Gender, socioeconomic development and health-seeking behaviour in Bangladesh

Abstract

In efforts to reduce gender and socioeconomic disparities in the health of populations, the provision of medical services alone is clearly inadequate. While socioeconomic development is assumed important in rectifying gender and socioeconomic inequities in health care access, service use and ultimately, outcomes, empirical evidence of its impact is limited. Using cross-sectional data from the BRAC-ICDDR,B Joint Research Project in Matlab, Bangladesh, this paper examines the impact of membership in BRAC’s integrated Rural Development Programme (RDP) on gender equity and health-seeking behaviour. Differences in health care seeking are explored by comparing a sample of households who are BRAC members with a sample of BRAC-eligible non-members. Individuals from the BRAC member group report significantly less morbidity (15-day recall) than those from the non-member group, although no gender differences in the prevalence of self-reported morbidity are apparent in either group. Sick individuals from BRAC member households tend to seek care less frequently than non-members. When treatment is sought, BRAC members rely to a greater extent on home remedies, traditional care, and unqualified allopaths than non-member households. While reported treatment seeking from qualified allopaths is more prevalent in the BRAC group, non-members use the para-professional services of community health care workers almost twice as frequently. In both BRAC member and non-member groups, women suffering illness report seeking care significantly less often than men. The policy and programmatic implications of between group and gender differences in care seeking are discussed with reference to the literature.

Introduction

In efforts to reduce disparities in the health of populations, it is well recognized that the provision of medical services alone is inadequate. In Bangladesh, inequities, or inequalities in attainment that are judged unacceptable or unfair, are particularly evident in gender and socioeconomic spaces (Whitehead, 1992). Gender is the socioculturally constructed role of the men and women in the society in contrast to sex, which refers to biological differences, and places a variety of expectations and constraints on women. It influences the health of women by putting emphasis on women’s reproductive roles, resulting in early and excessive childbearing; sex preference manifested in discrimination against female children in health, nutrition and general care; lack of autonomy leading to lack of decision-making power and independent income, and to violence and abuse, causing severe repercussions on health and self-respect and so on (Okojie, 1994, Vlassoff, 1994). Gender inequity in health is manifested by marked inequalities between males and females in health related options and outcomes (e.g. child survival and life expectancy), and attributed to powerful social and cultural forces that overwhelm the supposed biological advantage of women (Chen et al., 1981, Waldron, 1983, Koenig and D’Souza, 1986, Bhuiya and Streatfield, 1991). Thus, in Bangladesh, women have a lower life expectancy at birth compared to men, and male-biased sex ratios (105 male per 100 female) contradict expected patterns. Food and health care are disproportionately distributed to male children, and neonatal, infant and child mortality rates are higher among girls. Levels of female literacy remain among the lowest in Asia (24%) while the maternal mortality rate (4.5 per live births) ranks among the highest in the developing world (MOHFW, 1998). Equally vivid in Bangladesh are socioeconomic differentials between the health status of the wealthy few and the vast legions of the poor, due to inequalities in education, health care access and ability to pay.

Socioeconomic development is generally regarded as an important means of reducing gender and socioeconomic inequities in health care access, service use and ultimately, outcomes (Caldwell, 1986, Evans et al., 1994). Indeed, a host of non-governmental development organizations (NGOs) in Bangladesh have organized to improve the health and livelihood of the poor in general, and women in particular, through the support of integrated socioeconomic development activities including women’s micro-credit and education. Implicit in these activities is the assumption that increased income and awareness arising through involvement in socioeconomic development programmes will result in more enlightened health-seeking behaviour, and hence, relative improvements in the health status of women and the poor. To date, however, a systematic examination of the validity of this assumption is lacking in the published literature.

Health-seeking behaviour refers to the sequence of remedial actions that individuals undertake to rectify perceived ill health (Christman, 1977, Ward et al., 1996). Health-seeking behaviour is initiated with symptom definition, whereupon a strategy for treatment action is devised (Christakis, Ware & Kleinman, 1994). Previous research has established, however, that symptoms will not necessarily be identified in biomedical terms nor will their recognition necessarily result in health action of the variety that “scientific medicine” deems most appropriate. Treatment choice involves a myriad of factors related to illness type and severity, pre-existing lay beliefs about illness causation, the range and accessibility of therapeutic options available, and their perceived efficacy (Zola, 1966, Kleinman, 1980, Kleinman and Gale, 1982, Young, 1981, Helman, 1995).

Like much of the developing world, medical pluralism, or the existence of several distinct therapeutic systems in a single cultural setting, is an important feature of health care in Bangladesh. Indeed, a wide range of therapeutic choices is available, ranging from self-care to folk and western medicine, although both illness incidence and treatment options are importantly determined by poverty and gender. Kleinman provides a useful typology that establishes popular, folk and professional domains or sectors of health care and their interconnected and overlapping function (Kleinman, 1980). The popular sector refers to the lay, non-professional arena of care where the symptoms of ill health are first recognized and health-seeking initiated. It includes all the therapeutic options that people employ without recourse to paid consultations with folk or professional practitioners. Among these options are self-care or self-medication, whereby people function on their behalf in health promotion and prevention, and in disease detection and treatment (Levin, 1981).

The ‘folk’ sector includes diverse practitioners of sacred or secular healing who tend to adopt a holistic approach that takes into account physical and emotional symptoms in the broader context of people’s lives. Because folk healers articulate and reinforce the cultural values of the communities in which they live, they have advantages over the professional sector in their ability to define, explain and treat the social, psychological and moral dimensions of ill-health. Although traditional medical systems may also become professionalized to some extent, in Kleinman’s typology, the ‘professional’ sector refers to organized, legally sanctioned practitioners of modern scientific medicine, also known as allopathy or biomedicine.

Using a set of cross-sectional data from Matlab Thana in Bangladesh, this paper tests the hypothesis that socioeconomic development will have positive externalities for gender equity and health seeking behaviour. Specifically, it proposes that participation in socioeconomic development programmes will increase informational and material resources for preventive and therapeutic health care, and support their equitable distribution between male and female household members. Among beneficiary households, these changes will be manifested in a shift from folk and popular care seeking to the professional sector, and increased gender equality in treatment seeking among those reporting ill-health.