Do consumers' preferences for improved provision of malaria treatment services differ by their socio-economic status and geographic location? A study in southeast Nigeria

Malaria is a major cause of mortality and morbidity in Nigeria, and is responsible for 30% of childhood mortality, 11% of maternal mortality and more than 60% of out-patient visits [1]. This disease has also impacted negatively on the Nation's economy so much so that Nigeria loses about 132 billion Naira annually to the disease [2]. One of the key strategies endorsed by the Abuja meeting was to take actions to ensure that by 2005 at least 60% of those suffering from malaria have prompt access to appropriate and affordable treatment and are able to initiate treatment within 24 hours of the onset of symptoms. This was termed effective management of malaria nearer the home and was thus adopted as another strategy to combat malaria [3].

The limited healthcare facilities that exist in rural Nigeria make it difficult to provide the required good quality malaria management services [4, 5]. Poor quality of treatment amongst other factors has shown to be contributory to the ineffective control of malaria [6–10]. Similarly, some other studies have shown that the public and private sector are usually ineffective in managing malaria because of inappropriate prescription, lack of drugs and diagnostic facilities [6, 11]

The preferences of consumers for sources for improving treatment of malaria should be understood and used to improve provision and utilization of appropriate malaria treatment services. Peoples' perception of the ease of accessing the various providers of malaria treatment can potentially determine their health-seeking behavior [12] and by extension their preferences for different providers. Majority of households named the hospital as their preferred choice for malaria treatment, with the availability of drugs and trained personnel as very important reasons for their preferences [13].

There is need to increase the body of knowledge about the link of socio-economic status to consumers' preferences for improved malaria treatment, for proving appropriate and timely treatment of malaria. However, some strategies have been suggested which will be useful for providing timely, appropriate, and potentially equitable management of malaria within communities these include health education to mothers [5, 14, 15]; and the use of village or community health workers [16, 17].

Many of the recommended interventions for improving appropriate treatment of malaria could be at variance with what the communities really prefer. This will lead to poor utilization of such services thereby negating the original ideas behind their deployment. The ability for successful and sustainable disease control programs depends very much on "listening to the people" [18]. Therefore it is better to determine consumers' preferences and needs and use the information to guide program design because imposed programs invariably fail as they reflect professional views and may not meet the priorities and aspirations of communities [19].

This study examined the preferences for improved malaria treatment by consumers and disaggregates these preferences by socio-economic status and geographic location of the respondents. The study also compared whether the rating and ranking scales will produce similar results, so as to assure the internal validity of the preferences. The findings are useful for evidence-based policy-making and development of strategies for equitably improving the deployment of demand-responsive malaria treatment services in different geographic areas for different population groups.

Public hospitals were ranked and rated the most preferred choice for the improvement of malaria treatment services in both the higher socio-economic status (SES) group and rural areas. The fact that majority of the respondents stated that the best way to improve malaria treatment services in their community was to improve the quality in services being rendered by public hospitals, might be because public hospitals are known to have a large array of specialist services. Training of mothers that was also highly preferred will help to improve the treatment of malaria. This is line with the Roll Back Malaria (RBM) target for provision of timely and appropriate treatment of malaria [3]. The use of role model mothers has been adopted as one of the strategies for improving the treatment of malaria in Nigeria and in many sub-Saharan African countries.

The SES of the individual influenced their preferences. The finding that the preference for public hospital was highest for the least poor SES (Q4) compared to others may be because the better-off quartiles are usually more educated, and thus have more information about the advantages of having treatment in a public hospital where there is usually a presence of qualified personnel. Herbalists must have been viewed as inferior goods, where preferences fall as SES increases as was alluded to by their low preference as SES increased. The finding that the use of PMDs was ranked higher by poorer quartiles compared to the least poor quartile for improving malaria treatment is most likely due to the fact that it might be cheaper and easier for the poorer SES to visit PMDs. This corroborates the findings of some studies which showed that the poorer households were more likely to seek treatment from low level and informal providers rather than use the hospitals [12, 24].

The geographic differences in consumer preferences for providers which showed that herbalist were ranked higher in rural areas than in urban may be because of more familiarity and higher levels of availability of herbalists in the rural areas when compared to the urban areas. The higher preference of public hospitals in the rural area compared to the urban area suggest that those in the rural areas actually need increased availability of public hospitals which would invariably have more qualified health workers and would most likely provide good quality malaria treatment services.

It was seen that the rating scale and ranking of preferences produced similar findings, which is a sign of convergent validity of the findings [25]. Apart from preferences for training of mothers and use of Primary Health care (PHC) centres that switched between 2nd and 3rd most preferred treatment sources, the preferences for the other treatment sources mirrored themselves on both measurement scales, implying that the findings are convergent valid and really represent well thought-out preferences of the consumers. Hence, either can be validly used to determine preferences for malaria treatment.

A limitation of the study was the fact that only two risk factors, namely socio-economic status and geographic locations were explored in this study because the study was primarily concerned with issues of socio-economic and geographic equity. However, other factors such as parity, occupation and age may also affect the preferences of consumers for different providers. The exploration of the role of these other factors should be the focus of future studies. Also, the study did not have a qualitative component, which would have helped to generate qualitative data that will either strengthen or disprove the quantitative findings. Another possible limitation is that use of local residents to act as fieldworkers might bias the results, but regular quality assurance by the investigators ensured that data collected was of very good quality.

All in all, the paper has shown that preferences for provision of improved malaria treatment services were influenced mostly by SES and also by geographic location of the respondents to a lesser extent. The reasons for the differences in preferences were not explored in the study, but could be as a result of prior knowledge, experiences, costs and availability of the providers. However, it was obvious that people mostly preferred that improved malaria treatment services should be delivered through public health facilities such as hospitals and PHC centers. Hence, there should also be re-invigoration of public facilities for appropriate diagnosis and treatment of malaria, in addition to improving the financial and geographic accessibility of such facilities. However, there is a role of home management of malaria through training of mothers. However, home management will not work if the quality of services rendered by providers where drugs for home management are purchased are not improved. Therefore, there is the need for the government and development partners to also improve the quality of services of PMDs and pharmacy shops so that there is a holistic improvement of malaria treatment services.