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Keywords:

  • child mortality;
  • health systems research;
  • equity;
  • quality of care;
  • hospital;
  • community survey;
  • Guinea-Bissau;
  • Sub-Saharan Africa
  • mortalité infantile;
  • recherche sur les systèmes de santé;
  • équité;
  • qualité des soins;
  • hôpital;
  • surveillance de communauté;
  • Guinée-Bissau;
  • Afrique Subsaharienne
  • Mortalidad infantil;
  • Investigación en sistemas de salud;
  • Equidad;
  • Calidad de la atención;
  • Hospital;
  • Encuesta comunitaria;
  • Guinea-Bissau;
  • África Sub-Sahariana

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Background  To examine equity in access to public health services in Guinea-Bissau.

Methods  The study was conducted in 2000–2001 at the emergency clinic of the only paediatric ward in Bissau. Mothers of all children from the study area were interviewed about previous care seeking and relations with anybody working in the health sector. All management actions in the emergency clinic were registered. In-hospital and subsequent community mortality was ascertained through community surveillance. The measured outcome was mortality risk within 30 days of first consultation.

Results  We followed 1572 children with a first consultation. Of these, 8.2% died within 30 days. Acquaintance with a physician reduced 30-day mortality risk by 48% (95% CI: 18–66). The effect was strongest among post-neonatal children (54%; 95% CI: 18–74). Mortality within 30 days of consultation was also independently predicted by consultation after 7 pm, nurse team on duty, day of week and young mother. In a multivariate model, socioeconomic status and school education were not associated with 30-day mortality when acquaintance with a medical doctor was taken into account.

Conclusion  Favouritism may be a significant factor for quality of care and child mortality in developing countries. Interventions to improve hospital and health worker performance should be given high priority.

Données de base  Examiner l’équité dans l'accès aux services de santé publique en Guinée-Bissau.

Méthodes  Etude menée en 2000–2001 dans la clinique d'urgence de l'unique unité pédiatrique à Bissau. Les mères et enfants dans la zone étudiée ont été interviewés au sujet de précédents recours aux soins de santé et des relations avec toute personne travaillant dans le secteur de la santé. Toutes les actions de prise en charge dans la clinique d'urgence ont été enregistrées. La mortalitéà l'hôpital et subséquemment dans la communauté a été confirmée par une surveillance de communauté. Le résultat final mesure a été la mortalité endéans les 30 jours suivant la première consultation.

Résultats  1576 enfants avec une première consultation ont été suivis. Parmi eux, 8,2% sont décédés endéans les 30 jours. La connaissance avec un médecin réduisait de 48% (IC95%: 18–66) le risque de mortalité endéans les 30 jours. Cet effet était plus accentué chez les enfants en stade post-néonatal (54%; IC95%: 18–74). La mortalité endéans les 30 jours suivant la consultation était aussi indépendamment influencée par la consultation après 19 heures, par l’équipe infirmières en poste, par le jour de la semaine et par les jeunes mères. Dans un modèle multivarié, le statut socioéconomique et l’éducation scolaire n’étaient pas associés avec une mortalité endéans les 30 jours, lorsque la connaissance avec un médecin était prise en compte.

Conclusion  Le favoritisme peut être un facteur important dans la qualité des soins et la mortalité infantile dans les pays en développement. Une haute priorité devrait être accordée aux interventions visant à améliorer la performance des hôpitaux et des agents de la santé.

Antecedentes  Evaluar la equidad en el acceso a los servicios de la sanidad pública en Guinea-Bissau.

Métodos  El estudio se realizó entre el 2000 y 2001, en la sala de urgencias del único pabellón pediátrico de Bissau. Se entrevistó a las madres de los niños del área de estudio sobre experiencias previas en la búsqueda de cuidados médicos, así como sobre la existencia de relaciones con cualquiera que trabajase en el sector salud. Se registraron todos los trámites administrativos realizados en Urgencias. Se obtuvo la mortalidad intrahospitalaria y comunitaria mediante vigilancia comunitaria. El resultado medido fue el riesgo de mortalidad dentro de los 30 días después de la primera consulta.

Resultados  Se siguieron 1572 niños con una primera consulta. De estos, 8.2% murieron dentro de los 30 días posteriores a la consulta. El que su familia conociese a algún médico redujo el riesgo de mortalidad dentro de los siguientes 30 días en un 48% (95% IC: 18–66%). El efecto fue mayor entre recién nacidos (54%; 95% IC: 18–74%). La mortalidad dentro de los 30 días después de la consulta podía también predecirse de forma independiente por haber consultado después de las 7 pm, por el equipo de enfermeras de guardia, el día de la semana o el tener una madre joven. En un modelo multivariado, y al tener en cuenta el conocer o no a un médico, el estatus socioeconómico y la educación escolar no estaban asociados con la mortalidad dentro de los 30 días siguientes a la consulta.

