Michael Thiede

Rethinking the economic costs of malaria at the household level: Evidence from applying a new analytical framework in rural Kenya

BackgroundMalaria imposes significant costs on households and the poor are disproportionately affected. However, cost data are often from quantitative surveys with a fixed recall period. They do not capture costs that unfold slowly over time, or seasonal variations. Few studies investigate the different pathways through which malaria contributes towards poverty. In this paper, a framework indicating the complex links between malaria, poverty and vulnerability at the household level is developed and applied using data from rural Kenya.MethodsCross-sectional surveys in a wet and dry season provide data on treatment-seeking, cost-burdens and coping strategies (n = 294 and n = 285 households respectively). 15 case study households purposively selected from the survey and followed for one year provide in-depth qualitative information on the links between malaria, vulnerability and poverty.ResultsMean direct cost burdens were 7.1% and 5.9% of total household expenditure in the wet and dry seasons respectively. Case study data revealed no clear relationship between cost burdens and vulnerability status at the end of the year. Most important was household vulnerability status at the outset. Households reporting major malaria episodes and other shocks prior to the study descended further into poverty over the year. Wealthier households were better able to cope.ConclusionThe impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications, influencing household ability to withstand malaria and other contingencies in future. To protect the poor and vulnerable, malaria control policies need to be integrated into development and poverty reduction programmes.

The Economics of Health Equity: Exploring the dimensions of access

Summary Equity in health care is often defined in terms of access to health services. Yet, in the literature and in policy, the extent to which the concept of access has been taken beyond the realms of principle is limited. This chapter explores the multifaceted concept of access to health services and indicates how it can be operationalized to address health system inequities. Access is interpreted as the freedom to use health services. Whilst health policy efforts to improve equity in access to services have been guided by a focus on the health system, we propose that household or individual aspects of access deserve more attention than they have received to date. The quality of interaction between an individual and the health systems attributes in terms of delivery and financing lies at the core of access. It is argued that, with a view to health policy, these interactions can be meaningfully and comprehensively presented in three dimensions: availability, affordability and acceptability. Each of these captures distinct interactions between the health system and individuals. There is a set of factors that describes each dimension and that can be represented by a set of clearly defined and measurable variables. Within and across the access dimensions, information is an important determinant of the quality of health system and individual interaction. This approach makes it possible to measure and to map access. Using a Ghanaian case study, this chapter illustrates the health policy relevance of this conceptual approach.

Synthesizing qualitative and quantitative evidence on non-financial access barriers: implications for assessment at the district level

IntroductionA key element of the global drive to universal health coverage is ensuring access to needed health services for everyone, and to pursue this goal in an equitable way. This requires concerted efforts to reduce disparities in access through understanding and acting on barriers facing communities with the lowest utilisation levels. Financial barriers dominate the empirical literature on health service access. Unless the full range of access barriers are investigated, efforts to promote equitable access to health care are unlikely to succeed. This paper therefore focuses on exploring the nature and extent of non-financial access barriers.MethodsWe draw upon two structured literature reviews on barriers to access and utilization of maternal, newborn and child health services in Ghana, Bangladesh, Vietnam and Rwanda. One review analyses access barriers identified in published literature using qualitative research methods; the other in published literature using quantitative analysis of household survey data. We then synthesised the key qualitative and quantitative findings through a conjoint iterative analysis.ResultsFive dominant themes on non-financial access barriers were identified: ethnicity; religion; physical accessibility; decision-making, gender and autonomy; and knowledge, information and education. The analysis highlighted that non-financial factors pose considerable barriers to access, many of which relate to the acceptability dimension of access and are challenging to address. Another key finding is that quantitative research methods, while yielding important findings, are inadequate for understanding non-financial access barriers in sufficient detail to develop effective responses. Qualitative research is critical in filling this gap. The analysis also indicates that the nature of non-financial access barriers vary considerably, not only between countries but also between different communities within individual countries.ConclusionsTo adequately understand access barriers as a basis for developing effective strategies to address them, mixed-methods approaches are required. From an equity perspective, communities with the lowest utilisation levels should be prioritised and the access barriers specific to that community identified. It is, therefore, critical to develop approaches that can be used at the district level to diagnose and act upon access barriers if we are to pursue an equitable path to universal health coverage.