Overcoming access barriers to paediatric healthcare services

Users’ point of view analysis of the Emergency Paediatric Outpatients Department in Goderich, Sierra Leone

Master's Thesis 2008 57 Pages

Politics - International Politics - Topic: Development Politics


Table of contents

List of figures and tables

Abbreviations and acronyms


Executive summary

Chapters one: Introduction
1.1 Rationale of the study and research objectives
1.2 Outline of the dissertation

Chapter two: Literature review
2.1 Gender and household
2.2 Human capital approach to health and care-seeking strategies
2.3 Access and barriers to healthcare services
2.3.1 Demand side barriers
2.3.2 Demand and supply-demand interaction barriers
2.4 Conclusion

Chapter three: Background
3.1 Sierra Leone – poverty and healthcare profile
3.2 Emergency in Sierra Leone

Chapter four: Methodology
4.1 Data collection methods and process
4.2 Ethical issues, study limitations and bias

Chapter five: Findings and analysis
5.1 Provider choice and demand side barriers
5.1.1 Demand side barriers at the individual level
5.1.2 Demand side barrier at the household level

5.1.3 Demand side barriers at the community level
5.2 Demand-supply interaction and supply side barriers
5.3 Conclusion

Chapter six: Conclusion
6.1 Conclusion
6.2 Recommendations


List of figures and tables


Figure 2.1 - DFID Sustainable Livelihoods Framework

Figure 2.2 Theoretical framework - summary of the barriers accessing healthcare

Figure 3.1 - Paediatric OPD patients diseases between January 2008 and June 2008


Table 1 - Annual budget of the Sierra Leone Program – Emergency 2006-2007

Abbreviations and Acronyms

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The first thank goes to Fatmata Camara, Mary Sesay, Fatima, Ramatu, Fanishila, Memana, Mayali, Mabinty, Adama, Fatmata, Hanna T., Fatmata T., Adama T., Kodiatu T., Mariama, Finda, Hanna K., Annie, Kodiatu S., May S. and Rugiatu that found the time to talk about their life and their children, allowing me to write this dissertation.

I wish to express my sincere gratitude to all those who contributed to the study and supported me both during the fieldwork in Sierra Leone and my period in Birmingham. I would like to thank the people working for Emergency both at the central office and in Sierra Leone, especially Pietro Parrino, Fabio Frigeni, Mirco Barchetta, Rachel Ward and Arold Louis for their time, cooperation and support before, during and after the fieldwork.

I am very grateful also to my interpreter, Isatu Jalloh, precious for her translations and insights on local culture, and to the local guide and informant Bai Moseray Bangura, always available to walk me safely around Goderich, and introducing me to local people. I would like to thank also the paramount chief and the elderly council of Goderich that welcomed me in their village and granted their authorisation to conduct the research.

The research would have been much harder without the support of Doctor Bobson Sesay and his family that hosted me during my period in Sierra Leone. A special thank to Namassa Sesay, for her kindness and patience introducing me to life in Sierra Leone and driving me around Freetown, and to Mrs. Sesay for her wonderful food. I would also like to thank Michael Yumba for his support at my arrival in Sierra Leone. A sincere thank goes to Sahid Conteh for the time and effort spent to provide me with useful contacts in Sierra Leone that made my stay very comfortable. A special gratitude goes to the children living around the Emergency hospital that welcomed me everyday with their wonderful smiles and joyful voices, making my days in Sierra Leone unique.

Obviously I wish to thank my family, without them would have not been possible to achieve this important goal, and my girlfriend Eluka her support during this year we spent together. Another important person that contributed to this work is my friend Helen Brodrick who excellently accomplished the task of proofreading the final version.

Finally I would like to thank Lucy Ferguson, my supervisor, for her valuable support, positive criticism and precious feedback.

Executive summary

In the last sixty years international institutions explicitly recognised the primary role of healthcare for people‟s well being. In 1948, the United Nation in the Universal Declaration of Human Right declared that all the human beings are equal and that childhood and motherhood should be especially protected. In 1978, the World Health Organisation and UNICEF with the declaration of Alma Ata jointly confirmed that health is a fundamental human right. More recently the United Nations included in the Millennium Development Goals the goal to drastically reduce under five mortality. Despite the official documents, in Sub Saharian Africa 157 children every thousand births still die before reaching the age of five years old. Access to healthcare is the key to improve children‟s healthcare but also to alleviate part of women‟s daily burden of activities. The Italian NGO Emergency provide free and high quality healthcare in country such as Sierra Leone, where the rate of under five children mortality is of 288 every thousand.