Conclusión  El favoritismo puede ser un factor significativo en la calidad de la atención recibida y la mortalidad infantil en países en vías de desarrollo. Las intervenciones para mejorar el desempeño hospitalario y el de los trabajadores sanitarios deberían ser prioritarias.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

During the past 10–15 years, most developing countries (DC) in sub-Saharan Africa have undergone extensive structural re-adjustments, which have incorporated a considerable cut in government health budgets. The countries have adopted a district and community-based health system with decentralization of resources and decision making. At the same time, vertical primary health care (PHC) programmes have absorbed a relatively large proportion of global funds for health improvements. This has left the referral level in the hospital sector in a financial vacuum with poor performance, low staff morale and low confidence as a result (Rutkove et al. 1990; Van Lerberghe et al. 1997). Equity and access to public health services in DC has become a priority for donors, e.g. The World Bank investing in the health sector. Most equity studies have focused on PHC. Studies on equity and quality of care in hospital settings have not been carried out. There are certain indications that better curative services are needed, as most PHC programmes have a limited effect on age groups with the highest mortality rates (Fauveau et al. 1990; Schofield & Ashworth 1996; Weber 2000). Furthermore, these interventions do not reach the poorest population groups (Castro-Leal et al. 2000; Victora et al. 2003). A small number of studies assessing hospital performance and problems of triage have pointed to the weak spots in the quality of care for sick children seen at the third level hospitals in low-income countries (Mirza et al. 1990; Sodemann et al. 1997; Reyes et al. 1998; Barreto et al. 2000; Nolan et al. 2001). Unfortunately, there are no studies of the influence of illegal or unofficial user fees, corruption or ‘favouritism’ on type of care provided at different levels of public health care (Mebtoul et al. 1999).

In 1989, the Bandim Health Project (BHP) in Guinea-Bissau established a surveillance system linking the community registration system and the only paediatric ward in the country. Through this surveillance system, it has become increasingly clear that favouritism, defined as making use of an acquaintance or family ties with a person working in the health sector, could potentially affect child survival in settings with limited resources (Sodemann et al. 1997, 2004). In a previous study, we have shown that mothers are concerned with the importance of favouritism in relation to successful care seeking (Sodemann & Rodrigues 2005). We therefore carried out a study of child mortality in relation to care-seeking behaviour testing the hypothesis that maternal acquaintance with a health person would increase chances of survival among sick children consulting at the outpatient and emergency clinic of the paediatric ward, Simão Mendes National Hospital, Bissau, Guinea-Bissau.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Hospital and community surveillance

Data were collected at the Department of Paediatrics, Simão Mendes National Hospital and through the surveillance system of the BHP, Bissau, Guinea-Bissau. Since 1978, the core of the surveillance system has been a continuous follow-up of mothers and children through home visits to collect information on pregnancies, births, growth, vaccinations, childhood diseases, use of health services and survival. As part of the ongoing community studies, the Bandim Project has, since 1989, conducted a continuous registration of all hospitalizations from the study area at the (only) paediatric ward in Bissau. In 1997, registration was expanded to include all hospitalizations at the ward. A team of field assistants daily collect information on diagnoses and survival during hospital stay as well as status at discharge: ‘cured’, ‘improved’, ‘dead’ or ‘fled’. The ward has 100 beds and there are normally 6000–6500 admissions per year. Mothers were interviewed, and for children from the study area, information was collected to enable identification in the community register. The longitudinal community study covers around 15% of the hospital's catchment population. It is possible to link hospital and community data before and after hospitalization. Information on socioeconomic class, background factors, birth history, previous hospitalizations, previous loss of children and survival was derived from the longitudinal demographic health surveillance system in Bandim (Sodemann et al. 2002).

Study population

From June 2000 to November 2001, two field assistants registered all consultations at the emergency clinic. Each mother bringing a child was interviewed upon arrival, by a trained field assistant, about previous care seeking, family or social relation with anybody working in the health sector. Information on ‘acquaintance or familiarity with health-related personnel’ was asked as a simple question: ‘Do you know anybody working in the health sector or Ministry of Health?’ If the answer was positive, the respondent was asked to indicate the type of profession and place of employment of the person. Information on acquaintance with a health person was not obtained from mothers of 188/1572 (7.5%) enrolled children. The main reason for this lack of information was that in acute clinical situations parents were sometimes frightened, disturbed and stressed, in which case the field assistant had instructions not to interview them. All management actions in the emergency clinic were registered together with timing. Time to attention was measured from when the mother arrived at the clinic to first attention from either the nurse or the medical doctor on duty.

