treatment times encourage people to use self-medication and over-the-counter providers compared to public and private providers. Caregivers with health insurance coverage also use care from public providers compared to over-the-counter or private providers. Caregivers with higher incomes use public and private providers over self-medication while higher treatment charges and longer times at public facilities encourage caregivers to resort to private providers. Besides, caregivers of female under-fives use self-care while caregivers of male under-fives use public providers instead of self-care, implying gender disparity in the choice of treatment.</p> <p>Conclusions</p> <p>The results of this study imply that efforts at curbing under-five mortality due to malaria and pneumonia need to take into account care-seeking behaviour of caregivers of under-fives as well as implementation of strategies.</p

Quality of private and public ambulatory health care in low and middle income countries: systematic review of comparative studies

Paul Garner and colleagues conducted a systematic review of 80 studies to compare the quality of private versus public ambulatory health care in low- and middle-income countries

Promoting Universal Financial Protection: Evidence from Seven Low- and Middle-Income Countries on Factors Facilitating or Hindering Progress.

Although universal health coverage (UHC) is a global health policy priority, there remains limited evidence on UHC reforms in low- and middle-income countries (LMICs). This paper provides an overview of key insights from case studies in this thematic series, undertaken in seven LMICs (Costa Rica, Georgia, India, Malawi, Nigeria, Tanzania, and Thailand) at very different stages in the transition to UHC.These studies highlight the importance of increasing pre-payment funding through tax funding and sometimes mandatory insurance contributions when trying to improve financial protection by reducing out-of-pocket payments. Increased tax funding is particularly important if efforts are being made to extend financial protection to those outside formal-sector employment, raising questions about the value of pursuing contributory insurance schemes for this group. The prioritisation of insurance scheme coverage for civil servants in the first instance in some LMICs also raises questions about the most appropriate use of limited government funds.The diverse reforms in these countries provide some insights into experiences with policies targeted at the poor compared with universalist reform approaches. Countries that have made the greatest progress to UHC, such as Costa Rica and Thailand, made an explicit commitment to ensuring financial protection and access to needed care for the entire population as soon as possible, while this was not necessarily the case in countries adopting targeted reforms. There also tends to be less fragmentation in funding pools in countries adopting a universalist rather than targeting approach. Apart from limiting cross-subsidies, fragmentation of pools has contributed to differential benefit packages, leading to inequities in access to needed care and financial protection across population groups; once such differentials are entrenched, they are difficult to overcome. Capacity constraints, particularly in purchasing organisations, are a pervasive problem in LMICs. The case studies also highlighted the critical role of high-level political leadership in pursuing UHC policies and citizen support in sustaining these policies.This series demonstrates the value of promoting greater sharing of experiences on UHC reforms across LMICs. It also identifies key areas of future research on health care financing in LMICs that would support progress towards UHC

Choice of treatment for fever at household level in Malawi: examining spatial patterns

BACKGROUND: Although malaria imposes an enormous burden on Malawi, it remains a controllable disease. The key strategies for control are based on early diagnosis and prompt treatment with effective antimalarials. Its success, however, depends on understanding the factors influencing health care decision making at household level, which has implications for implementing policies aimed at promoting health care practices and utilization. METHODS: An analysis of patterns of treatment-seeking behaviour among care-givers of children of malarial fever in Malawi, based on the 2000 Malawi demographic and health survey, is presented. The choice of treatment provider (home, shop, or formal hospital care, others) was considered as a multi-categorical response, and a multinomial logistic regression model was used to investigate determinants of choosing any particular provider. The model incorporated random effects, at subdistrict level, to measure the influence of geographical location on the choice of any treatment provider. Inference was Bayesian and based on Markov chain Monte Carlo techniques. RESULTS AND CONCLUSION: Spatial variation was found in the choice of a provider and determinants of choice of any provider differed. Important risk factors included place of residence, access to media, care-giver's age and care factors including unavailability and inaccessibility of care. A greater effort is needed to improve the quality of malaria home treatment or expand health facility utilization, at all levels of administration if reducing malaria is to be realised in Malawi. Health promotion and education interventions should stress promptness of health facility visits, improved access to appropriate drugs, and accurate dosing for home-based treatments

