CII and FGD participants from both central and remote areas explained that in the majority of instances they initially spent time assessing the illness severity. Participants differentiated between “ordinary fever”, and that requiring malaria treatment, using a ‘wait and see’ approach which usually took between 2 and 5 days (A detailed analysis of this approach and perceptions of severity has been published elsewhere ). Participants explained that formal health facilities were the most appropriate source of care for fever assessed as requiring malaria treatment. However, their ability to seek formal healthcare and the timing of this was shaped by interactions between the geographic accessibility of facilities, related costs, access to and control over resources to meet these costs and gendered intra-household decision-making authority.
Geographic accessibility of formal health facilities
Once the need for formal healthcare was recognized, distance from a health facility was raised in both CIIs and FGDs as a barrier to seeking timely care. Three of the CII participants explained that they had decided not to seek care from a health facility, or delayed care seeking because of the distance to a health facility. Participants in all FGDs described the time of day that illness occurred as an important consideration for care seeking, and it influenced delayed health facility attendance in a number of CII participants. Travel to a health facility at night was considered dangerous, wherever the participant lived, as it was perceived to put the primary caregiver, who was usually female, at risk of murder or mugging, or accusation of criminal activity by police. Participants stated that extremely sick children would be taken to the hospital at night, but the caregiver would require accompanying by the husband or neighbours. This issue in combination with distance from a health facility posed particular problems for those living in remote villages. Night-travel was avoided, rather participants considered whether they could feasibly travel to the hospital, receive treatment and travel back again before night-time. If not they preferred to wait and leave early the following morning, unless they perceived the child to be severely ill:
Not many people will rush to the hospital in the first place, mostly when we consider the distance to be covered. Supposing the child is sick now, I can’t go to Chikwawa and come back. It will be too late. Usually, we wait first because we think about the long distance. That’s our problem here. (Men’s FGD, remote, 07/10/10).
The above quote illustrates that the distance to a facility influences the length of the assessment period in the “wait and see” approach. However, participants were aware that sometimes the illness might become serious before the need for care is recognized:
When he is in trouble, sometimes I don’t realize that he has malaria but I just realize that he has fever… I realize that the child has collapsed; then I know that it must have started long ago but I didn’t know. (Young women’s FGD, central, 22/01/11).
Thus the “wait and see” approach has greater potential adverse consequences for those living in remote villages due to the additional time needed to travel to the health facility once the need for care is recognized.
Costs, access to and control over resources
Households experienced considerable financial costs associated with attending a formal health facility. Despite care that was free at the point of delivery, finances were often needed for transport and food, so money for anticipated costs was needed prior to seeking treatment. In general men were identified as responsible for budgeting and decision-making with regard to household finances in both communities. Women had limited financial autonomy, and women’s, often considerable contributions to income generation were minimized in participants’ narratives.
Some of the women explained that they had no right to control or contribute in decisions over finances because they were ‘just’ beneficiaries of their husbands, who were seen as the income generators. Women living in remote areas tended to express more limited control over resources, such as in the following quote:
When he decides that the money is supposed to be used in such and such a way, I just have to obey what he says. (CII, attended a health facility, remote, 04/11/10).
A small number of women stated that they conducted the budgeting together with their husband; it was notable that all of these women also had a source of income of their own, such as working as a vendor, and most of them were living in the central area. However, most women in all areas do have some access to finances, since they are typically responsible for selling fruits and vegetables produced by the household, beyond that needed for consumption, and for buying items necessary for daily household running.
Women and men in all areas agreed that it was a child’s father’s responsibility to provide money, if required, for treatment-seeking. In the majority of the cases discussed in CIIs husbands had fulfilled this responsibility by providing the necessary money for treatment. In addition some male and female FGD members stated that if the husband went away, he would leave money for emergencies; this was confirmed in one of the CIIs. Men may need to borrow money in order to be able to provide it for their children’s treatment. However, men did not always provide money and were sometimes unable to. Women in all areas described a variety of strategies that they used to access finances when required: this included accumulating savings by hiding some of the change when given money for purchases; selling vegetables from the garden; and borrowing from friends, family members and grocery store owners. Both men and women described giving clothing as a pledge to either traditional healers or money-lenders in exchange for treatment or cash.
