Seni Kouanda

Communities of practice: the missing link for knowledge management on implementation issues in low-income countries?

The implementation of policies remains a huge challenge in many low‐income countries. Several factors play a role in this, but improper management of existing knowledge is no doubt a major issue. In this article, we argue that new platforms should be created that gather all stakeholders who hold pieces of relevant knowledge for successful policies. To build our case, we capitalize on our experience in our domain of practice, health care financing in sub‐Saharan Africa. We recently adopted a community of practice strategy in the region. More in general, we consider these platforms as the way forward for knowledge management of implementation issues.

Reducing the medical cost of deliveries in Burkina Faso is good for everyone, including the poor

Since 2007, Burkina Faso has subsidized 80% of the costs of child birth. Women are required to pay 20% (900 F CFA = 1.4 Euros), except for the indigent, who are supposed to be exempted. The objective of the policy is to increase service utilization and reduce costs for households. We analyze the efficacy of the policy and the distribution of its benefits. The study was carried out in Ouargaye district. The analysis was based on two distinct cross-sectional household surveys, conducted before (2006; n = 1170) and after (2010; n = 905) the policy, of all women who had had a vaginal delivery in a public health centre. Medical expenses for delivery decreased from a median of 4,060 F CFA in 2006 to 900 F CFA in 2010 (p<0.001). There was pronounced contraction in the distribution of expenses and a reduction in interquartile range. Total expenses for delivery went from a median of 7,366 F CFA in 2006 to 4,750 F CFA in 2010 (p = 0.001). There was no exacerbation of the initial inequalities of the share in consumption after the policy. The distribution of benefits for medical expenses showed a progressive evolution. The greatest reduction in risk of excessive expenses was seen in women in the bottom quintile living less than 5 km from the health centres. Only 10% of those in the poorest quintile were exempted. The subsidy policy was more effective in Burkina Faso than in other African countries. All categories of the population benefited from this policy, including the poorest. Yet despite the subsidy, women still carry a significant cost burden; half of them pay more than they should, and few indigents are fully exempted. Efforts must still be made to reach the indigent and to reduce geographic barriers for all women.

The Kaya HDSS, Burkina Faso: a platform for epidemiological studies and health programme evaluation

The Kaya Health and Demographic Surveillance System (Kaya HDSS) is located in the North Central region of Burkina Faso in the Kaya health district. The main purposes of the Kaya HDSS are to study demographic, infectious and chronic disease indicators in the district, to observe changes in health over time, evaluate health programmes and to provide a basis for policy decisions and capacity building in order to enhance the health of the community. Kaya HDSS was established in late 2007 following a baseline census of the population of the HDSS area. Homes were visited every 6 months to collect demographic information and data on morbidity and mortality. A verbal autopsy questionnaire is used to collect information on the causes of death. The Kaya HDSS reached 64,480 residents in 10,587 households by the end of 2011, with an average of 6.1 ± 4.3 persons per household. The site is 70% urban and 30% rural. The population is 51.8% female. Over 55% of deaths occur outside health facilities. Malaria is the leading cause of death, primarily affecting children under 5 years of age (44%) and those 5 to 14 years old (36%). The Kaya HDSS data can be obtained by sending a request via the HDSS website (http://kaya-hdss.org/).

Implementation Fidelity of the National Malaria Control Program in Burkina Faso

Background Every year 40,000 people die of malaria in Burkina Faso. In 2010, the Burkinabè authorities implemented a national malaria control program that provides for the distribution of mosquito nets and the home-based treatment of children with fever by community health workers. The objective of this study was to measure the implementation fidelity of this program. Methods We conducted a case study in two comparable districts (Kaya and Zorgho). Data were collected one year after the program’s implementation through field observations (10 weeks), documentary analysis, and individual interviews with stakeholders (n = 48) working at different levels of the program. The analysis framework looked at the fidelity of (i) the intervention’s content, (ii) its coverage, and (iii) its schedule. Results The program’s implementation was relatively faithful to what was originally planned and was comparable in the two districts. It encountered certain obstacles in terms of the provision of supplies. Coverage fidelity was better in Kaya than in Zorgho, where many community health workers (CHW) experienced problems with the restocking of artemisinin-based combination therapy and with remuneration for periods of training. In both districts, the community was rarely involved in the process of selecting CHWs. The components affected by scheduling all experienced successive implementation delays that pushed nets distribution and the initial provision of artemisinin-based combination therapies to the CHWs past the 2010 malaria season. Conclusions The activities intended by the program were mostly implemented with good fidelity. However, the implementation was plagued by delays that probably postponed the expected beneficial effects.

Impact of maternal HAART on the prevention of mother-to-child transmission of HIV: results of an 18-month follow-up study in Ouagadougou Burkina Faso.

