Responding to Crisis: Patterns of Health Care Utilization in Central Kenya Amid Economic Decline

Abstract:

African states have become increasingly unable to provide adequate health care to their citizens due to debt, structural adjustment, poverty, and mismanagement. The health crisis is worsening in many areas and driving up mortality rates after decades of decline. This article investigates how African communities and their citizens respond in light of state inability to deliver health-related services. Drawing on a survey of more than five hundred rural Kenyans, our analysis shows that people are dissatisfied with government facilities and are turning to mission clinics and hospitals as well as to private clinics. A number of factors determine choice of health-care facility, including cost, level of education, socioeconomic background, the time taken to reach a facility, the type of disease requiring treatment, and agro-ecological zones. These findings have profound theoretical implications for health and development models, which normally are biased in favor of developed Western countries.

Résumé: A cause de la dette, de l'ajustement structurel, de la pauvreté et d'une mauvaise gestion, les états africains sont devenus de plus en plus incapables d'offrir une couverture médicale adéquate à leurs citoyens. La crise de la santé s'aggrave dans de nombreuses régions et fait grimper les taux de mortalité après des années de régression. Cet article examine comment les communautés africaines et leurs citoyens réagissent au vu de l'incapacité de l'état à leur offrir des services liés à la santé. En s'inspirant d'une enquête effectuée sur plus de cinq cent Kenyans ruraux, notre analyse montre que la population n'est pas satisfaite des structures offertes par le gouvernement et qu'elle se tourne vers les cliniques et hôpitaux de mission ainsi que vers les cliniques privées. Un nombre de facteurs détermine le choix de ces structures médicales, comme par exemple le coût, le niveau d'instruction, le milieu socio-économique, le temps nécessaire pour atteindre une structure, le type de maladie à traiter, et les zones agro-écologiques. Ces résultats ont de profondes implications théoriques sur les modèles de santé et de développement qui d'habitude sont influencés en faveur des pays occidentaux développés.

Introduction

It is an unfortunate reality that the world region most in need of health care is least able to provide it. African states-burdened by debt, structural adjustment, poverty, and poor governance-are increasingly unable to allocate resources to combat the leading killers across the continent: pneumonia, diarrheal diseases, measles, malaria, and now HIV/AIDS. The health crisis is worsening in many areas and driving up mortality rates after decades of decline. This leads to a simple but important question: How do African communities and their citizens respond when states have less capacity to deliver health services?

Several responses are possible. People may rely on home treatment, they may seek out nongovernment facilities, they may turn to traditional healers, or they may opt for private clinics. These options are influenced by a wide variety of individual arid community characteristics such as income, seriousness of the disease, cost of treatment, and some additional factors that are unique to developing societies. In fact, few studies have examined the sociological determinants of changing patterns of health care utilization amid economic decline. This limits our knowledge and encourages the use of inappropriate theoretical models.

In response, this paper addresses these issues by reporting the results of a comprehensive and representative survey of over five hundred rural Kenyans from the central part of the country in 1995. The survey is important for a number of reasons. It ascertains the illnesses and diseases that afflict people, determines how they respond to sickness, and measures how satisfied (or dissatisfied) they are with several health-care alternatives. Moreover, it reports various economic, social, community, and cultural factors that help condition individual decision-making in health care. In addition to the rich descriptive data produced by the survey, it makes possible a logistic regression analysis that formalizes a number of associations.

Before presenting the survey and data analysis, we discuss general theories of development, health, and state capacity in African societies. We also apply the theoretical model to the case of Kenya. Our primary purpose is not to break new theoretical ground, but instead to place the study in theoretical context and to provide strong evidence that a community-based approach to health care is the best strategy at the present time.

Searching for a Model of Health and Development in Africa

Recent scholarship among Africanist social scientists has expressed extreme dissatisfaction with extant development theories (see Bradshaw, Kaiser, & Ndegwa 1995). One of the primary complaints is that development theories, even those used to explain the continent's economic decline, were developed in the West and thus are biased in favor of Western nations. Ironically, many African development plans have attempted to mirror Western-based health models. Such plans normally stress "topdown," urban-based, and curative approaches to health care, as well as the intensive use of highly trained health professionals and medical technology (Asthana 1994; Good 1988). All of these models operate under the assumption that there are adequate resources-either public or privatefor physicians, health practitioners, equipment, and the general administration of a comprehensive health care system. It also assumes that there is sufficient support for an overall approach requiring heavy investments in treatment for cancer, heart disease, and other largely "Western diseases."