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Background The current COVID-19 pandemic affects the entire world population and has serious health, economic and social consequences. Assessing the prevalence of COVID-19 through population-based serological surveys is essential to monitor the progression of the epidemic, especially in African countries where the extent of SARS-CoV-2 spread remains unclear. Methods A two-stage cluster population-based SARS-CoV-2 seroprevalence survey was conducted in Bobo-Dioulasso and in Ouagadougou, Burkina Faso, Fianarantsoa, Madagascar and Kumasi, Ghana between February and June 2021. IgG seropositivity was determined in 2,163 households with a specificity improved SARS-CoV-2 Enzyme-linked Immunosorbent Assay. Population seroprevalence was evaluated using a Bayesian logistic regression model that accounted for test performance and age, sex and neighbourhood of the participants. Results Seroprevalence adjusted for test performance and population characteristics were 55.7% [95% Credible Interval (CrI) 49·0; 62·8] in Bobo-Dioulasso, 37·4% [95% CrI 31·3; 43·5] in Ouagadougou, 41·5% [95% CrI 36·5; 47·2] in Fianarantsoa, and 41·2% [95% CrI 34·5; 49·0] in Kumasi. Within the study population, less than 6% of participants performed a test for acute SARS-CoV-2 infection since the onset of the pandemic. Conclusions High exposure to SARS-CoV-2 was found in the surveyed regions albeit below the herd immunity threshold and with a low rate of previous testing for acute infections. Despite the high seroprevalence in our study population, the duration of protection from naturally acquired immunity remains unclear and new virus variants continue to emerge. This highlights the importance of vaccine deployment and continued preventive measures to protect the population at risk.

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.

IntroductionThe current COVID-19 pandemic has impacted the entire world with increasing morbidity and mortality and has resulted in serious economic and social consequences. Assessing the burden of COVID-19 is essential for developing efficient pandemic preparedness and response strategies and for determining the impact of implemented control measures. Population-based seroprevalence surveys are critical to estimate infection rates, monitor the progression of the epidemic and to allow for the identification of persons exposed to the infection who may either have been asymptomatic or were never tested. This is especially important for countries where effective testing and tracking systems could not be established and where non-severe cases or under-reported deaths might have blurred the true burden of COVID-19. Most seroprevalence surveys performed in sub-Saharan Africa have targeted specific high risk or more easily accessible populations such as healthcare workers or blood donors, and household-based estimates are rarely available. Here, we present the study protocol for a SARS-CoV-2 seroprevalence estimation in the general population of Burkina Faso, Ghana and Madagascar in 2021.Methods and analysisThe SeroCoV study is a household-based cross-sectional prevalence investigation in persons aged 10 years and older living in urban areas in six cities using a two-stage geographical cluster sampling method stratified by age and sex. The presence of anti-SARS-CoV-2 IgG antibodies will be determined using a sensitive and specific SARS-CoV-2 IgG ELISA. In addition, questionnaires will cover sociodemographic information, episodes of diseases and history of testing and treatment for COVID-like symptoms, travel history and safety measures. We will estimate the seroprevalence of SARS-CoV-2, taking into account test performance and adjusting for the age and sex of the respective populations.Ethics and disseminationEthical approval was received for all participating countries. Results will be disseminated through reports and presentations at the country level as well as peer-reviewed publications and international scientific conferences presentations.

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)

Objectives This study investigated the molecular epidemiology of respiratory syncytial virus (RSV) among febrile children with acute respiratory tract infection in Ghana, Gabon, Tanzania and Burkina Faso between 2014 and 2017 as well as the evolution and diversification of RSV strains from other sub-Saharan countries. Methods Pharyngeal swabs were collected at four study sites (Agogo, Ghana: n = 490; Lambarene, Gabon: n = 182; Mbeya, Tanzania: n = 293; Nouna, Burkina Faso: n = 115) and analysed for RSV and other respiratory viruses using rtPCR. For RSV-positive samples, sequence analysis of the second hypervariable region of the G gene was performed. A dataset of RSV strains from sub-Saharan Africa (2011-2017) currently available in GenBank was compiled. Phylogenetic analysis was conducted to identify the diversity of circulating RSV genotypes. Results In total, 46 samples were tested RSV positive (Ghana n = 31 (6.3%), Gabon n = 4 (2.2%), Tanzania n = 9 (3.1%) and Burkina Faso n = 2 (1.7%)). The most common RSV co-infection was with rhinovirus. All RSV A strains clustered with genotype ON1 strains with a 72-nucleotide duplication and all RSV B strains belonged to genotype BAIX. Phylogenetic analysis of amino acid sequences from sub-Saharan Africa revealed the diversification into 11 different ON1 and 22 different BAIX lineages and differentiation of ON1 and BAIX strains into potential new sub-genotypes, provisionally named ON1-NGR, BAIX-KEN1, BAIX-KEN2 and BAIX-KEN3. Conclusion The study contributes to an improved understanding of the molecular epidemiology of RSV infection in sub-Saharan Africa. It provides the first phylogenetic data for RSV from Tanzania, Gabon and Burkina Faso and combines it with RSV strains from all other sub-Saharan countries currently available in GenBank.

