Health care seeking in modern urban LMIC settings: evidence from Lusaka, Zambia

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Study Justification:
The study aims to investigate health care seeking patterns in urban areas of low- and middle-income countries (LMICs), specifically focusing on Lusaka, Zambia. This research is important because urban areas in LMICs have a growing population and offer more options for seeking care compared to rural areas. Understanding care-seeking trajectories and bypassing patterns in urban areas is crucial for improving population health and optimizing the use of public primary care facilities.
Highlights:
1. The study collected data from 620 households and 88 health facilities in Lusaka District, Zambia.
2. Among adults seeking non-emergency care, 65% sought care at a hospital, indicating a low utilization of public primary health facilities.
3. For children seeking care for common illnesses, 34% sought care at a hospital, and 21% were treated at drug shops or pharmacies.
4. Bypassing of primary care facilities was observed in 71% of adults and 59% of children, indicating a preference for seeking care at higher-level facilities or outside the formal care sector.
5. The complexity of urban health systems was highlighted, emphasizing the need for major efforts to establish health centers as the principal primary care access point.
Recommendations:
1. Increase awareness and promote the use of public primary health facilities for non-emergency care among adults in urban areas.
2. Improve the quality and accessibility of primary care services to attract patients and reduce bypassing.
3. Strengthen the referral system between primary care facilities and higher-level hospitals to ensure appropriate care pathways.
4. Enhance the regulation and quality control of drug shops and pharmacies to ensure safe and effective treatment for children.
5. Conduct further research to explore the reasons behind bypassing patterns and identify strategies to address them effectively.
Key Role Players:
1. Ministry of Health: Responsible for policy-making, planning, and implementation of interventions to improve health care seeking in urban areas.
2. Health Facility Managers: Involved in improving the quality and accessibility of primary care services in health centers and health posts.
3. Community Health Workers: Engaged in raising awareness and promoting the use of public primary health facilities among the community.
4. Pharmaceutical Regulatory Authority: Responsible for regulating drug shops and pharmacies to ensure the provision of safe and effective treatments.
5. Non-Governmental Organizations: Collaborate with the government to implement interventions and support community health initiatives.
Cost Items for Planning Recommendations:
1. Health Facility Upgrades: Budget for improving infrastructure, equipment, and staffing in health centers and health posts to enhance the quality of care.
2. Training and Capacity Building: Allocate funds for training health care providers in primary care facilities to improve their skills and knowledge.
3. Awareness Campaigns: Invest in public health campaigns to raise awareness about the importance of using public primary health facilities for non-emergency care.
4. Referral System Strengthening: Allocate resources for establishing effective referral systems between primary care facilities and higher-level hospitals.
5. Regulatory Measures: Budget for strengthening the regulation and quality control of drug shops and pharmacies to ensure compliance with standards.
Please note that the cost items provided are general categories and not actual cost estimates. The specific budget allocation would depend on the context, priorities, and resources available in Lusaka, Zambia.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it presents findings from a cross-sectional household survey conducted in Lusaka, Zambia. The study collected data from a large sample size of 620 households and 88 health facilities, providing a comprehensive understanding of care-seeking trajectories and bypassing patterns in urban areas. The study used geocoded data and mapping techniques to analyze three types of bypassing and identified the complexity of urban health systems. The results highlight that most adult patients in Lusaka do not use public primary health facilities for non-emergency care and heavily rely on pharmacies and drug shops for the treatment of children. The study also provides information on the Zambian health system structure and the characteristics of the study population. To improve the evidence, future studies could consider including a comparison group of rural areas to further understand the differences in care-seeking patterns between urban and rural settings.

