[Assessment of management of patients with sexually transmitted infections in Burkina Faso]. / Evaluation de la prise en charge des cas d'infections sexuellement transmissibles au Burkina Faso.

BACKGROUND: In order to offer wide and efficient health care to patients, Burkina Faso has instituted the syndromic approach to sexually transmitted infections (STIs) since 1996. The current assessment has been carried out in view of measuring the degree of application of this approach in the management of the STIs in the health centres of the country. The assessment should specifically allow to: i) analyse the quality of the clinical health care of the patients coming in the health services with STI symptoms;ii) to determine the proportions of those patients to whom the care-provider give basic counselling on the use of condoms and the information of their sexual partners. METHODS: The study has been carried out from the 1(st) to the 28(th) July 2001 in all the 53 health districts and the two national hospitals of Burkina Faso. A one-day cross-section survey per health centres was used. The data were collected from a direct observation of the provider-patient relationship; and the handling of the anamnesis, the physical examination, the diagnosis and the prescriptions were analysed. RESULTS: During the survey, 358 patients had been consulted in the health centres. Only 4% of the patients who came in the health centres with STI or for STI consultation had been assessed and treated in accordance with national algorithm or WHO recommendations (Prevention indicator n degrees 6=4%); and 13% of those who came to consult with or for STI in the health centres had received basic counselling on condoms and the notification to their sexual partners (Prevention indicator n degrees 7=13%). CONCLUSION: These prevention indicators remain of a very weak level, showing therefore a poor quality of the management of STIs. Meanwhile, they show the areas of deficiencies on which a supervision and a recycling of the providers might bear.

Episiotomy in Burkina Faso.

Episiotomy is a common obstetric intervention in many countries of the world, although little is known about rates in African countries. In recent years, the effectiveness of routine episiotomy to prevent severe tears and neonatal asphyxia has been questioned, and evidence shows that the procedure results in considerable maternal morbidity. This study estimates episiotomy rates in Burkina Faso. A high proportion of primigravidae (46%) received an episiotomy when trained midwives attended the delivery; a level which indicates the procedure has to be regarded as routine practice. The episiotomy rate was lower (26%) in primigravidae delivered by auxillary midwives. This proportion is closer to recommended selective approaches derived from good research summaries. The tear rate in women assisted by midwife and auxiliary staff was similar, suggesting that women tear even when the procedure is performed. These results indicate that obstetricians and midwives in Burkina Faso should critically appraise whether routine episiotomy should be abandoned. The introduction of a labour chart is a good vehicle to introduce a policy on avoiding episiotomies.

Direct and indirect estimates of maternal mortality in rural Burkina Faso.

A retrospective study of maternal mortality was conducted in Nouna, a rural area of Burkina Faso in 1992. Strong evidence was found of a major mortality decline among children and young adults over the 50 years preceding the study: The estimated life expectancy of 36 years in around 1945 rose to 58 years in 1991. Direct and indirect (using the sisterhood method) estimates of the maternal mortality ratio (MMR) were compared. Overall, the direct estimate of the MMR (389 deaths per 100,000 live births) for women aged 15 and older was slightly lower than the indirect estimate (428 deaths per 100,000). Taking into account the biases involved in the use of information obtained from sisters, the direct estimates indicated a marked decline in maternal mortality over time from 569 deaths per 100,000 around 1941 to 305 deaths around 1987. The validity of both data and approach, as well as the discrepancies between the direct and indirect methods, are discussed.

PIP: A retrospective study of maternal mortality was conducted in Nouna, a rural area of Burkina Faso in 1992. Strong evidence was found of a major mortality decline among children and young adults over the 50 years preceding the study: the estimated life expectancy of 36 years around 1945 rose to 58 years in 1991. Direct and indirect (using the sisterhood method) estimates of the maternal mortality ratio (MMR) were compared. Overall, the direct estimate of the MMR (389 deaths/100,000 live births) for women aged 15 years and older was slightly lower than the indirect estimate (428 deaths/100,000 live births). Taking into account the biases involved in the use of information obtained from sisters, the direct estimates indicated a marked decline in maternal mortality over time from 569 deaths/100,000 live births around 1941 to 305 deaths/100,000 live births around 1987. The validity of both data and approach, as well as the discrepancies between the direct and indirect methods, are discussed.