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)

The Ministry of Health in Samoa, in partnership with the Pacific Community, successfully implemented enhanced surveillance for the high-profile Third United Nations Conference on Small Island Developing States held concurrently with the popular local Teuila festival during a widespread chikungunya outbreak in September 2014. Samoa's weekly syndromic surveillance system was expanded to 12 syndromes and 10 sentinel sites from four syndromes and seven sentinel sites; sites included the national hospital, four private health clinics and three national health service clinics. Daily situation reports were produced and were disseminated through PacNet (the e-mail alert and communication tool of the Pacific Public Health Surveillance Network) together with daily prioritized line lists of syndrome activity to facilitate rapid response and investigation by the Samoan EpiNet team. Standard operating procedures for surveillance and response were introduced, together with a sustainability plan, including a monitoring and evaluation framework, to facilitate the transition of the mass gathering surveillance improvements to routine surveillance. The enhanced surveillance performed well, providing vital disease early warning and health security assurance. A total of 2386 encounters and 708 syndrome cases were reported. Influenza-like illness was the most frequently seen syndrome (17%). No new infectious disease outbreaks were recorded. The experience emphasized: (1) the need for a long lead time to pilot the surveillance enhancements and to maximize their sustainability; (2) the importance of good communication between key stakeholders; and (3) having sufficient staff dedicated to both surveillance and response.

Introduction: Extended-Spectrum Beta-Lactamases (ESBL) are a common mechanism of bacterial resistance in Enterobacteriaceae. The purpose of this study is to characterize the ESBL genes produced by community-acquired uropathogenic Escherichia coli strains in the Nouna District, in the West-African country, Burkina Faso. Methodology: Samples were collected from non-hospitalized patients who came for consultation at the CMA (Centre Médical avec Antenne chirurgicale) in Nouna and were sent to the laboratory for a urine culture test. The detection of ESBL production by the bacteria was carried out with the double-disc synergy test and the extraction of the ESBL genes with the heat shock method. Molecular characterization of ESBL genes was performed with three sequential multiplex polymerase chain reaction (PCR) assays. Results: One hundred and eighty-two (182) bacteriological cultures were analyzed and 29 E. coli isolated, between 01/07/2017 and 01/07/2018. The ESBL phenotype was found in 13/29 (44.8%). Multiplex PCR yielded many beta-lactamase genes, predominantly blaCTX-M-1,3,15 (12/13; 92.3%) followed by beta-lactamase genes blaOXA-1,4,30 (8/13; 61.5%) and beta-lactamase genes blaTEM-1,2 (7/13; 53.8%). Conclusion: This study showed that the blaCTX-M-1,3,15 genes produced by uropathogenic E. coli were predominant. Sequencing of these genes would be needed to better characterize the different types of ESBL circulating in Nouna.

Background This qualitative study aimed to investigate the health seeking behaviour of rural women in northern Tajikistan, with specific focus on antenatal and obstetric complications as a result of delayed access to health services. Due to the unprecedented level of labour migration among men in the border region of Tajikistan, Isfara, the study specifically focused on migrants’ wives residing with their in-laws. Methods Using an adapted “Three delays” model which suggests three major causes of delayed access to maternity services - decision to seek care , reaching a healthcare facility and receiving necessary care – we conducted 29 in-depth interviews with labour migrants’ wives, 16 semi-structured interviews with healthcare service providers and 2 focus-group discussions with 16 mothers-in-law in Isfara district. Results Our study demonstrated that the most crucial and conditioned factor of access to maternity services for labour migrants’ wives is a decision to seek care. While reaching a healthcare facility (geographical accessibility, time and transportation costs) and receiving necessary care (availability of services, financial affordability and perceived quality of care) were rarely reported as obstacles towards timely access to maternity services, decision to seek care was found to be an intricate interplay of several factors: traditional gender and family roles (particularly in the absence of the husband), the age of the mother-in-law, cultural beliefs and perceptions about pregnancy and maternity, and widely spread myths about certain health conditions and services. Conclusions Our study concludes that the traditional pattern of seeking health care among women in northern Tajikistan may often cause delays in accessing necessary maternity services and result in adverse health outcomes for women. We suggest that effective strategies to reduce maternal morbidity and mortality in rural Tajikistan should, along with strengthening healthcare structures, embark on community education and awareness raising with special focus on mothers-in-law and other traditional decision-makers in households.

