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Potential Barriers to Healthcare in Malawi for Under-Five Children with Cough and Fever: a National Household Survey

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Potential Barriers to Healthcare in Malawi for Under-Five Children with Cough and Fever: a National Household Survey J HEALTH POPUL NUTR 2014 Mar;32(1):68-78 ©INTERNATIONAL CENTRE FOR DIARRHOEAL ISSN 1606-0997 | $ 5.00+0.20 DISEASE RESEARCH, BANGLADESH Potential Barriers to Healthcare in Malawi for Under-five Children with Cough and Fever: A National Household Survey Marte Ustrup1, Bagrey Ngwira2, Lauren J. Stockman3, Michael Deming3, Peter Nyasulu4, Cameron Bowie2, Kelias Msyamboza2, Dan W. Meyrowitsch1, 5 3 3 Nigel A. Cunliffe , Joseph Bresee , Thea K. Fischer 1Department of Public Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; 2Department of Community Health, College of Medicine, University of Malawi, Blantyre, Malawi; 3Centers for Disease Control and Prevention, Atlanta, GA, USA; 4Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 5Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom ABSTRACT Failure to access healthcare is an important contributor to child mortality in many developing countries. In a national household survey in Malawi, we explored demographic and socioeconomic barriers to health- care for childhood illnesses and assessed the direct and indirect costs of seeking care. Using a cluster-sample design, we selected 2,697 households and interviewed 1,669 caretakers. The main reason for households not being surveyed was the absence of a primary caretaker in the household. Among 2,077 children aged less than five years, 504 episodes of cough and fever during the previous two weeks were reported. A trained healthcare provider was visited for 48.0% of illness episodes. A multivariate regression model showed that children from the poorest households (p=0.02) and children aged >12 months (p=0.02) were less likely to seek care when ill compared to those living in wealthier households and children of higher age-group re- spectively. Families from rural households spent more time travelling compared to urban households (68.9 vs 14.1 minutes; p<0.001). In addition, visiting a trained healthcare provider was associated with longer travel time (p<0.001) and higher direct costs (p<0.001) compared to visiting an untrained provider. Thus, several barriers to accessing healthcare in Malawi for childhood illnesses exist. Continued efforts to reduce these barriers are needed to narrow the gap in the health and healthcare equity in Malawi. Key words: Healthcare surveys; Health expenditure; Health services accessibility; Malaria; Pneumonia; Malawi INTRODUCTION inequities are not only widespread across countries but also within countries. Children from the poor- Worldwide, an estimated 8.8 million children aged est households are more likely than children from below five years die annually. Acute respiratory in- wealthier households to be exposed to health risks, fection is the primary cause of these deaths, account- to be malnourished, to experience reduced access ing for 18% of under-five mortality, followed by di- to preventive and curative healthcare services and, arrhoea and malaria (1). The vast majority of child consequently, to die in childhood (1-5). deaths occur in developing countries, and health Adequate access to and utilization of healthcare Correspondence and reprint requests: Dr. Marte Ustrup services are crucial to improve child health in de- Department of Public Health veloping countries (2,3). However, the rate of ob- Faculty of Health Sciences taining care from a trained healthcare provider re- University of Copenhagen mains low in many developing countries; instead, Oester Farimagsgade 5 children are often treated at home, by an untrained DK-1014 Copenhagen care provider, or not treated at all (2-4). Studies have Denmark Email: [email protected] demonstrated that multiple barriers to healthcare Fax: +45 35327487 exist. Geographic accessibility of facilities is a key Barriers to healthcare of under-five children Ustrup M et al. determinant of utilization, and factors, such as ru- 20% of children have been respectively 2.2% and ral residency, long distance, and high travel costs, 2.7% during the same period (18). Thus, pro-poor have been shown to reduce accessibility (6-8). Eco- targeting has not yet resulted in equal progress in nomic affordability is another major determinant, mortality reduction across socioeconomic strata. and there is ample evidence that low household Consequently, inequities in health and access to income and high care-seeking costs are barriers healthcare disfavouring the poor have persisted to healthcare (6-10). In addition, a wide range of and widened (5,17,18). This situation may poten- demographic factors have been identified to affect tially affect Malawi’s progress towards the United utilization of services, including age, sex, educa- Nations’ Millennium Development Goal to reduce tional level, ethnicity and religion, socioeconomic child mortality (17). status, and family-size and composition (6-8,10). Finally, cultural