particularly under-covered. The density of services and availability of qualified health professionals is much lower compared with urban centers (Banerjee et al. 2008; Mishra 2005; Peters et al. 2002).
Various studies have highlighted distance as an important barrier toaccessin rural areas and even in some urban communities. For the NSSO (2006), the fact that the proportion of people getting treated for ailments is much better inurban setting is an illustration of the impact of the geographic availability of health centers. In that survey, 12% of rural respondents said they did not seek care for minor ailments because there were no medical facilities available in their community. In a study in rural Orissa, physical accesstohealth services has been shown to be restricted by distance and communications (Ager et al. 2005). In this study, the only care available near the community was private and public facilities were located hours away from the village. On top of this, the principal ways to reach these health centers were driving a bull cart, riding a bicycle or walking. Moreover, communications are even completely disrupted during the monsoon season. In poor urban communities, distance is also a self-reported reason for untreated morbidity. Even though health services are concentrated inurban centers, they are not necessarily accessible to the poor in slums neighborhood. In a study of health services utilization in two poor slums of Mumbai, 50.6% of the respondents that lived in a slum at the outskirt of the city and 12.5% of the respondents that lived in a slum at the center of the city said they did not go for treatment in municipal facilities because they were located too far away from their home (Yesudian 1999). As it was seen earlier, primary care centers inIndia are intended for rural regions. In reality, the lack of primary health services inurban areas has been suggested as a factor that affects the poor’s accessinurban centers(Duggal 1992, Lévesque 2006). The poor cannot afford private care or higher levels of services.
When asked to describe how the phenomenon could affect the health system, all participants agreed that accesstohealthcare was seriously compromised by this practice. It appears that poor people are unable to afford even pri- mary care, while the majority of the population cannot access specialized services at all inurban public hospitals. "Those who can't manage to bribe; they will all die since they will never be able toaccess the treatments. Just imagine the women who are about to deliver, or children and those who are really sick, or the poor: do you think they will survive? They will all die just for [inability to make] informal payments" (Midwife, Tumbi Hospital).
In existing literature reviews of the effects of different payment methods on cost, quality and access, no study was identified which looked specifically at the impact of different payment methods on accesstocare controlling for health need across socioeconomic groups (Gosden et al., 1999, 2000). Therefore, we are unable to draw firm hypothesis about the impact of different payment methods on equity. But we note that in FFS systems, often physician care is not entirely free at the point of delivery, while in capitation and salary systems this is usually the case. Also in systems where doctors are under capitation, they have a responsibility with respect to the population in charge with often specific objectives targeting the low socioeconomic groups such as in the United Kingdom, the Netherlands, and Sweden (Couffinhal et al., 2005b). Moreover, several critics point that capitation may have advantage over FFS and salary systems in terms of better case management and coordination of services especially for people with chronic or multiple diseases (Mitchell and Gaskin, 2007). And this type of coordination is likely to be more important for ensuring access for those with a low level of education/income who seem to be less well informed on care pathways.
other words, the provision of healthcare is distributed according to a gradient proportional to the level of development and, in this case, to the population densities.
The most populated state inSouthIndia, Andhra Pradesh is characterized by real regional contrasts. Broadly speaking, the state includes two semi-arid climatic entities and a coastal area. Telengana extends to the north-east, while Rayalaseema includes the four districts in the south of this region. Finally, coastal Andhra corresponds to the deltaic region composed in particular of the Krishna and Godavari Rivers. On this map, two regions acquire distinctly individual characteristics through a high density of infrastructures compared to the rest of the state. The first region concerned is organized along the seafront and is characterized mainly by an exacerbated polarity around the main rivers mentioned above and corresponds overall to coastal Andhra and to the richest deltas of Andhra Pradesh, such as that of the Godavari. This sub-region took advantage of its geographic location through an optimal utilization of its territory. In particular, due to the efforts made to extend the percentage of irrigated lands, this region has ensured itself a relatively prosperous development in both the agricultural and industrial sectors. This has naturally entailed higher population densities than elsewhere and a real demand for medical care facilities. We are not examining whether these needs are completely met, but it appears that in this region the healthcare provision is the densest and probably the best.
