Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.
University of Basel, Basel, Switzerland.
BMC Public Health. 2022 Jun 16;22(1):1205. doi: 10.1186/s12889-022-13549-3.
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.
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.
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.
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.
为了改善人口健康，许多低收入和中等收入国家（LMICs）扩大了公共初级保健设施的覆盖范围，并取消了这些设施的服务费用。然而，越来越多的文献表明，许多患者会绕过附近的初级保健设施，选择前往更远或更高层次的设施寻求医疗服务。在这些国家，城市地区的人口不断增长，与农村地区的患者相比，他们通常有更多的选择来寻求医疗服务。然而，关于城市地区的求医轨迹和绕过模式的证据仍然相对较少。
我们获取了卢萨卡地区 31 个城市的所有公共卫生机构的完整清单，并对这些城市的随机选择的非正规部门家庭进行了访谈。所有列出的家庭和设施都进行了地理编码，并绘制了整个城市的求医轨迹图。我们分析了三种类型的绕过行为：i）不使用卫生中心或卫生所进行初级保健；ii）到居住地以外的地方寻求医疗服务；iii）直接到教学医院就诊。
共访谈了 620 户家庭，与 88 家卫生机构建立了联系。在最近非紧急情况下寻求医疗服务的 571 名成年人中，有 65%的人选择去医院就诊。在最近因腹泻、咳嗽、发烧或呼吸急促而寻求医疗服务的 141 名儿童中，有 34%的人选择去医院就诊。71%的成年人绕过了初级保健设施，26%的人绕过了离他们较近的卫生中心和医院，而去更远的医疗机构就诊，8%的人直接到教学医院就诊。59%的儿童也出现了绕过行为，他们更有可能到正规医疗服务部门之外寻求医疗服务，其中 21%的儿童在药店或药房接受治疗。
这里呈现的结果强烈凸显了城市卫生系统的复杂性。卢萨卡的大多数成年患者不会因非紧急情况而去公立初级卫生保健机构就诊，他们严重依赖药店和药房来治疗儿童。如果政府想在这种情况下将卫生中心作为主要的初级保健服务接入点，可能需要做出重大努力。
