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Non-communicable diseases are rapidly becoming one of the leading causes of morbidity and mortality in sub-Saharan Africa. Yet, little is known about patterns of healthcare seeking among people with chronic conditions in these settings. We aimed to explore determinants of healthcare seeking among people who reported at least one chronic condition in rural Burkina Faso.Data were drawn from a cross-sectional population-based survey conducted across 24 districts on 52 562 individuals from March to June 2017. We used multinomial logistic regression to assess factors associated with seeking care at a formal provider (facility-based care) or at an informal provider (home and traditional treatment) compared to no care.1124 individuals (2% of all respondents) reported at least one chronic condition. Among those, 22.8% reported formal care use, 10.6% informal care use, and 66.6% no care. The presence of other household members reporting a chronic condition (RRR = 0.57, 95%-CI [0.39, 0.82]) was negatively associated with seeking formal care. Wealthier households (RRR = 2.14, 95%-CI [1.26, 3.64]), perceived illness severity (RRR = 3.23, 95%-CI [2.22, 4.70]) and suffering from major chronic conditions (RRR = 1.54, 95%-CI [1.13, 2.11]) were positively associated with seeking formal care.Only a minority of individuals with chronic conditions sought formal care, with important differences due to socio-economic status. Policies and interventions aimed at increasing the availability and affordability of services for early detection and management in peripheral settings should be prioritised.Les maladies non transmissibles deviennent rapidement l'une des principales causes de morbidité et de mortalité en Afrique subsaharienne. Pourtant, on en sait peu sur les profils de recherche de soins de santé chez les personnes atteintes de maladies chroniques dans ces milieux. Nous visions à explorer les déterminants de la recherche de soins de santé chez les personnes qui ont déclaré au moins une maladie chronique dans les régions rurales du Burkina Faso. MÉTHODES: Les données ont été tirées d'une enquête transversale de population menée dans 24 districts auprès de 52.562 personnes de mars à juin 2017. Nous avons utilisé une régression logistique multinomiale pour évaluer les facteurs associés à la recherche de soins chez un prestataire formels (soins en établissement) ou chez un prestataire informel (traitement à domicile et traditionnel) par rapport à l'absence de soins. RÉSULTATS: 1.124 personnes (2% de tous les répondants) ont déclaré au moins une maladie chronique. Parmi ceux-ci, 22,8% ont déclaré avoir recours à des soins formels, 10,6% à des soins informels et 66,6% à aucun soin. La présence d'autres membres du ménage déclarant une maladie chronique (RRR = 0,57, IC95%: 0,39, 0,82) était associée négativement à la recherche de soins formels. Les ménages plus riches (RRR = 2,14; IC95%: 1,26-3,64), la sévérité perçue de la maladie (RRR = 3,23 ; IC95%: 2,22-4,70) et souffrir de maladies chroniques majeures (RRR = 1,54 ; IC95%: 1,13-2,11) étaient positivement associés à la recherche de soins formels.Seule une minorité de personnes atteintes de maladies chroniques ont recherché des soins formels, avec des différences importantes en raison du statut socioéconomique. Les politiques et interventions visant à accroître la disponibilité et l'accessibilité des services de détection précoce et de prise en charge dans les régions périphériques doivent être prioritaires.

Background In 2017, 80% of 425 million adults with diabetes worldwide were living in low and middle-income countries. Diabetes affected 6.9 million adults in Bangladesh and accounted for 3% of the country’s total mortality. Proper management of diabetes is the key to positive health outcomes. This study investigated how mobile phone-based health intervention could increase patient adherence and thereby improve the disease outcomes for diabetes type 2 in Bangladesh. Methods A mobile phone-based health project (including mobile phone reminders and 24/7 call center) was implemented in Dhaka District, Bangladesh from January to December 2014. A randomized control trial was carried out, recruiting randomly in intervention and control groups among the patients receiving treatment for type 2 diabetes at the Bangladesh Institute of Health Sciences Hospital, Dhaka, Bangladesh. A total of 320 patients from both groups at baseline and 273 at endline were interviewed. Results A significant improvement in patient adherence to diet, physical exercise, the cessation of use of tobacco and betel nut, and blood glycaemic control was found in the intervention group, whereas no such significant improvement was found in the control group. Cost and other co-morbidities were found to be the main reasons for non-adherence. Conclusion A mobile-health intervention should be considered as an additional option for non-communicable disease programs.

Background Most data on COVID-19 was collected in hospitalized cases. Much less is known about the spectrum of disease in entire populations. In this study, we examine a representative cohort of primarily symptomatic cases in an administrative district in Southern Germany. Methods We contacted all confirmed SARS-CoV-2 cases in the administrative district. Consenting participants answered a retrospective survey either via a telephone, electronically or via mail. Clinical and sociodemographic features were compared between hospitalized and non-hospitalized patients. Additionally, we assessed potential risk factors for hospitalization and time to hospitalization in a series of regression models. Results We included 897 participants in our study, 69% out of 1,305 total cases in the district with a mean age of 47 years (range 2–97), 51% of which were female and 47% had a pre-existing illness. The percentage of asymptomatic, mild, moderate (leading to hospital admission) and critical illness (requiring mechanical ventilation) was 54 patients (6%), 713 (79%), 97 (11%) and 16 (2%), respectively. Seventeen patients (2%) died. The most prevalent symptoms were fatigue (65%), cough (62%) and dysgeusia (60%). The risk factors for hospitalization included older age (OR 1.05 per year increase; 95% CI 1.04–1.07) preexisting lung conditions (OR 3.09; 95% CI 1.62–5.88). Female sex was a protective factor (OR 0.51; 95% CI 0.33–0.77). Conclusion This representative analysis of primarily symptomatic COVID-19 cases confirms age, male sex and preexisting lung conditions but not cardiovascular disease as risk factors for severe illness. Almost 80% of infection take a mild course, whereas 13% of patients suffer moderate to severe illness. Trial registration German Clinical Trials Register, DRKS00022926. URL: https://www.drks.de/drks_web/setLocale_EN.do

Climate change (CC) constitutes one of the greatest threats to human health, and requires political awareness for effective and efficient adaptation planning. This study identified the perceptions of climate change and health adaptation (CC&amp, H) among relevant stakeholders, decision-makers, and policymakers (SDPs) in Burkina Faso (BF) by determining their perceptions of CC, of related health risks and vulnerabilities, and of CC impacts on agriculture and food security. We carried out 35 semi-structured, qualitative in-depth interviews with SDPs, representing national governmental institutions, international organizations, and civil society organizations. The interviews were analyzed using content analysis. SDPs shared similar perceptions of CC and concurred with three ideas (1) CC is a real and lived experience in BF, (2) the population is aware of climatic changes in their environment, (3) CC is intertwined with the agricultural and economic development of the country. SDPs identified biodiversity loss, floods, droughts, and extreme heat as posing the highest risk to health. They elaborated five exposure pathways that are and will be affected by CC: water quality and quantity, heat stress, food supply and safety, vector borne diseases, and air quality. In conclusion, SDPs in Burkina Faso are highly aware of CC hazards, relevant health exposure pathways, and their corresponding health outcomes. Mental health and the interplay between social factors and complex health risks constitute perception gaps. SDPs perceived CC&amp, H risks and vulnerabilities align with current evidence.

