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 population's capacity to enjoy the benefits of insurance once insured.

Breast milk as the "water that supports and preserves life"--socio-cultural constructions of breastfeeding and their implications for the prevention of mother to child transmission of HIV in sub-Saharan Africa.

OBJECTIVES: Complementary breastfeeding represents an important source of risk of HIV infection for infants born to HIV positive mothers. The World Health Organisation recommends that infants born to HIV positive mothers receive either replacement feeding or exclusive breastfeeding (EBF) followed by early weaning. Beyond the clinical and epidemiological debate, it remains unclear how acceptable and feasible the two options are for rural populations in sub-Saharan Africa. This qualitative study aims to fill this gap in knowledge by exploring both the socio-cultural construction and the practice of breastfeeding in the Nouna Health District, rural Burkina Faso. METHODS: Information was collected through 32 individual interviews and 3 focus group discussions with women of all ages, and 6 interviews with local guérisseurs. RESULTS: The findings highlight that breastfeeding is perceived as central to motherhood, but that women practice complementary, rather than exclusive, breastfeeding. The findings also indicate that women recognise both the nutritional value of breast milk and its potential to act as a source of disease transmission. CONCLUSIONS: The findings suggest that given the socio-cultural importance attributed to breastfeeding and the prevailing poverty, it may be more acceptable and more feasible to promote EBF followed by early weaning than replacement feeding. A set of operational strategies are proposed to favour the prevention of mother to child transmission of HIV in the respect of the local socio-cultural setting.

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

BACKGROUND: We 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. METHODS: First, 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. CONCLUSION: We 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.

Assessment of indirect cost-of-illness in a subsistence farming society by using different valuation methods.

Indirect costs or productive labour time lost are the largest share of household economic burden of illness. However, the estimate of household indirect cost can vary depending on the valuation methods used. We therefore estimated household indirect cost in a subsistence farming society in Burkina Faso based on daily production value. These results were validated by using willingness-to-pay method and current wage rate. Among the three methods, the value of a day lost for adults assessed by willingness-to-pay method was considerably higher than other methods. There were no significant differences in indirect costs estimated by daily production value and wage rate. There were significantly higher indirect costs for households which were of higher economic status when daily production value was used. It might raise a question of equity. The willingness-to-pay method can capture the various aspects of indirect cost such as differences among age groups and gender, important individual characteristics and seasons. Thus, it is an appropriate approach for rural subsistence farmer communities. Estimation of indirect cost by wage rate can also be used as a rapid estimation of indirect cost in a rural area in developing countries as an alternative for daily production value.

A qualitative investigation into knowledge, beliefs, and practices surrounding mastitis in sub-Saharan Africa: what implications for vertical transmission of HIV?

BACKGROUND: Mastitis constitutes an important risk factor in HIV vertical transmission. Very little, however, is known on how women in sub-Saharan Africa conceptualise health problems related to breastfeeding, such as mastitis, and how they act when sick. We aimed at filling this gap in knowledge, by documenting the indigenous nosography of mastitis, health seeking behaviour, and remedies for prophylaxis and treatment in rural sub-Saharan Africa. METHODS: The study was conducted in the Nouna Health District, rural Burkina Faso. We employed a combination of in-depth individual interviews and focus group discussions reaching both women and guérisseuers. All material was transcribed, translated, and analysed inductively, applying data and analyst triangulation. RESULTS: Respondents perceived breast problems related to lactation to be highly prevalent and described a sequence of symptoms which resembles the biomedical understanding of pathologies related to breastfeeding, ranging from breast engorgement (stasis) to inflammation (mastitis) and infection (breast abscess). The aetiology of disease, however, differed from biomedical notions as both women and guerisseurs distinguished between "natural" and "unnatural" causes of health problems related to breastfeeding. To prevent and treat such pathologies, women used a combination of traditional and biomedical therapies, depending on the perceived cause of illness. In general, however, a marked preference for traditional systems of care was observed. CONCLUSION: Health problems related to breastfeeding are perceived to be very common in rural Burkina Faso. Further epidemiological research to assess the actual prevalence of such pathologies is urgently needed to inform the design of adequate control measures, especially given the impact of mastitis on HIV vertical transmission. Our investigation into local illness concepts and health care seeking behaviour is useful to ensure that such measures be culturally sensitive. Further research into the efficacy of local customs and traditional healing methods and their effect on viral load in breast milk is also urgently needed.

Understanding enrolment in community health insurance in sub-Saharan Africa: a population-based case-control study in rural Burkina Faso.

