Out-of-pocket costs and other determinants of access to healthcare for children with febrile illnesses: A case-control study in rural Tanzania

Objectives To study private costs and other determinants of access to healthcare for childhood fevers in rural Tanzania. Methods A case-control study was conducted in Tanzania to establish factors that determine access to a health facility in acute febrile illnesses in children less than 5 years of age. Carers of eligible children were interviewed in the community; cases were represented by patients who went to a facility and controls by those who did not. A Household Wealth Index was estimated using principal components analysis. A multivariable logistic regression analysis was performed to understand the factors which influenced attendance of healthcare facility including severity of the illness and household wealth/socio-demographic indicators. To complement the data on costs from community interviews, a hospital-based study obtained details of private expenditures for hospitalised children under the age of 5. Results Severe febrile illness is strongly associated with health facility attendance (OR: 35.76, 95% CI: 3.68-347.43, p = 0.002 compared with less severe febrile illness). Overall, the private costs of an illness for patients who went to a hospital were six times larger than private costs of controls ($5.68 vs. $0.90, p<0.0001). Household wealth was not significantly correlated with total costs incurred. The separate hospital based cost study indicated that private costs were three times greater for admissions at the mission versus public hospital: $13.68 mission vs. $4.47 public hospital (difference $ 9.21 (95% CI: 7.89 -10.52), p<0.0001). In both locations, approximately 50% of the cost was determined by the duration of admission, with each day in hospital increasing private costs by about 12% (95% CI: 5% - 21%). Conclusion The more severely ill a child, the higher the probability of attending hospital. We did not find association between household wealth and attending a health facility; nor was there an association between household wealth and private cost. Our study was implemented in two rural, malaria-endemic areas of Tanzania: Kilosa and Mvomero Districts, between September 2010 and March 2011. In Kilosa District, there is access to free care at a public hospital, and most families farm on their own land. In contrast, family income in Mvomero District is dependent upon large-scale, estate-owned, irrigated sugarcane and rice to which families contribute labour. The extensive irrigation makes malaria transmission intense and non-seasonal compared with surrounding areas [12]. Access to immediate care is through a mission hospital located close to the irrigated areas that charges fees. At Kilosa District Hospital, facility registration/consultation, bed costs, inpatient cost of drugs and laboratory examinations are provided free of charge for young children. However, for older children and adults, a fixed fee of US$1.4 is charged for registration/consultation/ medication plus $0.3 per night per bed and per test for each laboratory investigation. In public hospitals such as Kilosa District Hospital, drugs or other supplies used for patient care are provided at no cost when they are in stock. However if essential commodities happen to be out-of-stock at the time of the consultation/admission, the responsibility for purchase rests with the patient’s carer. Turiani Missionary Hospital in Mvomero District was set up in 1961 to provide medical services labourers of the local irrigation schemes [13]. Young children are charged $2.4 for the first visit for registration/consultation plus $0.7 per bed per night, $1.2 for the second visit plus $0.7 per night per bed. The cost for older children and adults is double that of Kilosa: $2.8 for registration/consultation plus $0.7 per night per bed. The cost of drugs and laboratory examinations are charged separately, per test and per drug. Although costs charged to the patient are different between public and private facilities, both hospitals follow national treatment guidelines and provide the same standard of care. The number and quality of staff attending patients were not noticeably different between the two hospitals, but greater attention seemed to be paid to patient notes, hospital files, documentation of patient care and follow up in Turiani Missionary Hospital. These hospitals serving both Districts represent the highest level of care; they are supported by several other public and private facilities (called health centres and dispensaries) which provide inpatient and outpatient health care respectively. The dispensary managed by nurses is usually the first point of consultation for patients and they are closer to the patients’ residences and are more numerous than hospitals. The health centre admits patients, and is staffed by doctors and nurses and often located at an intermediate distance between the dispensary and hospital. In addition, there are a variety of private laboratories, governmental maternal-care clinics, traditional healers and voluntary health workers to whom patients can go for advice and care, in addition to the shops which sell medicines (antipyretics, antibiotics, and antimalarials including quinine) without prescription. The case-control study was carried out in Kilosa and Mvomero Districts. The purpose was to establish why some parents or carers went to hospital/health centre with their child and others did not, especially for children who had a severe febrile illness. A list was developed identifying the villages where the majority of hospital/health-centre-admitted patients resided (excluding villages next to those facilities) and community interviews occurred in the twelve top communities listed, so that geographical distance was similar for patients admitted or not admitted to these facilities. In each community, the study was explained to chiefs of villages and community health workers (CHWs) who are the front-line workers for community health care. These CHWs are required to keep a ledger of sick children in the community with their symptoms, consultations and outcome. We outlined our desire to interview parents of sick children focusing on those who had symptoms of a febrile illness in the past month. CHWs were approached to identify patients who met the inclusion criteria of age (between 3–59 months), symptoms (a febrile illness which prevented oral drug intake at some point during the illness), and illness resolution within the past month. Children who did not meet these eligibility criteria, whose guardian was not present during the illness, who had been already interviewed regarding a previous episode of illness in the household or who refused to sign the informed consent form were excluded from interview. Once eligible children were identified by village health workers or village chiefs, the parents or guardians of the children were approached, the study was explained, informed consent obtained, and interviews were conducted. Allocation of the participants to the cases or controls and determination of whether the episode met eligibility criteria could only occur post-interview. Cases were defined as children who had attended a health facility (i.e. hospital or health centre) and