Background To achieve higher effectiveness in population-based SARS-CoV-2 surveillance and to reliably predict the course of an outbreak, screening, and monitoring of infected individuals without major symptoms (about 40% of the population) will be necessary. While current testing capacities are also used to identify such asymptomatic cases, this rather passive approach is not suitable in generating reliable population-based estimates of the prevalence of asymptomatic carriers to allow any dependable predictions on the course of the pandemic. Methods This trial implements a two-factorial, randomized, controlled, multi-arm, prospective, interventional, single-blinded design with cluster sampling and four study arms, each representing a different SARS-CoV-2 testing and surveillance strategy based on individuals’ self-collection of saliva samples which are then sent to and analyzed by a laboratory. The targeted sample size for the trial is 10,000 saliva samples equally allocated to the four study arms (2500 participants per arm). Strategies differ with respect to tested population groups (individuals vs. all household members) and testing approach (without vs. with pre-screening survey). The trial is complemented by an economic evaluation and qualitative assessment of user experiences. Primary outcomes include costs per completely screened person, costs per positive case, positive detection rate, and precision of positive detection rate. Discussion Systems for active surveillance of the general population will gain more importance in the context of pandemics and related disease prevention efforts. The pandemic parameters derived from such active surveillance with routine population monitoring therefore not only enable a prospective assessment of the short-term course of a pandemic, but also a more targeted and thus more effective use of local and short-term countermeasures. Trial registration ClinicalTrials.gov DRKS00023271. Registered November 30, 2020, with the German Clinical Trials Register (Deutsches Register Klinischer Studien)

In West Africa, climate change aggravates subsistence farmers&rsquo, vulnerability to weather variability to sustain their agricultural and nutritional requirements. For successful adaptation policies, in-depth understanding of farmers&rsquo, perceptions about climate change, agriculture, and adaptation strategies is essential. This qualitative study in rural Burkina Faso characterized farmers&rsquo, perceptions and knowledge through in-depth interviews. The study enumerated the barriers, possibilities, strategies/practices, and support sources of farmers. There was awareness but limited understanding of climate change amongst farmers. Those unable to adapt, faced increased health difficulties, specifically regarding nutrition and mental health. Farmers could implement some dietary and agricultural adaptation strategies (reduce meal size, frequency and variety, preemptive purchase of cereals, multi-cropping, crop rotation, modified seeds) but were unable to implement others (soil rehabilitation, water management). Barriers to implementation comprised financial and time constraints, material and labor shortages, and inaccessible information. Farmers did not understand, trust or utilize meteorological services, but appreciated and relied on agricultural extension services. They reported that social and governmental support was sporadic and inconsistent. This study uncovers the following targets for climate change adaptation policies in rural Burkina Faso: promoting meteorological services, expanding agricultural extension services, increasing access to financial resources, and framing sustainable adaptation within national development goals.

OBJECTIVE To identify factors associated with both crude and effective health service coverage of under-fives in rural Burkina Faso. METHODS In a cross-sectional study, 494 first-line health facilities, 7347 households and 12 497 under-fives were surveyed. Two sequential logistic random effects models were conducted to assess factors associated with crude and effective coverage. RESULTS Of 614 children under-five with a reported illness episode, 427 (69.5%) received care at a health facility. Of those, 274 (64.1%) received care at a health facility providing at least the minimum threshold of service quality. We found that younger age, having a severe illness, shorter distance between household and health facility, and being from wealthier households were positively associated with crude coverage. In addition, low patient caseload and longer consultation had a positive association, while frequent facility supervisions had a negative association with effective coverage. Moreover, the nurse to clinical staff ratio at the health facility was positively associated with both crude and effective coverage. CONCLUSION Our study found that crude coverage is associated with pre-disposing and enabling factors of health care access, while the availability of nurses is a strong predictor for both crude and effective coverage. This suggests that in the context of scarcity of resources, investing in human resources in health sector could be one of the priorities for decision-makers to ensure children in need not only access to healthcare but also good quality of care.

PROBLEM: The Pacific region has widely dispersed populations, limited financial and human resources and a high burden of disease. There is an urgent need to improve the availability, reliability and timeliness of useable health data.CONTEXT: The purpose of this paper is to share lessons learnt from a three-year pilot field epidemiology training programme that was designed to respond to these Pacific health challenges. The pilot programme built on and further developed an existing field epidemiology training programme for Pacific health staff.ACTION: The programme was delivered in country by epidemiologists working for Pacific Public Health Surveillance Network partners. The programme consisted of five courses: four one-week classroom-based courses and one field epidemiology project. Sessions were structured so that theoretical understanding was achieved through interaction and reinforced through practical hands-on group activities, case studies and other interactive practical learning methods.OUTCOME: As of September 2016, 258 students had commenced the programme. Twenty-six course workshops were delivered and one cohort of students had completed the full five-course programme. The programme proved popular and gained a high level of student engagement.DISCUSSION: Face-to-face delivery, a low student-to-facilitator ratio, substantial group work and practical exercises were identified as key factors that contributed to the students developing skills and confidence. Close engagement of leaders and the need to quickly evaluate and adapt the curriculum were important lessons, and the collaboration between external partners was considered important for promoting a harmonized approach to health needs in the Pacific. (Less)

Background Developing countries are devising strategies and mechanisms to expand coverage and benefit-package access for their citizens through national health insurance schemes (NHIS). In Nigeria, the scheme aims to provide affordable healthcare services to insured-persons and their dependants. However, inclusion of dependants is restricted to four biological children and a spouse per user. This study assesses the progress of implementation of the NHIS in Nigeria, relating to coverage and benefit-package access, and examines individual factors associated with the implementation, according to users' perspectives. Methods A retrospective, cross-sectional survey was done between October 2010 and March 2011 in Kaduna state and 796 users were randomly interviewed. Questions regarding coverage of immediate-family members and access to benefit-package for treatment were analysed. Indicators of coverage and benefit-package access were each further aggregated and assessed by unit-weighted composite. The additive-ordinary least square regression model was used to identify user factors that may influence coverage and benefit-package access. Results With respect to coverage, immediate-dependants were included for 62.3% of the users, and 49.6 rated this inclusion 'good' (49.6%). In contrast, 60.2% supported the abolishment of the policy restriction for non-inclusion of enrolees' additional children and spouses. With respect to benefit-package access, 82.7% of users had received full treatments, and 77.6% of them rated this as 'good'. Also, 14.4% of users had been refused treatments because they could not afford them. The coverage of immediate-dependants was associated with age, sex, educational status, children and enrolment duration. The benefit-package access was associated with types of providers, marital status and duration of enrolment. Conclusion This study revealed that coverage of family members was relatively poor, while benefit-package access was more adequate. Non-inclusion of family members could hinder effective coverage by the scheme. Potential policy implications towards effective coverage and benefit-package access are discussed.

Objective : To provide background information for strengthening cervical cancer prevention in the Pacific by mapping current human papillomavirus (HPV) vaccination and cervical cancer screening practices, as well as intent and barriers to the introduction and maintenance of national HPV vaccination programmes in the region. Materials and Methods: A cross-sectional questionnaire-based survey among ministry of health officials from 21 Pacific Island countries and territories (n=21). Results: Cervical cancer prevention was rated as highly important, but implementation of prevention programs were insufficient, with only two of 21 countries and territories having achieved coverage of cervical cancer screening above 40%. Ten of 21 countries and territories had included HPV vaccination in their immunization schedule, but only two countries reported coverage of HPV vaccination above 60% among the targeted population. Key barriers to the introduction and continuation of HPV vaccination were reported to be: (i) Lack of sustainable financing for HPV vaccine programs; (ii) Lack of visible government endorsement; (iii) Critical public perception of the value and safety of the HPV vaccine; and (iv) Lack of clear guidelines and policies for HPV vaccination. Conclusion: Current practices to prevent cervical cancer in the Pacific Region do not match the high burden of disease from cervical cancer. A regional approach, including reducing vaccine prices by bulk purchase of vaccine, technical support for implementation of prevention programs, operational research and advocacy could strengthen political momentum for cervical cancer prevention and avoid risking the lives of many women in the Pacific.

Objective: In September 2012, there was an unexpected increase of acute febrile illness (AFI) in Chuuk State of the Federated States of Micronesia. At the same time, dengue outbreaks were occurring in two of the Federated States of Micronesia’s other three states. The cause of AFI was suspected to be dengue; however, by the end of October, only one of 39 samples was positive for dengue. The objective of the investigation was to establish the cause of the outbreak. Methods: A line list was created and data analysed by time, place, person and clinical features. Reported symptoms were compared with the published symptoms of several diagnoses and laboratory testing undertaken. Results: Of the 168 suspected cases, 62% were less than 20 years of age and 60% were male. The clinical features of the cases were not typical for dengue but suggestive of respiratory illness. Nasopharyngeal swabs were subsequently collected and found to be positive for influenza. Public health measures were undertaken and the AFI returned to expected levels. Discussion: Clinical diagnosis of acute febrile illness (AFI) can often be difficult and misleading. This can mean that opportunities for preventive measures early on in an outbreak are missed. In any outbreak, descriptive epidemiological analyses are valuable in helping to ascertain the cause of the outbreak.