Mass gatherings pose public health challenges to host countries, as they can cause or exacerbate disease outbreaks within the host location or elsewhere. In July 2012, the 11th Festival of Pacific Arts (FOPA), a mass gathering event involving 22 Pacific island states and territories, was hosted by Solomon Islands. An enhanced syndromic surveillance (ESS) system was implemented for the event. Throughout the capital city, Honiara, 15 sentinel sites were established and successfully took part in the ESS system, which commenced one week before the FOPA (25 June) and concluded eight days after the event (22 July). The ESS involved expanding on the existing syndromic surveillance parameters: from one to 15 sentinel sites, from four to eight syndromes, from aggregated to case-based reporting and from weekly to daily reporting. A web-based system was developed to enable data entry, data storage and data analysis. Towards the end of the ESS period, a focus group discussion and series of key informant interviews were conducted. The ESS was considered a success and played an important role in the early detection of possible outbreaks. For the period of the ESS, 1668 patients with syndrome presentations were received across the 15 sentinel sites. There were no major events of public health significance. Several lessons were learnt that are relevant to ESS in mass gathering scenarios, including the importance of having adequate lead in time for engagement and preparation to ensure appropriate policy and institutional frameworks are put in place.

Background The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. Methods This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. Discussion We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention’s impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. Trial registration Registered with RIDIE (RIDIE-STUDY-ID-54412a964bce8) on 10/17/2014.

Objective To estimate both crude and effective curative health services coverage provided by rural health facilities to under 5-year-old (U5YO) children in Burkina Faso. Methods We surveyed 1298 child health providers and 1681 clinical cases across 494 primary-level health facilities, as well as 12 497 U5YO children across 7347households in the facilities’ catchment areas. Facilities were scored based on a set of indicators along three quality-of-care dimensions: management of common childhood diseases, management of severe childhood diseases and general service readiness. Linking service quality to service utilisation, we estimated both crude and effective coverage of U5YO children by these selected curative services. Results Measured performance quality among facilities was generally low with only 12.7% of facilities surveyed reaching our definition of high and 57.1% our definition of intermediate quality of care. The crude coverage was 69.5% while the effective coverages indicated that 5.3% and 44.6% of children reporting an illness episode received services of only high or high and intermediate quality, respectively. Conclusion Our study showed that the quality of U5YO child health services provided by primary-level health facilities in Burkina Faso was low, resulting in relatively ineffective population coverage. Poor adherence to clinical treatment guidelines combined with the lack of equipment and qualified clinical staff that performed U5YO consultations seemed to be contributors to the gap between crude and effective coverage.

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.

French Contexte La motivation des agents de santé dans les pays à revenu faible et intermédiaire est devenue un sujet de grand intérêt pour les décideurs et les chercheurs au cours des dernières années. Pourtant, de nombreux aspects de la motivation des agents de santé ne sont pas encore bien compris. Ceci est dû en particulier à l’absence d’outils de mesure appropriés. Cet article présente une preuve de la validité conceptuelle d’une échelle psychométrique développée pour mesurer la composition de la motivation, c’est-à-dire le degré auquel des types de motivation d’origine différente à l’intérieur et à l’extérieur d’une personne contribuent à leur motivation globale au travail. L’échelle est fondée sur la théorie de l’auto-détermination (Self-Determination Theory). Méthodes Une enquête transversale a été mise en place auprès de 1 142 infirmières dans 522 formations sanitaires gouvernementales de 24 districts du Burkina Faso. Par analyse factorielle confirmatoire, nous avons examiné si l’échelle mesure ce qu’elle était supposée mesurer (validité structurelle et convergente/discriminante) et si ses propriétés de mesures sont comparables dans différentes sous-groupes d’agents de santé (invariance de la mesure). Résultats Les résultats montrent que l’échelle mesure une version légèrement modifiée du continuum de motivation proposée par la théorie de l’auto-détermination. Les propriétés de mesure étaient globalement comparables entre les sous-groupes, mais une certaine prudence est indiquée si une comparaison des moyennes entre les groupes est l’objectif principal de l’analyse. Conclusion L’échelle est une un apport important au référentiel des outils de mesure de la motivation des agents de santé dans les pays à revenu faible et modérés. Elle sera utile pour une meilleure compréhension de la motivation des prestataires, ainsi que des effets positifs et potentiellement secondaires des interventions visant à renforcer la motivation.