OBJECTIVE: To identify factors associated with decision to enrol in a community health insurance (CHI) scheme. METHODS: We conducted a population-based case-control study among 15 communities offered insurance in 2004 in rural Burkina Faso. For inclusion in the study, we selected all 154 enrolled (cases) and a random sample of 393 non-enrolled (controls) households. We used unconditional logistic regression (applying Huber-White correction to account for clustering at the community level) to explore the association between enrolment status and a set of household head, household and community characteristics. FINDINGS: Multivariate analysis revealed that enrolment in CHI was associated with Bwaba ethnicity, higher education, higher socioeconomic status, a negative perception of the adequacy of traditional care, a higher proportion of children living within the household, greater distance from the health facility, and a lower level of socioeconomic inequality within the community, but not with household health status or previous household health service utilization. CONCLUSION: Our study provides evidence that the decision to enrol in CHI is shaped by a combination of household head, household, and community factors. Policies aimed at enhancing enrolment ought to act at all three levels. On the basis of our findings, we discuss specific policy recommendations and highlight areas for further research.

Biomass solid fuel and acute respiratory infections: the ventilation factor.

Biomass solid fuel smoke is linked to acute respiratory infections (ARI). In future, its use will likely increase among poor households, and better ventilation is one important measure that can reduce this health impact. The authors aimed to study the extent to which improvement in ventilation-related factors reduces the fraction of ARI attributable to exposure to biomass smoke in children under 5 years old. An explorative study was carried out in 2004 by applying a questionnaire on 51 households randomly selected from a health district in Burkina Faso. The prevalence of exposure in the population was estimated using ventilation coefficients, and proportions of households with different stove types and locations. An attributable fraction of 0.56 (95% CI: 0.47-0.62) was estimated using the traditional formula for attributable fraction, and 0.26 (95% CI: 0.19-0.31) after weighting exposure by ventilation coefficients, stove type and location. Two scenarios were created: (1) Assuming that most households cooked inside, the fraction becomes 0.54 (95% CI: 0.45-0.61). (2) Assuming that indoor ventilation and cooking device are improved by 20%, the fractions decreased slightly. Improving cooking devices and indoor ventilation reduces the fraction of ARI in children under 5 years attributable to exposure to biomass smoke, but a higher reduction is achieved by cooking outdoors.

Understanding consumers' preferences and decision to enrol in community-based health insurance in rural West Africa.

This paper presents a qualitative investigation of consumers' preferences regarding the single elements of a community-based health insurance (CBI) scheme recently implemented in a rural region in west Africa. The aim is to provide adequate policy-guidance to decision makers in low and middle income countries by producing an in-depth understanding of how consumers' preferences may affect decision to participate in such schemes. Although it has long been suggested that feeble levels of participation may very well be an expression of consumers' dissatisfaction with scheme design, little systematic efforts have so far been channelled towards supporting such argument with empirical evidence. Consumers' preferences were explored through means of 32 individual interviews with household heads. Analysis used the method of constant comparison and was conducted by two independent researchers. Data from 10 focus group discussions provided an additional valuable source of triangulation. Findings suggest that decision to enrol is closely linked to whether the single elements of the scheme match consumers' needs and expectations. In particular, consumers justified decision to join or not to join the insurance scheme in relation to their preference for the unit of enrolment, the premium level and the payment modalities, the benefit package, the health service provider network and the CBI managerial structure. The discussion of the findings focuses on how understanding consumers' preferences and incorporating them in the design of a CBI scheme may result in increased participation rates, ensuring that poor populations gain better access to health services and enjoy greater protection against the cost of illness.

"To enrol or not to enrol?": A qualitative investigation of demand for health insurance in rural West Africa.

In spite of the fact that feeble levels of participation have long been identified as a major constraint to the successful long-term implementation of community-based health insurance (CBI) in low-income countries, evidence on determinants of enrolment in CBI is still lacking. The application of econometric modelling has provided a partial answer to the question, but on its own it has proved to be insufficient to guide policy making. This paper aims to fill this gap in knowledge using qualitative research methods. In-depth interviews with 32 household heads were conducted in the Nouna Health District, Burkina Faso, West Africa to assess determinants of enrolment in a newly established CBI scheme. The findings highlight that factors previously neglected in the literature, such as institutional rigidities and socio-cultural practices, play an important role in shaping the decision to enrol. The discussion of the findings focuses on the policy implications, offering concrete recommendations to maximise enrolment, within and beyond Burkina Faso.

Comparison of individual and group valuation of health state scenarios across communities in West Africa.

