Determinants of provider choice for malaria treatment: Experiences from The Gambia

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Abstract

Malaria is responsible for an estimated one million deaths per year, the vast majority in sub-Saharan Africa. Many of these deaths are attributed to delays in seeking treatment and poor adherence to drug regimes. While there are a growing number of studies describing the factors influencing treatment seeking for malaria, far less is known about the relative weight given to these factors in different settings. This study estimates two models of demand for malaria treatment in the Farafenni region of The Gambia. The first examines the determinants of seeking malaria treatment outside the home versus no treatment or self-care while the second identifies the determinants of provider choice conditional on having decided to seek malaria treatment outside the home. Providers included hospital; health centre; and ‘other’ which included pharmacies, kiosks; petty traders; neighbours; and traditional healers. Results show that older people were more likely to opt for self-care, or no treatment. The longer the time spent ill or the more severe the fever, the more likely a treatment was sought outside the home. Time of the year and availability of community infrastructure played a key role in both models. Poorer households and those from the Fula ethnic group were much more likely to visit an ‘other’ provider than a hospital. The policy and methodological implications of these findings are discussed.

Section snippets

Introduction and background

Over one million people die of malaria each year, most in Africa (WHO, 2007). In The Gambia, malaria constitutes the main public health problem and is the leading killer of children under five years of age (UNICEF, 2007). While medicines and prevention products are repeatedly shown to be cost-effective in low- and middle-income countries, reducing the incidence and prevalence of malaria can only be achieved through population awareness of effective prevention strategies and adequate access to

Gambian health care system

There are four broad components to the health care delivery system in The Gambia: central referral hospitals; the village-based Primary Health Care (PHC) or Village Health Service (VHS); the facility-based Basic Health Service (BHS); and the Divisional Health Teams (DHT) that supervise and supply the BHS and the VHS.

There are three major referral hospitals in Banjul, Farafenni and Basang that provide tertiary care for patients. Primary health care villages are selected from those with a

Results

Five hundred and sixty members were reported to have had malaria, fever or convulsions in the past two weeks. Of these, 554 reported whether they consulted a health care provider outside of the home or not. Table 1 shows that 107 (19%) chose self-care, 269 (49%) went to a hospital; 120 (22%) visited a health centre; and 25 (5%) visited a clinic. Less than 6% went to a dispensary, pharmacy or shop/kiosk. No one sought initial treatment from a neighbour or traditional healer. Only 67 (15%)

Discussion

In this study, the majority of those with fever first sought treatment from a hospital or health centre. No one chose a petty trader, traditional healer or a neighbour as first treatment option. This is consistent with previous findings. Clarke, Rowley, Bogh, Walraven, & Lindsay (2003) found that home treatment was rare in rural areas of The Gambia with most patients seeking treatment at a government clinic or hospital. The relatively low cost of health services (especially for children) in The

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    The authors would like to thank the people of Farafenni for agreeing to be interviewed and for sharing their experiences. The tireless efforts of our field team in The Gambia lead by Fafanding Kinteh also deserve mention. We are grateful to Drs Paul Snell and David Jeffries from The Medical Research Council (The Gambia) for their support in designing the database, Professor Paul Milligan (LSHTM) for his statistical advice and Dr Amy Ratcliffe formerly from the Medical Research Council in The Gambia, now at U.S. Centres for Disease Control and Prevention, for her advice on study design. Finally, we wish to acknowledge the financial support provided by the Gates Malaria Partnership at the London School of Hygiene and Tropical Medicine and by the Medical Research Council in The Gambia.

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