Health-seeking behaviour in the city of Lubumbashi, Democratic Republic of the Congo: results from a cross-sectional household survey.

BACKGROUND: Concerns about the occurrence of disease among household members generally initiate treatment-seeking actions. This study aims to identify the various treatment-seeking options of patients in Lubumbashi, analyze their health-seeking behaviour, identify determinants for the use of formal care, and analyze direct health care expenditure. METHODS: A cross-sectional survey of households in Lubumbashi was conducted in July 2010. Information was collected from a randomly selected sample of 251 households with at least one member who had been ill in the 2 weeks preceding the survey. RESULTS: Frequently used initial treatment-seeking options consist of self-medication based on modern medicines (54.6%), the use of first-line health services (23.1%) and hospitals (11.9%), with a perceived effectiveness of 51%, 83% and 91% respectively. If people go for a second option, then formal health care services are most often preferred. The majority (60%) of patients' spontaneous itineraries reflect the expected functioning of a local health care system, with a patient flow characterised by the use of a first line health facility prior to the use of hospital-based services. Chronicity of the disease is the main determinant of seeking formal care. Analysis of care expenditure reveals that drugs are the only line of expenditure in the informal system and the main source of expenditure in the formal system; costs do not discriminate between first-line health services and hospitals, and the payment system is regressive since the poorest patients pay the same amounts as the richest. CONCLUSIONS: This study points to the importance of self-medication as the first therapeutic option for the majority of patients in Lubumbashi, whatever the nature of the health problem. There is a lot of room to rationalise this practice. Although formal care is not common initial therapeutic option, it is the source of care most patients turn to, especially when they believe having a chronic disease. Patients' itineraries in this urban environment are complex; health managers should try and deal with this reality. Finally, our study indicates that poor patients face the same level of out-of-pocket payments as the more wealthy ones, hence the need for more equitable health care financing arrangements.

[Difficulties in partnerships between health professionals and Mutual Health Organisations: the case of Maliando in Guinea-Conakry]. / La difficulté du partenariat entre professionels de santé et mutualistes: le cas de al mutuelle de santé Maliando en Guinée-Conakry.

In 1998, a Mutual Health Organization (MHO) was created in the region of Guinee forestiere in Guinea-Conakry, West Africa, in the context of the action-research project PRIMA (Projet de recherche sur le partage du risque maladie). The aim of the project was to test whether, and under which conditions, an MHO can improve the access to quality health care. The specificity of the model is double-sided: on the one hand, the wish to integrate the organization into the local health system through a partnership between MHO and health services; on the other hand, the systematic efforts by the local research team to involve health professionals, at both the operational and managerial level of the system, in the planning and implementation of the MHO. We present the results of a study that investigates the health professionals' perception of this model. In April 2000, semi-structured interviews were held with 16 health professionals working at the different operational, managerial and administrative levels of the Guinean health system. The professionals perceive the MHO as an effective strategy to overcome financial accessibility problems. However, the interviews highlight the uncertainties and worries of the health professionals, their lack of understanding of the model, their reluctance even to fully accept it. The partnership approach was not internalized. They understand the technical instrument, but are confused and uncomfortable in their dialogue with the population. This study illustrates the difficulties of establishing a real partnership between population and health services, as well as the need for proper training and coaching of the health workers in the set-up of MHOs. The importance of this aspect was insufficiently recognized by the research team, despite its good intentions and its huge investment in organizing exchange between stakeholders. An important lesson of this experience is the need for promoters to conceive and operate MHO systems in which the expectations and fears of the health care providers are better identified and better taken into account.

A plea for an initiative to strengthen family medicine in public health care services of developing countries.

An analysis of standards for the best practice of family medicine in Northern European countries provides a framework for identifying the difficulties and deficiencies in the health services of developing countries, and offers strategies and criteria for improving primary health care practice. Besides well-documented socioeconomic and political problems, poor quality of care is an important factor in the weaknesses of health services. In particular, a patient-centered perspective in primary care practice is barely reflected in the medical curriculum of developing countries. Instead, public sector general practitioners are required to concentrate on preventive programs that tackle a few well-defined diseases and that tend to be dominated by quantitative objectives, at the expense of individually tailored prevention and treatment. Reasons for this include training oriented to hospital medicine and aspects of GPs' social status and health care organization that have undermined motivation and restricted change. A range of strategies is urgently required, including training to improve both clinical skills and aspects of the doctor-patient interaction. More effective government health policies are also needed. Co-operation agencies can contribute by granting political protection to public health centers and working to orient the care delivered at this level toward patient-centered medicine.