Which Care-Seekers are Prioritized for Preventive Maternal and Child Health Services in a Low-Resource Setting? A Vignette Experiment in Rural Guinea-Bissau

Abstract

Objectives: Human resource shortages create bottlenecks to preventive maternal and child health service provision in low-resource settings, making ad-hoc service rationing at the point of care necessary. Little is known about how healthcare providers prioritise. We explored healthcare providers' rationing decisions for preventive maternal and child health services in rural Guinea-Bissau through an experimental vignette design considering situational and care-seeker characteristics and performance goals. Methods: We implemented two vignette experiments, one for antenatal care, and one for childhood vaccinations. At 55 health facilities, providers were requested to state their willingness to provide antenatal care/vaccination given a scenario of an acute facility-level human-resource shortage and combinations of contextualised factors, summarised in 16 vignettes per experiment: provider-care-seeker relationship (stranger/related) and distance (close/far) between care-seeker residence and facility (both experiments); gestational age (2nd/3rd trimester) and consultation number (1st/4th) (antenatal care experiment); child age (5/13 months), vaccine sought (Bacillus Calmette-Guérin/3rd Pentavalent vaccine (Penta3)), and number of other children waiting (3/12) (vaccination experiment). We also inquired about facility and interviewee characteristics. Using multilevel logistic regressions, we assessed associations between the factors and providers' stated willingness for each experiment. Results: We interviewed a total of 159 healthcare providers; 112 provided antenatal care, 118 vaccinations. Interviewees in the antenatal care experiment stated willingness for antenatal care provision for 94% (1691/1792) of the vignettes (range across vignettes: 88%–99%). Last pregnancy trimester, long distance, and providers' work experience were associated with stated increased willingness. In the vaccination experiment, the interviewees stated their willingness to vaccinate for 72% (1357/1887) of the vignettes (range: 54%–95%). Younger child age, long distance, a higher number of other children waiting, and inquiring Penta3 rather than Bacillus Calmette-Guérin were associated with stated increased willingness, and we found a statistically significant interaction between age and the inquired vaccine. Conclusions: Situational and care-seeker characteristics and performance goals may influence facility-based ad-hoc service rationing in rural Guinea-Bissau.