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.

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.

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.

International audience; In September 2010, autochthonous transmission of chikungunya virus was recorded in southeastern France, where the Aedes albopictus mosquito vector is present. Sequence analysis of the viral genomes of imported and autochthonous isolates indicated new features for the potential emergence and spread of the virus in Europe.

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.

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: Micro health insurance schemes have been implemented across developing countries as a means of facilitating access to modern medical care, with the ultimate aim of improving health. This effect, however, has not been explored sufficiently.Objective: We investigated the effect of enrolment into community-based health insurance on mortality in children under 5 years of age in a health and demographic surveillance system in Nouna, Burkina Faso.Design: We analysed the effect of health insurance enrolment on child mortality with a Cox regression model. We adjusted for variables that we found to be related to the enrolment in health insurance in a preceding analysis.Results: Based on the analysis of 33,500 children, the risk of mortality was 46% lower in children enrolled in health insurance as compared to the non-enrolled children (HR=0.54, 95% CI 0.43–0.68) after adjustment for possible confounders. We identified socioeconomic status, father’s education, distance to the health facility, year of birth, and insurance status of the mother at time of birth as the major determinants of health insurance enrolment.Conclusions: The strong effect of health insurance enrolment on child mortality may be explained by increased utilisation of health services by enrolled children; however, other non-observed factors cannot be excluded. Because malaria is a main cause of death in the study area, early consultation of health services in case of infection could prevent many deaths. Concerning the magnitude of the effect, implementation of health insurance could be a major driving factor of reduction in child mortality in the developing world.Keywords: health insurance; Africa South of the Sahara; child mortality; population surveillance; Burkina Faso; health services accessibility; survival analysis(Published: 28 April 2015)Citation: Glob Health Action 2015, 8: 27327 - http://dx.doi.org/10.3402/gha.v8.27327

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.

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.

International audience; Since January 2012, the Pacific Region has experienced 28 new documented outbreaks and circulation of dengue, chikungunya and Zika virus. These mosquito-borne disease epidemics seem to become more frequent and diverse, and it is likely that this is only the early stages of a wave that will continue for several years. Improved surveillance and response measures are needed to mitigate the already heavy burden on island health systems and limit further spread to other parts of the world.

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.

Background This study aimed to investigate the relationship between household wealth and under-5 year mortality in rural and semi-urban Burkina Faso. Methods The study included 15 543 children born between 2005 and 2010 in the Nouna Health and Demographic Surveillance System. Information on household wealth was collected in 2009. Two separate wealth indicators were calculated by principal components analysis for the rural and the semi-urban households, which were then divided into quintiles accordingly. Multivariable Cox proportional hazards regression was used to study the effect of the respective wealth measure on under-5 mortality. Results We observed 1201 childhood deaths, corresponding to 5-year survival probability of 93.6% and 88% in the semi-urban and rural area, respectively. In the semi-urban area, household wealth was significantly related to under-5 mortality after adjustment for confounding. There was a similar but non-significant effect of household wealth on infant mortality, too. There was no effect of household wealth on under-5 mortality in rural children. Conclusions Results from this study indicate that the more privileged children from the semi-urban area with access to piped water and electricity have an advantage in under-5 survival, while under-5 mortality in the rural area is rather homogeneous and still relatively high

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.

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.

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.

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.

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.

Objective: To evaluate whether community-based health insurance (CBHI) protects household assets in rural Burkina Faso, Africa \ud \ud Data sources: Data was used from a household survey that collected primary data from randomly selected households, covering 42 villages and 1 town, during 2004-07(n=890). \ud \ud Study design: The study area was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004-06. We applied different strategies to control for selection bias ? ordinary least squares with covariates, two-stage least squares with instrumental variable and fixed effects models. \ud \ud Data collection: Household members were interviewed in their local language every year and information was collected on demographic and socioeconomic indicators including ownership of assets, and on self-reported morbidity.\ud \ud Principal findings: Fixed effects and ordinary least squares models showed that CBHI protected household assets during 2004-07. The two-stage least squares with instrumental variable model showed that CBHI increased household assets during 2004-05. \ud \ud Conclusions: CBHI protects household assets. For a subsidized scheme, CBHI also has the potential to increase household assets. Similar studies from developing countries that evaluate the impact of health insurance on household economic indicators are needed to benchmark these results with other settings.

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.