Background: In an effort to improve population health, many low- and middle-income countries (LMICs) have expanded access to public primary care facilities and removed user fees for services in these facilities. However, a growing literature suggests that many patients bypass nearby primary care facilities to seek care at more distant or higher-level facilities. Patients in urban areas, a growing segment of the population in LMICs, generally have more options for where to seek care than patients in rural areas. However, evidence on care-seeking trajectories and bypassing patterns in urban areas remains relatively scarce. Methods: We obtained a complete list of public health facilities and interviewed randomly selected informal sector households across 31 urban areas in Lusaka District, Zambia. All households and facilities listed were geocoded, and care-seeking trajectories mapped across the entire urban area. We analyzed three types of bypassing: i) not using health centers or health posts for primary care; ii) seeking care outside of the residential neighborhood; iii) directly seeking care at teaching hospitals. Results: A total of 620 households were interviewed, linked to 88 health facilities. Among 571 adults who had recently sought non-emergency care, 65% sought care at a hospital. Among 141 children who recently sought care for diarrhea, cough, fever, or fast breathing, 34% sought care at a hospital. 71% of adults bypassed primary care facilities, 26% bypassed health centers and hospitals close to them for more distant facilities, and 8% directly sought care at a teaching hospital. Bypassing was also observed for 59% of children, who were more likely to seek care outside of the formal care sector, with 21% of children treated at drug shops or pharmacies. Conclusions: The results presented here strongly highlight the complexity of urban health systems. Most adult patients in Lusaka do not use public primary health facilities for non-emergency care, and heavily rely on pharmacies and drug shops for treatment of children. Major efforts will likely be needed if the government wants to instate health centers as the principal primary care access point in this setting.