Clinical indicators

Because of the focus on favouritism, we applied several direct and indirect measures of clinical severity at the first visit: waiting time to attention, hospitalization and, as an external measure, the field assistant conducting the interview was asked to rate the clinical state of the child (severely ill, moderately ill and not very ill); this assistant has more than 10 years of interviewing at the paediatric ward. As many hospitalized children flee and these children may have an increased mortality risk, outcome was defined as the mortality risk within 30 days of the first visit at the outpatient clinic. Medical doctors were grouped into three case fatality groups (high, medium and low) according to the level of case fatality of the children they hospitalized during the study period. Medical doctors were asked to assess the level of clinical skills of their colleagues in three groups (inexperienced, somewhat experienced or quite experienced). This was considered the closest we could do to obtaining an objective validation of the level of medical experience because of the very diverse medical training Guinean doctors have received in terms of country they graduated from, quality of that medical training as well as post-graduation training often in more than 10 countries for each doctor. Medical doctors were grouped into one of two groups according to their tendency to hospitalize children from the outpatient clinic.

Discharged children and children not hospitalized were followed with routine home visits of the BHP until December 2003.

Statistical methods

Risk ratios for mortality were estimated as odds ratios (OR) by logistic regression. Risk factors for 30-day mortality were first analysed in three models with appropriate adjustment of estimates: background factors (Table 1), care-related factors (Table 2) and factors associated with maternal encounter with the health system (Table 3). In the multiple regression analysis, predictors from each of these models were included in the final model with a significance level of 0.1 and eliminated by backward elimination with a significance level of 0.1. The presence of interaction was assessed by adding an interaction term together with adjustment terms with a significance level of 0.05. Trends in proportions were estimated with Mantel–Haenszel test. The population-attributable risk was defined as PAR = P × (MR − 1)/[P × (MR − 1) + 1], where P is the proportion exposed and MR the mortality risk.

Table 1.   Post-consultation 30-day mortality: background risk factors; 1572 sick children seeking consultation at the paediatric outpatient and emergency department of the Simão Mendes National Hospital, Bissau, Guinea-Bissau
  Mortality risk, Odds ratio (OR, 95% CI)
Crude ORAdjusted OR†
  1. †Adjusted for age, hospitalization at the first visit and severity assessment of the assistant.

Overall129/1572 (8.21) 
 Sex
 Male57/854 (6.67)0.64 (0.47–0.92)0.48 (0.31–0.73)
 Female72/718 (10.0)11
Child age
 0–30 days30/83 (36.1)6.33 (3.66–11.0)5.59 (2.82–11.0)
 31–364 days35/436 (8.00)0.98 (0.61–1.56)1.08 (0.63–1.84)
 1–2 years42/512 (8.20)11
 3–4 years9/218 (4.13)0.48 (0.23–1.00)0.45 (0.20–0.98)
 5–15 years13/323 (4.02)0.47 (0.25–0.88)0.46 (0.23–0.90)
Mother's age
 14–20 years29/173 (16.8)2.62 (1.67–4.10)2.23 (1.26–3.95)
 21–54 years100/1399 (7.15)11
Mother's school education
 More than 7 years34/468 (7.26)0.82 (0.47–1.42)0.81 (0.43–1.53)
 4–7 years35/525 (6.67)0.57 (0.35–0.92)0.61 (0.35–1.07)
 1–3 years23/247 (9.31)0.82 (0.47–1.41)0.81 (0.43–1.53)
 None37/332 (11.1)11
Socioeconomic status
 Poorest18/138 (13.0)1.82 (1.01–3.26)1.87 (1.00–3.82)
 Less poor68/881 (7.72)1.01 (0.68–1.51)1.09 (0.69–1.72)
 Richest42/551 (7.62)11
Number of pregnancies
 6–1018/169 (10.7)1.25 (0.59–1.33)0.91 (0.49–1.69)
 1–5111/1376 (8.07)11
Ethnic group
 Pepel53/564 (9.40)11
 Manjaco20/249 (8.03)0.84 (0.49–1.44)1.33 (0.71–2.47)
 Muslim11/154 (7.14)0.74 (0.38–1.46)0.77 (0.34–1.75)
 Mancanha11/181 (6.08)0.62 (0.32–1.22)0.50 (0.22–1.10)
 Balanta17/153 (11.1)1.21 (0.68–2.14)1.27 (0.64–2.54)
 Mixto6/95 (6.32)0.65 (0.27–1.56)0.64 (0.22–1.88)
 Other11/176 (6.25)0.64 (0.32–1.26)0.69 (0.32–1.49)
Residential area
 Bandim 162/770 (8.05)1.02 (0.65–1.59)1.13 (0.68–1.89)
 Bandim 236/407 (8.85)1.13 (0.68–1.86)1.18 (0.66–2.09)
 Belem31/392 (7.91)11
Mother gave birth in hospital
 Yes61/779 (7.83)0.87 (0.60—1.26)0.79 (0.50–1.24)
 No61/687 (8.88)11
Table 2.   Post-consultation 30-day mortality: clinical history and care-related risk factors; 1572 sick children seeking consultation at the paediatric outpatient and emergency department of the Simão Mendes National Hospital, Bissau, Guinea-Bissau
 Deaths/children in group (%)Mortality risk Odds ratio (OR, 95% CI)
Crude ORAdjusted OR†
  1. †Adjusted for age, hospitalization at the first visit and severity assessment of the assistant.

