Purpose: This study investigated the role of facility attributes as well as respondent demographics in influencing preference for treatment at local health care clinics.
Method: A discrete choice experiment (DCE) was conducted as part of a population-based, random cluster survey of 1,434 adults aged 18 years or older in Liberia's Nimba County. Respondents were asked to select their preferred health facility to use for their next episodic illness based on six attributes: waiting time, cost, respectfulness of provider, availability of drugs, thoroughness of medical examination, and facility manager (government v. non-governmental organization). Two mixed logit models were used to estimate utility functions: without and with respondent characteristics (e.g., gender, age, education, wealth status, and post-traumatic stress disorder (PTSD) status). Based on significance of demographic characteristics, stratified mixed logit models were estimated among subgroups to characterize how preferences vary in this population.
Result: In the full model, a thorough examination (β 3.31, P < 0.01), available drugs (β 1.55, P < 0.01), respectful providers (β 0.40, P < 0.01) and lower cost (β -0.25, P < 0.01) were significant drivers of preference. Gender, relative wealth (richest 20% versus rest), and having presumptive PTSD influenced preference. Stratified models showed that females valued non-governmental organization management (β 0.51, P < 0.01) while males showed no significant preference for management. The wealthiest group's preferences were influenced by high quality examinations (β 3.52, P < 0.01) and availability of medicines (β 1.88, P < 0.01) only, while the remainder of the population also valued the remaining attributes (except for waiting time). Preferences of people with PTSD were not influenced by cost, unlike those of people without PTSD.
Conclusion: For the residents of Nimba County, Liberia, markers of technical quality of health care, i.e. a thorough examination and available drugs, were most important in choosing a health facility. Health system reforms aimed at increasing service utilization should focus on investing in health workers and ensuring that dispensaries and health centers are supplied with drugs. Gender, wealth status, and PTSD status were associated with differences in health facility attribute preferences. The factors should be considered in initiatives aimed at increasing utilization of essential health services.
Candidate for the Lee B. Lusted Student Prize Competition