Inequalities in health care utilization for common illnesses among under five children in Bangladesh

Globally, child mortality has dropped from 12.6 million in 1990 to 5.3 million in 2017 [1]. Despite such remarkable progress in reducing under 5 mortality rates, disparities exist across countries and regions as 52% deaths of under 5 children took place in sub-Saharan Africa while another 29% child deaths occurred in Central and Southern Asia in 2018 [2]. These deaths across the world are mainly attributed to various infectious diseases that are largely amenable to available preventive treatment and measures [3]. Acute diarrheal diseases and acute respiratory infections are considered as the most common forms of acute childhood illnesses [4]. The World Health Organization (WHO) also estimated that using quick and proper care during episodes of acute diarrheal diseases and acute respiratory infections could reduce child deaths by about 30%. However, the morbidities of children caused by various infectious diseases lead to a huge burden both from health and economic perspectives. One of the main reasons for the slow progress of developing countries in reducing child mortality is the socio-economic inequalities in these countries. Socio-economic inequities – as considered one of the fundamental reasons, are solely responsible for slow progress in terms of reducing child mortality especially in the context of developing countries [4]. Reducing mortality and morbidity of children is critically related to seeking appropriate care from medically trained providers coupled with sufficiently equipped health care facilities [5]. Inefficiency and insufficiency of health care facilities especially for children is prevalent in developing countries. Studies from different countries suggest that health care seeking is not adequate in cases of childhood illnesses [4, 6, 7]. Mothers or caregivers more often resort to over-the-counter drug peddlers, traditional or faith healers, or self-medication [4].

Bangladesh has made noteworthy progress in achieving MDG goal of reducing child mortality, the child mortality rate has dropped from 143.8 per 1000 live births in 1990 to 32.4 per 1000 live births in 2017 [8]. In 2016, the death rate of children under 5 years was 5.5 (per 1000 live births) due to pneumonia while this figure was 2.3 for diarrhea [9]. The country with a view to alleviating child mortality has made an extensive infrastructure development of public healthcare facilities from the local level (ward level) to the national level, where almost all types of treatment are intended to be available to patients typically free of charge [10]. According to Bangladesh Health Facility Survey 2014, 93.6% of the rural health facilities have available outpatient curative care services for sick children while 81.6% of urban health facilities have curative care for children. In Sylhet division, 99.8% health facilities provide health care for children followed by Khulna (98.6%), Barisal (96%), Rangpur (95.5%), Chittagong (92.1%), Dhaka (90%), and Rajshahi (85%) [11]. Evidences show that though health services are supposed to be free at government facilities, patients have to pay the costs of medicines and laboratory tests along with some additional costs [12]. Therefore, the care-seeking behavior for sick under 5 children is significantly low and still the childhood mortality and morbidity rate is sufficiently high in Bangladesh [13]. This poor use of health care services poses a great impediment to attaining child health development mainly in respect of the Sustainable Development Goal (SDG) of ending preventable deaths of under-five by 2030 [14]. One possible reason for this may be the low utilization of health care services from qualified sources for under-five children.

Improving child health status through formulating and implementing proper initiatives, policymakers must have a good understanding of the overall health services utilization. In this regard, an important question to ask is, what the care seeking pattern is and what factors are influencing the utilization of health care. Many studies have been conducted in different countries to identify the care seeking pattern and influential factors for the utilization of health care services in cases of childhood illnesses [4, 12‐17]. Wealth possession of households is widely recognized as predictor of health care utilization where children from wealthy families can afford to receive health care [12‐14, 16, 18‐21]. Besides, parent’s education level, religion were also found to be associated with the inequality in the utilization of child health services [12, 21]. People with higher education have greater perceived benefits from treatment compared to the people with low education [12]. Population from Protestant and Muslim religion are found to have higher likelihood of medical treatment seeking behavior than respondents from Orthodox Christian group [21]. Furthermore, children’s age and sex, mothers’ age, and access to electronic media tend to influence the treatment seeking behavior for childhood illnesses [12, 19‐21]. Female children are less likely to receive medical care compared to male children [12]. Another study found that medical care utilization rate was lower among rural children compared to urban children [20]. Some studies mentioned that distance to the health facility reduces the likelihood of utilization of medical care [20, 22].

However, there are few studies in Bangladesh which examined the influence of socio-demographic, household characteristics and geographical access in seeking health care for childhood illnesses on a national scale. Sarker et al. (2016) studied the prevalence of childhood diarrheal disease and their treatment seeking behavior in Bangladesh. They found some of the socio-economic factors, especially, wealth index and number of children in the household as the most important predictors. Another study on prevalence and determinants of acute respiratory tract infections (ARI) of children in Bangladesh found sex of children and wealth status of household as significant determinants of health care seeking [18]. These studies focused on a single disease e.g. diarrhea and ARI. Besides, a study by Mahumud et al. (2019) attempted to explore the inequality of childhood morbidity in Bangladesh. However, the study did not capture the inequality in treatment use [23]. Contingent upon this backdrop, the objective of this study is to find out the determining factors which influence equitable health care utilization among children with fever, cough, and diarrhea in Bangladesh so as to provide information for future planning, policy making, and appropriate interventions in reducing the level of under-five morbidity and mortality in Bangladesh.

