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«Jelle Stekelenburg Stekelenburg, Jelle Health care seeking behaviour and utilisation of health services in Kalabo District, Zambia Thesis Vrije ...»

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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


Health care seeking behaviour and utilisation of health services in Kalabo District, Zambia


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

–  –  –

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. On the first day of introductions at the Ministry of Health in Lusaka, I was told about the vision of the Health Sector Reforms, which


“to provide all Zambians with equity of access to cost-effective quality health care as close to the family as possible” and I was requested by Mr. Musowe, one of the most prominent founders of the, once famous, Western Province Primary Health Care Programme and later Zambia’s Health Sector Reform, to carry out my work in Kalabo in line with this vision. I was impressed, and somehow also touched, and promised to do so. At that time I could not yet know what impact this vision was going to have on my life in the years to come.

Later, I discovered that all health workers, even those in the most remote outposts, knew the vision by heart, but only few could explain to me more into detail what exactly the vision statement meant to them and how they upheld the vision in their daily practice. This puzzled me.

During my contract as the Medical Superintendent of Kalabo District Hospital, I was given the opportunity to become closely involved in the affairs at the District Health Office. There were several reasons for that. First, there was no Technical Advisor Health (TAH), like in other districts, so there was a vacancy, which I was allowed to fill. Secondly, my wife also worked as a Medical Officer in the hospital so that we could share many medical duties and responsibilities. Thirdly, sometimes the hospital was not very busy. Utilisation of the health services we offered was not that high, and I frequently asked myself why.

15Chapter 1

As a medical student at the ‘Vrije Universiteit’ in Amsterdam, I came in contact with Ivan Wolffers, who is Professor of Health Care in Developing Countries. He was the one who encouraged my wish to be trained as a tropical doctor. However, he never made a secret of his opinion that medical doctors are about the last people who are needed in developing countries. What should I do? I was already advanced in my study of medicine, and still wished to go to Africa. Fortunately, I knew other doctors and other people who nor did and still not do agree with Wolffers’ opinion. One of them is Jos van Roosmalen, a former tropical doctor, who is now an obstetrician and an active member of the Dutch Society for Tropical Medicine and International Health. We first met during my training as a Tropical Doctor. He impressed me with his slides with instructions on symphysiotomy and he encouraged and inspired me. He strongly advised me to think hard about what I wanted to do after my first 3year contract abroad and to try to prepare for that. I did not know for sure, but I thought that I would probably want to continue my career in international health, but if not, then I would like to become a gynaecologist/obstetrician.

After consulting people who had worked in Kalabo before, and carrying out a literature study about Safe Motherhood, I decided to design a research protocol in a field of health related to Safe Motherhood, Public Health and Obstetrics. The study proposal was to assess the feasibility of a Maternity Waiting Home in Kalabo District, as a contribution to solving the problem of high maternal mortality. The proposal was approved by the Stimuleringsfonds of the Dutch Society for Tropical Medicine and International Health and I received modest funding. Armed with this study proposal, I left for Kalabo.

In Kalabo, after an ‘introduction period’ of about four months, I felt ready to start drawing preliminary conclusions about what I saw, heard and experienced. The study seemed to be useful, I made some improvements to the protocol, and then went ahead. Many data were collected and even today, I am still fighting with the data-processing.

In my role as a Medical Superintendent and ‘acting TAH’, I also discovered many more sources of information and data. Firstly, there were patient-related data. I saw so many patients with interesting cases that I felt should be shared with others in case reports. Copies of their files are still on my desk, waiting to be processed to case reports. There were also

16 Introduction

very interesting data from maternal mortality audits. Then, I was asked by PAIDESA1 to supervise students taking a course on ‘District Health Management’, during their field research. Four members of the Kalabo District Health Management Team (DHMT) completed the course during my stay in Kalabo, and with two of them I published a paper about the findings of their field research.

Back in the Netherlands in 2001, I enjoyed four months of paid study leave and I worked hard on processing my data. It was during this period that both Jos en Ivan talked to me about the possibility of further developing my papers into a PhD thesis, which had never been my plan.

At first, the idea did not attract me much. What I wanted was just to continue writing papers and working with my data, because I liked it so much and I had probably not yet reached the necessary psychological state to leave my Kalabo experience completely. So, I continued to do what I was doing, undecided. Papers were published, discussions were repeated, and slowly but steadily the thesis acquired form, first in my head and later on paper.