Consultation in
 First quarter23/338 (6.80)0.64 (0.35–1.16)0.81 (0.40–1.61)
 Second quarter24/233 (10.3)11
 Third quarter43/442 (9.73)0.94 (0.55–1.59)1.13 (0.59–2.11)
 Fourth quarter39/559 (6.98)0.65 (0.38–1.11)0.85 (0.43–1.58)
Severity rating
 Severely ill52/145 (35.9)29.5 (15.7–55.3)3.87 (1.72–8.68)
 Moderately ill59/663 (8.90)5.89 (3.26–10.7)1.09 (0.51–2.32)
 Not very ill18/764 (2.36)11
Consulted anywhere <48 h
 Yes12/149 (8.05)0.98 (0.53–1.82)0.46 (0.24–0.91)
 No117/1423 (8.22)11
Consultation elsewhere >48 h, less than 14 days
 Yes54/381 (14.2)2.46 (1.70–3.56)2.16 (1.38–3.39)
 No75/1191 (6.30)11
Hospitalization within 30 days
 No8/958 (0.84)11
 At the first visit115/590 (19.5)28.8 (13.97–59.4)19.5 (7.91–47.9)
 Only after one or more further visits6/24 (25.0)39.6 (12.5–126)40.6 (11.8–139)
Mother previously lost a child
 No68/949 (7.17)11
 Yes, once40/421 (9.50)1.36 (0.91–2.05)1.38 (0.84–2.21)
 Yes, twice or more18/154 (11.7)1.72 (0.99–2.97)1.36 (0.70–2.61)
Child previously hospitalized
 Yes13/149 (8.71)1.08 (0.59–1.96)0.86 (0.44–1.71)
 No116/1423 (8.15)1 
Parents sent out to find money and drugs
 Yes37/244 (15.2)2.40 (1.60–3.61)0.72 (0.44–1.18)
 No92/1328 (6.93)11
Waiting time to attention
 0–25 min29/177 (16.4)3.84 (2.28–6.46)1.69 (0.92–3.10)
 26–180 min60/636 (9.43)2.04 (1.33–3.13)1.15 (0.70–1.88)
 >180 min36/742 (4.85)11
Table 3.   Post-consultation 30-day mortality: factors related to the maternal encounter with health professionals; 1572 sick children seeking consultation at the paediatric outpatient and emergency department of the Simão Mendes National Hospital, Bissau, Guinea-Bissau
 Deaths/children in group (%)Mortality risk Odds ratio (OR, 95% CI)
Crude ORAdjusted OR†
  1. †Adjusted for assistant-rated severity, hospitalization at the first visit and age of child.

  2. ‡Midwife, laboratory technician, administrative person and cleaner.

