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

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Study Justification:
The study aimed to investigate the private costs and other factors that affect access to healthcare for childhood fevers in rural Tanzania. The objective was to understand the determinants of healthcare facility attendance for febrile illnesses in children under 5 years of age. The study was conducted in two rural, malaria-endemic areas of Tanzania to provide insights into the barriers and challenges faced by families in accessing healthcare for their sick children.
Highlights:
– Severe febrile illness was strongly associated with health facility attendance.
– Private costs for patients who went to a hospital were six times larger than those for controls.
– Household wealth was not significantly correlated with total costs incurred.
– Private costs were three times greater for admissions at the mission hospital compared to the public hospital.
– Duration of admission was a major determinant of private costs, with each day in the hospital increasing costs by about 12%.
Recommendations:
– Improve access to healthcare facilities for children with severe febrile illnesses.
– Address the financial burden of private costs for families seeking healthcare.
– Ensure availability of essential commodities and medications in healthcare facilities.
– Consider strategies to reduce the duration of hospital admissions and associated costs.
Key Role Players:
– Ministry of Health: Responsible for policy development and implementation.
– District Medical Officers: Oversee healthcare services at the district level.
– Community Health Workers: Provide frontline healthcare services and support.
– Hospital Administrators: Manage hospital operations and services.
– Non-Governmental Organizations: Provide support and resources for healthcare initiatives.
Cost Items for Planning Recommendations:
– Availability of essential commodities and medications in healthcare facilities.
– Training and capacity building for healthcare staff.
– Infrastructure and equipment upgrades in healthcare facilities.
– Outreach programs and community health education initiatives.
– Monitoring and evaluation of healthcare services.
Please note that the provided information is based on the description and findings of the study.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it presents the findings of a case-control study conducted in rural Tanzania. The study used multivariable logistic regression analysis to understand the factors influencing attendance at healthcare facilities for childhood fevers. The study also obtained details of private expenditures for hospitalised children. The results show a strong association between severe febrile illness and health facility attendance, as well as significant differences in private costs between patients who went to a hospital and those who did not. The abstract provides specific numbers and statistical measures to support the findings. To improve the evidence, the abstract could include more information about the sample size and characteristics of the study population, as well as the limitations of the study.

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.

Based on the information provided, here are some potential recommendations for innovations to improve access to maternal health:

1. Financial support programs: Develop programs that provide financial assistance to families for out-of-pocket costs associated with maternal health care, such as transportation, registration fees, and medication costs.

2. Mobile health clinics: Implement mobile health clinics that can travel to rural areas, providing access to maternal health services for communities that are far from healthcare facilities.

3. Telemedicine: Introduce telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video calls or phone consultations, reducing the need for travel.

4. Community health workers: Train and deploy community health workers to provide basic maternal health services and education in rural areas, improving access to care and increasing awareness about the importance of maternal health.

5. Public-private partnerships: Foster collaborations between public and private healthcare providers to expand access to maternal health services in underserved areas, leveraging the resources and expertise of both sectors.

6. Health education programs: Develop and implement health education programs that focus on maternal health, targeting both women and their families to increase awareness and knowledge about prenatal care, childbirth, and postnatal care.

7. Infrastructure development: Invest in improving healthcare infrastructure in rural areas, including the construction and renovation of healthcare facilities, ensuring that they are equipped to provide quality maternal health services.

8. Transportation support: Establish transportation support systems, such as ambulance services or transportation vouchers, to help pregnant women reach healthcare facilities in a timely and safe manner.

9. Maternal health insurance: Introduce or expand maternal health insurance programs that provide coverage for prenatal, childbirth, and postnatal care, reducing the financial burden on families and increasing access to quality care.

10. Quality improvement initiatives: Implement quality improvement initiatives in healthcare facilities, focusing on maternal health services, to ensure that women receive safe and effective care during pregnancy, childbirth, and postpartum.

These recommendations aim to address the barriers to accessing maternal health services, particularly in rural areas, and improve the overall health outcomes for pregnant women and their babies.
AI Innovations Description
The study mentioned in the description focuses on private costs and other determinants of access to healthcare for childhood fevers in rural Tanzania. The objective of the study was to understand the factors that influence attendance at healthcare facilities for children with febrile illnesses. The study found that severe febrile illness is strongly associated with health facility attendance. It also found that the private costs of an illness for patients who went to a hospital were six times larger than the private costs of controls. Household wealth was not significantly correlated with total costs incurred.

Based on the findings of this study, a recommendation to improve access to maternal health could be to reduce or eliminate out-of-pocket costs for maternal healthcare services. This could help remove financial barriers that prevent women from seeking necessary maternal healthcare. By providing free or affordable maternal healthcare services, more women would be able to access the care they need, leading to improved maternal and child health outcomes. Additionally, efforts should be made to ensure that essential commodities and medications are consistently available in healthcare facilities to avoid additional costs being borne by patients.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Reduce out-of-pocket costs: The study found that private costs for hospital visits were significantly higher than costs for those who did not visit a facility. Reducing or eliminating out-of-pocket costs for maternal health services can help improve access for women, especially those from low-income households.

2. Improve availability of free care: In areas where free care is available, efforts should be made to ensure that women are aware of these services and can easily access them. This may involve increasing the number of facilities that provide free care or improving transportation options to reach these facilities.

3. Strengthen public healthcare facilities: The study found that private costs were higher at mission hospitals compared to public hospitals. Investing in public healthcare facilities, including staffing, equipment, and supplies, can help improve access to quality maternal health services without the burden of high costs.

4. Increase community awareness and education: Many women in the study sought care from traditional healers or purchased medicines from shops without a prescription. Increasing awareness about the importance of seeking care from trained healthcare providers and the potential risks of self-medication can help improve access to appropriate maternal health services.

Methodology to simulate the impact of these recommendations on improving access to maternal health:

1. Define the target population: Determine the specific population that will be the focus of the simulation, such as pregnant women or women of reproductive age in a particular geographic area.

2. Collect baseline data: Gather data on the current access to maternal health services, including utilization rates, out-of-pocket costs, and availability of free care. This can be done through surveys, interviews, or existing data sources.

3. Develop a simulation model: Create a model that simulates the impact of the recommendations on access to maternal health services. This can be done using statistical software or specialized simulation tools.

4. Input the recommendations: Incorporate the recommendations into the simulation model, adjusting relevant variables such as out-of-pocket costs, availability of free care, and improvements in public healthcare facilities.

5. Run the simulation: Run the simulation model to simulate the impact of the recommendations on access to maternal health services. This will provide estimates of the potential changes in utilization rates, costs, and other relevant outcomes.

6. Analyze the results: Analyze the results of the simulation to understand the potential impact of the recommendations on improving access to maternal health services. This may involve comparing the simulated outcomes to the baseline data and identifying any significant changes.

7. Refine and iterate: Based on the results of the simulation, refine the recommendations and the simulation model if necessary. Repeat the simulation process to further explore the potential impact of different scenarios or variations in the recommendations.

8. Communicate the findings: Present the findings of the simulation to relevant stakeholders, such as policymakers, healthcare providers, and community organizations. Use the findings to advocate for the implementation of the recommendations and inform decision-making processes.

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