1.2 Aims A thesis should answer questions. This thesis does, in fact, answer questions, even though I wrote it ‘the other way around’. Papers were already (nearly) published when I started thinking about the general aims of the thesis. However, a crucial issue in my daily work in Kalabo has been what I was actually doing there and whether my work made any sense, or at least enough sense to justify the expenses made by the Dutch government to pay my salary and benefits. Another issue was why people do sometimes not use health services. Why do pregnant women who know that they are at high risk go back home to their village? Why do mothers not bring their little children to see a doctor when they are critically ill with pneumonia? I knew something about these things from literature, but it was not very conclusive. I struggled to understand individual people, to understand how they came to make their decisions. At the same time, I understood that not only people’s individual decisions, but also the features of the health care system itself made people stay away from clinics. I became interested in the role the district health system played in people’s lives, but I was also curious 1 Pan African Institute for Development of Eastern and Southern Africa

–  –  –

to see the impact of the Health Sector Reforms. I wanted to understand what it all meant, the mission statement of the Health Reforms: equity, access, quality of care?

I have been extremely lucky to be part of a very active DHMT, with experienced people who knew a lot about the district and who taught me so much about the people in the district and their culture, and also about myself. I believe that I and my collegues, Kyanamina, Kashumba, Mukelabai and Sepiso, to mention just a few, formed a strong team. We were very complementary. Demands and research questions were generated in the DHMT-meetings almost every day, studies were designed and carried out and we had many visits from students from Amsterdam, who also contributed to our studies.

More technically the key questions that are adressed in this thesis are as follows:

• How do providers and consumers within the health system (with emphasis on maternal and child health care) in Kalabo, influenced by key issues of the Primary Health Care (PHC) approach, the District Health Care system and the Health Reforms, interact, and what is the impact of such interaction on the utilisation and quality of health services?

• How do people in Kalabo decide whether, when and where to go for treatment if they are ill, and which factors play a role in such decisions?

• What role can or should both providers and consumers within the health system play to improve health?

• What is demand-driven research, and how can it contribute to development?

1.3 Outline To ensure that the studies can be firmly positioned within their geographical, social and economical context, Chapter 2 provides general information about Zambia and its health system. It provides the reader with socio-demographic facts and information about the history and political situation of the country. The Health Sector Reforms are introduced and the health system is described, including some of the most important issues: the infrastructure, the distribution of services, the utilisation of services, community programmes, the referral system and the quality of the care provided. Important sociological trends with impact on the

18 Introduction

health situation are poverty, the impact of the HIV/AIDS epidemic, gender inequalities and the introduction of user fees. The most important demographic indicators and the most important public health problems in the country are explained. Two important issues in the provision of health care are discussed at the end of the chapter: drugs and medical supplies, and human resources.

Chapter 3 is a summary of the literature study that was performed to understand more about terms such as utilisation, coverage and quality of care. Some important models of health service coverage and utilisation are introduced to the reader. Models from both ‘groups’, the health belief models and the socio-behavioural models, are described. Based on the different models, the factors that potentially influence the decision-making process in seeking health care are described.

Chapter 4 reports on a study that was carried out to determine factors that contribute to high mortality due to pneumonia among children under five years of age in Kalabo District. It concludes that pneumonia is an important public health problem in the district, where among health workers and mothers knowledge about the disease and its treatment is inadequate. Low birth weight and distance to facilities contribute to high mortality. To reduce the problem of pneumonia in Kalabo District, the DHMT should concentrate on educating the community and the health workers. People should be taught how to recognise the signs and symptoms of pneumonia and to understand the importance of early and adequate treatment. The Mother and Child Health (MCH) clinics can play an important role, and health workers, especially at rural health centre level, should be re-trained in diagnostics, case management and the use of available protocols.

Strategies to fight the impact of pneumonia in the district should be part of an integral care package, focussing on all the other prevalent childhood diseases, which are co-existent in many cases.

Chapter 5 reports on a study that was conducted to determine factors contributing to the poor performance of community health workers in Kalabo District. It shows that the

–  –  –

comprehensive approach to primary health care is no longer functioning in Kalabo.

Community health workers are mainly valued because of their curative services. Communities do not adhere to the official criteria for the selection of people to be trained, but have other considerations.

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