Maternal acquaintance or familiarity with
 Medical doctor
  Yes28/526 (5.32)0.51 (0.33–0.79)0.55 (0.33–0.92)
  No83/858 (9.67)11
 Nurse
  Yes33/364 (9.07)1.20 (0.79–1.84)1.28 (0.77–2.12)
  No78/1020 (7.65)11
 Other health worker‡
  Yes12/120 (10.0)1.31 (0.70–2.46)1.04 (0.48–2.23)
  No99/1264 (7.83)11
 Field assistant
  Yes8/130 (6.15)0.73 (0.35–1.54)1.62 (0.71–3.70)
  No103/1254 (8.21)11
  No information18/188 (9.57)
Clinical team on duty (period 1)
 111/176 (6.25)0.56 (0.25–1.23)0.60 (0.24–1.49)
 213/168 (7.74)0.70 (0.33–1.49)0.58 (0.24–1.39)
 318/169 (10.7)11
 48/165 (4.85)0.42 (0.18–0.92)0.29 (0.10–0.80)
 510/150 (6.67)0.60 (0.27–1.34)0.43 (0.17–1.11)
Clinical team on duty (period 2)
 119/221 (8.60)1.40 (0.57–3.43)1.20 (0.41–3.47)
 220/131 (15.3)2.68 (1.10–6.59)2.66 (0.88–8.03)
 313/143 (9.09)1.49 (0.57–3.85)1.74 (0.55–5.05)
 410/138 (7.25)1.16 (0.43–3.15)0.99 (0.30–3.26)
 57/111 (6.31)11
Tendency group of paediatrician to hospitalize
 Likely group105/1180 (8.90)1.50 (0.95–2.36)1.27 (0.74–2.16)
 Less likely group24/392 (6.12)11
Paediatrician mortality
 Highest52/549 (9.47)1.89 (1.11–3.21)1.91 (1.03–3.52)
 Medium57/641 (8.89)1.76 (1.04–2.99)2.16 (1.16–4.01)
 Lowest20/382 (5.24)11
Paediatrician experience level
 Experienced62/703 (8.82)1.16 (0.81–1.66)1.31 (0.86–2.00)
 Less experienced67/869 (7.71)11
Mother arrived between 7 pm and 7 am
 Yes36/253 (14.2)2.19 (1.45–3.30)1.83 (1.12–2.98)
 No93/1319 (7.05)11
Consultation at day of week
 Monday21/264 (7.95)0.66 (0.36–1.20)0.88 (0.44–1.77)
 Tuesday25/266 (9.40)0.79 (0.44–1.41)0.68 (0.34–1.34)
 Wednesday12/274 (4.38)0.35 (0.17–0.71)0.40 (0.18–0.93)
 Thursday20/232 (8.62)0.72 (0.39–1.33)0.86 (0.42–1.75)
 Friday26/225 (11.6)11
 Saturday12/171 (7.02)0.57 (0.28–1.18)0.40 (0.17–0.95)
 Sunday13/140 (9.29)0.78 (0.39–1.58)0.88 (0.38–2.02)

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Care-seeking pattern and mortality

At the hospital, 1572 children were registered at their first consultation, 589 (37.5%) were hospitalized immediately and 23 children were hospitalized following repeated consultations within 30 days of the first contact. Within 30 days of the first visit, we recorded 129 deaths in the cohort; 104 died in the hospital, 17 were hospitalized but died at home and 8 died at home without being hospitalized.

Background factors

The relation between background factors and 30-day mortality is shown in Table 1. Socioeconomic status and school education had the expected relation to mortality in univariate analysis as did child age, maternal age and ethnic group. The lower mortality for boys was not explained by severity (P = 0.42), immediate attention (P = 0.53) or chance of hospitalization (P = 0.36). Eighty-three children were of neonatal age at the time of consultation, of whom 30 eventually died. Of those who died, 24 had been born at the hospital, 2 at the health centre and 4 at home.

Clinical and management factors

Factors related to clinical history, clinical state and management in relation to 30-day mortality are listed in Table 2. The severity rating of the field assistant correlated well with the 30-day mortality risk [OR = 0.20 (0.15–0.27); for every step less severe, P-trend < 0.0001]. Adjusting for the factors in the final mortality model did not alter the significance level of the trend. The assistant identified 90.0% (530/589) of children who were hospitalized at the first visit with a rating of either moderately or severely ill. With the same rating, the assistant identified 87.7% (64/73) of children who died within 24 h of the first consultation and 86.3% (88/102) of children who died within 7 days. Eight of nine children who were not hospitalized at the first consultation and who died within 7 days of this visit were rated moderately to severely ill by the assistant. Likewise, waiting time to first attention correlated well with 30-day mortality risk, OR = 0.49 (0.35–0.67), for each group of increasing waiting time. Mothers belonging to Muslim ethnic groups were less likely than other ethnic groups to present a child rated as severely ill by the field assistant [OR = 0.27 (0.12–0.62), age adjusted]. Mothers who previously lost a child were not more likely to bring a child rated severely ill (P = 0.56), nor did they have a greater chance of being hospitalized (P = 0.99). Previous hospitalization did not predict mortality.