Abstract Mother-to-child transmission remains the main cause of global pediatric HIV infections, especially in sub-Saharan Africa. Many interventions based on single-dose antiretroviral therapy have been implemented to reduce the mother-to-child transmission of HIV. In resource-limited settings, highly active antiretroviral therapy (HAART) has only been recommended for HIV-infected pregnant women requiring treatment for their own health. Here, we assessed the efficacy over 18 months of maternal HAART versus peripartum short-course antiretroviral therapy (SCART) regimens for the prevention of mother-to-child transmission (PMTCT) of HIV. We conducted a retrospective cohort study of patients from two medical centers in Ouagadougou, Burkina Faso. The PMTCT files and registers from 1 January 2003 to 31 December 2006 were obtained from routine data collected at these sites. The main assessment criterion was the rate of HIV-1 positivity in children born to HIV-positive mothers as measured with HIV-1 rapid tests at 18 months. A total of 586 pregnant HIV-1-infected women in PMTCT programs were selected. Among these women, 260 were undergoing HAART and 326 received single-dose nevirapine (91.3%) or single-dose zidovudine (8.7%) at delivery. HIV-1 serological tests were performed on 454 children at 18 months old. The rate of HIV-1 vertical transmission was 0% (0/195) in the HAART group and 4.6% (12/259) in the single-dose monotherapy group (P<0.01). Eight infants in the HAART cohort and 30 in the SCART cohort were breastfed; three in the SCART group were HIV-positive. A total of 62 children died, 19 in the HAART group and 43 in the single-dose monotherapy group. Our study confirms that HAART for mothers effectively reduces the risk of infant HIV infection while preserving the breastfeeding option for mothers.

Gender differences in mobility disability during young, middle and older age in West African adults

Abstract The objective of this study was to assess the prevalence and the contribution of socio-demographic factors and chronic diseases to mobility disability in West African countries. Data were obtained from the World Health Survey (2002–2003) in which adults≥18 years participated, from Burkina Faso (n=4822), Mali (n=4230) and Senegal (n=3197). Participants reporting mild, moderate, severe, extreme difficulty or inability to move around were defined as having mobility disability. All estimates were corrected for sampling design. Association measures were estimated using logistic regression methods. Mobility disability was frequent at young ages (35–44 years old) in men and women, respectively: 17% and 23% in Burkina Faso, 12% and 23% in Mali and 22% and 34% in Senegal. Women had higher odds of mobility difficulty than men at every age group in the three countries: 1.34 (95%CI 1.06; 1.70) in Burkina Faso; 2.33 (95% CI 1.84; 2.71) in Mali and 1.82 (95%CI 1.41; 2.36) in Senegal. Controlling for socio-economic factors and chronic disease, these odds changed respectively to 0.94 (95%CI 0.70; 1.25), 2.19 (95%CI 1.61; 2.96) and 1.90 (95%CI 1.27; 2.84). These results constitute a benchmark for the study of trends of mobility disability in West Africa and could be used by policy planners.

Determinants and causes of mortality in HIV-infected patients receiving antiretroviral therapy in Burkina Faso: a five-year retrospective cohort study

Abstract In this study, we investigated the causes of death and the factors associated with mortality in a cohort of patients receiving highly active antiretroviral therapy (HAART) in Burkina Faso, an African country with limited resources. This retrospective cohort study included patients aged 15 years and older who started HAART for the first time between January 2003 and December 2008 in 14 health districts. We used survival analyses, including the Kaplan–Meier method, to examine potential predictors of death and two Cox proportional hazard models to estimate hazard ratios for death, first from baseline covariates and then from time-dependent covariates. A total of 6641 patients initiated HAART during this period; of these, 5608 were included in the analysis. By the end of the study period, 4310 of those patients were still receiving HAART, 690 had died, 207 had been transferred and 401 were lost to follow-up. The median duration of follow-up was 23.2 months [interquartile range (IQR): 12.4–36.9], and the overall incidence of mortality was 6 per 100 person-years. The clinical stage, CD4 count, body mass index (BMI), haemoglobin level, HAART regimen, gender, age, profession and year of initiation were the primary risk factors associated with death. In the multivariate analysis, BMI, clinical stage, treatment regimen and CD4 count remained significantly associated with death. The most frequent causes of death were wasting syndrome, tuberculosis and anaemia. This result highlights the already advanced stage of immunodeficiency among patients in Burkina Faso when they start HAART. Testing patients for HIV and starting antiretroviral therapy earlier are necessary to further reduce the mortality of patients living with HIV. This study provides a solid evidence base with which future evaluations of HAART in Burkina Faso can be compared.