In a community-based health insurance (CBHI) introduced in 2004 in Nouna health district, Burkina Faso, poor perceived quality of care by CBHI enrollees has been a key factor in observed high drop-out rates. The poor quality perceptions have been previously attributed to health worker dissatisfaction with the provider payment method used by the scheme and the resulting financial risk of health centers. This study applied a mixed-methods approach to investigate how health workers working in facilities contracted by the CBHI view the methods of provider payment used by the CBHI. In order to analyze these relationships, we conducted 23 in-depth interviews and a quantitative survey with 98 health workers working in the CBHI intervention zone. The qualitative in-depth interviews identified that insufficient levels of capitation payments, the infrequent schedule of capitation payment, and lack of a payment mechanism for reimbursing service fees were perceived as significant sources of health worker dissatisfaction and loss of work-related motivation. Combining qualitative interview and quantitative survey data in a mixed-methods analysis, this study identified that the declining quality of care due to the CBHI provider payment method was a source of significant professional stress and role strain for health workers. Health workers felt that the following five changes due to the provider payment methods introduced by the CBHI impeded their ability to fulfill professional roles and responsibilities: (i) increased financial volatility of health facilities, (ii) dissatisfaction with eligible costs to be covered by capitation; (iii) increased pharmacy stock-outs; (iv) limited financial and material support from the CBHI; and (v) the lack of mechanisms to increase provider motivation to support the CBHI. To address these challenges and improve CBHI uptake and health outcomes in the targeted populations, the health care financing and delivery model in the study zone should be reformed. We discuss concrete options for reform based on the study findings.

Some developing countries have incorporated managed care elements into their national health insurance schemes. In practice, hybrid health management organizations (Hmos) are insurers who, bearing some resemblance to managed care in the USA, are vertically integrated in the scheme's revenue collection and pool and purchase healthcare services within a competitive framework. To date, few studies have focused on these organizations and their level of satisfaction with the scheme's optimal-resource-use (ORU) implementation. In Nigeria, the study site, Hmos were categorized on the basis of their satisfaction with ORU activities. One hundred forty-seven Hmo staff were randomly interviewed. The types of ORU domain categories were provider payment mechanism, administrative efficiency, benefit package inclusions and active monitoring mechanism. Bivariate analysis was used to determine differences among the Hmos' satisfaction with the various ORU domains. The Hmos' satisfaction with the health insurance scheme's ORU activities was 59.2% generally, and the associated factors were identified. According to the Hmos' perspectives related to the type of ORU, the fee-for-service payment method and regular inspection performed weakly. Hmos' limited satisfaction with the scheme's ORU raises concerns regarding ineffectiveness that may hinder implementation. To offset high risks in the scheme, it appears necessary for the regulatory agency to adapt and reform strategies of provider payment and active monitoring mechanisms according to stakeholder needs. Our findings further reveal that having Hmos evaluate ORU is useful for providing evidence-based information for policy making and regulatory utilization related to implementation of the health insurance scheme. Copyright © 2013 John Wiley & Sons, Ltd.

We used panel data from the Indonesian Family Life Survey to investigate the impact of health insurance programs on reducing out-of-pocket expenditures. We employed three linear panel data models, two of which accounted for endogeneity: pooled ordinary least squares (OLS), pooled two-stage least squares (2SLS) for instrumental variable (IV), and fixed effects (FE). The study revealed that two health insurance programs had a significantly negative impact on out-of-pocket expenditures by using IV estimates. In the IV model, Askeskin decreased out-of-pocket expenditures by 34% and Askes by 55% compared with non-Askeskin and non-Askes, respectively, while Jamsostek was found to bear a nonsignificant effect on out-of-pocket expenditures. In the FE model, only Askeskin had a significant negative effect with an 11% reduction on out-of-pocket expenditures. This study showed that two large existing health insurance programs in Indonesia, Askeskin and Askes, effectively reduced household out-of-pocket expenditures. The ability of programs to offer financial protection by reducing out-of-pocket expenditures is likely to be a direct function of their benefits package and co-payment policies.

Background: Chronic diseases have emerged as a serious threat for health, as well as for global development. They endenger considerably increased health care costs and diminish the productivity of the adult population group and, therefore, create a burden on health, as well as on the global economy. As the management of chronic diseases involves long-term care, often lifelong patient adherence is the key for better health outcomes. We carried out a systematic literature review on the impact of mobile health interventions -mobile phone texts and/or voice messages- in high, middle and low income countries to ascertain the impact on patients’ adherence to medical advice, as well as the impact on health outcomes in cases of chronic diseases. Methods: The review identified fourteen related studies following the defined inclusion and exclusion criteria, in PubMed, Cochrane Library, the Library of Congress, and Web Sciences. All the interventions were critically analysed according to the study design, sample size, duration, tools used, and the statistical methods used for analysing the primary data. Impacts of the different interventions on outcomes of interest were also analysed. Results: The findings showed evidence of improved adherence, as well as health outcomes in disease management, using mobile Short Message Systems and/or Voice Calls. Significant improvement has been found on adherence with taking medicine, following diet and physical activity advice, as well as improvement in clinical parameters like HbA1c, blood glucose, blood cholesterol and control of blood pressure and asthma. Conclusions: Though studies showed positive impacts on adherence and health outcomes, three caveats should be considered, (i) there was no clear understanding of the processes through which interventions worked; (ii) none of the studies showed cost data for the m-health interventions and (iii) only short term impacts were captured, it remains unclear whether the effects are sustained. More research is needed in these three areas before drawing concrete conclusions and making suggestions to policy makers for further decision and implementation.

SUMMARY This paper reports on a study, which assessed coverage with malaria control interventions in rural Burkina Faso, namely insecticide-treated mosquito nets (ITN) ownership, intermittent preventive treatment (IPTp) for pregnant women and artemisinin-based combination therapy (ACT) for under-five children. The study also addressed the distributional impact of such interventions, with specific reference to equity. The study used data from a representative household survey conducted on 1106 households in the Nouna Health District in 2010. Findings indicated that 59% of all households owned at least one ITN, 66% of all pregnant women received IPT at least once and 34% of under-five children reporting a malaria case were treated with ACT. Multivariate logistic regression revealed that higher socio-economic status, ownership of at least one radio and living in a village within a Health and Demographic Surveillance System were significantly positively associated with ITN, IPTp and ACT coverage. ITN coverage was higher among households in villages, which had previously hosted an ITN trial and/or the most favourable arm of a trial. Comparing current findings with previous estimates suggests that the country has made substantial progress towards scaling up malaria control interventions but that current coverage rates are still far from achieving the universal coverage targets set by the Roll Back Malaria Partnership. In addition, current coverage patterns reveal the existence of multiple inequities across groups, suggesting that current policies are inadequate to achieve equitable scaling up. Future planning of malaria control interventions ought to take into consideration current inadequacies and lead to programmes better designed to overcome them. Copyright © 2012 John Wiley & Sons, Ltd.