Children whose parents were sent out to find money and drugs had a twofold increase in mortality risk, but this was explained entirely by the severity rating of the field assistant (Table 2). There was a linear trend in increasing likelihood of being sent out to find money and drugs with increasing severity rating by the assistant (OR = 3.18 per increase in severity group, P-trend < 0.001). This trend remained significant with a P-trend < 0.001 when adjusted for the factors in the final multivariate mortality model.

Favouritism and background factors

Information on acquaintance and familiarity with health or health-related persons was available for 1384 children, of whom 810 claimed to know such a person and 574 did not. A physician was the health person most commonly known (n = 524) followed by a nurse (n = 364). Acquaintance with both a physician and a nurse was reported by 204 mothers. There was a significant increase in proportions of mothers being acquainted or familiar with a medical doctor with increasing school education (OR = 1.15 per year of school education, P < 0.001). The richest mothers were slightly more likely to know a health person than the poorest mothers [OR = 1.38 (1.02–1.87)]. There was no correlation between being acquainted or familiar with a field assistant from the surveillance project and school education (P = 0.79) or socioeconomic status (P = 0.85). There was no interaction with background factors and acquaintance with a physician. Ethnic groups of Muslim orientation were less likely to be acquainted with a health person [OR = 0.58 (0.38–0.90), adjusted for age of child], compared with other ethnic groups. There was no significant relation between being acquainted or familiar with health personnel and mother registered in the BHP surveillance system during pregnancy (P = 0.49), previous loss of child (P = 0.62), previous hospitalization (P = 0.79) or mother's age (P = 0.26).

Favouritism and 30-day mortality risk

Factors related to the clinical care situation between mothers and the staffs in the emergency clinic, in relation to 30-day mortality, are shown in Table 3. Acquaintance with a medical doctor reduced the 30-day mortality by nearly 45% [OR = 0.55 (0.33–0.92)], adjusted for age of child, assistant-rated severity and hospitalization at the first visit. This effect tended to be stronger among post-neonatal children [OR = 0.45 (0.25–0.81)] than neonates [OR = 1.59 (0.34–7.40)], adjusted for assistant-rated severity and hospitalization at the first visit (P = 0.07). Acquaintance with any other health worker or field assistant had no overall impact on survival, but the effect of being acquainted with a nurse was modified by the child's age: knowing a nurse elevated the mortality risk among infants OR = 2.42 (1.30–4.23), while there was no effect of knowing a nurse among older children OR = 1.00 (0.47–1.97), P < 0.001. Among mothers who knew more than one health person, there was no interaction between the different types of persons known and mortality risk. Mortality varied with consulting physician but was not significantly related to the experience level assessment of colleagues (Table 3).

Medical doctors who were associated with low mortality were less likely to belong to the group of doctors who hospitalized children most frequently from the outpatient clinic (58.1%) than doctors belonging to the medium or the highest mortality group (80.7%), P < 0.001. Mortality risk varied to a large extent with clinical team on duty in the outpatient clinic. Unfortunately, team members switched half way through the study period; hence, the variable could not be included in the multivariate analysis. Mortality varied markedly with day of week of consultation and hour of consultation even adjusting for assistant severity rating.

Multiple regression mortality model

The following variables with a probability of less than 0.10 were included in a multiple regression mortality model: tendency of doctor to hospitalize, sex, socioeconomic index, consultation after 7 pm, consultation elsewhere >48 h, child's age, mother's age, ethnic group, mother knows a doctor, day of week, mother multiparous, mother has 9 or more years of schooling, hospitalized at the first visit and assistant severity rating. Waiting time to attention was considered as an intermediate variable associated with the outcome and was excluded from the analysis. In the multivariate analysis, we found acquaintance or familiarity with a physician to be a strong and independent predictor of 30-day mortality reducing mortality by 48% (95% CI: 18–66) (model 1, Table 4). This estimate was not changed if school education and socioeconomic class were forced into the model, although they were significant in the model before knowing that a medical doctor was entered into the model (model 2, Table 4). In spite of the correlation between school education, socioeconomic group and acquaintance with a medical doctor, no interaction was observed with 30-day mortality as outcome (P = 0.67 and P = 0.98, respectively). There was no interaction between knowing a medical doctor and the assistant's severity rating of the child (P = 0.45) or hospitalization (P = 0.88). It is noteworthy that the variables – mothers consulting after 7 pm and mothers less than 20 years of age – retained their significance in the model. These factors are not normally considered to be associated with short-term mortality.