Zambia is a lower-middle-income country in southern Africa with a life expectancy at birth of 64 years, maternal mortality rate of 213 deaths per 100,000 live births, and child mortality ratio of 62 deaths per 1,000 live births [1]. In 2019, 44% of the population lived in an urban area [1]. Lusaka district, including the capital city, has a population of approximately two million people living in an area of approximately 418 square kilometers. In Lusaka province (of which 80% is Lusaka district), average household wealth, infrastructure, education levels, and access to health care services are generally higher than in other parts of Zambia. For example, in 2018, 50% of the population of Lusaka province was in the country’s highest wealth quintile; 98% had access to an improved source of drinking water compared with 71% nationwide; the female literacy rate was 80% compared with 66% nationwide; and 91% of live births in the preceding five years were in a health facility compared with 84% nationwide [39]. The Zambian health system has a pyramid-structure with three levels. Level 1 includes health posts (with catchment areas of 500 households in rural areas and1000 households in urban areas), health centers (with catchment areas of 10,000 in rural areas and 50,000 in urban areas), mini hospitals (catchment population between 50,000 and 80,000) and district hospitals (catchment population between 80,000 and 20,000). Level 2 includes provincial level hospitals (catchment population 200,000 to 800,000) which provide secondary care and curative care in pediatrics, obstetrics and gynecology and general surgery. Level 3 includes tertiary hospitals (catchment population 800,000 and above), such as the University Teaching Hospital in Lusaka, and specialized hospitals, such as the Cancer Diseases Hospital and the National Heart Hospital. Residential neighborhoods are generally assigned to a nearby health center or health post where they are expected to go as their first point-of-contact with the health system; they may then be referred to a hospital if needed. In practice, residents may choose to go to a different health center or health post from the one they are assigned to; in these cases, they do not incur a bypassing fee because they are still accessing the system at the recommended level. However, if they seek care directly at a hospital, then they incur a bypassing fee. In addition to the public system, there are private and not-for-profit health facilities throughout Zambia. These are registered by the National Health Professions Council [40]. In Lusaka, these are mainly health centers and Level 1 hospitals. At the data of data collection, residents of Lusaka mainly used Level 1 and Level 3 care, as there were few Level 2 hospitals in the city. Since data collection, many health facilities in Lusaka have been upgraded in levels. Throughout this paper, we focus on the levels as they were at the time of data collection. This study was a cross-sectional household survey conducted in Lusaka district in Zambia from November to December 2020. The target population for the study was all adults employed in the informal sector and aged between 18–65 years who lived in Lusaka district, and their children. We define the informal sector as businesses or other economic units that are not registered with a tax or licensing authority. Those who are employed in the informal sector tend not to have contracts or entitlements. As of 2014, the informal sector accounted for about 90% of employment in Zambia [41]. To determine whether respondents were employed in the formal or informal sector, we asked whether they had a formal employment contract and contributed to the National Pension Scheme Authority (NAPSA). We used a random clustered sampling approach to select households for participation in this study. The target sample size of 700 households was chosen for the purposes of a separate analysis of health insurance participation and health system confidence. To draw the sample, we first randomly sampled 35 enumeration areas (EAs) from the 1,225 listed in the 2010 Zambia Census of Population and Housing. Within each EA, we then approached every fourth household until we reached a sample of 20 informal sector households. Eligible heads of households or their spouse were provided information about the study and those who consented were interviewed using the questionnaire. For the purposes of this analysis, we defined the adult analytic sample to include all adults whose most recent health visit was for care for a chronic condition, a check-up, or a new (acute) health issue. We excluded adults whose most recent health visit was an emergency. We defined the child sample to include all children aged five and under who had received care in the past two weeks for fever, diarrhea, cough, or fast breathing. Interviewers were trained and supervised directly by a member of the study team (DOA). Household interviews were conducted from November 6 to December 19, 2020. During interviews, adults in the sample were asked about their own care-seeking during their most recent health visit, as well as care-seeking for fever, diarrhea, cough, or fast breathing in the past two weeks for children aged five and under in their household (up to a total of five children per household). All data were collected using the Open Data Kit (ODK) software package on hand-held tablets. Survey tools were developed in English and then translated to local languages by the survey team. Interviews were conducted in the respondent’s preferred language (English, Nyanja, or Bemba). Residential coordinates for all households were collected directly through the tablets using a geolocation function integrated into ODK. In addition, we collected information on the locations of health facilities in Lusaka. An initial list of facilities as well as their geolocations was obtained from the Zambian Ministry of Health. This list included public facilities as well as private and not-for-profit (e.g., religious) health facilities. It did not include pharmacies or drug shops. Geocodes of all facilities in the sample were verified by one of the authors (DOA) in January 2021 through a combination of online mapping resources (January 10–15) [42] and personal visits to facilities (January 17–22). We obtained ethical clearance from the University of Zambia Social Sciences and Humanities Ethical Clearance Committee (HSSREC-2020-SEP-012) and authority to conduct research from the National Health Research Authority (NHRA00018/15/10/2020). We also obtained ethical clearance from the Ethikkommission Nordwest- und Zentralschweiz (EKNZ) in Switzerland (AO_2020-00,029). The primary outcome was bypassing. We used three definitions of bypassing (Table ​(Table1).1). These definitions are not mutually exclusive, but each measure different bypassing constructs with different interpretations. First, we defined “primary care bypassing” as using a health facility other than a health center or health post for any non-emergency care. This strict definition of bypassing aligns with guidelines from Zambia’s Ministry of Health. Second, we defined “horizontal bypassing” as using a distant health facility or a pharmacy rather than a nearby facility for non-emergency care – this type of bypassing implies additional transport time and cost, and is likely a reflection of households anticipating to find higher quality of care outside of their residential areas. To identify nearby facilities, we asked all subjects in each neighborhood about the facility their neighborhood belonged to. In most cases, the large majority of respondents agreed on one specific facility. In some cases, two primary facilities were mentioned. We defined nearby facilities as the one (if only one was mentioned) or two (if two were mentioned) facilities that respondents mentioned, as well as the facility that was spatially closest to the respondent (if this was different from the one or two facilities mentioned). Of note, Ministry of Health guidelines do not specify which specific health facility people should go to for care, so horizontal bypassing can in principle be in line with Ministry of Health guidelines as long as people seek care for non-emergency conditions at a health centre or health post rather than a hospital. In practice, many patients seeking care outside of their residential area seek care at higher level facilities, in which case horizontal bypassing also implies primary care bypassing. Last, we defined “two-level” bypassing as using a teaching hospital (Level 3) for non-emergency care. Patients who do this are bypassing not only the available primary health care facilities but also the regular (Level 1, non-teaching) hospitals. Definitions of bypassing We began our analysis by describing the characteristics of the adult and child analytic samples. We described respondents’ demographic characteristics (e.g., gender and age) as well as the landscape of health facilities in the area the where respondents lived. To describe the landscape of health facilities, we calculated the number of health facilities within 1 km and within 5 km of where each respondent lived using Euclidean distance and then took the average across respondents. Next, we mapped and described the spatial distribution of the health facilities in Lusaka and the types of facilities that adults and children in the study sample visited. Mapping included any facilities on the Ministry of Health’s list of health facilities, but it did not include pharmacies or drug shops, even though some respondents sought care in these locations. We then calculated the rate of bypassing (using all three definitions above) for adults and children in the sample, disaggregated by the reason for their health visit. We mapped care-seeking patterns for each study participant meeting each of the three definitions of bypassing using QGIS Version 3 [43]. In addition, we examined how bypassing patterns varied across constituencies. Constituencies are administrative areas that contain multiple EAs; Lusaka has 7 constituencies covering 1,125 EAs. Finally, we used logistic regression to analyze associations between study participant characteristics (including sex, age, marital status, education level, wealth measured using an asset score, and reason for seeking care) and each of the three types of bypassing. We fit models in the adult and child samples separately. We clustered standard errors at the EA level. All analyses were conducted using Stata 16 [44].