Objective This study examines the role of community-based health insurance (CBHI) in influencing health-seeking behaviour in Burkina Faso, West Africa. Community-based health insurance was introduced in Nouna district, Burkina Faso, in 2004 with the goal to improve access to contracted providers based at primary- and secondary-level facilities. The paper specifically examines the effect of CBHI enrolment on reducing the prevalence of seeking modern and traditional methods of self-treatment as the first choice in care among the insured population. Methods Three stages of analysis were adopted to measure this effect. First, propensity score matching was used to minimize the observed baseline differences between the insured and uninsured populations. Second, through matching the average treatment effect on the treated, the effect of insurance enrolment on health-seeking behaviour was estimated. Finally, multinomial logistic regression was applied to model demand for available health care options, including no treatment, traditional self-treatment, modern self-treatment, traditional healers and facility-based care. Results For the first choice in care sought, there was no significant difference in the prevalence of self-treatment among the insured and uninsured populations, reaching over 55% for each group. When comparing the alternative option of no treatment, CBHI played no significant role in reducing the demand for self-care (either traditional or modern) or utilization of traditional healers, while it did significantly increase consumption of facility-based care. The average treatment effect on the treated was insignificant for traditional self-care, modern self-care and traditional healer, but was significant with a positive effect for use of facility care. Discussion While CBHI does have a positive impact on facility care utilization, its effect on reducing the prevalence of self-care is limited. The policy recommendations for improving the CBHI scheme’s responsiveness to population health care demand should incorporate community-based initiatives that offer attractive and appropriate alternatives to self-care.

Less than a year after the introduction of amodiaquine (AQ)/sulfadoxine-pyrimethamine (SP) as the first-line antimalarial treatment in Senegal, our study aimed to assess patients' drug intake and check its correspondence with nurses' prescription-adherence, the national guidelines regimen and theoretical dosage. The study was conducted at five health centers. Children aged 2-10 years who were prescribed AQ/SP by the nurse were recruited. At day 3, caregivers were questioned about treatment adherence. We collected information about nurses' prescriptions and conducted in-depth interviews on prescription patterns. Among the 289 children who were recruited, 35.3% took less than 80% of the prescribed doses. Nevertheless, 47.7% and 83.7% respectively for AQ and SP received a dosage higher than the theoretical dosage. Age-weight discrepancy leads to overprescribing drugs: nurses acknowledged using the child's age more often than weight to determine the dosage if the child has a low weight. Under and overdosing are not only due to patient practices but causes related to national guidelines and health staff practices. For successful implementation and utilization of antimalarial combinations in Africa, countries should really focus on nurses' training. National guidelines should also be based on national average weight instead of international tables.

BackgroundIn Africa, health research on indigent people has focused on how to target them for services, but little research has been conducted to identify the social groups that compose indigence. Our aim was to identify what makes someone indigent beyond being recognised by the community as needing a card for free healthcare.MethodsWe used data from a survey conducted to evaluate a state-led intervention for performance-based financing of health services in two districts of Burkina Faso. In 2015, we analysed data of 1783 non-indigents and 829 people defined as indigents by their community in 21 villages following community-based targeting processes. Using a classification tree, we built a model to select socioeconomic and health characteristics that were likely to distinguish between non-indigents and indigents. We described the screening performance of the tree using data from specific nodes.ResultsWidow(er)s under 45 years of age, unmarried people aged 45 years and over, and married women aged 60 years and over were more likely to be identified as indigents by their community. Simple rules based on age, marital status and gender detected indigents with sensitivity of 75.6% and specificity of 55% among those 45 years and over; among those under 45, sensitivity was 85.5% and specificity 92.2%. For both tests combined, sensitivity was 78% and specificity 81%.ConclusionIn moving towards universal health coverage, Burkina Faso should extend free access to priority healthcare services to widow(er)s under 45, unmarried people aged 45 years and over, and married women aged 60 years and over, and services should be adapted to their health needs.Ethics considerationsThe collection, storage and release of data for research purposes were authorised by a government ethics committee in Burkina Faso (Decision No. 2013-7-066). Respondent consent was obtained verbally.

Objective To quantify the impact of community-based health insurance (CBI) on utilization of health care services in rural Burkina Faso. Methods Propensity score matching was used to minimise the observed baseline differences in the characteristics of insured and uninsured groups such that the observed difference in healthcare utilisation could generally be attributed to the CBI. Results Compared with those who were not enrolled in the CBI, the overall increase in outpatient visits given illness in the insured group was about 40% higher, while the differential effect on utilization of inpatient care between insured and non-insured groups was insignificant. Not only were the very poor less likely to enroll in CBI, but even once insured, they were less likely to utilize health services compared to their wealthier counterparts. Conclusions The overall effect of CBI on health care utilization is significant and positive but the benefit of CBI is not equally enjoyed by all socioeconomic groups. The policy implications are: (a) there is a need to subsidize the premium to favor the enrolment of the very poor; and (b) various measures need to be placed in order to maximize the population’s capacity to enjoy the benefits of insurance once insured.

Background : There are more than 40 Health and Demographic Surveillance System (HDSS) sites in 19 different countries. The running costs of HDSS sites are high. The financing of HDSS activities is of major importance, and adding external health surveys to the HDSS is challenging. To investigate the ways of improving data quality and collection efficiency in the Nouna HDSS in Burkina Faso, the stand-alone data collection activities of the HDSS and the Household Morbidity Survey (HMS) were integrated, and the paper-based questionnaires were consolidated into a single tablet-based questionnaire, the Comprehensive Disease Assessment (CDA). Objective : The aims of this study are to estimate and compare the implementation costs of the two different survey approaches for measuring population health. Design : All financial costs of stand-alone (HDSS and HMS) and integrated (CDA) surveys were estimated from the perspective of the implementing agency. Fixed and variable costs of survey implementation and key cost drivers were identified. The costs per household visit were calculated for both survey approaches. Results : While fixed costs of survey implementation were similar for the two survey approaches, there were considerable variations in variable costs, resulting in an estimated annual cost saving of about US$45,000 under the integrated survey approach. This was primarily because the costs of data management for the tablet-based CDA survey were considerably lower than for the paper-based stand-alone surveys. The cost per household visit from the integrated survey approach was US$21 compared with US$25 from the stand-alone surveys for collecting the same amount of information from 10,000 HDSS households. Conclusions : The CDA tablet-based survey method appears to be feasible and efficient for collecting health and demographic data in the Nouna HDSS in rural Burkina Faso. The possibility of using the tablet-based data collection platform to improve the quality of population health data requires further exploration. Keywords: cost analysis; Health and Demographic Surveillance Systems; health surveys; data collection; survey approaches; Burkina Faso (Published: 7 August 2015) Citation: Glob Health Action 2015, 8 : 28330 - http://dx.doi.org/10.3402/gha.v8.28330

Background One of the biggest challenges in subsidizing premiums of poor households for community health insurance is the identification and selection of these households. Generally, poverty assessments in developing countries are based on monetary terms. The household is regarded as poor if its income or consumption is lower than a predefined poverty cut-off. These measures fail to recognize the multi-dimensional character of poverty, ignoring community members’ perception and understanding of poverty, leaving them voiceless and powerless in the identification process. Realizing this, the steering committee of Nouna’s health insurance devised a method to involve community members to better define ‘perceived’ poverty, using this as a key element for the poor selection. The community-identified poor were then used to effectively target premium subsidies for the insurance scheme. Methods The study was conducted in the Nouna’s Health District located in northwest Burkina Faso. Participants in each village were selected to take part in focus-group discussions (FGD) organized in 41 villages and 7 sectors of Nouna’s town to discuss criteria and perceptions of poverty. The discussions were audio recorded, transcribed and analyzed in French using the software NVivo 9. Results From the FGD on poverty and the subjective definitions and perceptions of the community members, we found that poverty was mainly seen as scarcity of basic needs, vulnerability, deprivation of capacities, powerlessness, voicelessness, indecent living conditions, and absence of social capital and community networks for support in times of need. Criteria and poverty groups as described by community members can be used to identify poor who can then be targeted for subsidies. Conclusion Policies targeting the poorest require the establishment of effective selection strategies. These policies are well-conditioned by proper identification of the poor people. Community perceptions and criteria of poverty are grounded in reality, to better appreciate the issue. It is crucial to take these perceptions into account in undertaking community development actions which target the poor. For most community-based health insurance schemes with limited financial resources, using a community-based definition of poverty in the targeting of the poorest might be a less costly alternative. Electronic supplementary material The online version of this article (doi:10.1186/s12889-014-1335-4) contains supplementary material, which is available to authorized users.