This research is a qualitative study mainly based on primary data collected during a three weeks fieldwork in Sierra Leone. It explores the factors preventing or discouraging women from accessing the paediatric service provided by Emergency in the village of Goderich. The primary data for this study were

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collected through twenty four semi-structured interviews, both with local women and with members of the Emergency staff.

The literature review introduces some theories used during the research such as the Gender and Development approach, the concepts of household level and care- seeking strategy and the theory of health as part of human capital. It furthermore includes a description of the main barriers to accessing healthcare service at individual, household and community level. A theoretical framework summarises the content of the literature and provides a tool to analyse the primary data. During the research it proved to be also useful to structure the checklist used for the semi-structured interviews.

The findings underline how the most important demand side barriers affecting the service are the indirect cost of accessing the service, but it should not be neglected the influence of informational, social and cultural factors. On the supply side, the strongest barrier is the attitude of part of the national medical staff working in the clinic. The final chapter answers to the research question and, based on the relevant literature, outlines some recommendations that could improve the access to the service.

To the Sierra Leonean children, their mothers and everyone that contributes to give them a better future.

“ If a right is not shared by everyone, its name is privilege.”

(Gino Strada, co-founder of Emergency)

Chapter one - Introduction

1.1 Rationale of the study and research objectives

On 10th December 1948, the United Nations General Assembly approved the Universal Declaration of Human Rights, stating in the first article that: “All human beings are born free and equal in dignity and rights.” (UN, 1948). In particular, article twenty five affirms:

( 1 ) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services […]

( 2 ) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

(Article 25 Universal Declaration of Human rights, UN, 1948)

Between 6th and 12th September 1978, the international conference organised by WHO

and UNICEF in Alma Ata, in the former Soviet Republic of Kazakhstan declared that:

[ H ] ealth, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right […]

(Article 1, Declaration of Alma Ata, WHO-UNICEF, 1978)

It established, contemporarily, the target to provide access to basic health care for everyone by the year 2000. Thus, following the guidelines of the Alma Ata Declaration (WHO-UNICEF, 1978), any health intervention should be based on the idea of equity, accessibility, participation and inclusion of the poorest and marginalised people. Furthermore, it suggested that when planning and implementing projects and programs, a user‟s perspective should be adopted. Twenty two years later, the fourth Millenium Development Goal (MDG), approved during the UN Millenium Summit, has a target to reduce, between 1990 and 2015, the mortality rate of under-five children by two thirds (UN, 2008). In Sub Saharian Africa the goal is to reduce the infant mortality rate to 66 for every thousand. Quite disappointingly, according to the last survey, in 2006, nine years before the fixed deadline, the rate was still 157/1000 (UN, 2008). This data underlines just how far children living in Sub Saharian Africa are from having access to an adequate level of healthcare. Accessibility is one of the determining factors of the level of healthcare. Therefore, addressing barriers undermining access to services is fundamental to improving the health care delivery. Moreover, reducing barriers to accessing paediatric service have the double effect of improving children‟s well-being and to relieve part of women‟s reproductive burden. The starting hypothesis of the research is that even if a paediatric healthcare service is free of charge, such as the one provided by the Non Governmental Organisation (NGO) Emergency, it does not mean that the access is completely unrestricted. There are other barriers that discourage or prevent users from using it. Hence, the primary question that structured the research is:

What sort of barriers affect access to the paediatric service provided by Emergency and by what factors are they influenced?

And secondarily:

What could be done to improve the access to the service?

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Therefore, the main aim of the research is to examine if there are any kinds of barriers such as temporal, socio-cultural or financial that discourage or prevent people from using the Emergency Paediatric Out Patient Department (OPD) located in Goderich, Sierra Leone. Firstly, it is important to identify how women choose a child healthcare provider, what the barriers that affect the analysed service are. In the conclusion I will also outline some helpful recommendations to reduce the identified barriers.

