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Abstract
We examine patterns of health seeking behaviour prior to death among 1282 individuals who lived in the Umkhanyakude District of Northern KwaZulu-Natal. Information on the health care choices of these individuals, who died between January 2003 and July 2004, was gathered after their deaths from their primary care-givers. We examine choices made concerning public and private medicine, western and traditional medicine, and non-prescribed self-medication. We find that virtually all adults who were ill prior to death sought treatment from a Western medical provider, visiting either a public clinic or a private doctor. In this district, which is predominantly poor, ninety percent of adults who sought treatment from a public clinic also visited a private doctor. Fifty percent also sought treatment from a traditional healer, suggesting that traditional medicine is seen as a complement to, rather than a substitute for, Western care. Better educated people who were ill for less than a month before
dying were significantly more likely to visit a private doctor, while those least well educated were more likely to visit a traditional healer. Controlling for length of illness, better educated and wealthier people sought care from a greater range of providers, and spent significantly more on their treatment.
Introduction and background
South Africa is currently struggling with both a deepening of its AIDS crisis and a heavy chronic disease burden. As a result, an understanding of how people seek medical care has become an ever larger priority. In South Africa, health services are offered through multiple, sometimes overlapping channels, echoing what is true in many parts of the developing world (Develay et al 1996, Ahmed et al 2000, Baume et al 2000). Quantifying the extent to which ill people are attending both at public clinics and at private doctors’ offices, and at the same time are seeking cures from traditional healers and non-prescribed treatments from pharmacies, is necessary if informed choices are to be made, for example, in designing an anti-retroviral therapy (ART) delivery programme. Successful adherence to ART will be influenced by the ways in which ill people interact with health care systems.
In this paper, we examine patterns of health seeking behaviour prior to death among 1282 individuals who lived in the Umkhanyakude District of Northern KwaZulu-Natal. Information on the health care choices and expenditures of these individuals, who died between January 2003 and July 2004, was gathered after their deaths from their primary care-giver (generally an adult in their household or a close relative). These data were collected through the Africa Centre for Health and Population Studies, which runs a longitudinal demographic surveillance system (DSS) in the District. Because the Africa Centre Demographic Information System (ACDIS) also collects information on the socioeconomic status of individuals and households, we can combine information on health seeking behaviour with characteristics of the deceased, including educational attainment and household asset holding, to examine the extent to which differences in socioeconomic status lead to differences in health seeking behaviour. We find significant positive associations between individuals’ socioeconomic status, measured using household assets, and individuals’ educations and work histories, and their use of medical services. Not surprisingly, length of illness prior to death has a significant effect on the probability that medical attention is sought— particularly treatment from traditional healers and non-prescribed treatments—and on the amount spent on all types of medical care. Of those who died after a short illness, less well
educated people were significantly more likely to have consulted a traditional healer than were those with more than 6 years of education, while better educated people were significantly more likely to have consulted a public doctor or clinic, or a private doctor.
Although it is understood that many people turn both to western medicine and traditional healers when ill, use of the latter has not been systematically quantified in South Africa (Ashforth 2004: 51). We find that traditional healers were consulted by almost half of all ill people in our sample, and by nearly 60 percent of the young adults who died. Almost all of those who consulted traditional healers also consulted a Western medical practitioner. The cost of traditional care varies substantially, and can be very expensive: of those who visited both private doctors and traditional healers, more was spent on the latter.
Our data allow us to document and analyse the health choices made by persons in Northern KwaZulu-Natal who were mortally ill. These data are not appropriate for answering the larger question of health seeking behaviour in the population at large. The use of medicines that kept people alive would have kept them out of our sample. However, given HIV prevalence rates in Northern KZN
and the current lack of ART in this region, our data do provide information on the behaviour of an important subset of the population.
The paper is organised as follows. We first introduce the Africa Centre Demographic Information System and our data collection effort on illness and death. We then lay out the patterns of health seeking behaviour we find in these data, before turning to their determinants, after which we conclude the paper.
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