The emergence of increasing plasmodium falciparum resistance to chloroquine in Africa has prompted national malaria programmes to develop new policies regarding appropriate and essential treatment, moving from the use of chloroquine to a new set of bi-therapy methods. In Senegal, the malaria treatment policy has shifted from chloroquine to amodiaquine/sulfadoxine-pyrimethamine. The authors studied the availability of these new drugs and their use by the care providers in 10 rural health district dispensaries. Patient records were examined and nurses were interviewed on their knowledge about and implementation of the new policy. It was noted that the nurses have not yet mastered the proper use of these new medications, and the prescriptions given were not always in line with regulations and practice corresponding to the required or necessary doses. The families which were interviewed stated that they were not aware of the changes in treatment which had been recommended. The conclusion of this study was that it brought to the forefront the need to put specific emphasis on population information and awareness campaigns as well as that of ensuring that caregivers receive thorough training to secure the successful and sustainable implementation and maintenance of the new policy.

Background The low quality of healthcare and the presence of user fees in Burkina Faso contribute to low utilization of healthcare and elevated levels of mortality. To improve access to high-quality healthcare and equity, national authorities are testing different intervention arms that combine performance-based financing with community-based health insurance and pro-poor targeting. There is a need to evaluate the implementation of these unique approaches. We developed a research protocol to analyze the conditions that led to the emergence of these intervention arms, the fidelity between the activities initially planned and those conducted, the implementation and adaptation processes, the sustainability of the interventions, the possibilities for scaling them up, and their ethical implications. Methods/Design The study adopts a longitudinal multiple case study design with several embedded levels of analyses. To represent the diversity of contexts where the intervention arms are carried out, we will select three districts. Within districts, we will select both primary healthcare centers (n =18) representing different intervention arms and the district or regional hospital (n =3). We will select contrasted cases in relation to their initial performance (good, fair, poor). Over a period of 18 months, we will use quantitative and qualitative data collection and analytical tools to study these cases including in-depth interviews, participatory observation, research diaries, and questionnaires. We will give more weight to qualitative methods compared to quantitative methods. Discussion Performance-based financing is expanding rapidly across low- and middle-income countries. The results of this study will enable researchers and decision makers to gain a better understanding of the factors that can influence the implementation and the sustainability of complex interventions aiming to increase healthcare quality as well as equity.

Chikungunya virus (CHIKV) caused significant outbreaks of illness during 2005–2007 in the Indian Ocean region. Chikungunya outbreaks have also occurred in the Pacific region, including in Papua New Guinea in 2012; New Caledonia in April 2013; and Yap State, Federated States of Micronesia, in August 2013. CHIKV is a threat in the Pacific, and the risk for further spread is high, given several similarities between the Pacific and Indian Ocean chikungunya outbreaks. Island health care systems have difficulties coping with high caseloads, which highlights the need for early multidisciplinary preparedness. The Pacific Public Health Surveillance Network has developed several strategies focusing on surveillance, case management, vector control, laboratory confirmation, and communication. The management of this CHIKV threat will likely have broad implications for global public health.

The Global Burden of Disease 2010 Study is the largest study of its kind. It provides a large volume of information about the global burden of disease and associated risk factors. It estimates that lower respiratory infections, diabetes, diarrhea, and tuberculosis cause the greatest burden in the Pacific, and noncommunicable diseases caused a substantially greater burden in 2010 compared with 1990. Although the Pacific is considered to be a region rich in data, very little of these data has been analyzed, synthesized, and made publically available. Consequently, burden estimates for the Pacific are derived from models built with very limited data, and it is difficult to know how accurate they are. Health information in the Pacific needs strengthening, particularly in relation to data collection, analysis, use, and sharing. This will improve the reliability and comparability of burden of disease estimates.

Background Performance measures are often neglected during the transition period of national health insurance scheme implementation in many low and middle income countries. These measurements evaluate the extent to which various aspects of the schemes meet their key objectives. This study assesses the implementation of a health insurance scheme using optimal resource use domains and examines possible factors that influence each domain, according to providers’ perspectives. Methods A retrospective, cross-sectional survey was done between August and December 2010 in Kaduna state, and 466 health care provider personnel were interviewed. Optimal-resource-use was defined in four domains: provider payment mechanism (capitation and fee-for-service payment methods), benefit package, administrative efficiency, and active monitoring mechanism. Logistic regression analysis was used to identify provider factors that may influence each domain. Results In the provider payment mechanism domain, capitation payment method (95%) performed better than fee-for-service payment method (62%). Benefit package domain performed strongly (97%), while active monitoring mechanism performed weakly (37%). In the administrative efficiency domain, both promptness of referral system (80%) and prompt arrival of funds (93%) performed well. At the individual level, providers with fewer enrolees encountered difficulties with reimbursement. Other factors significantly influenced each of the optimal-resource-use domains. Conclusions Fee-for-service payment method and claims review, in the provider payment and active monitoring mechanisms, respectively, performed weakly according to the providers’ (at individual-level) perspectives. A short-fall on the supply-side of health insurance could lead to a direct or indirect adverse effect on the demand-side of the scheme. Capitation payment per enrolees should be revised to conform to economic circumstances. Performance indicators and providers’ characteristics and experiences associated with resource use can assist policy makers to monitor and evaluate health insurance implementation.

Background Responsiveness of health care services in low and middle income countries has been given little attention. Despite being introduced over a decade ago in many developing countries, national health insurance schemes have yet to be evaluated in terms of responsiveness of health care services. Although this responsiveness has been evaluated in many developed countries, it has rarely been done in developing countries. The concept of responsiveness is multi-dimensional and can be measured across various domains including prompt attention, dignity, communication, autonomy, choice of provider, quality of facilities, confidentiality and access to family support. This study examines the insured users’ perspectives of their health care services’ responsiveness. Methods This retrospective, cross-sectional survey took place between October 2010 and March 2011. The study used a modified out-patient questionnaire from a responsiveness survey designed by the World Health Organization (WHO). Seven hundred and ninety six (796) enrolees, insured for more than one year in Kaduna State-Nigeria, were interviewed. Generalized ordered logistic regression was used to identify factors that influenced the users’ perspectives on responsiveness to health services and quantify their effects. Results Communication (55.4%), dignity (54.1%), and quality of facilities (52.0%) were rated as “extremely important” responsiveness domains. Users were particularly contented with quality of facilities (42.8%), dignity (42.3%), and choice of provider (40.7%). Enrolees indicated lower contentment on all other domains. Type of facility, gender, referral, duration of enrolment, educational status, income level, and type of marital status were most related with responsiveness domains. Conclusions Assessing the responsiveness of health care services within the NHIS is valuable in investigating the scheme’s implementation. The domains of autonomy, communication and prompt attention were identified as priority areas for action to improve this responsiveness. For the Nigerian context, we suggest that health care providers in the NHIS should pay attention to these domains, and the associated characteristics of users, when delivering health care services to their clients. Policy makers, and the insurance regulatory agency, should consider the reform strategies of monitoring and quality assurance which focus on the domains of responsiveness to lessen the gap between users’ expectations and their experiences with health services.

Objective To evaluate the technical quality of child health services at the first level facilities in Burkina Faso and determine the effective coverage of child health services. Methods A cross sectional study was conducted in six regions of Burkina Faso and the data was collected from facility and household surveys. To assess the quality of care we used signal functions of three dimensions of care (routine care, management of severe childhood diseases and non-medical aspects of care) the availability of relevant drugs, equipment and the staffing. Each of this dimension was categorized in high, intermediate and low quality level. Linking the household survey to health facility assessment we determined the proportion of children who sought care in facilities with high quality level. We calculate the effective coverage of preventive childcare defined as the proportion of children who have completed the specific vaccination schedule appropriate to their age. Results In total, 494 primary healthcare facilities and 8205 households were included in the study. More than half of health facilities (51%) had high quality level regarding non-medical care aspects while more than 70% of primary care health facilities had a low quality level in management of severe childhood diseases. We found globally that 50% of health facilities had a low quality in all dimensions. While 69.7% of sick children sought care in a health facility, only 18.8% of them went in facilities high quality. There was a large difference between effective coverage and crude coverage of vaccination in the study regions. Conclusion Our assessment found that the quality level in the health facilities was low, and the quality gap was large. In addition, there was a low effective coverage of vaccination in the study regions. Effective coverage could be a relevant metric to improve the performance of child health services.