Heavy burden of non-communicable diseases at early age and gender disparities in an adult population of Burkina Faso: world health survey

BackgroundWHO estimates suggest that age-specific death rates from non-communicable diseases are higher in sub-Saharan Africa than in high-income countries. The objectives of this study were to examine, in Burkina Faso, the prevalence of non-communicable disease symptoms by age, gender, socioeconomic group and setting (rural/urban), and to assess gender and socioeconomic inequalities in the prevalence of these symptoms.MethodsWe obtained data from the Burkina Faso World Health Survey, which was conducted in an adult population (18 years and over) with a high response rate (4822/4880 selected individuals). The survey used a multi-stage stratified random cluster sampling strategy to identify participants. The survey collected information on socio-demographic and economic characteristics, as well as data on symptoms of a variety of health conditions. Our study focused on joint disease, back pain, angina pectoris, and asthma. We estimated prevalence correcting for the sampling design. We used multiple Poisson regression to estimate associations between non-communicable disease symptoms, gender, socioeconomic status and setting.ResultsThe overall crude prevalence and 95% confidence intervals (CI) were: 16.2% [13.5; 19.2] for joint disease, 24% [21.5; 26.6] for back pain, 17.9% [15.8; 20.2] for angina pectoris, and 11.6% [9.5; 14.2] for asthma. Consistent relationships between age and the prevalence of non-communicable disease symptoms were observed in both men and women from rural and urban settings. There was markedly high prevalence in all conditions studied, starting with young adults. Women presented higher prevalence rates of symptoms than men for all conditions: prevalence ratios and 95% CIs were 1.20 [1.01; 1.43] for joint disease, 1.42 [1.21; 1.66] for back pain, 1.68 [1.39; 2.04] for angina pectoris, and 1.28 [0.99; 1.65] for asthma. Housewives and unemployed women had the highest prevalence rates of non-communicable disease symptoms.ConclusionsOur work suggests that social inequality extends into the distribution of non-communicable diseases among social groups and supports the thesis of a differential vulnerability in Burkinabè women. It raises the possibility of an abnormally high rate of premature morbidity that could manifest as a form of premature aging in the adult population. Increased prevention, screening and treatment are needed in Burkina Faso to address high prevalence and gender inequalities in non-communicable diseases.

Utilization of community health workers for malaria treatment: results from a three-year panel study in the districts of Kaya and Zorgho, Burkina Faso

BackgroundMalaria is holo-endemic in Burkina Faso and causes approximately 40,000 deaths every year. In 2010, health authorities scaled up community case management of malaria with artemisinin-based combination therapy. Previous trials and pilot project evaluations have shown that this strategy may be feasible, acceptable, and effective under controlled implementation conditions. However, little is known about its effectiveness or feasibility/acceptability under real-world conditions of implementation at national scale.MethodsA panel study was conducted in two health districts of Burkina Faso, Kaya and Zorgho. Three rounds of surveys were conducted during the peak malaria-transmission season (in August 2011, 2012 and 2013) in a panel of 2,232 randomly selected households. All sickness episodes in children under five and associated health-seeking practices were documented. Community health worker (CHW) treatment coverage was evaluated and the determinants of consulting a CHW were analysed using multi-level logistic regression.ResultsIn urban areas, less than 1% of sick children consulted a CHW, compared to 1%–9% in rural areas. Gaps remained between intentions and actual practices in treatment-seeking behaviour. In 2013, the most frequent reasons for not consulting the CHW were: the fact of not knowing him/her (78% in urban areas; 33% in rural areas); preferring the health centre (23% and 45%, respectively); and drug stock-outs (2% and 12%, respectively). The odds of visiting a CHW in rural areas significantly increased with the distance to the nearest health centre and if the household had been visited by a CHW during the previous three months.ConclusionsThis study shows that CHWs are rarely used in Burkina Faso to treat malaria in children. Issues of implementation fidelity, a lack of adaptation to the local context and problems of acceptability/feasibility might have undermined the effectiveness of community case management of malaria. While some suggest extending this strategy in urban areas, total absence of CHW services uptake in these areas suggest that caution is required. Even in rural areas, treatment coverage by CHWs was considerably less than that reported by previous trials and pilot projects. This study confirms the necessity of evaluating public health interventions under real-world conditions of implementation.

Why do women pay more than they should? A mixed methods study of the implementation gap in a policy to subsidize the costs of deliveries in Burkina Faso

In 2007, Burkina Faso launched a public policy to subsidize 80% of the cost of normal deliveries. Although women are required to pay only the remaining 20%, i.e., 900F CFA (1.4 Euros), some qualitative evidence suggests they actually pay more. The aim of this study is to test and then (if confirmed) to understand the hypothesis that the amounts paid by women are more than the official fee, i.e., their 20% portion. A mixed method sequential explanatory design giving equal priority to both quantitative (n=883) and qualitative (n=50) methods was used in a rural health district of Ouargaye. Half (50%, median) of the women reported paying more than the official fee for a delivery. Health workers questioned the methodology of the study and the veracity of the womens reports. The three most plausible explanations for this payment disparity are: (i) the payments were for products used that were not part of the delivery kit covered by the official fee; (ii) the implementers had difficulty in understanding the policy; and (iii) there was improper conduct on the part of some health workers. Institutional design and organizational practices, as well as weak rule enforcement and organizational capacity, need to be considered more carefully to avoid an implementation gap in this public policy.