Age bias, but no gender bias, in the intra-household resource allocation for health care in rural Burkina Faso.

Household survey data, time allocation data, and qualitative interviews were used to examine whether households allocate their resources for health care differently between age and gender groups. Households allocated significantly fewer resources to the health care of sick children compared to that of sick adults. In contrast there were no such differences with regard to gender. The underlying household rationale is to concentrate its resources spent for health care on productive members rather than to spread them equitably among all its sick members. While children are not productive, women were shown to contribute as much to household production as men, hence their health is valued equally with that of men. Unless we understand intra-household biases in resource allocation, policies will be undermined. Further research is needed to test the hypothesis for the households' preference of production maintenance over health maximization.

PIP: This study compares household allocation of resources in time and money for child care versus adult care and boys versus girls in Burkina Faso. Analysis is based on data and information from a household interview survey, a time allocation study, and qualitative in-depth interviews. Findings from interviews suggest that children were perceived as "unproductive" and health care was an investment. The household valued provision of health care to productive adults. Health care was underused by the elderly because it was perceived to be ineffective and it was deemed useless to interfere with disease at such a late stage in one's life. The support for an age bias in health care use and expenditure was consistent with multivariate findings of Nougtara et al. (1989) and Sauerborn et al. (1989). Findings suggest that households aimed to maintain production and income. Households gave priority to health care expenditures which stabilize and secure production and income. Households worked very hard to find the money for treatment of an ill but productive household member, whereas little effort was expended for treatment of illness among the very young or the old. Findings did not support gender discrimination in use of health care. Productivity among Burkina Faso women was as high as among men. Four other theories that might explain allocation of household resources to health care were dismissed as unsupported or unlikely. These theories include hypotheses about 1) the lack of information about the availability and effectiveness of health services for children; 2) cultural influences that interfere with modern medical care (Caldwell); 3) child fostering (Bledsoe, Ewbank, and Isiugo-Abanihe); and 4) maternal employment (Basu). Findings suggest that government health strategies might focus on reducing household costs of health care for children and/or adults or on insurance benefits. A better understanding of household priorities might yield better policies.

Seasonal variations of household costs of illness in Burkina Faso.

This paper assesses the seasonal variations of the time and financial costs of illness for rural households in Burkina Faso. It is based on a multiple round survey of 566 households, which included a time allocation study. The economic parameters of households which influence health seeking behavior changed substantially between the dry and rainy seasons: revenues fell in the rainy season and were exceeded by expenditures. Household production was at its peak in the rainy season resulting in significantly higher opportunity costs of time. At the same time illness perception changed: in the rainy season, significantly fewer illness episodes were perceived, and of those, the proportion perceived as severe decreased over-proportionally. Households shifted their healer choice in the rainy season away from high cost treatment, such as the hospital and dispensary, to low cost home treatment. For all these reasons, households incurred significantly fewer costs of illness in the rainy season (27% of dry season costs). Household health care expenditures were reduced to 1/6 of dry season levels, the time costs incurred by healthy household members to tend to the sick was reduced to 1/5 and the time costs of work incapacity due to sickness fell to about 1/2 of dry season levels. The authors stress the need to carry out research in all relevant seasons when studying health seeking behavior and the household costs of illness in order to avoid serious seasonal bias. They suggest policy options to increase health care utilization in the rainy season by reducing the financial and time costs of access to health care. Finally, the authors put forward a hypothesis to be tested by future research: They argue that the cognitive (changes in illness perception) and behavioral changes (different health care seeking) reflect the high opportunity costs of time and the low availability of cash households face during the rainy season. The paper discusses the negative implication that untreated illness has on the health status of household members.

The economic costs of illness for rural households in Burkina Faso.