This study aimed at exploring childhood illnesses and inequalities in health care seeking behavior. Alongside this, the study was conducted with the hope of finding out barriers to treatment for diarrhea, fever and cough which are leading causes of under-five mortality. We found that about 43.81% of the children suffered from fever/cough and 5.11% of the children suffered from diarrhea within 2 weeks preceding the survey. However, only 37% of those suffered from fever/cough sought medical treatment and approximately 36% of those suffered from diarrhea sought medical treatment.

These lower rates of health care services utilization might be a result of self-treatment or medicines from pharmacy that has been well documented in other literature [4, 27‐29]. It is to note that this analysis considered only medical treatment. Therefore, it is likely that these percentages of medical care use may be an underestimate for both fever/cough and diarrhea.

Most importantly, this study identified significant factors that led to inequalities in medical care utilization for diarrhea, fever, and/or cough of children less than 5 years of age in Bangladesh. Age of children, household wealth status, parent’s education level, region of residence, number of children in the household, access to electronic media were identified as factors contributing to inequality in health care utilization for childhood illnesses. Our study found age of children as a significant predictor of health care use for childhood diarrhea and fever/cough. Other studies in Bangladesh, Ethiopia, Zambia and Nigeria also found that children in the lower age group were more likely to receive treatment [16, 19, 20, 30]. This pattern may be due to the fact that parents usually perceive their children at the early stage as being especially “delicate” [30]. Wealth status of household was a significant factor of medical treatment for childhood diarrhea, fever and cough. Children from the richest household had higher likelihood of receiving treatment compared to children from poorest households. This finding aligns with findings from other studies in different settings [14, 16, 18‐21]. This inequality, largely due to the wealth status of households, can be explained as wealth has a direct positive influence on the utilization of health care services and a lack of resources can create bottlenecks to accessing health care services for children [21]. Paternal educational attainment was significantly associated with inequalities in medical treatment use for children with fever, cough and diarrhea. This finding aligns with our expectation that educated parents are more likely to seek health care for their children and this result is consistent with findings from other studies [18, 20, 21] . The reasoning behind this might be the fact that educated fathers have better knowledge and understanding about childhood illnesses which motivates their spouses to seek health care for their children [20]. In addition, education leads to an increased level of awareness regarding illnesses, and availability of services [21]. We found a significant impact of mothers’ access to electronic media, such as television and radio, on treatment seeking behavior for their children. Other studies conducted in Zambia and Nigeria also found that mothers who had access to electronic media had a greater likelihood of seeking medical treatment for their children [14, 16]. This might be attributed to the fact that information about coughing on television or radio could increase awareness among people about the necessity of seeking health care services for their children timely [21]. We also found that number of children in the household is an important determining factor of using medical care for fever and cough. This finding is consistent with the findings from a study in Tanzania which showed that children from households with fewer number of children are more likely to have better health care than children from households with many children [26]. This study in Tanzania also explained that by the resources and time constraints associated with caring for many young children can create impediments in seeking care timely [31]. Our study further indicated that region of residence was a significant influential factor for inequalities in health care utilization for childhood fever and cough. Children from urban areas are more likely to use medical care compared to children from rural areas. Another study in Bangladesh found similar result that children from rural areas are more likely to use care from traditional providers [18]. This can be attributed to the fact that mothers from rural areas are less educated and they are not aware of where to seek medical care when their children get sick. Furthermore, the majority of the poor people live in rural areas of Bangladesh [24] which might be responsible for the low utilization of medical care among children in rural areas. Though a study in Tanzania found distance to health facilities as an important predictor of medical care utilization [22], we did not find any significant impact of distance on medical care utilization.

As this study is based on a nationally representative household survey data, we can generalize the findings at the national level. However, our study has several limitations. As the survey was cross-sectional in nature, it was not possible to capture any causal association between childhood illnesses and the explanatory variables. Furthermore, all information on childhood illnesses was collected from mothers and the symptoms were not validated by any further medical examination, which might have created recall bias to some extent. Another limitation of this study is that there was no information on the costs of treatment (costs for consultation, diagnostics, medicines, transportation cost, etc.) for childhood illnesses in BDHS data. Finally, mothers could have misconception about childhood illnesses which might lead to misconception about treatment for childhood illnesses too. For instance, it is likely that mothers, in some cases, could not recognize the symptoms of varying types of diseases children suffered from and even if recognized, they could not resort to proper treatment sources.

The findings of this study show the importance of raising awareness of childhood illnesses in Bangladesh and developing interventions that target children at-risk groups, such as those who live in rural areas, who are from households with less wealth, whose fathers have limited schooling, whose family have many children, whose mothers do not have access to television and radio. Future policies aimed at tackling childhood morbidity and mortality should include comprehensive strategies that impact on socio-economic factors. Since the equitability of access to health care for children is a major concern, interventions should be designed targeting children from households with low socio-economic status. Furthermore, policies for increasing effective awareness raising and health education programs, poverty alleviation programs especially for rural areas can contribute to increased health care utilization for childhood illnesses. If accessibility and affordability of medical care can be increased through working in partnership with public facilities, private facilities as well as community-based organizations, equitable services for childhood illnesses will be boosted.