Based on the provided information, here are some potential innovations that could improve access to maternal health in Lusaka, Zambia:

1. Mobile Health Clinics: Implementing mobile health clinics that can travel to different neighborhoods in Lusaka, providing maternal health services directly to the community. This would reduce the need for residents to travel long distances to access healthcare facilities.

2. Telemedicine: Introducing telemedicine services that allow pregnant women to consult with healthcare professionals remotely. This would enable women to receive medical advice and support without having to physically visit a healthcare facility.

3. Community Health Workers: Expanding the role of community health workers in providing maternal health services. These workers can be trained to provide basic antenatal care, education, and support to pregnant women in their communities, improving access to essential services.

4. Public-Private Partnerships: Collaborating with private healthcare providers to increase the availability of maternal health services. This could involve subsidizing private clinics to offer affordable or free services to low-income women, expanding the options available for care.

5. Health Education Programs: Implementing comprehensive health education programs that focus on maternal health. These programs can raise awareness about the importance of antenatal care, safe delivery practices, and postnatal care, empowering women to take control of their own health.

6. Transportation Support: Providing transportation support for pregnant women to access healthcare facilities. This could involve establishing transportation networks or partnerships with local transportation providers to ensure that women can easily reach healthcare facilities when needed.

7. Maternal Health Vouchers: Introducing a voucher system that provides pregnant women with access to free or discounted maternal health services. This would remove financial barriers and encourage more women to seek care.

8. Strengthening Referral Systems: Improving the coordination and communication between different levels of healthcare facilities to ensure smooth referrals for pregnant women who require specialized care. This would ensure that women receive the appropriate level of care in a timely manner.

9. Maternal Health Hotline: Establishing a dedicated hotline for maternal health, where women can call to seek advice, ask questions, and receive guidance on accessing healthcare services. This would provide a convenient and accessible resource for pregnant women.

10. Quality Improvement Initiatives: Implementing quality improvement initiatives in healthcare facilities to enhance the overall quality of maternal health services. This could involve training healthcare providers, improving infrastructure and equipment, and ensuring the availability of essential supplies and medications.

These innovations have the potential to address the complex challenges of accessing maternal health services in urban areas like Lusaka, Zambia, and improve the overall health outcomes for pregnant women and their babies.
AI Innovations Description
Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Strengthening Primary Health Care Facilities: The study highlights that many patients bypass nearby primary care facilities and seek care at more distant or higher-level facilities. To improve access to maternal health, it is recommended to focus on strengthening primary health care facilities, such as health centers and health posts. This can be done by improving infrastructure, ensuring availability of essential equipment and supplies, and training healthcare providers to provide quality maternal health services.