Analyses of the health costs in developing countries have mainly dealt with provider costs. This is in spite of the fact that the bulk of illness related costs is borne by households. Where studied, household time and financial costs have not been treated in a comprehensive way. However, an incomplete cost assessment will lead to an underestimation of household costs. Using data from a household interview survey in a rural area of Burkina Faso, the authors carried out an exhaustive assessment of the economic cost of illness that households incur. Financial costs included out-of-pocket expenditures for drugs, fees, transport to the treatment site, lodging and food for accompanying household members. Time costs, in turn, were comprised of production foregone both by the sick person and by healthy household members, who tended to the sick. Time costs amounted to by far the largest proportion (73%) of total household costs. Of the total amount of illness related time loss of the average household, 45% was due to the fact that healthy household members tended to or accompanied their sick kin. Of the financial cost items, expenditures for drugs or traditional products represented 62%. When Western type services were sought, expenditures for transport, food etc., exceeded those for treatment fees. Total cost of illness was 4,002 F CFA/month for the average household. This amounted to 3.7% of household income and to 6.2% of household expenditures in the reference month. The authors discuss policy measures aimed to reduce household time costs.(ABSTRACT TRUNCATED AT 250 WORDS)

The elasticity of demand for health care in Burkina Faso: differences across age and income groups.

Like many other developing countries, Burkina Faso has been exploring how community resources can be tapped to co-finance health services. Although revenue generation is important for the viability of health services, effects on utilization and on equity of access to health care must also be considered. The authors present a logistic regression model to derive price elasticities of demand for health care based on cross-sectional survey data. While demand for health care appears inelastic overall (-0.79), subgroup analysis reveals differences in elasticity across age and income groups. Elasticities of demand for infants and children (-3.6 and -1.7) and for the lowest income quartile (-1.4) are substantially greater than overall elasticity. The method used is unusual in that it allows estimation of elasticities before the introduction of user fees. This increases the value of the information to policy makers.

Estimating the direct and indirect economic costs of malaria in a rural district of Burkina Faso.

Comprehensive estimates of the direct economic costs of malaria should include not only the costs of care at established health facilities, but also other expenditures, such as travel and out-of-pocket costs of drugs. They should include all episodes of illness, whether or not the patient attended a health facility. Also, the indirect economic costs, which are based on the value of time lost due to illness, consider seasonal variations in the marginal product of labor according to the agricultural season. A 1985 representative survey of 626 households in Solenzo medical district, Burkina Faso, provided household data on health service utilization, expenditures, and agricultural production with which to implement these refinements. Numbers of malaria deaths and cases were estimated by adjusting survey totals according to monthly patterns of reported malaria deaths. The marginal product of labor was valued according to typical activities in each of three agricultural seasons: brewing millet beer during the maintenance period (January-February), growing cotton during the cash crop season (March-April), and growing millet and sorghum during the food crop season (May-December). The resulting values were $0.28, $1.09, and $0.55 per day, respectively. Cost per case averaged $5.96 and cost per capita $1.15. Indirect cost due to mortality was the largest cost component ($0.79 per capita), followed by direct costs incurred by the user (e.g. transportation costs and drug purchases, $0.22 per capita). Direct costs paid by providers were small, only $0.04 per capita. A household survey provides the necessary data for more comprehensive population-based estimates of costs of malaria.

[Environment, public health and health education in Burkina-Faso (child-to-child program)]. / Environnement, santé publique et éducation sanitaire au Burkina-Faso (programme l'enfant pour l'enfant).

The environmental factors influence the health status at individual and community level. This seems to be more important in tropical countries. This, in developing and specially in tropical countries, public health activities are more concerned with environmental factors. It is well known that in a community, mothers and children are more "at risk". Environmental factors influence child health status at different developmental stages. Several studies have proved the impact of mothers and community education on their health status. Thus mothers and adults education are important to improve child health. However, it became evident that a direct education of the child has also an impact. "Child to child program" is an active and participative educational approach. This report is about child activities related to environmental factors. These activities are promoted by our Association involving health workers, teachers, social workers in Burkina-Faso (west Africa).

