Provider bias in the treatment of diarrhea among boys and girls attending public facilities in Minia, Egypt

doi:10.1016/S0277-9536(02)00072-2

Social Science & Medicine

Volume 56, Issue 4, February 2003, Pages 753-768

https://doi.org/10.1016/S0277-9536(02)00072-2 Get rights and content

Abstract

Girls’ excess mortality in early childhood persists in all regions of the world and has been attributed to parental discrimination in the allocation of food and healthcare. Consequently, researchers have paid scant attention to the potential for unequal treatment of boys and girls by health providers. Data from a longitudinal study of child morbidity conducted between 1995 and 1997 in Minia, Egypt are used to compare the frequency with which diarrheal cases of boys and girls were treated with oral rehydration solution (ORS) among children ever presenting at a formal source of care. Multivariate analysis suggests that public providers have marginally higher adjusted odds of administering ORS to boys than to girls and significantly higher adjusted odds of giving and recommending ORS to the caretakers of boys than of girls. Findings expose a need for further research on the supply side determinants of girls’ disadvantaged treatment in Upper Egypt and in other settings where son preference persists.

Introduction

Recent evidence suggests that girls’ excess mortality in early childhood persists in all regions of the world and in the majority of countries with available data (Hill & Upchurch, 1995; Arnold (1996), United Nations Secretariat (1998)). This differential has been attributed to parental discrimination in the allocation of food and healthcare, including differences in the duration of breast-feeding, nutritional intake, and amount and type of preventive and curative healthcare received (Arnold, 1992; Waldron, 1987). Research suggests that differential access to healthcare is the principal proximate determinant of girls’ excess mortality globally (Basu, 1989; Hill & Upchurch, 1995; Arnold (1996), United Nations Secretariat (1998)).

The abundant research on gender discrimination in early childhood, however, has focused almost exclusively on the behavior of adult family members, and scant attention has been paid to the behavior of health providers. Persistent excess in girls’ mortality in Upper Egypt (Langsten & Hill, 1996; Yount, 1999), the continued contribution of diarrheal disease to under-five mortality in Egypt (Langsten & Hill, 1994a), and the existence of national standards of care for the treatment of diarrheal diseases provides an excellent opportunity to explore providers’ behavior toward children with diarrhea in this setting. In this paper, data from a longitudinal study of child morbidity conducted between 1995 and 1997 in Minia, Egypt are used to compare the frequency with which providers administered, gave, or recommended oral rehydration solution (ORS) to boys and girls among reported cases of diarrhea that ever presented at a formal source of care. The behavior of providers in public and private service delivery environments is compared, and particular attention is given to the behavior of public providers because the implementation of guidelines and training programs is more established in the public sector.

Section snippets

Parental bias in the allocation of food and healthcare

In settings where girls’ excess mortality persists, the bulk of related research has focused on the discriminatory behavior of families rather than that of providers (see Pande, 1999; Arnold (1996), United Nations Secretariat (1998); Yount, 1999 for reviews). The primary mechanisms by which parents may discriminate against girls include the differential allocation of food (including breastmilk) and healthcare (Arnold (1996), United Nations Secretariat (1998)). Findings from Egypt regarding

Data

Data for this analysis come from the Two Governorate Linkages Survey (TGLS), a five-round longitudinal survey conducted between 1995 and 1997 in Minia and Qaliubia governorates. A household listing and basic demographic information on household residents were collected for a representative sample of ≈3000 households in each governorate. Background socio-demographic information was also collected on all ever-married female residents aged 15–54 years. At each round, respondents with children

Analytic methods

First, the percentages of boys and girls with diarrhea who ever visited public hospitals or clinics, private doctors, or pharmacies during the course of their illness are compared. This comparison provides some indication of the relative frequency with which families in Minia use public- and private-sector care for childhood diarrhea among all children and among boys and girls separately. Second, maternal reports of the case management of illnesses seen at public and private facilities are

Results

Table 1 shows ever visits to common sources of care among children reported to have had diarrhea in the 2 weeks before interview in Minia, Egypt. Results are disaggregated by age of the child to explore potential variation in gender differences in access to care by age group. Results are also disaggregated by round of interview to explore the consistency of reported patterns of behavior over time. Overall, parents more often take children to private than public care for the treatment of

Conclusions

This analysis has exposed an overall deficiency in the basic management of childhood diarrhea in public and private settings in Minia and confirms previously expressed concerns about the sustainability of the child survival initiative in Egypt (Langsten & Hill, 1994a). For the purpose of this study, however, the large female disadvantage in appropriate treatment of diarrhea in public facilities suggests that certain (unmeasured) characteristics of this care-giving environment may compound an

Acknowledgements

The comments of Dr. Ray Langsten, Dr. Kenneth Hill and Dr. Aryeh Stein, correspondence with Peter Miller, and comments from anonymous reviewers on earlier versions of this manuscript are greatly appreciated. The data for this analysis were collected while the author was a doctoral student in the Department of Population and Family Health Sciences at The Johns Hopkins School of Hygiene and Public Health. The support of Dr. Hoda Rashad and staff at the Social Research Center of the American

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