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Determinants of Utilization of Formal and Informal Health Care in Postconflict Liberia

Kruk, Margaret E., MD, MPH*; Rockers, Peter C., MPH; Varpilah, S. Tornorlah, MS; Macauley, Rose, MD, MPH‡,§

doi: 10.1097/MLR.0b013e31820f0dd4
Original Articles

Background Liberia is rebuilding its health system after a lengthy civil war in which traditional health care was the only reliable source of care.

Objective This study explored individual, village, and health system factors related to the utilization of health clinics versus informal providers (eg, healers, medicine sellers) in Liberia.

Research Design, Participants, and Measures This was a cross-sectional population-representative survey of 1435 adults living in rural Nimba County, Liberia. Participants were asked about past year visits to traditional and formal health care providers and demographics, health, and trauma indicators. The association between formal and informal visits and potential determinants was estimated in separate models using generalized estimating equations to adjust for village-level clustering.

Results The median number of visits in the past year to formal and informal providers was 3 and 10, respectively. Clinic visits increased with younger age and female sex, past trauma exposure, the number of traditional healers, and the presence of a facility dispenser. Frequency of informal visits increased with poor self-reported mental and physical health, the presence of facility fees and decreased with literacy and wealth and satisfaction with the formal health system.

Conclusions Rural Liberians use both formal and informal health care extensively and as complements rather than substitutes. The reliance on traditional medicine to address health needs is of concern in a country with a high disease burden. Health system investments that build public confidence in the health system may help shift demand from informal to formal health care.

*Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY

Department of Global Health and Population, Harvard School of Public Health, Cambridge, MA

Republic of Liberia Ministry of Health and Social Welfare

§Basic Support for Institutionalizing Child Survival (BASICS), Monrovia, Liberia

Funded in part by the McNerney Grant from the Department of Health Management and Policy at the University of Michigan School of Public Health. The funder did not have any role in the design, analysis, or writing of this paper or in the decision to submit the paper for publication.

Conflict of interest statement: The authors declare that they have no conflict of interest.

Reprints: Margaret E. Kruk, MD, MPH, Department of Health Policy and Management, Columbia University Mailman School of Public Health, 600 W. 168th Street, Room 606, New York, NY 10032. E-mail:

© 2011 Lippincott Williams & Wilkins, Inc.