1.2 Outline of the dissertation

Chapter two is a review of the international literature on barriers to accessing healthcare. It does not aim to be a complete description of all the barriers accessing healthcare, but tries to outline the most important barriers affecting the study case. The research is focused on the individual, household and community levels, therefore barriers at the national and international levels are not included. The barriers outlined in the chapter structure the theoretical framework used to analyse the findings and identify the final recommendations. This section also introduces the concepts of household, of care seeking strategy, the theory of human capital approach to health and the Gender and Development approach. Chapter three provides the background to the research, introducing a factual overview of the social situation in Sierra Leone focusing on health and poverty issues. The chapter also presents a short description of the evolution of the activities undertaken by the Italian NGO Emergency in the country. Chapter four illustrates the methodology and the methods adopted during the data collection process, underlining the advantages and disadvantages of each one with the help of some methodological literature. Moreover, it delineates the ethical issues faced and the limitations of the study. Chapter five presents the findings on the main barriers undermining access to the paediatric OPD such as indirect costs, distance, lack of information and the attitudes of medical staff. The chapter also contains a discussion of the barriers in relation to the relevant literature review. The final chapter concludes the study by addressing the initial hypothesis and research questions. It also provides some recommendations as to how the service could be improved.

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Chapter two - Review of the literature

The literature review introduces the most recent findings on barriers accessing healthcare services. At the same time it outlines the theoretical framework that systematises the barriers and, in chapter five, structures the analysis of the findings of the research. The first two paragraphs place the literature on the barriers in the wider context of development research. The first paragraph briefly delineates the GAD approach used as research background, while the second paragraph introduces the human capital approach and the concept of care seeking strategies, integrating them into the sustainable livelihood framework. The description of the barriers to healthcare access is based on two of the most recent articles on the topic. The first article, by Ensor and Cooper (2004) is useful especially for its distinction between supply side barriers, demand side barriers and supply-demand interaction barriers. The second article, by Streatfield et al. (2008), structures the classification of the demand side barriers into different social levels. This research is mainly focused on the individual, household and community levels, therefore the literature review describes the barriers affecting those levels in more detail. Furthermore, it is important to underline how the single barriers and levels are not autonomous units. They are interdependent and influence each other, both within the same level and across different levels.

This research is based on the users‟ point of view, thus, the literature review is mainly focused on demand side barriers. Nonetheless, it also describes the most important supply side and supply-demand interaction barriers.

2.1 Gender and household

The feminist approach used as a background of the research is the GAD one described by Caroline Moser (1989), a pillar in feminist thinking (Jaquette and Staudt, 2006). Moser‟s interpretation of the GAD approach illustrates how, in the traditional social division, women have a triple role. The first is the reproductive role and it consists mainly of having the responsibility of bearing and rearing children as well as the related home

chores. The second is the productive role, usually in the agricultural or in the informal sectors. The third role is to manage community work, organising pressure groups and local level protests. Accepting these three roles means accepting the current situation and therefore, the present situation of discrimination that most of the women are experiencing (Moser, 1989). From a feminist point of view, a women‟s role is not a natural and universal condition, but it is socio-culturally determined and evolving over time. It is shaped by factors such as history, religion, ethical values, economic systems and cultural factors. Men and women are subjects of two different socialisation processes that lead them to adopt different social roles. Different gender roles also mean different gender needs, therefore in order to improve women‟s social condition, it is important to specifically consider women‟s needs when planning development interventions (Moser,


The household is a social group formed by individuals living together, interacting and sharing the same means of livelihood. It is a very important social dimension for the analysis of gender roles and it is considered a useful unit to analyse the barriers accessing healthcare services (Brydon and Chant, 1989; Odaga 2004). Furthermore, it is one of the primary sites where women‟s experience of gender relations is constructed. In the traditional patriarchal distribution of gender roles, household relations are characterised by the allegedly natural, and therefore unpaid and underestimated attribution of the reproductive burden to women1 (Harris, 1981). Wolf (1997) and Townsend and Momsen (1987) describe households, especially if relying on scarce financial resources, as not homogeneous and characterised by unbalanced relationships of power that generate dynamics of domination and subordination. They deny the description of poor households as collaborative and peaceful units conveyed by most of the neoclassical tradition of thought. Wolf sustains that the head of the household is the main decision-maker and the other members just obey to his will. The dominated people can however, adopt some resistance strategies such as income retention, non-compliance and open conflict (Wolf,

1997). Similarly, Harris (1981) suggests that household relations are not based on equality and cooperation, therefore the concept of household should not be used to study

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women living in developing countries. She also adds that pooling resources does not

1 In Stewart, F., 1985, Planning to meet basic needs, London: Macmillan, it is estimated that household activities in some countries can represent up to 40% of the Gross National Product.

mean that the head of the household has the complete control over the resources, as a result, his power is rarely absolute (Harris, 1981). It is within the household that the family‟s productive and reproductive workload is structured and distributed, shaping gender relations and furthermore:

[ H ] o u s ehold is the arena of subordination. It is within the household that income is pooled and redistributed among the members by agreement, custom or conflict (Townsend and Momsen, 1987:40).