2. Enhancing Community Engagement: Engaging the community is crucial in improving access to maternal health. Innovative approaches can be developed to raise awareness about the importance of utilizing primary health care facilities for maternal health services. This can include community-based education programs, outreach activities, and involving community leaders and influencers to promote the use of primary health care facilities for maternal health.

3. Mobile Health (mHealth) Solutions: Leveraging technology, such as mobile health (mHealth) solutions, can play a significant role in improving access to maternal health. Innovative mobile applications can be developed to provide information and resources related to maternal health, including antenatal care, postnatal care, and family planning. These applications can also facilitate appointment scheduling, reminders, and teleconsultations with healthcare providers.

4. Public-Private Partnerships: Collaboration between the public and private sectors can help improve access to maternal health. Partnerships can be formed with private healthcare providers, pharmacies, and drug shops to ensure that they adhere to quality standards and provide appropriate maternal health services. This can expand the reach of maternal health services and provide more options for women seeking care.

5. Addressing Financial Barriers: The study mentions that bypassing fees are incurred when seeking care directly at a hospital. To address financial barriers, innovative financing mechanisms can be explored, such as health insurance schemes specifically designed for maternal health. This can help reduce out-of-pocket expenses for women seeking maternal health services and encourage utilization of primary health care facilities.

Overall, the recommendation is to focus on strengthening primary health care facilities, enhancing community engagement, leveraging technology, promoting public-private partnerships, and addressing financial barriers to improve access to maternal health. These innovations can help ensure that women have timely access to quality maternal health services, leading to improved maternal and child health outcomes.
AI Innovations Methodology
To improve access to maternal health in urban areas of Lusaka, Zambia, several innovations can be considered:

1. Mobile Health Clinics: Implementing mobile health clinics that travel to different neighborhoods can increase access to maternal health services. These clinics can provide prenatal care, postnatal care, family planning services, and health education to pregnant women and new mothers.

2. Telemedicine: Introducing telemedicine services can enable pregnant women to consult with healthcare providers remotely. This can be particularly beneficial for women who face transportation challenges or live in remote areas. Telemedicine can provide prenatal check-ups, counseling, and advice on maternal health issues.

3. Community Health Workers: Training and deploying community health workers can improve access to maternal health services. These workers can provide education, counseling, and basic healthcare services to pregnant women and new mothers in their communities. They can also facilitate referrals to higher-level healthcare facilities when necessary.

4. Maternal Health Vouchers: Implementing a voucher system for maternal health services can help reduce financial barriers and improve access. Vouchers can be provided to pregnant women, allowing them to receive essential maternal health services at designated healthcare facilities free of charge or at a reduced cost.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data Collection: Gather data on the current utilization of maternal health services in urban areas of Lusaka. This can include information on the number of women accessing prenatal care, postnatal care, and delivery services, as well as the barriers they face.

2. Baseline Analysis: Analyze the current access to maternal health services and identify the key challenges and gaps in the system. This can involve mapping the distribution of healthcare facilities, assessing transportation infrastructure, and understanding socio-economic factors that affect access.

3. Modeling the Innovations: Develop a simulation model that incorporates the proposed innovations, such as mobile health clinics, telemedicine, community health workers, and maternal health vouchers. The model should consider factors such as population density, healthcare facility locations, and the target population for each innovation.

4. Impact Assessment: Simulate the impact of the innovations on improving access to maternal health services. This can involve estimating the increase in the number of women accessing prenatal care, postnatal care, and delivery services, as well as the reduction in travel time and costs.

5. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the results. This can involve varying parameters such as the coverage of the innovations, the effectiveness of the interventions, and the population distribution.

6. Policy Recommendations: Based on the simulation results, provide policy recommendations on the implementation of the innovations to improve access to maternal health services. Consider factors such as feasibility, cost-effectiveness, and scalability.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different innovations on improving access to maternal health services in urban areas of Lusaka, Zambia. This can inform decision-making and resource allocation to address the complex challenges of urban health systems.

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