Background: National surveys in low-income countries increasingly rely on self-reported measures of health. The ease, speed, and economy of collecting self-reports of health make such collection attractive for rapid appraisals. However, the interpretation of these measures is complicated since different cultures understand and respond to the same question in different ways. Objective: The aim of this pilot study was to develop a culturally sensitive tool to study the self-reported health (SRH) of the local adult population in Burkina Faso. Design: The study was carried out in the 2009 rainy season. The sample included 27 men and 25 women aged 18 or older who live in semi-urban Nouna, Burkina Faso. Three culturally adapted instruments were tested: a SRH question, a wooden visual analogue scale (VAS), and a drawn VAS. Respondents were asked to explain their answers to each instrument. The narratives were analyzed with the content analysis technique, and the prevalence of poor SRH was estimated from the quantitative data by stratification for respondent background variables (sex, age, literacy, education, marital status, ethnicity, chronic diseases). The correlation between the instruments was tested with Spearman’s correlation test. Results: The SRH question showed a 38.5% prevalence of poor SRH and 44.2% prevalence with both VAS. The correlation between the VAS was 0.89, whereas the correlation between the VAS and the SRH question was 0.600.64. Nevertheless, the question used as the basis of each instrument was culturally sensitive and clear to all respondents. Analysis of the narratives shows that respondents clearly differentiated between the various health statuses. Conclusion: In this pilot, we developed and tested a new version of the SRH question that may be more culturally sensitive than its non-adapted equivalents. Additional insight into this population’s understanding and reporting of health was also obtained. A larger sample is needed to further study the validity and reliability of the SRH question and the VAS and understand which instrument is best suited to study SRH in the low-income setting of semi-rural Burkina Faso. Keywords: self-reported health; visual analogue scale; Burkina Faso; sensitivity; adaptation (Published: 23 July 2012) Citation: Glob Health Action 2012, 5 : 8488 - http://dx.doi.org/10.3402/gha.v5i0.8488

Background In 2004, a community-based health insurance scheme (CBI) was introduced in Nouna health district, Burkina Faso. Since its inception, coverage has remained low and dropout rates high. One important reason for low coverage and high dropout is that health workers do not support the CBI scheme because they are dissatisfied with the provider payment mechanism of the CBI. Methods A discrete choice experiment (DCE) was used to examine CBI provider payment attributes that influence health workers’ stated preferences for payment mechanisms. The DCE was conducted among 176 health workers employed at one of the 34 primary care facilities or the district hospital in Nouna health district. Conditional logit models with main effects and interactions terms were used for analysis. Results Reimbursement of service fees (adjusted odds ratio (aOR) 1.49, p Conclusions Provider payment mechanisms can crucially determine CBI performance. Based on the results from this DCE, revised CBI payment mechanisms were introduced in Nouna health district in January 2011, taking into consideration health worker preferences on how they are paid.

The U.S.-Affiliated Pacific Islands (USAPI) are composed of three U.S. Territories (American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands) and three independent countries (the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau). These three countries are affiliated with the United States through Compacts of Free Association, which enable their citizens to travel to, and live and work in the United States without visas or additional screening.1 These island jurisdictions experience a number of endemic (tuberculosis, Hansen's disease, enteric diseases such as hepatitis A) and introduced communicable disease threats. Since 2000, the region has experienced outbreaks of cholera (2000–01 in the Federated States of Micronesia2 and the Marshall Islands3), measles (2003 in the Marshall Islands4), and a number of emerging vector-borne disease outbreaks, caused by dengue (2004 in FSM, 2011–13 in the Federated States of Micronesia5 and the Marshall Islands), Zika (Federated States of Micronesia in 20076), and chikungunya viruses (Federated States of Micronesia in 2013). The vulnerability to outbreaks in the U.S.-affiliated and other Pacific islands is heightened by limited epidemiologic and laboratory surveillance capacity,7 travel patterns that facilitate disease translocation, geographic remoteness that may delay and limit external assistance, small populations with limited specialized human resources, and health care systems with limited surge and tertiary care capacity. Moreover, the introduction of new pathogens into immunologically naive island populations can result in high attack rates.6 Increasing rates of noncommunicable diseases, including diabetes and associated conditions,8 further threaten the resiliency of these communities to communicable disease threats. The World Health Organization (WHO), the Secretariat of the Pacific Community (SPC), and the U.S. Centers for Disease Control and Prevention (CDC) each support national and territorial health authorities in the USAPI in strengthening detection and response capacity for communicable diseases. A key framework for coordinating technical assistance in the region is the Pacific Public Health Surveillance Network (PPHSN). This network was established in 1996 as a collaborative partnership between 22 Pacific Island countries and territories and technical assistance partners to strengthen communicable disease detection and response capacity.9 SPC, WHO, and CDC representatives currently serve on the PPHSN Coordinating Body, along with members from Fiji National University, the Pacific Island Health Officers Association, and representatives from Pacific Island health ministries and departments. The response to a dengue outbreak in the Republic of the Marshall Islands during 2011–12 highlighted the benefits of enhanced regional coordination among PPHSN and other partners. In October 2011, dengue virus-type 4 was detected by Marshall Islands Ministry of Health (MOH) physicians and laboratory staff. Early detection was enabled by clinical knowledge of dengue and the local availability of dengue rapid diagnostic tests pre-positioned by WHO in public health laboratories throughout the Pacific. Following notification of CDC, WHO, and SPC, daily support conference calls were convened with Marshall Islands health authorities. At the request of the MOH, Hawaii-based CDC staff assumed a coordinating role to guide external partner assistance in support of the extensive MOH outbreak response efforts. A total of 33 formal coordination teleconferences were conducted during October 2011–February 2012. Through these teleconferences, interagency partnerships and assistance from the U.S. Embassy in the Marshall Islands were engaged to coordinate additional support from the U.S. Agency for International Development, U.S. Department of State, U.S. Department of Defense, U.S. Department of Interior, the Association of State and Territorial Health Officers, the Hawaii State Department of Health, U.S. Coast Guard, and the Pacific Island Health Officers Association. The coordinated international and interagency support enhanced the robust Marshall Islands government response to the outbreak. The MOH established dedicated hospital dengue wards, implemented enhanced epidemiologic and laboratory surveillance, and worked with other government agencies and community partners to reduce mosquito breeding sites and conduct community education for preventing and responding to dengue. CDC and WHO staff provided epidemiologic and entomologic technical assistance and conducted dengue clinical management training. CDC provided reference laboratory testing. CDC, WHO, and SPC provided laboratory supplies, including dengue rapid diagnostic test kits. U.S. Naval Medical Research Unit 2 deployed a five-person vector-control team, including personnel from Navy Environmental and Preventive Medicine Unit 6, to support Marshall Islands government pesticide application efforts. The vector-control team was later augmented by three Japan-based personnel from U.S. Army Public Health Command Region-Pacific.10 Epidemiologic investigation guided vector-control activities. U.S. Coast Guard aircraft on unrelated missions transported the Department of Defense vector-control team from Hawaii to the Marshall Islands and assisted with transport of diagnostic specimens. The Hawaii Department of Health donated mosquito larvicide that was transported at no charge by United Airlines. The Association of State and Territorial Health Officials worked with a nongovernmental organization (Direct Relief USA) to facilitate donation and shipping of insect repellents (valued at $100,000) for the Marshall Islands and Federated States of Micronesia (which was experiencing a discrete but concurrent dengue outbreak). Of the more than 1,600 suspected dengue cases reported among persons in the Marshall Islands during this outbreak, 10% were hospitalized and none were fatal. Large disease outbreaks can quickly overwhelm the capacities of small Pacific island health departments and coordination of external organizations and agencies can be a challenge to manage effectively. More than fifteen external organizations and agencies were involved in the RMI dengue outbreak response and, because of the large number of partners, the Marshall Islands MOH requested CDC assistance to coordinate external partner support. The regular teleconference calls between the MOH outbreak response team and all external partners assured that gaps were identified and communicated, facilitated smooth and well-coordinated external partner response activities, and enabled timely external partner updates. When compared to other large disease outbreaks in the Pacific that lacked a dedicated external partner coordination mechanism, the external partner response in Marshall Islands was smooth, effective, and efficient and provides a model for responding to future large outbreaks in the Pacific and beyond.