We propose to take a different stance, based upon our fieldwork research in rural Bihar (India). We contend that as different as they are, both ‘legalist’ and ‘realist’ discourses share a common view on the informal practice as materializing the existence of a parallel health market, ‘on the margins of formalized medicine’ (Gautham et al., 2014), out of the reach of regulatory authorities and most importantly, outside the realm of government and the state. Contrary to that shared view, we will show that not only are IPs essential com- ponents of the health system from the patient perspective – a point that has well been demonstrated by others (Gautham et al., 2014; May et al., 2014) – but also that they are integral to the way the Indian state today assumes its functions in rural and deprived areas. In that sense, the term ‘informal’ can be misleading, as anthropologist Janet Roitman has shown in the case of informal economy: whereas informal economy is ‘often signaled as a residual category’, it can be ‘at the heart of productive economic life’ (Roitman, 2005: 20). Informal health markets indeed appear to be at the heart of medical life in rural Bihar, simultaneously from the point of view of patients, public and private practitioners, and authorities. Informality then constitutes one crucial aspect of the government of health- carein the rural areas of India and plays a crucial part in the contemporary ‘government rationale’ (in the sense of Foucault, 2004). According to Foucault, the analysis of power should not be reduced to the state’s main attributes (such as the parliament or the army). Rather, power spreads within the multiple sites and moments that compose social life. In that sense, one can identify the exercise of power not only in governmental declarations and state actions, but also in what is typically not taken charge of by the state, and appears to be left to the people, be it attributed to a lack of will, justified by the production of a particular knowledge, or even due to simple ignorance.
Results. Foreigners make up 40% of Mayotte population (total 186,452), of which a quarter is
children born in Mayotte and 80% have no regular residence status. The median length of residence of migrant foreigners is 10 years. Foreigners represent a majority of the female population, of the 20-35 years old population and of the urban areas. Main determinants for migration were economical (50%) or family-related (26%). Health was stated as a cause of migration by 11% of migrants. The social situation of foreigners is more precarious and their perceived health poorer than the ones of the French. Their accesstocare is also perceived as more difficult. We did not observe any notable difference in term of frequency of healthcare attendance over the last 12 months between the 2 groups, but foreigners have consulted less often private GPs and more often traditional practitioners than French.
I got on a plane and arrived in Tenerife on 25 January 2004 with 50 euros in my pocket. I found a job as a kitchen aid even though I have no experience in that area. Eight months later I got in touch with some people from Galicia and could finally afford a ticket to go there. Even though I’m South American and my ancestors came from Spain, I was treated the same as any other immigrant from Morocco or sub-Saharan Africa… The only jobs I found had terrible working conditions. I’ve even been offered work as a prostitute.With help from various NGOs (Medicos del Mundo was the first NGO I knew), I obtained the necessary information for papers, health insurance, aid, services and the personal and emotional support you often need when you’re in a borderline situation.Those groups helped me cope with many of the administrative hurdles I stumbled over; complications getting the health card, problems with my papers, which were often rejected when I requested services (…)”
The role de of the distance
Different aspects compose the distance factor: the quality of the road network, means of transportation and their role in the shaping of the different areas of influence
About the quality of the road network in Vapy district: the main axis of the district is a transversal road (East/West) that goes through the entire province and links Saravan to the road 13, the main North/South axis of the country. This road was recently paved. The secondary network is mostly constituted by dirt roads which raises accessibility issues. Indeed, during the rainy season, half of the dirt roads are flooded.
2: Public Health Department, Tropical Institute of Medicine of Antwerp, Belgium.
Introduction: Coordination between levels of care is not facilitated in the Belgian health system. Indeed, patients have uninhibited accessto every level of care, there is no gatekeeping system, and few structural coordination between levels of care. On one hand, the occurrence of more complex care situations in the ambulatory setting is enhancing the need for coordination while on the other hand, hospitals face financial constraints to provide carein the community.