Malaria-related mortality based on verbal autopsy in an area of low endemicity in a predominantly rural population in Ethiopia

<p>Abstract</p> <p>Background</p> <p>Although malaria is one of the most important causes of death in Ethiopia, measuring the magnitude of malaria-attributed deaths at community level poses a considerable difficulty. Nevertheless, despite its low sensitivity and specificity, verbal autopsy (VA) has been the most important technique to determine malaria-specific cause of death for community-based studies. The present study was undertaken to assess the magnitude of malaria mortality in a predominantly rural population of Ethiopia using VA technique at Butajira Rural Health Programme (BRHP) Demographic Surveillance Site (DSS).</p> <p>Methods</p> <p>A verbal autopsy was carried out for a year from August 2003 to July 2004 for all deaths identified at BRPH-DSS. Two trained physicians independently reviewed each VA questionnaire and indicated the most likely causes of death. Finally, all malaria related deaths were identified and used for analysis.</p> <p>Results</p> <p>A verbal autopsy study was successfully conducted in 325 deaths, of which 42 (13%) were attributed to malaria. The majority of malaria deaths (47.6%) were from the rural lowlands compared to those that occurred in the rural highlands (31%) and urban (21.4%) areas. The proportional mortality attributable to malaria was not statistically significant among the specific age groups and ecological zones. Mortality from malaria was reckoned to be seasonal; 57% occurred during a three-month period at the end of the rainy season between September and November. About 71% of the deceased received some form of treatment before death, while 12 (28.6%) of those who died neither sought care from a traditional healer nor were taken to a conventional health facility before death. Of those who sought treatment, 53.3% were first taken to a private clinic, 40% sought care from public health facilities, and the remaining two (6.7%) received traditional medicine. Only 11.9% of the total malaria-related deaths received some sort of treatment within 24h after the onset of illness.</p> <p>Conclusion</p> <p>The results of this study suggest that malaria plays a considerable role as a cause of death in the study area. Further data on malaria mortality with a relatively large sample size for at least two years will be needed to substantially describe the burden of malaria mortality in the study area.</p

Contextual influences on health worker motivation in district hospitals in Kenya

<p>Abstract</p> <p>Background</p> <p>Organizational factors are considered to be an important influence on health workers' uptake of interventions that improve their practices. These are additionally influenced by factors operating at individual and broader health system levels. We sought to explore contextual influences on worker motivation, a factor that may modify the effect of an intervention aimed at changing clinical practices in Kenyan hospitals.</p> <p>Methods</p> <p>Franco LM, et al's (Health sector reform and public sector health worker motivation: a conceptual framework. Soc Sci Med. 2002, 54: 1255–66) model of motivational influences was used to frame the study Qualitative methods including individual in-depth interviews, small-group interviews and focus group discussions were used to gather data from 185 health workers during one-week visits to each of eight district hospitals. Data were collected prior to a planned intervention aiming to implement new practice guidelines and improve quality of care. Additionally, on-site observations of routine health worker behaviour in the study sites were used to inform analyses.</p> <p>Results</p> <p>Study settings are likely to have important influences on worker motivation. Effective management at hospital level may create an enabling working environment modifying the impact of resource shortfalls. Supportive leadership may foster good working relationships between cadres, improve motivation through provision of local incentives and appropriately handle workers' expectations in terms of promotions, performance appraisal processes, and good communication. Such organisational attributes may counteract de-motivating factors at a national level, such as poor schemes of service, and enhance personally motivating factors such as the desire to maintain professional standards.</p> <p>Conclusion</p> <p>Motivation is likely to influence powerfully any attempts to change or improve health worker and hospital practices. Some factors influencing motivation may themselves be influenced by the processes chosen to implement change.</p

Understanding informal payments in health care: motivation of health workers in Tanzania