Introduction Human resource crises in developing countries have been identified as a critical aspect of poor quality and low accessibility in health care. Worker motivation is an important facet of this issue. Specifically, motivation among physicians, who are an important bridge between health systems and patients, should be considered. This study aimed to identify the determinants of job motivation among physicians, a neglected perspective, especially in developing countries. Methods A stratified random sample of 360 physicians was selected from public primary, public secondary and public and private tertiary health facilities in the Lahore district, Pakistan. Pretested, semi-structured, self-administered questionnaires were used. For the descriptive part of this study, physicians were asked to report their 5 most important work motivators and demotivators within the context of their current jobs and in general. Responses were coded according to emergent themes and frequencies calculated. Of the 30 factors identified, 10 were classified as intrinsic, 16 as organizational and 4 as socio-cultural. Results Intrinsic and socio-cultural factors like serving people, respect and career growth were important motivators. Conversely, demotivators across setups were mostly organizational, especially in current jobs. Among these, less pay was reported the most frequently. Fewer opportunities for higher qualifications was a demotivator among primary and secondary physicians. Less personal safety and poor working conditions were important in the public sector, particularly among female physicians. Among private tertiary physicians financial incentives other than pay and good working conditions were motivators in current jobs. Socio-cultural and intrinsic factors like less personal and social time and the inability to financially support oneself and family were more important among male physicians. Conclusion Motivational determinants differed across different levels of care, sectors and genders. Nonetheless, the important motivators across setups in this study were mostly intrinsic and socio-cultural, which are difficult to affect while the demotivators were largely organizational. Many can be addressed even at the facility level such as less personal safety and poor working conditions. Thus, in resource limited settings a good strategic starting point could be small scale changes that may markedly improve physicians' motivation and subsequently the quality of health care.

Knowledge and practices with respect to malaria are aspects that need to be considered as part of effective malaria programs. We assessed and compared malaria practices and knowledge among those who had recently visited a health care provider and those who had not. A matched, population-based case-control study was conducted among 338 women between 15 and 45 years of age and caretakers of children ≤ 9 years of age in Nouna, Burkina Faso. Little difference was found in the reported responses between the cases and controls, which indicates that recent visits to health care providers may not have an effect on malaria risk or knowledge. Differences were noted in malaria practices, which could suggest that health care providers are consulted only after home treatments fail. Therefore, programs and policies targeted to health care providers aimed at improving the dissemination of information may be of some benefit.

Access to health-care is low in developing countries. Poor people are less likely to seek care than those who are better off. Community-based health insurance (CBI) aims to improve healthcare utilisation by removing financial barriers, unfortunately CBI has been less effective in securing equity than expected. Poor people, who probably require greater protection from catastrophic health expenses, are less likely to enrol in such schemes. Therefore, it is important to implement targeted interventions so that the most in need are not left out. CBI has been offered to a district in Burkina Faso, comprising 7762 households in 41 villages and the district capital of Nouna since 2004. Community wealth ranking (CWR) was used in 2007 to identify the poorest quintile of households who were subsequently offered insurance at half the usual premium rate. The CWR is easy to implement and requires minimal resources such as interviews with local informants. As used in this study, the agreement between the key informants was more (37.5%) in the villages than in Nouna town (27.3%). CBI management unit only received nine complaints from villagers who considered that some households had been wrongly identified. Among the poorest, the annual enrolment increased from 18 households (1.1%) in 2006 to 186 (11.1%) in 2007 after subsidies. CWR is an alternative methodology to identify poor households and was found to be more cost and time efficient compared to other methods. It could be successfully replicated in low-income countries with similar contexts. Moreover, targeted subsidies had a positive impact on enrolment.

Background The introduction of new anti-malarial treatment that is effective, but more expensive, raises questions about whether the high level of effectiveness observed in clinical trials can be found in a context of family use. The objective of this study was to determine the factors related to adherence, when using the amodiaquine/sulphadoxine-pyrimethamine (AQ/SP) association, a transitory strategy before ACT implementation in Senegal. Methods The study was conducted in five rural dispensaries. Children, between two and 10 years of age, who presented mild malaria were recruited at the time of the consultation and were prescribed AQ/SP. The child's primary caretaker was questioned at home on D3 about treatment compliance and factors that could have influenced his or her adherence to treatment. A logistic regression model was used for the analyses. Results The study sample included 289 children. The adherence rate was 64.7%. Two risks factors for non-adherence were identified: the children's age (8–10 years) (ORa = 3.07 [1.49–6.29]; p = 0.004); and the profession of the head of household (retailer/employee versus farmer) (ORa = 2.71 [1.34–5.48]; p = 0.006). Previously seeking care (ORa = 0.28 [0.105–0.736], p=0.001] satisfaction with received information (ORa = 0.45 [0.24–0.84]; p = 0.013), and the quality of history taking (ORa = 0.38 [0.21–0.69]; p = 0.001) were significantly associated with good compliance. Conclusion The results of the study show the importance of information and communication between caregivers and health center staff. The experience gained from this therapeutic transition emphasizes the importance of information given to the patients at the time of the consultation and drug delivery in order to improve drug use and thus prevent the emergence of rapid drug resistance.

Background Although there are many methods available for measuring compliance, there is no formal gold standard. Different techniques used to measure compliance were compared among children treated by the anti-malarial amodiaquine/sulphadoxine-pyrimethamine (AQ/SP) combination therapy, in use in Senegal between 2004 and 2006. Methods The study was carried out in 2004, in five health centres located in the Thies region (Senegal). Children who had AQ/SP prescribed for three and one day respectively at the health centre were recruited. The day following the theoretical last intake of AQ, venous blood, and urine samples were collected for anti-malarial drugs dosage. Caregivers and children above five years were interviewed concerning children's drug intake. Results Among the children, 64.7% adhered to 80% of the prescribed dose and only 37.7% were strict full adherent to the prescription. There was 72.7% agreement between self-reported data and blood drug dosage for amodiaquine treatment. Concerning SP, results found that blood dosages were 91.4% concordant with urine tests and 90% with self-reported data based on questionnaires. Conclusion Self-reported data could provide useful quantitative information on drug intake and administration. Under strict methodological conditions this method, easy to implement, can be used to describe patients' behaviors and their use of new anti-malarial treatment. Self-reported data is a major tool for assessing compliance in resource poor countries. Blood and urine drug dosages provide qualitative results that confirm any drug intake. Urine assays for SP could be useful to obtain public health data, for example on chemoprophylaxis among pregnant women.

Objectives This study aims to identify the reasons why enrolled people decide not to renew their membership in following years. Methods Household survey is used to collect information on the factors influencing dropping out from community-based health insurance (CBI). Information from CBI agency databank is used to describe the general situation of enrolment and drop-out. Results Since the launch of CBI the enrolment rate has been low ranging from 5.2% to 6.3%. The drop-out rate, however, has been high ranging from 30.9% to 45.7%. It is found, by the multivariate analysis, that female household head, higher age or lower education of a household head, lower number of illness episodes in the past three months, fewer children or elderly in a household, poor perceived health care quality, less seeking care in the past month positively effected on drop-out, increasing the rate. However, the household six-month expenditure and the distance to the contracted health facility did not have the hypothesised sign. In contrast, a higher household expenditure and a shorter distance to the contracted health facility increased the drop-out. Conclusions High drop-out rates endanger the sustainability of CBI not only because they reduce the size of the insurance pool, but also because they bear a negative impact on further enrolment and drop-out. The drop-out rate in the scheme of the Nouna Health District, Burkina Faso, is very high. The reasons for drop-out may be related to affordability, health-needs and health demand, quality of care, household head and household characteristics. This study represents a valuable attempt towards further increasing the sustainability of CBI schemes, by understanding not what motivates people to first enrol in CBI, but what motivates them to renew membership year after year.