The socio-spatial context usually studied using the urban and rural divide. However each of these settings is not homogeneous and the urban area is particularly complex in this respect. 5 Given the recent and fast growth 6 of urban space in Africa, its restructuring is an on-
going process between a “stabilized pole” including an “artificialized” space with functional networks for facilities and public services, and a formalized social space (the wage system and school education) and an “insecure pole” which comprises a partly “natural” space and a relocated and informal social space that lacks collective equipment and public services (Faye & Thioub, 2003; Goerg, 2003). The African city is not only “dual” but also plural with segregations identified between different neighbourhoods or larger housing areas. The neighbourhood people live in is a place where they have accessto resources and exchange practices and ideas. Thus, the neighbourhood shapes behaviours and is also the result of behaviours. On the one hand, residents’ behaviours are influenced from the outside through the neighbourhood’s physical and administrative features. On the other hand, the neighbourhood is also shaped by its residents and becomes a desired and built living environment (Faye & Thioub, 2003; Goerg, 2003). As a space that is “seized”, the neighbourhood eventually becomes a vector of social identity (Goerg, 2003). In these conditions, the studies that are based on an approach too focused on individual factors may have a limited explanatory power (Carpentier & Ducharme, 2003; Chaix & Chauvin, 2002; Davidson et al., 2007; Diez-Roux et al., 1997; Stierle et al., 1999).
Excessive crying is not appropriate… You shouldn’t exaggerate because everything has a limit. Q: Can the person cry during the funeral period? No, that’s not good. Religion doesn’t tolerate a person crying for so long… Of course religion allows us to cry but if you persist, it’s like calling into question Divine will (head of district, Guédiawaye). In the workshops, community participants explained that they thought it was normal to cry if you lose someone you were close to, but you should cry ' discretely' , that is, ' quietly' . In the policy workshops, Muslim religious leaders confirmed that people could show their emotions through tears, but Islam disapproved of crying loudly, or saying despairing words such as 'what will become of us now?' or 'where will I go?' since as one Islamic leader commented: '..that's a way of saying...it's as though God isn't there. A Muslim believes that it's God who solves these problems' . One imam associated crying loudly with animist practices linked to ethnicity, particularly the role of 'wailers' who may be paid to cry at funerals. Many participants commented that Islam recommended that, instead of crying too much, people should pray for the deceased. In a few instances, adult interviewees described themselves as being overwhelmed by their feelings, for example, Simone (aged 39, widow, Catholic) said she was ‘ going crazy’, while Malang (aged 47, Muslim) described having complete breakdown after his wife’s death:
Socialization is broadly composed of distinct inter- and intra-generational processes. Both involve the harmonization of an individual’s attitudes and behaviours with that of their socio-cultural milieu. The first is the more widely understood view of socialization,
particularly in psychology: the learning view that sees parents, peers and teachers as principal agents of socialization in childhood. Socialization through childhood would lead to similarity in attitudes, beliefs and behaviours across generations. The second mechanism involves the socializing influence of an individual’s own socioeconomic environment through the lifecourse on attitudes, beliefs, and behaviours. The socioeconomic position occupied by adults conditions the way in which they live and work, which in turn is critically linked tohealth (Marmot, 2004). Research suggests that both these pathways are in play in the intergenerational similarity of religious and political ideology (Glass, Bengston & Dunham, 1986), personality and behavioural attributes (Brook, Whiteman & Zheng 2002), and occupational status (Korupp, Sanders & Ganzeboom 2002).
Some recent studies have been interested in reporting biases related to self-assessed health, which is the most regularly collected measurement of healthin household surveys. Even if this indicator is a good predictor of mortality (Idler and Benyamini, 1997) and healthcare utilisation (DeSalvo et al., 2005), it is also the result of a complex aggregation process of several elements that an individual knows on his health status. Initially, self-assessed health integrates morbidity, which depends not only on diseases and on functional limitations for which he is treated, but also on diagnosed health problems, and thus, on interactions with health professionals. This measurement being subjective, it also integrates personal expectations of good health, which are influenced by social and cultural environments. Several studies have highlighted discordance between health perception and other health indicators considered to be more objective. The literature underlines four sets of factors that can affect individual health judgement and therefore self-assessed health. A first group is related to the nature of pathologies from which the individual suffers. For example, Van Doorslaer and Gerdtham (2003) observe that hypertensive men report a better health than women at a given death risk. Age and gender also influence reports: women would report a poorer health status than men for similar levels of incapacities. Moesgaard et al. (2002) explain it by the fact that women would have higher expectations of good health. In addition, Baron-Epel and Kaplan (2001) show that old people more favourably judge their health status than youngest people. Reporting biases related to socioeconomic status are also found. In France, self-assessed health is affected by optimism biases for both rich people and the poorest people for a given clinical health (Etilé and Milcent, 2006). Lastly, health perception seems to depend on cultural characteristics: an Australian study shows that indigenous population declares being in better health than general population in spite of higher incidence rates of serious health problems (Mathers and Douglas, 1998).
