What influences where they seek care? Caregivers’ preferences for under-five child healthcare services in urban slums of Malawi: A discrete choice experiment

Abstract

Access to and utilisation of quality healthcare promotes positive child health outcomes. However, to be optimally utilised, the healthcare system needs to be responsive to the expectations of the population it serves. Health systems in many sub-Saharan African countries, including Malawi, have historically focused on promoting access to health services by the rural poor. However, in the context of increasing urbanisation and consequent proliferation of urban slums, promoting health of children under five years of age in these settings is a public health imperative. We conducted a discrete choice experiment to determine the relative importance of health facility factors in seeking healthcare for childhood illnesses in urban slums of Malawi. Caregivers of children under five years of age were presented with choice cards that depicted two hypothetical health facilities using six health facility attributes: availability of medicines and supplies, thoroughness of physical examination of the child, attitude of health workers, cost, distance, and waiting time. Caregivers were asked to indicate the health facility they would prefer to use. A mixed logit model was used to estimate the relative importance of and willingness to pay (WTP) for health facility attributes. Attributes with greatest influence on choice were: availability of medicines and supplies (β = 0.842, p<0.001) and thorough examination of the child (β = 0.479, p <0.001) with WTP of MK3698.32 ($11) (95% CI: $8–$13) and MK2049.13 ($6) (95% CI: $3–$9) respectively. Respondents were willing to pay 1.8 and 2.4 times more for medicine availability over thorough examination and positive attitude of health workers respectively. Therefore, strengthening health service delivery system through investment in sustained availability of essential medicines and supplies, sufficient and competent health workforce with positive attitude and clinical discipline to undertake thorough examination, and reductions in waiting times have the potential to improve child healthcare utilization in the urban slums.

Determinants of healthcare seeking for childhood illnesses among caregivers of under-five children in urban slums in Malawi: a population-based cross-sectional study

“…It is probable that the fact that a significant majority of caregivers utilized public health facilities which provide free services at the point of use in Malawi, entailed that household wealth may not have had a significant effect in care-seeking dynamics. Relatedly, our discrete choice experiment study responded to by a subset of participants used in this study revealed that cost of healthcare negatively influenced the choice of a health facility in the event of childhood illness, effectively intimating caregivers' aversion with cost of healthcare [51].…”

“…In the context of urban health, iCCM in urban slums will reduce congestion at urban health centres effectively lessening the burden of long waiting times, and potentially contributing to more time spent on examining children with severe illness at a health facility. Indeed, long waiting times and suboptimal examination of the sick child by health workers have been shown to have negative effect on preference for health facility in the event of childhood illness [51][52][53]. It entails that implementing iCCM may arguably also have a positive effect on overall use of biomedical health services at facility level.…”

“…This finding may relate to an observation by the Knowledge Network on Urban Settings (KNUS) for the World Health Organisation's Commission on Social Determinants of Health that within urban areas, it is cost and not proximity to health facilities that may be key to accessing healthcare in urban areas [22]. Moreover, some discrete choice experiment studies have also demonstrated that distance to health facility may not be a very significant determinant factor influencing choice of health facility or careseeking as people are willing to travel longer if any of the other significant health facility considerations are present [51,62].…”

Urban-Rural Disparities in The Utilization of Primary Health Care Center Among Elderly in East Java, Indonesia

“…Even though there are complaints, they will not refer them to the health office. As a result, their disease tends to be severe and directly requires an inpatient treatment (Gonzales et al, 2017;Lungu et al, 2018). Table 2 shows that age variable also influences the use of puskesmas like the use of inpatient services.…”

How Do Type 2 Diabetes Patients Value Urban Integrated Primary Care in China? Results of a Discrete Choice Experiment

“…We used 27 alternatives, which is more manageable, using a fractional factorial experimental design [31]. The alternative with the most attributes at the middle level was selected as a comparator and the other 26 alternatives were compared to it, to make the choices easier to understand for respondents [32]. Each choice set consisted of two community health station alternatives, alternative A (the comparator) and alternative B, for which attribute levels were varied systematically.…”