Health Care Seeking Behaviour and Utilisation of Health Services in Kalabo District, Zambia
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View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by DSpace at VU HEALTH CARE SEEKING BEHAVIOUR AND UTILISATION OF HEALTH SERVICES IN KALABO DISTRICT, ZAMBIA Jelle Stekelenburg Stekelenburg, Jelle Health care seeking behaviour and utilisation of health services in Kalabo District, Zambia Thesis Vrije Universiteit, Amsterdam – With references – With summary in Dutch ISBN 90-9018603-4 © J. Stekelenburg, 2004 Cover illustration: Christine van der Pal Printed by: Stichting Drukkerij C. Regenboog, Groningen Financial support: Department of Obstetrics & Gynaecology, University Hospital, Groningen VRIJE UNIVERSITEIT Health care seeking behaviour and utilisation of health services in Kalabo District, Zambia ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Vrije Universiteit van Amsterdam, op gezag van de rector magnificus prof.dr. T. Sminia, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de faculteit der Geneeskunde op vrijdag 22 oktober 2004 om 13.45 uur in de aula van de universiteit, De Boelelaan 1105 door Jelle Stekelenburg geboren te Klundert promotor: prof.dr. I.N. Wolffers copromotor: dr. J.J.M. van Roosmalen Leden beoordelingscommissie: prof.dr. A.P. Hardon dr. A. Mantingh prof.dr. E.J. Ruitenberg prof.dr. A.J.P. Veerman prof.dr. J.I.P. de Vries “I am, because we are” Old African proverb, expressing the importance of the community Contents List of abbreviations 13 1 Introduction 15 1.1 Justification 15 1.2 Aim 17 1.3 Outline 18 2 Zambia: History, Poverty, Ill-health and the Health Sector Reforms 23 2.1 Socio-demographic facts 23 2.2 History and politics 24 2.3 The Health Sector Reforms 27 2.3.1 Background 27 2.3.2 Goal, aim, vision and principles 29 2.3.3 The infrastructure 30 2.3.4 Main elements of the reformed Health Services 32 2.3.5 Distribution of services 33 2.3.6 Utilisation 34 2.3.7 Community based health care 37 2.3.8 The referral system 39 2.3.9 Quality of care 40 2.4 The socio-political context 41 2.4.1 Patterns and trends in poverty 42 2.4.2 The impact of HIV/AIDS 43 2.4.3 Gender inequalities 44 2.4.4 User fees and access to health care 46 2.5 Public health priorities 48 2.5.1 Malaria 48 2.5.2 Reproductive health and family planning 49 2.5.3 HIV/AIDS and sexually transmitted diseases 51 2.5.4 Child health and nutrition 53 2.5.5 Tuberculosis 54 2.5.6 Water and sanitation 55 2.6 Human resources 56 2.6.1 Categories and numbers of health care staff 57 2.6.2 Distribution of staff 58 2.6.3 Impact of HIV/AIDS 60 2.6.4 The role of expatriate doctors 61 2.7 Medical supplies 63 2.8 Conclusion 65 References chapter 2 67 3 Utilisation of health care services 75 3.1 Introduction 75 3.2 The health belief model and socio-behavioural model 79 3.3 Quality of care 83 3.4 Determinants of utilisation in the socio-behavioural model 84 3.5 Determinants of utilisation in the health belief model 89 3.6 Conclusions 90 References chapter 3 92 4 Factors related to high mortality due to pneumonia in underfives in Kalabo District, Zambia 97 4.1 Abstract 98 4.2 Introduction 99 4.3 Objectives 101 4.4 Methods 101 4.5 Results 102 4.6 Discussion 107 4.7 Conclusion 110 References chapter 4 112 5 Poor performance of Community Health Workers in Kalabo District, Zambia 115 5.1 Abstract 116 5.2 Introduction 117 5.3 Objectives 119 5.4 Methods 119 5.4.1 Study area and population 119 5.4.2 Methodologies 120 5.5 Results 121 5.5.1 Establishing the functioning of the community health worker programme 122 5.5.2 Factors causing low performance 123 5.6 Discussion 128 5.7 Conclusion 130 References chapter 5 133 6 Health care seeking behaviour and utilisation of traditional healers in Kalabo, Zambia 135 6.1 Abstract 136 6.2 Introduction 137 6.2.1 Traditional healers 137 6.2.2 Utilisation, coverage and satisfaction 139 6.3 Materials and methods 142 6.3.1 Methodology 142 6.3.2 Study area 143 6.4 Results 145 6.4.1 Background data 145 6.4.2 Health service attendance 145 6.4.3 Affordability 154 6.4.4 Satisfaction 155 6.4.5 Co-operation 156 6.5 Discussion 156 References chapter 6 162 7 Waiting too long; low use of maternal health services in Kalabo, Zambia 165 7.1 Abstract 166 7.2 Introduction 167 7.3 Objectives 169 7.4 Methods 169 7.4.1 Study area and population 169 7.4.2 Methodology 170 7.4.3 Definitions 172 7.5 Results 172 7.6 Discussion 179 References chapter 7 183 8 The maternal mortality review meeting; experiences from Kalabo District Hospital, Zambia 185 8.1 Abstract 186 8.2 Introduction 187 8.3 Methods 189 8.3.1 Study area and population 189 8.3.2 Methodology 190 8.3.3 Definitions 190 8.4 Results 191 8.5 Discussion 191 8.6 Conclusion 193 References chapter 8 197 9 Maternal mortality in Zambia, The Gambia, Namibia and The Netherlands; Just a difference between the poor and the rich? 199 9.1 Abstract 200 9.2 Introduction 201 9.2.1 Maternal morbidity and mortality 201 9.2.2 Delay in accessing quality health care 203 9.2.3 Facility-based maternal death review 204 9.3 Objectives 205 9.4 Methodology 205 9.4.1 Study areas and population 205 9.4.2 Methods 209 9.4.3 Definitions 209 9.5 Results 209 9.6 Discussion 215 References chapter 9 221 10 Maternity waiting homes in rural districts; a cornerstone of Safe Motherhood? 