Table 4.   Reduced multivariate model for post-consultation 30-day mortality risk; 1572 sick children seeking consultation at the paediatric outpatient and emergency department of the Simão Mendes National Hospital, Bissau, Guinea-Bissau
PredictorMortality risk Odds ratio (95% CI)
Model 1Model 2†
  1. †Socioeconomic status and mother's school education forced into the model.

Maternal acquaintance or familiarity with a medical doctor
 Yes0.55 (0.33–0.94)0.58 (0.35–1.00)
 No11
Mother arrived between 7pm and 7 am
 Yes1.74 (1.00–3.01)1.78 (1.02–3.09)
 No11
Clinical state
 Severely ill4.81 (2.00–11.6)4.87 (2.02–11.8)
 Moderately ill1.22 (0.55–2.69)1.21 (0.54–2.67)
 Not very ill11
Child consulted elsewhere >48 h, <14 days
 Yes2.84 (1.72–4.71)2.91 (1.75–4.84)
 No11
Mother less than 20 years old
 Yes1.92 (1.00–3.67)1.93 (1.00–3.71)
 No11
Sex of child
 Male0.45 (0.28–0.73)0.47 (0.29–0.76)
 Female11
Child age
 0–30 days5.58 (2.59–12.0)5.78 (2.66–12.6)
 31–364 days0.87 (0.47–1.60)0.88 (0.47–1.62)
 1–2 years11
 3–4 years0.42 (0.18–1.00)0.43 (0.18–1.02)
 5–15 years0.62 (0.30–1.29)0.56 (0.26–1.19)
Socioeconomic status
 Poorest1.45 (0.63–3.31)
 Less poor1.06 (0.62–1.81)
 Richest1
Mother's school education
 More than 7 years0.74 (0.37–1.48)
 4–7 years0.71 (0.37–1.36)
 1–3 years0.88 (0.42–1.85)
 None1

In a multivariate model including an interaction term signifying whether the child was younger than 30 days (neonatal) or older (post-neonatal), the effect of knowing a medical doctor was OR = 0.46 (0.27–0.87) among post-neonatal children, while the effect tended to be the opposite among neonates, OR = 1.74 (0.21–14.5) (P = 0.09 for interaction term). Mothers consulting neonates were more likely to have given birth in hospital [OR = 1.78 (95% CI: 1.11–2.87)], more likely to be younger than 20 years and more likely to have lost a child previously [OR = 1.74 (95% CI: 1.11–2.73)]; they were less likely to know a medical doctor [OR = 0.51 (95% CI: 0.30–0.87)].

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

It is well established that socioeconomic and other background factors predict mortality. Our finding that mortality among sick consulting children, may be as well or better predicted by unjustified and non-medically grounded variations in the quality of care is surprising. The most distinct of these non-medically grounded factors was that acquaintance with a medical doctor reduced the 30-day mortality risk by nearly 50%.

Although the present study was not designed to investigate the association of socioeconomic class and maternal acquaintance with a health person, there is no doubt that among sick children seeking consultation knowing a health person may be a stronger risk factor for a fatal outcome than socioeconomic status. There was, as expected, a significant association between the two factors, but it was weaker than anticipated, suggesting that there is indeed an independent effect of an acquaintance regardless of socioeconomic class. This is supported by the fact that maternal school education, which is normally regarded a stronger protective factor than socioeconomic class, retained its significance in the multivariate model. It is possible that the acquaintance factor adds further dimensions to the effect of preventive health care, school education and social class. We will investigate this in a risk factor study and an ongoing prospective birth cohort study.

Acquaintance with a health person could be the consequence of previous contact with the health sector or of higher maternal age or higher parity. Acquaintance with a health person was unrelated to previous contact with the health sector measured by previous loss of a child, hospital delivery and number of pregnancies. We included these variables in the multivariate analysis but none of them altered the independent effect of favouritism, physician and nurse skills, consultation time or day of week.

The association was probably not caused by previous contact with the health sector, as acquaintance with a nurse made no significant difference. It seems plausible that there was a negative effect of acquaintance with a medical doctor among hospitalized neonatal children for whom a certain level of skills and availability of equipment, birth weight, maturity and other perinatal risk factors are likely to be more important. This is supported by the observations that mothers consulting with neonates seem to be a selected group associated with young mothers, giving birth in hospital and previous loss of child. Furthermore, mothers consulting with neonates were 50% less likely to know a medical doctor.

