title: What determines providers' stated preference for the treatment of uncomplicated malaria?
abstract: As agents for their patients, providers often make treatment decisions on behalf of patients, and their choices can affect health outcomes. However, providers operate within a network of relationships and are agents not only for their patients, but also other health sector actors, such as their employer, the Ministry of Health, and pharmaceutical suppliers. Providers' stated preferences for the treatment of uncomplicated malaria were examined to determine what factors predict their choice of treatment in the absence of information and institutional constraints, such as the stock of medicines or the patient's ability to pay. 518 providers working at non-profit health facilities and for-profit pharmacies and drug stores in Yaoundé and Bamenda in Cameroon and in Enugu State in Nigeria were surveyed between July and December 2009 to elicit the antimalarial they prefer to supply for uncomplicated malaria. Multilevel modelling was used to determine the effect of financial and non-financial incentives on their preference, while controlling for information and institutional constraints, and accounting for the clustering of providers within facilities and geographic areas. 69% of providers stated a preference for artemisinin-combination therapy (ACT), which is the recommended treatment for uncomplicated malaria in Cameroon and Nigeria. A preference for ACT was significantly associated with working at a for-profit facility, reporting that patients prefer ACT, and working at facilities that obtain antimalarials from drug company representatives. Preferences were similar among colleagues within a facility, and among providers working in the same locality. Knowing the government recommends ACT was a significant predictor, though having access to clinical guidelines was not sufficient. Providers are agents serving multiple principals and their preferences over alternative antimalarials were influenced by patients, drug company representatives, and other providers working at the same facility and in the local area. Efforts to disseminate drug policy should target the full range of actors involved in supplying drugs, including providers, employers, suppliers and local communities.
authors.affiliation: Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. Electronic address: lindsay.mangham-jefferies@lshtm.ac.uk.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Mangham-Jefferies
authors.affiliation: Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. Electronic address: kara.hanson@lshtm.ac.uk.
authors.forename: Kara
authors.initials: K
authors.lastname: Hanson
authors.affiliation: Laboratory for Public Health Research Biotechnologies, University of Yaoundé 1, Nkolbisson, Yaoundé, Cameroon. Electronic address: wfmbacham@prd.college.eu.
authors.forename: Wilfred
authors.initials: W
authors.lastname: Mbacham
authors.affiliation: Department of Health Administration and Management, College of Medicine, University of Nigeria (Enugu Campus), Old UNTH Road, 40001, Enugu, Nigeria. Electronic address: obinna.onwujewke@unn.edu.ng.
authors.forename: Obinna
authors.initials: O
authors.lastname: Onwujekwe
authors.affiliation: Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. Electronic address: virginia.wiseman@lshtm.ac.uk.
authors.forename: Virginia
authors.initials: V
authors.lastname: Wiseman
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use*; D037621:Artemisinins / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D002163:Cameroon; D004359:Drug Therapy, Combination; D006268:Health Facilities / Q000191:economics; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D008288:Malaria / Q000188:drug therapy*; D017059:Models, Econometric; D055361:Multilevel Analysis; D009549:Nigeria; D010594:Pharmacies / Q000191:economics; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*
chemical_list: D000962:Antimalarials; D037621:Artemisinins; C031327:artemisinin
keywords: Agency theory; Cameroon; Malaria; Multilevel modelling; Nigeria; Practice variation; Stated preference