Manuela De Allegri

Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso

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.

Determinants of utilisation of maternal care services after the reduction of user fees: A case study from rural Burkina Faso

OBJECTIVE To identify determinants of utilisation for antenatal care (ANC) and skilled attendance at birth after a substantial reduction in user fees. METHODS The study was conducted in the Nouna Health District in north-western Burkina Faso in early 2009. Data was collected by means of a representative survey on a sample of 435 women who reported a pregnancy in the prior 12 months. Two independent logit models were used to assess the determinants of (a) ANC utilisation (defined as having attended at least 3 visits) and (b) skilled assistance at birth (defined as having delivered in a health facility). RESULTS 76% of women had attended at least 3 ANC visits and 72% had delivered in a facility. Living within 5 km from a facility was positively associated, while animist religion, some ethnicities, and household wealth were negatively associated with ANC utilisation. Some ethnicities, living within 5 km from a health facility, and having attended at least 3 ANC visits were positively associated with delivering in a facility. CONCLUSIONS User fee alleviation secured equitable access to care across socio-economic groups, but alone did not ensure that all women benefited from ANC and from skilled attendance at birth. Investments in policies to address barriers beyond financial ones are urgently needed.

Malaria in rural Burkina Faso: local illness concepts, patterns of traditional treatment and influence on health-seeking behaviour

BackgroundThe literature on health care seeking behaviour in sub-Saharan Africa for children suffering from malaria is quite extensive. This literature, however, is predominately quantitative and, inevitably, fails to explore how the local concepts of illness may affect peoples choices. Understanding local concepts of illness and their influence on health care-seeking behaviour can complement existing knowledge and lead to the development of more effective malaria control interventions.MethodsIn a rural area of Burkina Faso, four local concepts of illness resembling the biomedical picture of malaria were described according to symptoms, aetiology, and treatment. Data were collected through eight focus group discussions, 17 semi-structured interviews with key informants, and through the analysis of 100 verbal autopsy questionnaires of children under-five diagnosed with malaria.ResultsSumaya, dusukun yelema, kono, and djoliban were identified as the four main local illness concepts resembling respectively uncomplicated malaria, respiratory distress syndrome, cerebral malaria, and severe anaemia. The local disease categorization was found to affect both treatment and provider choice. While sumaya is usually treated by a mix of traditional and modern methods, dusukun yelema and kono are preferably treated by traditional healers, and djoliban is preferably treated in modern health facilities. Besides the conceptualization of illness, poverty was found to be another important influencing factor of health care-seeking behaviour.ConclusionThe findings complement previous evidence on health care-seeking behaviour, by showing how local concepts of illness strongly influence treatment and choice of provider. Local concepts of illness need to be considered when developing specific malaria control programmes.

The effect of community-based health insurance on the utilization of modern health care services: evidence from Burkina Faso.

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 populations capacity to enjoy the benefits of insurance once insured.

Community health insurance in sub-Saharan Africa: what operational difficulties hamper its successful development?

In recent years, a number of reviews have generated evidence on the potential of community health insurance (CHI) to increase access to care and offer financial protection against the cost of illness for poor people excluded from formal insurance systems. Field experience, however, shows that in sub‐Saharan Africa (SSA), a series of operational difficulties still hampers the successful development of CHI, yielding negative effects on potential progress towards increased access to care and improved financial protection. Through a careful assessment of the existing literature, including peer‐reviewed articles, books, consultancy reports, and manuscripts from international organizations, we produce an analytical review of such difficulties. Our aim is to provide policy makers with the necessary knowledge on the problems at stake and with policy propositions to offset such problems, strengthening CHI and enhancing its role within SSA health systems. Our review of the literature reveals that the major difficulties currently faced by CHI in SSA are operational in nature and cluster around five areas: (i) lack of clear legislative and regulatory framework; (ii) low enrolment rates; (iii) insufficient risk management measures; (iv) weak managerial capacity; and (v) high overhead costs. Consequently, our review calls for appropriate policy interventions, specifically: (i) greater commitment towards the development of adequate legislation in support of CHI; (ii) increasing uptake of measures to expand equitable enrolment; (iii) the adoption of adequate risk management measures in all schemes; (iv) substantial investments from host countries as well as from sponsoring agencies to improve managerial capacity; and (v) collective efforts to contain overhead costs.

The Great Failure of Malaria Control in Africa: A District Perspective from Burkina Faso

Too many African children are dying from a disease for which we have effective and cost-effective prevention and treatment options, say the authors.