attitudes and beliefs of the popula- To take appropriate measures towards improved tion influence their healthcare utilization patterns and equitable access to healthcare services, the de- (6-8). There is a need for analyzing the interrelation terminants of limited access need to be identified between the different restrictive factors in more de- in the specific context of Malawi (2,3,18,19). The tail (6). overall aim of the present study was to assess po- tential barriers to healthcare in Malawi for children The healthcare delivery system in Malawi is three- aged below five years, with cough and fever. We tiered, consisting of primary, secondary, and tertia- studied the interrelated effects of demographic and ry-care levels. Sixty-eight percent of health services socioeconomic predictors of obtaining care from are provided by the public sector and 32% by the trained providers. Furthermore, we estimated the private sector, including the not-for-profit Chris- direct and indirect costs of seeking care, thereby tian Health Association of Malawi (CHAM). In ad- providing detailed cost data which are sparse in the dition, traditional healers are widely used (11,12). literature (6,9). To ensure effective services and equitable access, the Government of Malawi implemented an Essen- MATERIALS AND METHODS tial Health Package (EHP) in 2002 and launched a Study site and population sector-wide approach in 2004 as the vehicle to de- liver EHP services which are provided free of charge The Republic of Malawi is a small sub-Saharan Afri- (13). However, the healthcare system has been can country bordering Zambia and Tanzania to the constrained in the provision of services in recent north and partly embedded into Mozambique to years due to a number of factors (11). The finan- the south. The total population in 2011 was 15.4 cial resources for health service delivery have been million (20). Malawi is among the poorest and the inadequate and unpredictable. Consequently, Ma- least developed countries in the world, ranking 171 lawi’s EHP services have been underfunded since out of 187 countries in the Human Development its implementation (11,14). Furthermore, there has Index (20). Eighty percent of the population lives been an increasing shortage of medical staff since in rural areas, and approximately 74% lives below 1990 as a result of poor working conditions, low the poverty line and 40% in severe poverty (20). wages, deaths caused by the HIV/AIDS epidemic, The life expectancy at birth is 54.2 years, and the and migration of skilled personnel to developed infant and under-five mortality rates are 53 and countries (11,15). Quality of care has been further 110 per 1,000 livebirths respectively (20). compromised by a periodic stock-out of essential drugs and medical supplies (11). Despite these chal- The transmission of malaria is perennial in Malawi, lenges, Malawi has achieved significant reductions with a peak in the rainy season from November to in the infant and under-five mortality rates, with April (21). The transmission of acute respiratory an annual average decline of 4.3% and 4.7% re- infections peaks in the beginning of the cold dry spectively during the period 1990-2011 (16). Key season in April to June (22). factors responsible for this progress include consis- Study design and data collection tent investment in child survival interventions and strong coordination between the Government of We conducted a national household survey from Malawi and the development partners (17). How- the end of February to mid-April 2005, using a clus- ever, while national averages have improved, the ter-sample design with compact segments (23,24). poorest children have benefited the least from this We aimed for a nationally-representative sample of progress (18). The annual average reduction rates 600 children, equaling 3,000 households. Sample- in infant and under-five mortality for the poorest size calculation took into account the expected pro- Volume 32 | Number 1 | March 2014 69 Barriers to healthcare of under-five children Ustrup M et al. portion of interest (i.e. the proportion of children Figure 1. Flowchart of selecting participants with cough and fever seeking care from a trained healthcare provider), the level of precision de- sired, and the expected design effect (23). Malawi’s Households selected for survey 1998 Population and Housing Census provided a (N=2,697) complete list of enumeration areas (EAs) (25). The projected number of households in each EA was Households not interviewed calculated based on census data, then divided by (n=87) due to: 100 and rounded to the nearest integer, which was • No eligible respondent at home (n=36) considered to be the size of the EA in segments. • Household members absent (n=5) This predetermined segment-size was based on the • Refusal (n=2) prediction that the survey team could complete in- • Household vacant (n=7) terviews in 100 households per day. Subsequently, • Household not found (n=7) 30 EAs were chosen by systematic sampling with • Other (n=30) probability of selection proportional to the size of each EA in segments (23).
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