<p>Abstract</p> <p>Background</p> <p>There is growing evidence that informal payments for health care are fairly common in many low- and middle-income countries. Informal payments are reported to have a negative consequence on equity and quality of care; it has been suggested, however, that they may contribute to health worker motivation and retention. Given the significance of motivation and retention issues in human resources for health, a better understanding of the relationships between the two phenomena is needed. This study attempts to assess whether and in what ways informal payments occur in Kibaha, Tanzania. Moreover, it aims to assess how informal earnings might help boost health worker motivation and retention.</p> <p>Methods</p> <p>Nine focus groups were conducted in three health facilities of different levels in the health system. In total, 64 health workers participated in the focus group discussions (81% female, 19% male) and where possible, focus groups were divided by cadre. All data were processed and analysed by means of the NVivo software package.</p> <p>Results</p> <p>The use of informal payments in the study area was confirmed by this study. Furthermore, a negative relationship between informal payments and job satisfaction and better motivation is suggested. Participants mentioned that they felt enslaved by patients as a result of being bribed and this resulted in loss of self-esteem. Furthermore, fear of detection was a main demotivating factor. These factors seem to counterbalance the positive effect of financial incentives. Moreover, informal payments were not found to be related to retention of health workers in the public health system. Other factors such as job security seemed to be more relevant for retention.</p> <p>Conclusion</p> <p>This study suggests that the practice of informal payments contributes to the general demotivation of health workers and negatively affects access to health care services and quality of the health system. Policy action is needed that not only provides better financial incentives for individuals but also tackles an environment in which corruption is endemic.</p

Developing a tool to measure health worker motivation in district hospitals in Kenya

BACKGROUND: We wanted to try to account for worker motivation as a key factor that might affect the success of an intervention to improve implementation of health worker practices in eight district hospitals in Kenya. In the absence of available tools, we therefore aimed to develop a tool that could enable a rapid measurement of motivation at baseline and at subsequent points during the 18-month intervention study. METHODS: After a literature review, a self-administered questionnaire was developed to assess the outcomes and determinants of motivation of Kenyan government hospital staff. The initial questionnaire included 23 questions (from seven underlying constructs) related to motivational outcomes that were then used to construct a simpler tool to measure motivation. Parallel qualitative work was undertaken to assess the relevance of the questions chosen and the face validity of the tool. RESULTS: Six hundred eighty-four health workers completed the questionnaires at baseline. Reliability analysis and factor analysis were used to produce the simplified motivational index, which consisted of 10 equally-weighted items from three underlying factors. Scores on the 10-item index were closely correlated with scores for the 23-item index, indicating that in future rapid assessments might be based on the 10 questions alone. The 10-item motivation index was also able to identify statistically significant differences in mean health worker motivation scores between the study hospitals (p<0.001). The parallel qualitative work in general supported these conclusions and contributed to our understanding of the three identified components of motivation. CONCLUSION: The 10-item score developed may be useful to monitor changes in motivation over time within our study or be used for more extensive rapid assessments of health worker motivation in Kenya

Comparison of infant malaria incidence in districts of Maputo province, Mozambique

<p>Abstract</p> <p>Background</p> <p>Malaria is one of the principal health problems in Mozambique, representing 48% of total external consultations and 63% of paediatric hospital admissions in rural and general hospitals with 26.7% of total mortality. <it>Plasmodium falciparum </it>is responsible for 90% of all infections being also the species associated with most severe cases. The aim of this study was to identify zones of high malaria risk, showing their spatially and temporal pattern.</p> <p>Methods</p> <p>Space and time Poison model for the analysis of malaria data is proposed. This model allows for the inclusion of environmental factors: rainfall, temperature and humidity as predictor variables. Modelling and inference use the fully Bayesian approach via Markov Chain Monte Carlo (MCMC) simulation techniques. The methodology is applied to analyse paediatric data arising from districts of Maputo province, Mozambique, between 2007 and 2008.</p> <p>Results</p> <p>Malaria incidence risk is greater for children in districts of Manhiça, Matola and Magude. Rainfall and humidity are significant predictors of malaria incidence. The risk increased with rainfall (relative risk - RR: .006761, 95% interval: .001874, .01304), and humidity (RR: .049, 95% interval: .03048, .06531). Malaria incidence was found to be independent of temperature.</p> <p>Conclusions</p> <p>The model revealed a spatial and temporal pattern of malaria incidence. These patterns were found to exhibit a stable malaria transmission in most non-coastal districts. The findings may be useful for malaria control, planning and management.</p