title: The Choice of Healthcare Providers for Febrile Children after Introducing Non-professional Health Workers in a Malaria Endemic Area in Papua New Guinea.
abstract: BACKGROUND
  Disease burden of malaria in Papua New Guinea (PNG) is the highest in Asia and the Pacific, and prompt access to effective drugs is the key strategy for controlling malaria. Despite the rapid economic growth, primary healthcare services have deteriorated in rural areas; the introduction of non-professional health workers [village health volunteers (VHVs)] is expected to improve antimalarial drug deliveries. Previous studies on PNG suggested that distance from households negatively affected the utilization of health services; however, price effect on healthcare demand decisions has not been explored. Empirical studies on household's affordability as well as accessibility of healthcare services contribute to policy implications, such as efficient introduction of out-of-pocket costs and effective allocation of health facilities. Therefore, we investigate price responsiveness and other determinants of healthcare provider choice for febrile children in a malaria endemic rural area wherein VHVs were introduced.
  
  
  METHODS
  Cross-sectional surveys were conducted using a structured questionnaire distributed in a health center's catchment area of East Sepik Province in the 2011/2012 rainy seasons. Caretakers were interviewed and data on fever episodes of their children in the preceding 2 weeks were collected. Mixed logit model was employed to estimate the determinants of healthcare provider choice.
  
  
  RESULTS
  Among 257 fever episodes reported, the main choices of healthcare providers were limited to self-care, VHV, and a health center. Direct cost and walking distance negatively affected the choice of a VHV and the health center. An increase of VHV's direct cost or walking distance did not much affect predicted probability of the health center, but rather that of self-care, while drug availability and illness severity increased the choice probability of a VHV and the health center.
  
  
  CONCLUSIONS
  The results suggest that the net healthcare demand increases with the introduction of a VHV. Allocations from the government's budget are required to sustain VHV activities because the introduction of a small user fee could impede the utilization of a VHV. A large travel cost related to the choice of the health center suggests that resource allocation is required for the expansion of formal healthcare providers to adequately operate a referral system.
authors.affiliation: Department of International Affairs and Tropical Medicine, Tokyo Women's Medical University, Tokyo, Japan; School of Economics, Hosei University Graduate School, Tokyo, Japan.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Tsukahara
authors.affiliation: Hosei Institute of Aging, Hosei University , Tokyo , Japan.
authors.forename: Seiritsu
authors.initials: S
authors.lastname: Ogura
authors.affiliation: School of Economics, Hosei University Graduate School , Tokyo , Japan.
authors.forename: Takuma
authors.initials: T
authors.lastname: Sugahara
authors.affiliation: Department of International Affairs and Tropical Medicine, Tokyo Women's Medical University , Tokyo , Japan.
authors.forename: Makoto
authors.initials: M
authors.lastname: Sekihara
authors.affiliation: Division of Southeast Asian Area Studies, Graduate School of Asian and African Area Studies, Kyoto University , Kyoto , Japan.
authors.forename: Takuro
authors.initials: T
authors.lastname: Furusawa
authors.affiliation: Department of Health and Social Behavior, School of Public Health, The University of Tokyo , Tokyo , Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Kondo
authors.affiliation: Department of Molecular and Cellular Parasitology, Juntendo University School of Medicine , Tokyo , Japan.
authors.forename: Toshihiro
authors.initials: T
authors.lastname: Mita
authors.affiliation: Department of International Affairs and Tropical Medicine, Tokyo Women's Medical University , Tokyo , Japan.
authors.forename: Hiroyoshi
authors.initials: H
authors.lastname: Endo
authors.affiliation: Centre for Health Research and Diagnostics, Divine Word University , Madang , Papua New Guinea.
authors.forename: Francis
authors.initials: F
authors.lastname: Hombhanje
keywords: community health workers; health services demand; health-seeking behavior; healthcare utilization; malaria