Poor provider care leads to poor health-seeking behaviour

What are the causes of AIDS denialism? What are the factors that lead to a loss of public confidence in medical science? Often on aidstruth.org we have focused on debunking the false propaganda of prominent AIDS denialists, but there are other very important causes of people with chronic illnesses choosing to forsake scientifically based medical advice. A crucial one is the often substandard quality of care people receive from their medical practitioners. In the United States, tens of millions of uninsured and under-insured people experience the health system as uncaring and unproviding. In South Africa, where AIDS denialism had its worst effects, a study by Jane Goudge and colleagues at the Centre for Health Policy on the University of Witwatersrand found that "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." Healer shopping, or perhaps more appropriately quack shopping, is a consequence of poor health services characterised by disrespectful behaviour from overworked health staff, long waiting lists, queues, and the unavailability of essential medicines and diagnostics. It is here where prominent AIDS denialists and charlatans step into the breach and lead vulnerable people away from proven health interventions. This is yet another excellent reason why decent medical services need to be accessible by middle- and low-income people. Below is the abstract of this study.

Affordability, availability and acceptability barriers to health care for the chronically ill: longitudinal case studies from South Africa.

BMC Health Serv Res. 2009; 9: 75.

Pubmed abstract: http://www.ncbi.nlm.nih.gov/pubmed/19426533 [1]

Full free text available here: http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid... [2]

Goudge J, Gilson L, Russell S, Gumede T, Mills A.

Centre for Health Policy, School of Public Health, University of Witwatersrand, Johannesburg, South Africa. jane.goudge@gmail.com [3]

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.