Elsevier

The Lancet

Volume 361, Issue 9357, 15 February 2003, Pages 561-566
The Lancet

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Inequities among the very poor: health care for children in rural southern Tanzania

https://doi.org/10.1016/S0140-6736(03)12515-9Get rights and content

Summary

Background

Few studies have been done to assess socioeconomic inequities in health in African countries. We sought evidence of inequities in health care by sex and socioeconomic status for young children living in a poor rural area of southern Tanzania.

Methods

In a baseline household survey in Tanzania early in the implementation phase of integrated management of childhood illness (IMCI), we included cluster samples of 2006 children younger than 5 years in four rural districts. Questions focused on the extent to which carers' knowledge of illness, care-seeking outside the home, and care in health facilities were consistent with IMCI guidelines and messages. We used principal components analysis to develop a relative index of household socioeconomic status, with weighted scores of information on income sources, education of the household head, and household assets.

Findings

1026 (52%) of 1968 children reported having been ill in the 2 weeks before the survey. Carers of 415 (41%) of 1014 of these children had sought care first from an appropriate provider. 71 (26%) carers from families in the wealthiest quintile knew ⩾2 danger signs compared with 48 (20%) of those from the poorest (p=0·03 for linear trend across quintiles) and wealthier families were more likely to bring their sick children to a health facility (p=0·02). Their children were more likely than poorer children to have received antimalarials, and antibiotics for pneumonia (p=0·0001 and 0·0048, respectively).

Interpretation

Care-seeking behaviour is worse in poorer than in relatively rich families, even within a rural society that might easily be assumed to be uniformly poor.

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Introduction

Health inequities occur at many levels: between regions of the world, between countries in regions, between provinces or states in countries, between districts, towns, or cities in provinces, and between social groups. Sub-Saharan Africa has the poorest overall health indicators of any region of the world.1 Its estimated under-5-year mortality rate of 173 per thousand live births is almost twice that of south Asia, the second-highest mortality region, and nearly 30 times higher than the rate in developed countries.2 Furthermore, uniquely among world regions, child mortality rates in sub-Saharan Africa seem to be increasing, partly because of AIDS, but also because of other diseases.3

In spite of this disturbing picture, few studies have been done to assess socioeconomic inequities in health in African countries. Such studies have important policy and programme implications. We searched Medline and found only 102 articles on equity or inequity in Africa, compared with 1151 in the Americas. Of these articles, virtually all had to do with equity issues relevant to health-sector reform and financing, or with inequities in South Africa, especially between ethnic groups. None of the studies described inequities in health outcomes or care-seeking behaviour in rural child populations. We use the term care-seeking following the usual convention, for what might better be termed care-obtaining: the part of health-seeking behaviour that is successful in obtaining the help that is sought.

The World Bank's health, nutrition, and population programme has supported re-analysis, focused on inequities, of the results of demographic and health surveys in several African countries.4 These analyses include urban and rural populations, often showing important differentials between richer and poorer households in mortality, nutrition, and care-seeking behaviour. The results, however, have not been widely disseminated to a public health audience. The apparent lack of interest on equity issues in Africa by health researchers might arise from the erroneous perception that families living in rural villages are fairly homogeneous with respect to socioeconomic status. In rural Africa, signs of social or economic stratification are often hard for outsiders to recognise. For example, most houses are fairly simple constructions and inequalities in land tenure are not obvious.

Health inequity refers to health inequalities that are unjust according to some theory of social justice. Thus, the study of health equity involves a value judgment.5 Awareness is increasing of the importance of development efforts that not only improve the overall burden of disease, but also measure the proportion of this burden borne by poor people and the difference in burden between rich and poor. The aim of these efforts is to work towards keeping inequity to a minimum while health problems are tackled through new initiatives.

Baseline community surveys of families with young children are being done in three countries as part of the multicountry evaluation of the integrated management of childhood illnesses (IMCI) strategy.6 IMCI combines prevention and treatment of the most common childhood illnesses into simple guidelines and messages for use in health facilities and households. Countries adapt these guidelines to meet their needs, and use them to train health workers, improve supervision, ensure essential drugs are available, and mobilise families and communities in support of child health. In a household survey in Tanzania of children younger than 5 years, we aimed to assess inequalities in the use of child health-care services with respect to sex and socioeconomic status in two districts in the early phase of IMCI implementation and in two others without this programme.

Section snippets

Study area

Kilombero, Morogoro Rural, Rufiji, and Ulanga Districts are in southern Tanzania (6–8° south, 36–39°east) and have a total population of about 1·2 million people.7 Kilombero and Rufiji are low-lying (<300 m above sea level) and much of the land is in the fertile flood plain of the Kilombero and Rufiji rivers; Morogoro Rural and Ulanga have mountainous areas as well as low-lying plains. There are two main rainy seasons, October–December and February–May. There is a broad mix of ethnic groups:

Results

The survey included 2246 households in 115 rural clusters in four districts: 21 households (1%) refused to take part, a further 137 (6%) were unavailable for interview. 1321 (63%) of the remaining 2088 households had one or more children under 5 years. 2006 children were included in the main analysis, of whom 1008 (50%) were boys and 489 (24%) were infants (table 1). The sample of children was broadly representative of the population7 with regard to age and sex (data not shown).

In the 2 weeks

Discussion

In a very poor area of rural Tanzania, with high morbidity and mortality rates, our results suggest that the main difference between the poorest children and those who are better off is not in the likelihood of falling ill, but in the probability of obtaining suitable treatment once ill. Carers of children from wealthier families had better knowledge about danger signs, were more likely to bring their children to a health facility when ill, and were more likely to have had a shorter journey to

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