Opportunities to catalyse improved healthcare access in pluralistic systems: a cross-sectional study in Haiti

Abstract

ObjectiveTo identify determinants of intended versus actual care-seeking behaviours in a pluralistic healthcare system that is reliant on both conventional and non-conventional providers and discover opportunities to catalyse improved healthcare access.DesignCross-sectional study.Setting and participantsIn Haiti 568 households (incorporating 2900 members) with children less than 5 years of age were randomly sampled geographically with stratifications for population density. These households identified the healthcare providers they frequented. Among 140 providers, 65 were located and enrolled.Outcome measuresHousehold questionnaires with standardised cases (intentions) were compared with self-recall of health events (behaviours). The connectedness of households and their providers was determined by network analysis.ResultsHouseholds reported 636 health events in the prior month. Households sought care for 35% (n=220) and treated with home remedies for 44% (n=277). The odds of seeking care increased 217% for severe events (adjusted OR (aOR)=3.17; 95% CI 1.99 to 5.05; p<0.001). The odds of seeking care from a conventional provider increased by 37% with increasing distance (aOR=1.37; 95% CI 1.06 to 1.79; p=0.016). Despite stating an intention to seek care from conventional providers, there was a lack of congruence in practice that favoured non-conventional providers (McNemar’s χ2 test p<0.001). Care was sought from primary providers for 68% (n=150) of cases within a three-tiered network; 25% (n=38/150) were non-conventional.ConclusionAddressing geographic barriers, possibly with technology solutions, should be prioritised to meet healthcare seeking intentions while developing approaches to connect non-conventional providers into healthcare networks when geographic barriers cannot be overcome.

A Nighttime Telemedicine and Medication Delivery Service to Avert Pediatric Emergencies in Haiti: An Exploratory Cost-Effectiveness Analysis

“… 1 In INACT-1, 9 pediatric patients who sought hospital emergency care reported an average transportation cost of $4.13 (daytime versus nighttime was not known). 21 In INACT-2, a single patient reported a transportation cost of $8.87 at night. Using these figures, the weighted average estimate for hospital transportation cost is approximately $5 per patient.…”

“…To better understand the barriers to pediatric healthcare in Haiti, we conducted a needs assessment to identify differences in household healthcare seeking intention (“would do”) and behavior (“did do”) 21 ; this initiative was part of the Improving Nighttime Access to Care and Treatment Study (INACT-1). 21 In this needs assessment, households expressed an intention to seek care from a provider within conventional networks, but, because of cost, distance, and nighttime hours, sought care from disconnected providers near to the household in practice. INACT-1 revealed that a pediatric telemedicine and medication delivery service, known as MotoMeds, might provide an innovative solution to one aspect of the crisis of limited access to pediatric healthcare.…”

“…INACT-1 found that families sought care for 32% of pediatric health events. 21 The 2016 DHS in Haiti found that children under 5 sought care for 40.4% of acute respiratory infections and 32.9% of diarrheal cases. 30 These figures were averaged to estimate 35.1% of families with a sick child seek care.…”

“…The INACT-1 found that 8% of care-seekers seek hospital care. 21 DHS data were used to determine the proportion of the accessible population under 1 year (2.2%), from 1 to 4 years (7.5%), and 5 to 9 years (11.3%). 30 The age distribution was assumed to be geographically uniform across Haiti.…”

“…During INACT-2, 30% of families paid in full and 25% paid in part (250 gourdes, $2.89). 21 We conservatively assumed the same ratio for these analyses.…”