Affordability, availability and acceptability barriers to health care for the chronically ill

Longitudinal case studies from South Africa

Bibliographic Data

ID23371905
AuthorsJane Goudge (0000-0001-6555-7510, University of the Witwatersrand, corresponding author), Lucy Gilson (0000-0002-2775-7703, University of the Witwatersrand), Steven Russell (0000-0001-8423-5891, University of East Anglia), Tebogo Gumede (0000-0002-3151-4579, University of the Witwatersrand), Antonia Mills (0000-0001-9863-9950, London School of Hygiene & Tropical Medicine), Anne Mills
Year2009
Volume9
Issue1
Pages75-75
Publication date2009-12-01
Peer ReviewedYes
Open AccessYes
TypeARTICLE
VenueBMC Health Services Research (JOURNAL)
Journal identifiersISSN: 1472-6963 • E-ISSN: 1472-6963
PublisherSpringer Science and Business Media LLC (PUBLISHER)
DOI10.1186/1472-6963-9-75
PMID19426533
PMCIDPMC2694171
OpenAlexW2046518205
LanguageEN
Citations received69
References cited40

BACKGROUND: There is an increasing burden of chronic illness in low and middle income countries, driven by TB/HIV, as well as non-communicable diseases. Few health systems are organized to meet the needs of chronically ill patients, and patients' perspectives on the difficulties of accessing care need to be better understood, particularly in poor resourced settings, to achieve this end. This paper describes the experience of poor households attempting to access chronic care in a rural area of South Africa. METHODS: A household survey (n = 1446 individuals) was combined with qualitative longitudinal research that followed 30 case study households over 10 months. Illness narratives and diaries provided descriptive textual data of household interactions with the health system. RESULTS: In the survey 74% of reported health problems were 'chronic', 48% of which had no treatment action taken in the previous month. Amongst the case study households, of the 34 cases of chronic illness, only 21 (62%) cases had an allopathic diagnosis and only 12 (35%) were receiving regular treatment. Livelihoods exhausted from previous illness and death, low income, and limited social networks, prevented consultation with monthly expenditure for repeated consultations as high as 60% of income. Interrupted drug supplies, insufficient clinical services at the clinic level necessitating referral, and a lack of ambulances further hampered access to care. Poor provider-patient interaction led to inadequate understanding of illness, inappropriate treatment action, 'healer shopping', and at times a break down in cooperation, with the patient 'giving up' on the public health system. However, productive patient-provider interactions not only facilitated appropriate treatment action but enabled patients to justify their need for financial assistance to family and neighbours, and so access care. In addition, patients and their families with understanding of a disease became a community resource drawn on to assist others. CONCLUSION: In strengthening the public sector it is important not only to improve drug supply chains, ambulance services, referral systems and clinical capacity at public clinics, and to address the financial constraints faced by the socially disadvantaged, but also to think through how providers can engage with patients in a way that strengthens the therapeutic alliance.

Economic growth · Environmental health · Family medicine · Health administration · Health care · Nursing research · Poverty · Public health · Referral · Diabetes Management and Education · Global Maternal and Child Health · Health Informatics · Healthcare Systems and Reforms · Medicine · Nursing