Thus, the household level remains a very important dimension when analysing paediatric health choices and access barriers from the women‟s point of view.

2.2 Human capital approach to health and care-seeking strategies

Human capital is formed by the education received at home and in schools, training courses, medical care and any other factor that contributes to personal culture, improved health or wealth level of individuals. Human capital is also related to development on a national scale. Indeed, a society characterised by high human capital has a better chance of achieving economic development (Becker, 1964; Mincer, 1974). Grossman‟s idea (2000), based on the idea of human capital elaborated by authors such as Becker (1964), and Mincer (1974), describes the concept of health capital as a particular kind of human capital. In Grossman‟s opinion, the stock of individual health determines the quantity of time a person is able to spend in productive and reproductive activities. Better health allows people to increase their productive and reproductive productivity level and consequently to improve their living conditions. A society in good health is a society where there is a balance between the supply and the demand for health (Grossman, 2000). The supply level is mainly determined by the official price of the service, input prices, knowledge of the technology and management efficiency. The level of demand is instead determined by official and unofficial prices, travel costs, opportunity cost of lost work, perceived quality of the service, income level, social, household, cultural characteristics, knowledge of available healthcare and level of education. Grossman (2000) divided

barriers to health capital into two main groups. The first group is formed by supply side barriers, i.e. barriers that can be influenced by improving existing healthcare. This goal can be achieved by ameliorating location and access conditions, referral patterns, lower charges and opportunity cost or waiting time. The second group is composed by demand side barriers, i.e. barrier that to be modified need investment in the demand, such as knowledge about health issues, information on available services, transport improvement, change of social, family, cultural and religious norms (Grossman, 2000). The Grossman‟s distinction between supply and demand for health is the base of the barriers categorisation defined by Ensor and Cooper2 (2004).

Figure 2.1 - DFID Sustainable Livelihoods Framework

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(source: figure based on DFID, 2000, Sustainable livelihoods guidance sheets)

Merging Grossman‟s theory with the perspective of the sustainable livelihoods framework (Ashley and Carney, 1999; DFID, 2000; Rakodi, 2002), it is possible to state that eliminating or ameliorating barriers affecting a healthcare service allows for the improvement of health capital in the interested area. As explained above, health capital is

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a component of human capital. Therefore, lower barriers to accessing healthcare favour

2 See next paragraph.

an enhancement of human capital. Human capital is one of the livelihood assets3 upon which poor people rely to overcome their situation of vulnerability to shocks, trends and seasonality. It is possible to conclude that better health is a key factor in helping people to improve their living conditions (Ashley and Carney, 1999; Harpman and Grant, 2002). Considering treatment seeking strategies from the point of view of the sustainable livelihoods framework, it is possible to confirm that they are livelihood strategies pursuing increased well-being, with positive repercussion on personal health or, in the case of a paediatric service, on the children‟s health (Ashley and Carney, 1999; Harpham and Grant, 2002). These findings are confirmed in a study by Leonard (2004) where he describes patients as active users of the health services that seek the best available provider to increase their health capital and not passive recipients of health care. In development research is very important to consider people‟s healthcare seeking decisions because the range of different strategies usually available to poor people living in developing countries are very wide and diversified. The list of possible providers includes public health posts and hospitals, national and international non profit healthcare organisations, village doctors and Traditional Birth Assistant (Ensor and Cooper, 2004). Pelto (2006,4 in Streatfield, 2008) states that in developing countries, people seeking healthcare usually follow a similar pattern. After a first recognition and interpretation of the specific symptoms of a disease, called labelling, the care seeker tries to find a home remedy or looks for help within the family or local traditional healers. If the first strategy fails, the care seeker looks for professional medical help. There can also be several steps that establish a sort of hierarchy of preferences within the category of professional care. This articulated process can cause delays in the cure, waste of money and sometimes a danger of choosing harmful treatments (Pelto, 2006 in Streatfield, 2008).



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NGO Africa Sierra Leone Emergency healthcare barriers access paediatric outpatients




Title: Overcoming access barriers to paediatric healthcare services