Improving equity by removing healthcare fees for children in Burkina Faso

BACKGROUND

This study evaluated the effects on healthcare access inequities of an intervention exempting children under 5 years from user fees in Burkina Faso.

METHODS

The design consisted of two complementary studies. The first was an interrupted time series (56 months before and 12 months after) study of daily curative consultations according to distance (<5, 5-9 and ≥10 km) in a stratified random sample of 18 health centres: 12 with the intervention and 6 without. The second was a household panel survey (n=1214) assessing the evolution of health-seeking behaviours. Multilevel regression was used throughout.

RESULTS

Attendance doubled under the intervention, after adjusting for Centres de Santé et de Promotion Sociale size, districts, secular trend and seasonal variation. Utilisation increased for all distance ranges and in all of the 12 health centres of the intervention area. The exemption benefited all children (rate ratios (RR)=1.52 (1.23 to 1.88)), whether their health needs were high (RR=1.69 (1.22 to 2.32)) or not (RR=1.46 (1.10 to 1.93)) and whether the children lived near (RR=1.42 (1.09 to 1.85)) or far from a health centre (RR=1.79 (1.31 to 2.43)). The exemption benefited the children of poor families when health need was high and services near (RR=5.23; (1.30 to 20.99)). The amount saved for a child's treatment by the exemption was on average and median 2500 F CFA (≈US$5).

CONCLUSIONS

Exempting children under five from user fees is effective and helps reduce inequities of access. It benefits vulnerable populations, although their service utilisation remains constrained by limitations in geographic accessibility of services.

Rationality of drug prescriptions in rural health centres in Burkina Faso

The objective of this study is to investigate the quality of drug prescriptions in nine health centres of three districts in rural Burkina Faso. 313 outpatient consultations were studied by methods of guided observation. Additionally interviews were held with the health care workers involved in the study. A total of 793 drugs prescribed by 15 health care workers during the observation period and 2815 prescribed drugs copied from the patient register were analyzed. An average of 2.3 drugs were prescribed per visit. 88.0% of the prescribed drugs were on the essential drug list. 88.4% were indicated according to the national treatment guidelines. 79.4% had a correct dosage. The study revealed serious deficiencies in drug prescribing that could not be detected by assessing selected quantitative drug-use indicators as recommended by the WHO. In two-thirds of the cases the patients received no information on how long the drug had to be taken. Errors in dosage occurred significantly more often in children under 5 years. The combined analysis of choice and dosage of drugs showed that 59.3% of all the patients received a correct prescription. Seven out of 21 pregnant women received drugs contraindicated in pregnancy. We conclude that assessment of quantitative drug-use indicators alone does not suffice in identifying specific needs for improvement in treatment quality. We recommend that prescribing for children under 5 and for pregnant women should be targeted in future interventions and that the lay-out, content and distribution of treatment guidelines must be improved.

Performance of village pharmacies and patient compliance after implementation of essential drug programme in rural Burkina Faso

After implementation of a nation-wide essential drug programme in Burkina Faso a prospective study was undertaken consisting of non-participant observation in the health centre and in the village pharmacy, and of household interviews with the patients. The study covered all general consultations in nine health centres in three districts over a two-week period as well as all client-vendor contacts in the corresponding village pharmacies; comprising 313 patients in consultations and 498 clients in eight village pharmacies with 12 vendors involved in dispensing 908 drugs. Additionally patients were interviewed in their households. Performance and utilization of the village pharmacy: 82.0% of the drugs prescribed in the health centres were actually dispensed at the village pharmacy, 5.9% of the drugs were not available at the village pharmacy. Wrong drugs were dispensed in 2.1% of cases. 41.3% of the drugs dispensed in the village pharmacy were bought without a prescription. Differences are seen between the district and are put in relation to different onset of the essential drug programme. Patient compliance: Patients could recall the correct dosage for 68.3% of the drugs. Drug taking compliance was 63.1%, derived from the pills remaining in the households. 11.5% of the drugs had obviously been taken incorrectly to such an extent that the occurrence of undesired drug effects was likely. The study demonstrates the success of the essential drug programme not only in performance but also in acceptability and utilization by the population.

Diagnostic quality in rural health centres in Burkina Faso

OBJECTIVE

To study the quality of diagnostic practice in rural Burkina Faso.

METHOD

In 9 health centres of 3 districts, 313 outpatient consultations were observed, and 417 diagnoses by 15 nurses were analysed. Criteria for evaluation of patient history and clinical examination were based on the diagnostic guidelines distributed by the Ministry of Health.

RESULTS

In only 20% of the diagnoses the nurses took a sufficient history and in only 40% they conducted a sufficient clinical examination. In 21% patients underwent no clinical examination at all. Only 12% of all diagnoses were based on sufficient history-taking and adequate clinical examinations. The individual elements of clinical examination were performed correctly in 82% of cases. The variation between nurses was immense, but no correlation could be found with regard to their basic training. However, nurses who had received the diagnostic guidelines examined patients more carefully than those who had not. Larger numbers of patients per day are not associated with shorter nurse-patient contact, and neither is sufficiency of patient history associated with duration of the consultation.

CONCLUSION

The low diagnostic quality of the outpatient consultations in the studied area indicates that this issue has been neglected in national public health initiatives. But examination skills are good and diagnostic guidelines may have had a positive effect on the diagnostic quality.