Module 2: Unique Barriers to Health Care for Children and Adolescents

Introduction

A number of financial and non-financial barriers may delay or prevent poor households from seeking health care for their sick infants and children. Such obstacles are common in low- and middle-income countries and include distance, financial barriers, sociocultural norms, language barriers, and lack of knowledge and awareness. These difficulties affect all age groups and can lead to low demand for and use of services, particularly by the poor.

Unique Barriers for Children

Children and adolescents face additional and unique barriers to obtaining adequate health care. Such barriers prevent access to care and create health disparities. Inequalities in child survival are not the result of a lack of technological solutions. Rather, poor children continue to suffer because cost-effective child health interventions fail to reach them. It has been estimated that taking existing child health interventions to scale can result in a two-thirds reduction in child mortality.(1)

Infants, children, and adolescents face unique barriers to accessing care for several reasons. First, in many societies, the young fulfill a submissive social role relative to their elders. This power imbalance results in the subjugation of young people to their parents, relatives, and elder siblings. When at the bottom of the social structure in a family with limited resources, this can mean that priority will be given to others when medical care is needed. Similarly, children lack full adult rights which can lead to further reliance on others for appropriate care.

In addition, many health problems that occur in children require specialized health care procedures by specially trained health care personnel. For example, in the United States, pediatricians must specialize and train differently from general practitioners, and pediatric sub-specialists exist within all other specialties (surgery, ENT, ophthalmology, etc.). Access to these highly-trained physicians and healthcare workers may be limited or nonexistent in low- and middle-income countries, creating unique barriers for children in need.

Case Study: Adolescent Sexual Health

In global health research, adolescent sexual health has emerged as an area of key concern, particularly in developing nations and regions such as sub-Saharan Africa where HIV and AIDS account for the second highest number of deaths. Globally, one-fourth of these cases represent people under the age of 25 years.(2) The increased focus on adolescent sexual health is due to the recognition that young age can contribute to vulnerability to HIV, in addition to other factors such as gender, poverty, and periods of social-cultural and political transitions.(3) In sub-Saharan Africa, girls aged 15-24 years old are about three times more likely to become infected with HIV/AIDS as compared to young men of the same age. In South Africa, Zambia, and Zimbabwe, the girls are up to six times more likely to become infected.(4) This high prevalence of HIV infection in young women stems more from power differentials and the resulting marginalization than from any biological predisposition.(5)

The power imbalance in the relationship between adolescents and adults is obvious. First, young people often do not have full political and civil rights until they reach the age of full-fledged adulthood. The lack of full political rights can translate into the absence of social and economic rights, undermining the autonomy of the young. Thus, children’s physical and legal dependence on adults increases their vulnerability to disease.(6)

In fact, many children and youth do not have protection when negotiating their social and sexual lives, and they may get too little authoritative support from parents, the community, or the state. This powerlessness at an intergenerational level allows for more vulnerability to HIV infection. This also contributes to vulnerability with regard to their reproductive health since elders may consider their queries to be “morally inappropriate” worries. They also can have concerns about voicing opinions on issues where youth are not supposed to have opinions. This vulnerability becomes particularly evident in the case of orphans who feel that they may even risk losing the little support and security that they have.(7)

The sexualization of children, particularly adolescent girls, exemplifies and reinforces the power differentials that exist between the young and the old, particularly between young women and older men. One way in which age differentials marginalize women is through the constraints of poverty.(8) Women who are poor are more likely to be HIV infected. Regardless of whether the relationship between poverty and HIV infection is causal, the social status of being poor is a major cofactor in the spread of HIV. Poverty is a condition characterized by dominance and dependence, and it consequently exacerbates other risk factors. Thus, when combined with age differentials, poverty can further disempower women and increase their dependence on an oftentimes older male partner for resources. This can ultimately result in less control over sexual practices and increased exposure to HIV.