Assessment of MCH services in the district of Solenzo, Burkina Faso. II. Acceptability.

Acceptability of professional MCH services in the district of Solenzo was assessed using the techniques of time and motion study combined with a user survey of attending mothers. A large proportion of mothers said to have difficulty in using the services. Three types of problems were identified and their relevance discussed: (i) wasting mothers' time through inappropriate opening hours, long waiting time in contrast with short contact time; (ii) organizational features, i.e. fragmentation of clinics offering single MCH components at different times; and (iii) staff behaviour, i.e. poor communication with users. While services do little to help mothers to utilize them, mothers were shown to receive little support in their work at home from their families while attending the clinic. Possible ways to increase acceptability of MCH care are outlined.

Assessment of MCH services offered by professional and community health workers in the district of Solenzo, Burkina Faso. I. Utilization of MCH services.

A representative household survey of a district of Burkina Faso was carried out in order to study the utilization of trained birth attendants (TBA) versus professional health workers as providers of under fives' (UFC), antenatal (ANC), and maternity care (MC). Overall utilization by the target groups varied between 13 per cent (UFC), 31 per cent (ANC), and 32 per cent (MC). The presence of a village health post did not increase utilization of MCH care. Furthermore, those who did utilize, preferred to choose another source of care: the professional midwife for ANC, the traditional 'old woman' for delivery. Sick infants were generally not taken to the village health worker (VHW), but rather treated by the family itself. The determinants of utilization were assessed by means of multivariate analysis. The level of care offered in the village (health post, dispensary, and medical centre), educational level of both the mother and the husband, and ethnic group were identified as major factors influencing health seeking behaviour in MCH. A strong case is made for improvement of quality of care before extension of geographical coverage. The importance of involving husbands in sensitization for the utilization of MCH-care is stressed and the implications are discussed for the role of the community health workers in caring for mothers and children.

Assessment of MCH services in the district of Solenzo, Burkina Faso. III. Effectiveness of MCH services in detecting of and caring for mothers and children at risk.

A time and motion study was carried out in all five professional MCH-facilities in the study area. The chain of decision making process--from (i) collecting information, (ii) interpreting it as indicating risk to (iii) action--was followed while taking care not to interfere with it. At each step specific shortcomings were identified: a great number of commonly accepted risk factors was not looked for (e.g. outcome of previous pregnancies in a woman in labour). On the other hand, information indicating risk was collected, but not recognized as such (e.g. weight loss). The most striking feature of both under fives' (UFC), antenatal clinics (ANC) and maternity care was the consistent lack of any action taken as a consequence of a recognized risk factor. The possible underlying causes for the poor functioning of the risk approach in the studied peripheral services are discussed: (i) implementation failure, (ii) inappropriateness of cut-off points for risk definition leading to an unmanageably great proportion of risk clients, and (iii) a conceptual problem, i.e. the reluctance of the auxiliary staff as well as the patients to act on the basis of risk prediction, i.e. something that has not yet happened.

Low utilization of community health workers: results from a household interview survey in Burkina Faso.

A representative household survey was carried out in order to study the utilization of community health workers (CHW) in relation to other sources of health care. We found three main results: (1) For mild diseases, villagers consulted their CHW only in 8.8% of mild diseases, in 69% the family remained the main provider of primary care. (2) In the case of serious diseases, which the CHW was supposed to identify and refer, the villagers bypassed the CHW in 96.5%. The professional health worker were consulted directly in the majority of serious disease. (3) Sick infants were not taken to the CHW for treatment. (4) No pattern of referral between professional and CHWs could be traced. Severity of disease and perceived effectiveness of the treatment were the most important determinants of health seeking behavior. Availability, distance, and cost of travel and drugs were important service related determinants. Individual and household characteristics such as income, ethnicity, and household size were only weakly associated with choice of curative care. Reasons for the low utilization of CHWs are outlined and policy implications discussed.