BACKGROUND: The correct valuation of health state scenarios is important for economic analyses, disease burden assessment and setting clinical guidelines. However, it is unclear whether we should use individual or group valuations. We aimed to compare individual and group valuations of a range of clinically and culturally relevant health state scenarios in a West African population. METHODS: Seventy subjects were purposely selected from seven randomly selected communities in a health district in Burkina Faso. Subjects were presented with ten health state scenarios. The valuation of the scenarios was with a culturally adapted visual analogue scale. Fixed-effects ANOVA were used to compare individual valuations from the seven locations. A paired t-test was used to compare individual mean and group valuations. The differences in the ranking of valuations were investigated using the Spearman rank correlation coefficients. RESULTS: On average, group valuations of the disability associated with the scenarios were higher than individual mean valuations by 20% (p = 0.00). The range of group valuations was wider than that of individual mean valuations. The differences in individual valuations of five scenarios across communities were significant (p < or = 0.01). Within the communities, group and individual rankings of scenarios differed. Across five communities, they correlated significantly and positively. CONCLUSIONS: Groups valued the disability associated with health state scenarios as being more severe than individuals. Group valuations could more clearly identify the preferences of different community groups. The use of one group's opinion in setting priorities and making guidelines that relate to the public still requires some caution. Policies that do not account for systematic subgroup differences should be made with caution.

Safety of the methylene blue plus chloroquine combination in the treatment of uncomplicated falciparum malaria in young children of Burkina Faso [ISRCTN27290841].

BACKGROUND: Safe, effective and affordable drug combinations against falciparum malaria are urgently needed for the poor populations in malaria endemic countries. Methylene blue (MB) combined with chloroquine (CQ) has been considered as one promising new regimen. OBJECTIVES: The primary objective of this study was to evaluate the safety of CQ-MB in African children with uncomplicated falciparum malaria. Secondary objectives were to assess the efficacy and the acceptance of CQ-MB in a rural population of West Africa. METHODS: In this hospital-based randomized controlled trial, 226 children (6-59 months) with uncomplicated falciparum malaria were treated in Burkina Faso. The children were 4:1 randomized to CQ-MB (n = 181; 25 mg/kg CQ and 12 mg/kg MB over three days) or CQ (n = 45; 25 mg/kg over three days) respectively. The primary outcome was the incidence of severe haemolysis or other serious adverse events (SAEs). Efficacy outcomes were defined according to the WHO 2003 classification system. Patients were hospitalized for four days and followed up until day 14. RESULTS: No differences in the incidence of SAEs and other adverse events were observed between children treated with CQ-MB (including 24 cases of G6PD deficiency) compared to children treated with CQ. There was no case of severe haemolysis and also no significant difference in mean haemoglobin between study groups. Treatment failure rates were 53.7% (95% CI [37.4%; 69.3%]) in the CQ group compared to 44.0% (95% CI [36.3%; 51.9%]) in the CQ-MB group. CONCLUSION: MB is safe for the treatment of uncomplicated falciparum malaria, even in G6PD deficient African children. However, the efficacy of the CQ-MB combination has not been sufficient at the MB dose used in this study. Future studies need to assess the efficacy of MB at higher doses and in combination with appropriate partner drugs.

Safety of the combination of chloroquine and methylene blue in healthy adult men with G6PD deficiency from rural Burkina Faso.

New drug combinations against falciparum malaria which are both effective and affordable for Sub-Saharan African populations are urgently needed. The combination of the well-known drugs chloroquine (CQ) and methylene blue (MB) is such a promising new regimen. However, there is some concern that MB could cause development of haemolysis in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency, a condition which is prevalent in malaria-endemic regions. Against this background, 74 G6PD-deficient but otherwise healthy adult men were given a 3-day oral regimen of a total of 1500 mg CQ and 780 mg MB in the District Hospital of Nouna in north-western Burkina Faso. Haemolysis did not occur, haemoglobin levels remained stable or even rose in the study participants, and the drug regimen was well tolerated. Therefore, standard dosages of MB appear to be safe in G6PD-deficient African populations with predominantly class III G6PD deficiency.

Informal risk-sharing arrangements (IRSAs) in rural Burkina Faso: lessons for the development of community-based insurance (CBI).

In resource-poor environments, community-based insurance (CBI) is increasingly being propagated as a strategy to improve access of poor rural populations to modern health care. It has been repeatedly hypothesized that CBI schemes need to be grounded in national as well as local traditions of solidarity. This paper presents a typology of informal risk sharing arrangements (IRSAs) in a rural area of North-Western Burkina Faso and discusses their modus operandi as well as the underlying concepts of solidarity and reciprocity. The research was explicitly multi-disciplinary, combining anthropological and economic as well as qualitative and quantitative data collection methods. Focus group and interview data were complemented by a census of existing IRSAs. In addition to presenting the main features of existing institutions, the paper discusses whether IRSAs can serve as entry points for CBI schemes. In spite of the fact that existing IRSAs fulfil important solidarity functions in the rural Burkinian context, we conclude that they cannot serve as institutional models for more formalized CBI schemes. Community participation in a future CBI scheme will need to tap into existing notions of solidarity and mutuality. The CBI scheme itself, however, needs to be newly tailored.