Increased Plasmodium falciparum resistance to chloroquine has prompted national malaria programs to develop new policies in several African countries. Less than a year after the introduction of amodiaquine/sulfadoxine-pyrimethamine (AQ/SP) as first-line treatment in Senegal, we examined adherence rates to therapy and its efficacy among children. The study was conducted in five dispensaries in rural Senegal. Children aged 2-10 years with a presumptive diagnosis of malaria were prescribed AQ/SP. Thick blood film analyses were carried out on days 0, 3, 7, 14 and 28. Blood and urine samples were collected on day 3 for drug level measurements. The principal caregivers were questioned on treatment adherence. Among the 289 recruited children, 144 had a parasitemia >2500/microl. The results demonstrated markedly good efficacy for the treatment, as no detectable parasitemia was observed on day 28 for 97.9% of the children. However, we noticed that 35.3% of children did not comply with the recommended doses and 62.3% did not exactly adhere to the drug schedule. Despite the good efficacy of the drugs, adherence to the therapeutic scheme was poor. Strategies to promote patient adherence would improve drug performance and thus might help to prevent the rapid emergence of drug resistance.

Background: As current dengue control strategies have been shown to be largely ineffective in reducing dengue in school-aged children, novel approaches towards dengue control need to be studied. Insecticide-impregnated school uniforms represent an innovative approach with the theoretical potential to reduce dengue infections in school children.Objectives: This study took place in the context of a randomised control trial (RCT) to test the effectiveness of permethrin-impregnated school uniforms (ISUs) for dengue prevention in Chachoengsao Province, Thailand. The objective was to assess the acceptability of ISUs among parents, teachers, and principals of school children involved in the trial.Methodology: Quantitative and qualitative tools were used in a mixed methods approach. Class-clustered randomised samples of school children enrolled in the RCT were selected and their parents completed 321 self-administered questionnaires. Descriptive statistics and logistic regression were used to analyse the quantitative data. Focus group discussions and individual semi-structured interviews were conducted with parents, teachers, and principals. Qualitative data analysis involved content analysis with coding and thematic development.Results: The knowledge and experience of dengue was substantial. The acceptability of ISUs was high. Parents (87.3%; 95% CI 82.9–90.8) would allow their child to wear an ISU and 59.9% (95% CI 53.7–65.9) of parents would incur additional costs for an ISU over a normal uniform. This was significantly associated with the total monthly income of a household and the educational level of the respondent. Parents (62.5%; 95% CI 56.6–68.1) indicated they would be willing to recommend ISUs to other parents.Conclusions: Acceptability of the novel tool of ISUs was high as defined by the lack of concern along with the willingness to pay and recommend. Considering issues of effectiveness and scalability, assessing acceptability of ISUs over time is recommended.Keywords: dengue; insecticide-treated material; permethrin; school uniforms; prevention; acceptability of impregnated school uniforms(Published: 1 September 2014)Citation: Glob Health Action 2014, 7: 24887 - http://dx.doi.org/10.3402/gha.v7.24887

Background Patient-centeredness is necessary for quality of care. Wide-spread incorporation of patient-centered practices across the health system is challenging in low and middle income countries (LMICs) given the complexity of scarce resources, competing priorities and rapidly changing social, economic and political landscapes. Health service managers and policy makers in these settings would benefit from a framework that allows comprehension and anticipation of forthcoming challenges for optimizing patient-centeredness in healthcare delivery. We set out to formulate such a framework, based primarily on analysis of general patterns of healthcare system evolution in LMICs and the current literature. Discussion We suggest that optimization of patient-centeredness in LMICs can be thought of as occurring in four phases, in accordance to particular patterns of macro transitions. Phase I is characterized by a deeply fragmented system based on conventional clinical approaches, dealing primarily with simple acute conditions. In phase II, the healthcare systems deal with increasing chronic cases and require redesign of existing acute-oriented services. In phase III, health services are increasingly confronted with multimorbid patients, requiring more coordinated and integrated care. Complex health care needs in individual patients are increasingly the norm in Phase IV, requiring the most optimal form of patient-centered care. This framework helps to identify and map the key challenges and implications for research, policy and practice, associated with the transitions ahead of time. Summary We have developed a framework based on observed patterns of healthcare and related macro-transitions in LMICs. The framework provides insights into critical issues to be considered by health service managers and policy makers.

Background Although most community-based health insurance (CBHI) schemes are voluntary, problem of adverse selection is hardly studied. Evidence on the impact of targeted subsidies on adverse selection is completely missing. This paper investigates adverse selection in a CBHI scheme in Burkina Faso. First, we studied the change in adverse selection over a period of 4 years. Second, we studied the effect of targeted subsidies on adverse selection. Methods The study area, covering 41 villages and 1 town, was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004–06. In 2007, premium subsidies were offered to the poor households. The data was collected by a household panel survey 2004–2007 from randomly selected households in these 33 clusters (n = 6795). We applied fixed effect models. Results We found weak evidence of adverse selection before the implementation of subsidies. Adverse selection significantly increased the next year and targeted subsidies largely explained this increase. Conclusions Adverse selection is an important concern for any voluntary health insurance scheme. Targeted subsidies are often used as a tool to pursue the vision of universal coverage. At the same time targeted subsidies are also associated with increased adverse selection as found in this study. Therefore, it’s essential that targeted subsidies for poor (or other high-risk groups) must be accompanied with a sound plan to bridge the financial gap due to adverse selection so that these schemes can continue to serve these populations.

This study provides the first systematic literature review of cervical cancer incidence and mortality as well as human papillomavirus (HPV) genotype prevalence among women with cervical cancer in the Pacific Island countries and territories. The cervical cancer burden in the Pacific Region is substantial, with age standardized incidence rates ranging from 8.2 to 50.7 and age standardized mortality rate from 2.7 to 23.9 per 100,000 women per year. The HPV genotype distribution suggests that 70-80% of these cancers could be preventable by the currently available bi- or quadrivalent HPV vaccines. There are only few comprehensive studies examining the epidemiology of cervical cancer in this region and no published data have hitherto described the current cervical cancer prevention initiatives in this region.

Introduction: In 2004, a community-based health insurance (CBI) scheme was introduced in Nouna health district, Burkina Faso, with the objective of improving financial access to high quality health services. We investigate the role of CBI enrollment in the quality of care provided at primary-care facilities in Nouna district, and measure differences in objective and perceived quality of care and patient satisfaction between enrolled and non-enrolled populations who visit the facilities. Methods: We interviewed a systematic random sample of 398 patients after their visit to one of the thirteen primary-care facilities contracted with the scheme; 34% (n = 135) of the patients were currently enrolled in the CBI scheme. We assessed objective quality of care as consultation, diagnostic and counselling tasks performed by providers during outpatient visits, perceived quality of care as patient evaluations of the structures and processes of service delivery, and overall patient satisfaction. Two-sample t-tests were performed for group comparison and ordinal logistic regression (OLR) analysis was used to estimate the association between CBI enrollment and overall patient satisfaction. Results: Objective quality of care evaluations show that CBI enrollees received substantially less comprehensive care for outpatient services than non-enrollees. In contrast, CBI enrollment was positively associated with overall patient satisfaction (aOR = 1.51, p = 0.014), controlling for potential confounders such as patient socio-economic status, illness symptoms, history of illness and characteristics of care received. Conclusions: CBI patients perceived better quality of care, while objectively receiving worse quality of care, compared to patients who were not enrolled in CBI. Systematic differences in quality of care expectations between CBI enrollees and non-enrollees may explain this finding. One factor influencing quality of care may be the type of provider payment used by the CBI scheme, which has been identified as a leading factor in reducing provider motivation to deliver high quality care to CBI enrollees in previous studies. Based on this study, it is unlikely that perceived quality of care and patient satisfaction explain the low CBI enrollment rates in this community.