Exploring the association between sick child healthcare utilisation and health facility quality in Malawi: a cross-sectional study

OBJECTIVE: Increasing the availability of basic healthcare services in low-and middle-income countries is not sufficient to meet the Sustainable Development Goal target for child survival in high-mortality settings, where healthcare utilisation is often inconsistent and quality of care can be poor. We assessed whether poor quality of sick child healthcare in Malawi is associated with low utilisation of sick child healthcare. DESIGN: We measured two elements of quality of sick child healthcare: facility structural readiness and process of care using data from the 2013 Malawi Service Provision Assessment. Overall quality was defined as the average of these metrics. We extracted demographic data from the 2013–2014 Malawi Multiple Indicator Cluster Survey and linked households to nearby facilities using geocodes. We used logistic regression to examine the association of facility quality with utilisation of formal health services for children under 5 years of age suffering diarrhoea, fever or cough/acute respiratory illness, controlling for demographic and socioeconomic characteristics. We conducted sensitivity analyses (SAs), modifying the travel distance and population—facility matching criteria. SETTING AND POPULATION: 568 facilities were linked with 9701 children with recent illness symptoms in Malawi, of whom 69% had been brought to a health facility. RESULTS: Overall, facilities showed gaps in structural quality (62% readiness) and major deficiencies in process quality (33%), for an overall quality score of 48%. Better facility quality was associated with higher odds of utilisation of sick child healthcare services (adjusted ORs (AOR): 1.66, 95% CI: 1.04 to 2.63), as was structural quality alone (AOR: 1.33, 95% CI: 0.95 to 1.87). SAs supported the main finding. CONCLUSION: Although Malawi’s health facilities for curative child care are widely available, quality and utilisation of sick child healthcare services are in short supply. Improving facility quality may provide a way to encourage higher utilisation of healthcare, thereby decreasing preventable childhood morbidity and mortality.