Compliance of young children with ITN protection in rural Burkina Faso

BackgroundInsecticide-treated bed nets (ITNs) are known to be highly effective in reducing malaria morbidity and mortality. The effectiveness of ITNs is largely influenced by behavioural factors and not much is known regarding such factors under programme conditions.MethodsThis descriptive study was nested into a large ITN effectiveness study in rural Burkina Faso. During two cross-sectional surveys in the dry and rainy season of 2003, random samples of young children from nine representative villages (n = 180 per survey) were investigated for compliance with ITN protection and related behaviour. Data were collected through direct observations and through interviews with mothers.ResultsITNs were perceived as very important for protection against mosquitoes and malaria particularly during the rainy season, but there were problems with their use during the dry season. Young children usually slept with their mother under the ITN and self-reported compliance was 66% and 98% during dry and rainy season, respectively (confirmed by direct observation in 34% and 79%, respectively). Important reasons for low compliance during the dry season were high temperatures inside houses and problems related to changing sleeping places during the night.ConclusionUnder programme conditions, compliance with ITN protection in young children is sufficient during the rainy season, but is rather low during the hot and dry season. Greater emphasis needs to be placed on information/education efforts to make people aware of the fact that the risk of contracting malaria may persist throughout the year.

Step-wedge cluster-randomised community-based trials: An application to the study of the impact of community health insurance

BackgroundWe describe a step-wedge cluster-randomised community-based trial which has been conducted since 2003 to accompany the implementation of a community health insurance (CHI) scheme in West Africa. The trial aims at overcoming the paucity of evidence-based information on the impact of CHI. Impact is defined in terms of changes in health service utilisation and household protection against the cost of illness. Our exclusive focus on the description and discussion of the methods is justified by the fact that the study relies on a methodology previously applied in the field of disease control, but never in the field of health financing.MethodsFirst, we clarify how clusters were defined both in respect of statistical considerations and of local geographical and socio-cultural concerns. Second, we illustrate how households within clusters were sampled. Third, we expound the data collection process and the survey instruments. Finally, we outline the statistical tools to be applied to estimate the impact of CHI.ConclusionWe discuss all design choices both in relation to methodological considerations and to specific ethical and organisational concerns faced in the field. On the basis of the appraisal of our experience, we postulate that conducting relatively sophisticated trials (such as our step-wedge cluster-randomised community-based trial) aimed at generating sound public health evidence, is both feasible and valuable also in low income settings. Our work shows that if accurately designed in conjunction with local health authorities, such trials have the potential to generate sound scientific evidence and do not hinder, but at times even facilitate, the implementation of complex health interventions such as CHI.

Quality of antenatal care in rural southern Tanzania: a reality check

BackgroundCounselling on the danger signs of unpredictable obstetric complications and the appropriate management of such complications are crucial in reducing maternal mortality. The objectives of this study were to identify gaps in the provision of ANC services and knowledge of danger signs as well as the quality of care women receive in case of complications.FindingsThe study took place in the Rufiji District of Tanzania in 2008 and was conducted in seven health facilities. The study used (1) observations from 63 antenatal care (ANC) sessions evaluated with an ANC checklist, (2) self-assessments of 11 Health workers, (3) interviews with 28 pregnant women and (4) follow-up of 12 women hospitalized for pregnancy-related conditions.Blood pressure measurements and abdominal examinations were common during ANC visits while urine testing for albumin or sugar or haemoglobin levels was rare which was often explained as due to a lack of supplies. The reasons for measuring blood pressure or abdominal examinations were usually not explained to the women. Only 15/28 (54%) women were able to mention at least one obstetric danger sign requiring medical attention. The outcomes of ten complicated cases were five stillbirths and three maternal complications. There was a considerable delay in first contact with a health professional or the start of timely interventions including checking vital signs, using a partograph, and detailed record keeping.ConclusionLinking danger signs to clinical and laboratory examination results during ANC with the appropriate follow up and avoiding delays in emergency obstetric care are crucial to the delivery of coordinated, effective care interventions.

Access to malaria treatment in young children of rural Burkina Faso

BackgroundEffective and timely treatment is an essential aspect of malaria control, but remains a challenge in many parts of sub-Saharan Africa. The objective of this study was to describe young childrens access to malaria treatment in Nouna Health District, Burkina Faso.MethodsIn February/March 2006, a survey was conducted in a representative sample of 1,052 households.ResultsOverall 149/1052 (14%) households reported the current possession of anti-malarial medicine, which was significantly associated with urban area, literacy of household head, having young children, and high socio-economic status. Out of a total of 802 children under five years, at least one malaria episode was reported for 239 (30%) within the last month. Overall 95% of children received treatment, either modern (72%), traditional (18%) or mixed (5%). Most of the medicines were provided as home treatment by the caregiver and half of children received some type of modern treatment within 24 hours of the occurrence of first symptoms. Despite a recent policy change to artemisinin-based combination therapy, modern anti-malarials consisted mainly of chloroquine (93%). Modern drugs were obtained more often from a health facility in localities with a health facility compared to those without (60% vs. 25.6%, p < 0.001). In contrast, beside informal providers, volunteer community health workers (CHW) were the main source of modern medicine in localities without a health centre (28% vs. 3%, p < 0.001).ConclusionAccess to modern health services providing quality controlled effective combination therapies against malaria needs to be strengthened in rural Africa, which should include a re-investigation of the role of CHW 30 years after Alma Ata.