For example, many poor young women in Southern Africa pursue older partners who can provide them with money and gifts that are unavailable from partners of their own age. In a discussion group from a study on the relationship between older men and younger women, one woman relates, “With a young man, it depends on his ability. If he can give you money, fine, but most of them usually don't have money. So you're forced to look for someone who has the ability to give you what you want.” (Female, Mombasa, aged 15-19) In fact, most participants in this study remarked that young women use money from older partners to obtain essential items for themselves or for their families.(9) Young women may engage in cross-generational relationships in order to secure funds to cover education-related expenses that parents cannot pay, such as school uniforms, fees, and books. Some said that young women often tell their families that they have taken a "casual" job to make ends meet. Thus, generational power imbalances are exacerbated by poverty and constitute a social and economic challenge for young women. This results in increased exposure to HIV and other sexually transmitted diseases when women trade sexual favors with older men in exchange for resources.

Implications

The barriers that inhibit children and adolescents from accessing care can lead to increased risk and higher rates of morbidity and mortality. In turn, this may compel parents to utilize their minimal amounts of money for income-generating activities instead of using the money to care for their sick child. A decrease in productivity or time away from work can reduce household income, pushing households further into poverty. In addition, illness and malnutrition in childhood are increasingly associated with lower productivity in the longer term.(10) Malnutrition, micronutrient deficiencies and illness in childhood have been found to impair cognitive development, school attendance, and learning capabilities.(11)(12)(13) For these reasons, an important challenge in global health today is to increase the availability of child and adolescent health resources and lower the barriers that inhibit access to care and that put youth at risk.

Go To Module 3: Reproductive Health and Family Planning>>

Footnotes

(1) Wagstaff A., Claeson M. The Millennium Development Goals for health: rising to the challenges. Washington D.C., World Bank, 2004.

(2) UNAIDS, 2004 and 2000, Joint United Nations Programme on HIV/AIDS/WHO World Health Organization, Epidemic Update: Sub-Saharan Africa.

(3) Barnett, B. with J. Schueller. Meeting the Needs of Young Clients: A Guide to Providing Reproductive Health Services to Adolescents. Research Triangle Park, NC: Family Health International, 2000.

(4) UNAIDS, 2004 and 2000, Joint United Nations Programme on HIV/AIDS/WHO World Health Organization, Epidemic Update: Sub-Saharan Africa.

(5) Daily, Joanna et al., "Women and HIV Infection." In Farmer, Paul, Margaret Connors and Janie Simmons. Women, Poverty and AIDS: Sex, Drugs and Structural Violence. Monroe: Common Courage Press, 1996.

(6) Croghan, et al., “Routes to Better Health for Children in Four Developing Countries,” The Milbank Quarterly 84 (2), 2006: 333-358.

(7) Barnett, B. with J. Schueller. Meeting the Needs of Young Clients: A Guide to Providing Reproductive Health Services to Adolescents. Research Triangle Park, NC: Family Health International, 2000.

(8) Simmons, Janie, Paul Farmer and Brooke Schoepf. "A Global Perspective." In Farmer, Paul, Margaret Connors and Janie Simmons. Women, Poverty and AIDS: Sex, Drugs and Structural Violence. Monroe: Common Courage.

(9) Longfield, Kim. Glick, Anne. “Relationships between Older Men and Younger Women: Implications for STIs/HIV in Kenya” Studies in Family Planning, Vol. 35, No. 2 (Jun., 2004), pp. 125-134  Published by: Population Council.

(10)Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva, World Health Organization, 2001.

(11) Balasz et al 1986 and Pollitt 1997 and 2001. In: Alleyne G, Cohen D. Chairs, Health, economic growth, and poverty reduction.

(12) Mendez M, Adair L. Severity and timing of stunting in the first two years of life affects performance on cognitive tests in late childhood. Journal of Nutrition, 1999 129: 1555-1562.

(13) World Bank. Filipino report card on pro-poor services: summary. World Bank, Environment and SocialDevelopment Unit, East Asia and Pacific Region, 2001.