Never Blame the Patient, Blame the System
‘Health seeking behaviour’ is one buzzword that’s never far from the lips of health experts when discussing health care across most of Africa.
‘Patients don’t come when they should’,
‘Patients are ignorant’,
‘Patients rely on faith healers’.
Phrases similar to these are never too far from the lips of many health professionals and development workers. Here in fact is a real world quote from the project lead of a donor funded program, pointed out to me viaa tweet from mamalette:
Apart from this, there is the poor health seeking behaviour of the people. Many people don’t seek care until it’s too late, and when they do, they don’t go to the appropriate places.”
Don’t know about you but this to me smacks of blaming the patient.
On a similar note, recently Dr Debo Odulana of Doctoora tweeted the following:
In response, I began on a trail of blaming the patient but stopped suddenly in my tracks. See, fortunately for me, my training and experience in medicine has forced me to look beyond the surface when assessing patient behavior. I’ve learned to first seek to empathize with the patient rather than blame them. Do this and you will find that more often than not, there is usually a rational reason why patients act the way they do particularly in life-threatening situations. That reason, is often a function of a poor health system and dire socioeconomic status that discourages health seeking behavior
To the example of the older man who’s lost his vision from diabetes, I wonder why he would continue to seek self medication. There are a few options to consider: Perhaps he is suicidal and has a death wish, I doubt it. Perhaps he doesn’t know that diabetes is lethal, again I doubt it. Why then would he persist in self medication despite its inherent dangers. I think there’s a rational explanation for this, cost!
The real reason why Africans have poor health seeking behavior is the immediate cost of that behavior. As any economist will tell you, it is entirely rational for one to avoid immediate costs especially if incurring them doesn’t necessarily translate to immediate relief. So if I have diabetes and have to choose between paying for drugs or buying food for my family, I’ll choose the latter every day and twice on Sunday. Health seeking behavior is simply a function of cost, we don’t talk about this enough.
Don’t believe me? Another example worthy of review is in maternity care. This paper looking at health seeking behavior in pregnant women in south western Nigeria determined that:
Economic factors contributed to the delay in access to appropriate services. There was a consistent concern regarding the cost barrier in accessing health services. The challenges of accessing services were well recognized and these were greater when referral was to a higher level of care which in most cases attracted unaffordable costs.
Another paper looking at the same subject concluded:
…There is a wide gap in the reproductive health seeking behavior of household members across the wealth quintiles with members of households in lower quintiles having lesser likelihood (33.0%) to receive antenatal care than among those in the highest quintiles (91.9%).
The richer you are, the more likely you are to seek out care. This is hardly news, we’ve always known that cost greatly affects health care consumption not just in Africa but also in other jurisdictions as well. The abstract for this 2014 paper on the subject in a peculiarly American situation is most instructive.
All states provide Medicaid until the age of 19 years. After 19 years, young adults may become ineligible for Medicaid. Using the Medical Expenditure Panel Survey, we find that the resulting loss of Medicaid coverage causes substantial changes to the level and composition of health care use. The total number of visits to health care providers falls by over 60%, two-thirds of which is due to a decline in office visits. Expenditures, in particular inpatient expenditures, also appear to fall sharply
There is clear evidence that even all important inpatient stays fall sharply once the costs for them are borne directly by the user. Africans now don’t seem so dumb for ‘poor health seeking behavior’.
The next time we as health professionals are tempted to blame our patients, we should instead apologize to them for the system then turn around and go fight for universal health care for all.