controls were those who did not. Thirteen trained interviewers, with extensive research experience in Kilosa, carried out structured interviews in Swahili and filled out a Case Record Form (available on request). There was no purposeful selection of families for interviews: in each village, all families identified with a sick child who met the inclusion criteria were interviewed. Only one interview per household occurred even if many children in the household had been sick, or a child had more than one episode of illness during the study period. To better understand the factors driving hospital costs, a complementary study was carried out in hospitals with a focus on all out-of-pocket costs of patients admitted, as well as the clinical history of children prior to admission. These interviews were carried out with parents of children about to be discharged from Kilosa District Hospital and Turiani Mission Hospital. Interviews occurred on the day of discharge so that most costs already incurred by parents could be captured. When many children were discharged on the same day, a selection of parents for interview was undertaken (first discharged, first interviewed); when only a few eligible children were to be discharged, every guardian (i.e. an adult carer accompanying the child) was interviewed. Our aim was to interview all patients meeting the eligibility criteria from the main 12 malaria endemic communities in the catchment areas of two major hospitals and one public health centre using CHWs records of childhood illnesses in the community. All families of a child meeting the eligibility criteria were interviewed. At intervals, after a visit to a village had already taken place, the CHW would inform the team that new patients had been identified, and the team would return to the village to complete additional interviews. The objective was to fully represent all eligible patients in these communities during the malaria season of September 2010 to March 2011. There was no attempt to have an equal number of patients from each of the 12 communities. All questionnaires were in Swahili and pilot tested before use. The hospital questionnaire was similar to the community questionnaire but captured additional information on the date and time of arrival of the patient at the hospital, the clinical diagnoses and the treatments received/prescribed at the hospital, extracted from the patient’s hospital file. Each interview lasted about fifty minutes. Participants were asked about the general social-demographic context of the family, and detailed information of the clinical course of the illness (timing, symptoms, actions taken, healthcare providers visited and costs incurred such as transportation, medicines, registration/consultation fees, laboratory/diagnostic tests, accommodation and food for each consultation). Demographic information on the patient (sex, age) and patient’s family (education, number of working members) was obtained. Household socioeconomic data focussed on living standards—durable family possessions (radio, lantern, bicycle, table, iron), ability to meet family food needs, and main occupation/means of the household. Baseline characteristics were compared between cases and controls. Classification of severity was by clinical symptoms as reported by the caretaker. Febrile children with reports of only some very short period of time when the child could not take oral drugs and where the child was largely able to take oral medications, were classified as Per Os (PO). This category included children who had fever only, diarrhoea, rash, cough, a cold/runny nose, headache, no appetite or abdominal pain. If the fever was accompanied by one of the following: repeated vomiting or lethargy (unable to sit/stand/walk unaided, too weak to eat, drink or suck) the illness was classified as Non-Per-Os (NPO). Children with repeated convulsions, altered consciousness or coma, difficulties in breathing or rapid breathing, a stiff neck, bulging fontanel or chest indrawing were classified as severely ill. There was no overlap in patients; children with symptoms in more than one category were categorised in the highest severity category. Out-of-pocket costs reported by the parent or guardian of the child were categorised into “hotel” costs (defined as accommodation costs, registration costs, food, drinks and other costs for carer or patient), diagnostic/laboratory investigations, drugs and patient management, and transport. Transport cost included costs of the parent or guardian but excluded costs paid by a third party (i.e. a person not related to the household) accompanying the parent/guardian and child. Total private costs were compared by case-control status for each location. Total hospital costs were compared by location also for the patients interviewed at the hospital. Costs are presented in US dollars ($) using the average exchange rate between September 2010 and March 2011: 1 US Dollar = 1,474.06 Tanzanian Shillings (www.oanda.com). All data were double entered (Epidata, 3.1) and analyzed using STATA v.9.2 (StataCorp, College Station, TX, USA). Information on household possessions (table, radio, lantern, bicycle and iron) and food problems (had or never had food problems) was used to calculate a Household Wealth Index (HWI) based upon principal components analysis to characterize the wealth variance between households within the community group [14, 15]. Households were grouped into pre-determined ‘wealth’ categories—the lowest 40%, middle 40% and highest 20%—reflecting different socioeconomic levels. Calculation of the HWI did not adjust for household size since the benefits of possessions would be available at the household level. Since one of our objectives was to study factors influencing hospital care, we undertook a multivariable logistic regression analysis using community-based data in which attendance at a hospital or health centre was the dependent variable and independent variables were demographic, social or economic in nature—location, age of the child, gender, highest education (in years) achieved within the family, number of working people in the household, severity of the illness and the household wealth index. Since the total private costs of illness were not known at the time of decision to go to a hospital/health centre, we excluded total private costs incurred for healthcare of the child during the episode of illness. A further linear regression analysis was used to determine which factors affected hospital costs. When the study population was stratified with respect to the characteristic of interest, we used either the chi-squared test of homogeneity or a linear trend of odds if there were more than two ordered groups. We also used the student’s t-test to determine equality of means. The level of significance of p = 0.05 and a confidence level of 95% were used throughout. The research protocol was approved by the National Institute for Medical Research Ethics Committee (NIMR) and the Commission for Science and Technology (COSTECH) in Tanzania. Additional local permission was granted by the Regional Medical Officer in Morogoro, the District Medical Officers in Kilosa and Mvomero and village leaders. Individual written informed consent was obtained from all participants prior to interview.