The second lesson from the brick kilns deals with labour struggles (Guérin et al. 2012a). Some workers do have some bargaining power, in particular those who have experience and who work in the kilns every year. They manage to avoid the worst places of production and limit the extraction of added value by labour intermediaries. However they also use their position to obtain higher advances, which feed their growing pursuit of consumerism. As shown by various ethnographies, most of rural circular migrants’ struggles remain engaged in political struggles ‘in the rural areas they identify as their first home’ (Gidwani & Sivaramakrishnan 2003: 349; see also Picherit 2012). Here this translates into expenses related to agriculture and to social and religious rituals. These expenses are instrumental in maintaining and even sometimes strengthening labourers’ status and their position in local hierarchies. At the same time, and since economic returns are extremely limited, these expenses lock them into debt traps. These costs also lead workers to demand larger advances, which in turn increase their dependence to the sector. The percentage of workers who return indebted at the end of the season, and who so are forced to return the following year, has continued to grow between 2000 and 2009 (Guérin et al. 2012a). My most recent field visits in January 2013 indicate that the gap between advances and wages is continuing to increase, which in turn reduces exit options. Some of the bonded labourers are not the poorest of villagers, insofar as wage advances are not only used for daily survival but also for consumption, agriculture, and social investments. Debt is still however used to cheapen wages, to impose hard working conditions and to restrict exit options. As a result, as paradoxical as it might be, I suggest that bonded labour is not only compatible with rising aspirations for equality and integration, as exemplified by the desire for consumption, but it also relies on these aspirations.
A third of the dental offices refused to provide care only to the people with HIV, most of these refusals being of the disguised type. Gynaecology appointment refusals were less frequent. Discriminatory remarks were made by 17% of the offices (table). These results reflect a lack of understanding of the modes of HIV transmission and the universal precautionary measures. Adherence to these measures is especially important because they are aimed at preventing infections other than HIV and because many people with HIV do not know their serological status (20% in France5). We advise that this kind of situation testing survey is done in all countries to fight refusals to provide care.
The approach on the micro-level has allowed of a more precise and more exact view of demographic phenomena. It also shows the limitations of the classic approach on the aggregated scale of district or state.
Thus, taking up examples given in this chapter, the organization of fertility along the coastal strip is clearly defined and the low fertility of the Coimbatore plateau better circumscribed. Having made this observation, it will be noted that Tamil Nadu, notwithstanding a significant internal heterogeneity, which is no doubt related as much to its geographic diversity as to its social history, is the state having the lowest local fertility. Likewise, this micro-spatialized approach shows us the behaviour of numerically weak populations dwelling in marginal spaces, such as tribal populations, which vanish entirely from the usual aggregated statistics.
Several Hospitals; ≅ 300 GP’s
From Grodos D, Mercenier P. Health systems research: a clearer methodology for more effective action. Antwerpen: ITGPress, 2000: 107 pp. (Studies inHealth Services Organisation & Policy; 15). [ITM Library: SOCA /16535] [Available from: http:// www.itg.be/]
Act with the families
Facilitators or difficulties in setting up the actions were never described. This review of reviews has also re- vealed, in particular, an assumed lack of knowledge among parents and even a lack of analysis of the rela- tional modalities between the professionals and the par- ents [ 21 , 31 , 35 , 45 , 48 ]. Collaboration involves the need for a common language between professionals from dif- ferent disciplines, parents with multiple issues with dif- ferent objectives. This review has shown, however, that studies focusing on the ability to listen and the quality of the professionals–mothers–parents–newborns relation- ship are under-represented [ 35 , 44 ]. Highlighting and theorising these interrelations represents an approach to understanding how interventions function, which en- ables them to be made more effective [ 55 – 57 ].