Households had to balance competing demands for resources. Women initially assessed the level of need for urgent treatment and the availability of resources and only requested financial assistance, or made use of their own finances, if they deemed it necessary. In most cases out-of-pocket expenditure was avoided:
We usually walk, not everyone will hire a bike. Most people walk because of financial constraints. Let’s imagine you only have K200 in the house and you have neither flour nor relish and the child falls ill, if you take a bicycle and go to the hospital, what will the child eat when you come back from the hospital? (Young women’s FGD, central, 06/10/10).
The above participant continued to explain that women might take the risk of spending some of their own income on transport if the case is serious, although they ultimately expected their husband to cover the cost:
When the sickness is very
, we spend the money to go to the hospital simply because it is a
case… We know that the husband will do his best to bring money home.
Women with an independent source of income were usually in a better position to seek care without financial assistance from their husband. One CII participant living in the central area sought care for her child on the day the illness started, using a bicycle taxi funded from the proceeds of a small business she ran.
Gender, generation and intra-household decision-making power
Women and men in all areas described a chain of communication, whereby the child’s mother usually identified childhood illness and informed the father. However, there were clear differences in the level of autonomy and authority that women possessed with regard to making treatment-seeking decisions in remote villages where patrilineal and patrilocal ethnic groups dominated versus central villages where matrilineal and matrilocal ethnic groups were in a majority. Mothers in remote villages not only had greater need for financial assistance for transport, but also experienced limited authority to make decisions about the appropriate course of action. The men in remote villages were in agreement that it is necessary for mothers to inform their husbands, or if not present, their in-laws, before seeking care for children. Paternal grandmothers were especially important in the treatment-seeking process, although if finances were required, the mother sometimes needed to wait for her husband to receive the necessary assistance. In the patrilineal/patrilocal communities in-laws were considered to ‘own’ the children and therefore the right to know what is happening and contribute to the decision-making process:
We tell them so that they should be aware, because our customs here require that the wife should live at the husband’s home and we believe that the husband’s parents and relatives are the owners of the children. (Young women’s FGD, remote, 14/01/11).
Within these patrilineal communities, participants were unanimous that the social consequences of mothers not informing relatives could be serious:
Suppose the woman leaves without informing anybody because the child is ill and perhaps the child dies or on the way the child dies, in our tradition it is a big issue, she has a case to answer. The question will be: why did she have to go without informing anyone? She must have done something bad to the child – this may cause a row.
Men in remote also showed great respect for elders; they suggested they would go along with the elders’ advice, even if it was contradictory to their own preferences. Unlike the women however, men were not required to seek the advice of elders before acting:
Women in remote villages explained important advantages of informing their relatives, for example informed relatives, particularly mothers-in-law, could provide any assistance necessary, such as childcare and food preparation. This was perhaps more of a concern for those living in remote villages due to the greater distance from home and greater difficulties of sending requests for help than for those living centrally. However, some women in remote villages criticized the existing system of authority and expressed frustration about delays caused by needing to inform others, with some suggesting they would be willing to disobey their seniors in order to ensure their child gets the care they need:
I would rather be shouted at, as long as my child is well. (Older women’s FGD, remote 081010).
Despite the challenges, women in remote villages still expressed preference for hospital treatment:
Our generation depends much on the hospital; therefore we go to the hospital first…(Young women’s FGD, remote, 08/10/10).
In contrast to those in remote villages, those in central villages did not refer to seeking advice from mothers-in-law. They were less likely to require financial assistance due to the closer proximity to the hospital, although they agreed that the husband has responsibility for decision-making, and should be informed of sickness. Some agreed that nearby relatives are particularly influential for women, usually her own, and explained there may be disagreements if she acted without their knowledge. However, the men in central villages considered the woman able to make decisions in the absence of the husband and in fact, that it was important for her to do so:
Respondent 2: …it might happen that a child falls sick when the husband is at work in Nchalo and the wife decides to wait for the husband to take the child to the hospital; now can we say that the woman is wise? When a child is sick, it is the responsibility of the one who is present to take the child to the hospital.
Respondent 1: I can say that it is a question of responsibility.
Respondent 4: Yes, both have the responsibility over the child. (Men’s FGD, central, 17/01/11).