We have previously shown that more than 90% of children who eventually die in the study area are seen at least once by a health worker before death and that 58% are seen at the paediatric outpatient clinic of the Simão Mendes National Hospital before death (Sodemann et al. 1997). The children we followed are therefore not likely to constitute a highly selected population. Mothers in DC are often blamed for negligence in seeking proper care in case of severe childhood illness and this is considered a major cause of the high child mortality in DC. Mothers seem to bring the right children for consultation judged by the high percentage of consulting children who were hospitalized and it seems unlikely that maternal negligence explains why the child is not hospitalized when he/she should have been.

Acquaintance or familiarity with health-related personnel was evaluated with a simple question, which relied on the respondent defining the exact content of these terms. We did therefore not estimate the closeness and type of relation, nor did we explore in detail where this person was employed, nor this person's charge. As a consequence, we have probably underestimated the effect of acquaintance with health-related personnel, because for some the acquaintances would be distant, i.e. a ‘useless’ relationship in terms of obtaining prompt and proper consultation. It is therefore most likely that we underestimated the effect of relations with the health worker. As we also controlled for an independent severity judgement by the assistant, we are confident that we did not overestimate the significance of a relationship with a medical doctor.

In a small questionnaire survey among paediatric doctors and nurses, carried out after the study to possibly explain the findings of this study, all interviewed persons agreed that the observed effect was likely and pointed to three factors possibly contributing to the positive effect: First, immediate attention when the child was really ill. Secondly, no need to pay suku di bas (unofficial fees), hence no valuable time is wasted raising money among family members and friends. Thirdly, medical follow-up during hospitalization as well as at home after discharge was common and expected because of the familiarity of the acquaintance.

We observed significant differences in the clinical quality by paediatrician, nurse team, late-hour consultation, consultation day of week and age of mother. Such differences are usually not taken into consideration. The observation could be a reflection of differences in severity, but mortality varies in spite of correction for a variety of severity measures. In the above-mentioned post-study survey, we asked the doctors and nurses how these variations in quality could be explained: the most frequent explanation was that there were generally fewer patients on Wednesdays and there was a shortage of staff on Fridays. The severity assessment of the field assistant correlated well with mortality, waiting time to attention and risk of hospitalization but also had an independent predictive value. If we can assume that the assessment of the assistant was objective, we have observed that the quality of care does vary by day of week and we have shown that some physicians are associated with threefold higher 30-day mortality than others. If our observations are valid in other settings, a large proportion of child deaths could be avoided by proper training of medical and nurse staff and by setting the goal to reach the lowest observed mortality in each team of nurses or physicians.

If we assume that we have controlled for all confounders, the 30-day mortality risk would be reduced by 24% (95% CI: 2–42), i.e. the population-attributable fraction, if all children had the same health benefits of the mother knowing a medical doctor. An intervention based on our findings in this outpatient clinic is likely to have a pronounced effect on childhood mortality in the study area.

Reinforcing care for sick children referred to a hospital should focus on feasible objectives with the greatest possible benefit for child survival. Potential targets for upgrading include primary triage, emergency care, clinical evaluation, inpatient treatment and monitoring (Nolan et al. 2001). Demonstration and presentation of results such as ours could potentially be used as tools in an audit or upgrading process, as most health workers would agree that such variations should not occur.

Short-term mortality among consulting children depended as much on non-clinical factors as on clinical factors, notably favouritism and significant differences in the quality of care measured as variations in mortality were by consulting physician and clinical team on duty. Being acquainted or familiar with a physician seems to be an independent determinant for receiving proper and prompt treatment of childhood illness and survival. Equity and access to health services in low-income countries has become a priority for large donors to the health sector in these countries (Dwatkin & Guillot 1999). However, a focus exclusively on poverty, health equity and community health can be misleading in the combat against the continuously high childhood mortality in many low-income countries. In some countries, child mortality is strongly related to the hospital sector and favouritism’ and not only socioeconomic status may play a role for how health care is provided. Improvement of hospital and health worker performance should be given a high priority, as these interventions may lower childhood mortality as cost-effectively as many large-scale public health interventions.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

We are grateful to the following for logistic or financial support: Ministry of Public Health, Guinea-Bissau; Danish Council for Development Research; Danish Medical Research Council (SSVF 9700716); Novo Nordisk Foundation and the Science and Technology for Development Programme of the European Community (TS3*CT91*0002 and ERBIC 18 CT95*0011). PA holds a research professorship grant from the Novo Nordisk Foundation.

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  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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