223 10.1 Abstract 224 10.2 Introduction 225 10.3 Objective 225 10.4 Maternal mortality and morbidity 226 10.5 Utilisation of maternal health services 227 10.6 Maternity Waiting Homes 229 10.7 Discussion 234 References chapter 10 236 11 Health System Research as a tool to improve health care in a rural district in Zambia 239 11.1 Abstract 240 11.2 Introduction 241 11.3 Demand-driven research 243 11.4 Kalabo District 244 11.5 Pneumonia and mortality in children under five 245 11.6 Community health workers 246 11.7 Health care seeking behaviour and traditional healers 247 11.8 Low use of maternal health services 248 11.9 Discussion 249 References chapter 11 250 12 General discussion 251 12.1 Use of services and barriers 252 12.2 Meaningfulness of services and the interaction between clients and providers 254 12.3 Poverty, HIV/AIDS and inadequate numbers of health care staff 258 12.4 Equity and the democratisation of science 260 12.5 The way forward in maternal health 262 12.6 Conclusion 264 References chapter 12 266 Acknowledgement 267 Samenvatting 271 Curriculum vitae 283 List of abbreviations AIDS Acquired Immuno Deficiency Syndrome ANC Ante Natal Clinic/Care ARI Acute Respiratory Infection ARC AIDS Related Complex ARV Anti Retro Viral (drugs) BCG Bacillus Calmette Guérin CBoH Central Board of Health CDE Classified Daily Employee CHW Community Health Worker CI Confidence Interval CMR Child Mortality Rate CSO Central Statistical Office DALY Disability Adjusted Life Year DHB District Health Board DHC District Health Care DHMT District Health Management Team DHS Demographic and Health Survey DIC Diffuse Intravascular Coagulation DOTS Directly Observed Therapy Short Course EDD Estimated Date of Delivery EHT Environmental Health Technician EOC Essential Obstetric Care FAMS Financial and Administrative Management System FHH Female Headed Household FIGO International Federation for Obstetrics & Gynaecology FP Family Planning GDP Gross Domestic Product GNP Gross National Product GRZ Government of the Republic of Zambia HFA Health For All HIV Human Immunodeficiency Virus HMB Health Management Board HMIS Health Management Information System HosMIS Hospital Management Information System HSR Health System Research or Health Sector Reform IAG Inter-Agency Group ICU Intensive Care Unit ILO International Labour Organization IMCI Integrated Management of Childhood Illnesses IMF International Monetary Fund IMR Infant Mortality Rate IV Intra Venous LCMS Living Conditions Monitoring Survey MCH Mother and Child Health care/clinic MHH Male Headed Household MMD Movement for Multiparty Democracy MMR Maternal Mortality Ratio MO Medical Officer MoH Ministry of Health MSL Medical Stores Limited MWH Maternity Waiting Home NGO Non Governmental Organization NHC Neighbourhood Health Committee NHSP National Health Strategy Plan O & G Obstetrics & Gynaecology OPD Out Patient Department OR Odds Ratio OT Operation Theatre PAIDESA Pan African Institute for the Development of Eastern and Southern Africa PHC Primary Health Care PhD Philosophers Degree PMO Provincial Medical Officer PMR Perinatal Mortality Rate PNC Post Natal Care PPH Post Partum Haemorrhage RBoH Regional Board of Health RHC Rural Health Centre STD Sexually Transmitted Disease TAZARA Tanzania Zambia Railways TAH Technical Advisor Health TB Tuberculosis TBA Traditional Birth Attendant tTBA trained Traditional Birth Attendant TFR Total Fertlity Rate U5MR Under-5 Mortality Rate UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UNIP United National Independence Party USD United States Dollar UNZA University of Zambia VIP Ventilated Improved Latrine WB World Bank WHO World Health Organization Introduction 1 Introduction 1.1 Justification Working at district level in the Zambian health system between 1997 and 2001 was a fantastic experience and a great privilege. It not only gave me the opportunity to carry responsibilities I had so long studied and worked for, but it also allowed me to closely follow the developments at district level in the era of the Health Sector Reforms.