Understanding patients' experience living with diabetes type 2 and effective disease management: a qualitative study following a mobile health intervention in Bangladesh.

BACKGROUND: In 2017, 425 million adults worldwide had diabetes; 80% were living in low and middle-income countries. Bangladesh had 6.9 million adults with diabetes; death from diabetes comprised 3% of the country's total mortality. This study looked at different factors (personal, familial, social, and financial) affecting both the life of patients with diabetes type 2 and the management of the disease. It also explored patient's perception of the mobile health intervention in the context of disease management and helped to explain the findings obtained from the quantitative part of this study. METHOD: The study was a mixed-method, sequential explanatory design. A mobile health project (interactive voice call and call center) was implemented in Dhaka district, Bangladesh from January to December, 2014. Patients received treatment at the outpatient department of Bangladesh Institute of Health Science Hospital, Dhaka, Bangladesh, were included in intervention and control groups of the main study following a Randomized Control Trial. Among them, a total of 18 patients (9 + 9) were selected purposefully for the qualitative study, which was conducted in July, 2015. The sample was selected purposefully considering the age, sex, socio-economic status and proximity of living due to the political instability of the country during the data collection period. The interviews were transcribed and analyzed applying investigator triangulation. RESULTS: Most patients stated that diabetes has affected their lives. In general, both groups´ evaluation of mobile health services were good and both regarded the recommendations for medication, diet, physical exercise, and other lifestyle behaviors (use of tobacco and betel nuts) as helpful. The cost of overall treatment (medications, physician consultations, laboratory investigations), the lack of availability of safe public places for physical exercise and unfavorable weather conditions (heat, rainfall) were mentioned as barriers to the overall management of the disease. CONCLUSION: A patient-centered mobile health intervention supported by a collaborative patient-provider relationship, a strong family support system, available public spaces for exercise and the introduction of a functional public health insurance system could be beneficial for the better management of diabetes.

Positive influence of short message service and voice call interventions on adherence and health outcomes in case of chronic disease care: a systematic review.

BACKGROUND: Chronic diseases have emerged as a serious threat for health, as well as for global development. They endenger considerably increased health care costs and diminish the productivity of the adult population group and, therefore, create a burden on health, as well as on the global economy. As the management of chronic diseases involves long-term care, often lifelong patient adherence is the key for better health outcomes. We carried out a systematic literature review on the impact of mobile health interventions -mobile phone texts and/or voice messages- in high, middle and low income countries to ascertain the impact on patients' adherence to medical advice, as well as the impact on health outcomes in cases of chronic diseases. METHODS: The review identified fourteen related studies following the defined inclusion and exclusion criteria, in PubMed, Cochrane Library, the Library of Congress, and Web Sciences. All the interventions were critically analysed according to the study design, sample size, duration, tools used, and the statistical methods used for analysing the primary data. Impacts of the different interventions on outcomes of interest were also analysed. RESULTS: The findings showed evidence of improved adherence, as well as health outcomes in disease management, using mobile Short Message Systems and/or Voice Calls. Significant improvement has been found on adherence with taking medicine, following diet and physical activity advice, as well as improvement in clinical parameters like HbA1c, blood glucose, blood cholesterol and control of blood pressure and asthma. CONCLUSIONS: Though studies showed positive impacts on adherence and health outcomes, three caveats should be considered, (i) there was no clear understanding of the processes through which interventions worked; (ii) none of the studies showed cost data for the m-health interventions and (iii) only short term impacts were captured, it remains unclear whether the effects are sustained. More research is needed in these three areas before drawing concrete conclusions and making suggestions to policy makers for further decision and implementation.

Establishing sustainable performance-based incentive schemes: views of rural health workers from qualitative research in three sub-Saharan African countries.

INTRODUCTION: Performance-based incentives (PBIs) are currently receiving attention as a strategy for improving the quality of care that health providers deliver. Experiences from several African countries have shown that PBIs can trigger improvements, particularly in the area of maternal and neonatal health. The involvement of health workers in deciding how their performance should be measured is recommended. Only limited information is available about how such schemes can be made sustainable. This study explored the types of PBIs that rural health workers suggested, their ideas regarding the management and sustainability of such schemes, and their views on which indicators best lend themselves to the monitoring of performance. In this article the authors reported the findings from a cross-country survey conducted in Burkina Faso, Ghana and Tanzania. METHODS: The study was exploratory with qualitative methodology. In-depth interviews were conducted with 29 maternal and neonatal healthcare providers, four district health managers and two policy makers (total 35 respondents) from one district in each of the three countries. The respondents were purposively selected from six peripheral health facilities. Care was taken to include providers who had a management role. By also including respondents from district and policy level a comparison of perspectives from different levels of the health system was facilitated. The data that was collected was coded and analysed with support of NVivo v8 software. RESULTS: The most frequently suggested PBIs amongst the respondents in Burkina Faso were training with per-diems, bonuses and recognition of work done. The respondents in Tanzania favoured training with per-diems, as well as payment of overtime, and timely promotion. The respondents in Ghana also called for training, including paid study leave, payment of overtime and recognition schemes for health workers or facilities. Respondents in the three countries supported the mobilisation of local resources to make incentive schemes more sustainable. There was a general view that it was easier to integrate the cost of non-financial incentives in local budgets. There were concerns about the fairness of such schemes from the provider level in all three countries. District managers were worried about the workload that would be required to manage the schemes. The providers themselves were less clear about which indicators best lent themselves to the purpose of performance monitoring. District managers and policy makers most commonly suggested indicators that were in line with national maternal and neonatal healthcare indicators. CONCLUSIONS: The study showed that health workers have considerable interest in performance-based incentive schemes and are concerned about their sustainability. There is a need to further explore the use of non-financial incentives in PBI schemes, as such incentives were considered to stand a greater chance of being integrated into local budgets. Ensuring participation of healthcare providers in the design of such schemes is likely to achieve buy-in and endorsement from the health workers involved. However, input from managers and policy makers is essential to keep expectations realistic and to ensure the indicators selected fit the purpose and are part of routine reporting systems.

Maternal and newborn healthcare providers in rural Tanzania: in-depth interviews exploring influences on motivation, performance and job satisfaction.

INTRODUCTION: Major improvements in maternal and neonatal health (MNH) remain elusive in Tanzania. The causes are closely related to the health system and overall human resource policy. Just 35% of the required workforce is actually in place and 43% of available staff consists of lower-level cadres such as auxiliaries. Staff motivation is also a challenge. In rural areas the problems of recruiting and retaining health staff are most pronounced. Yet, it is here that the majority of the population continues to reside. A detailed understanding of the influences on the motivation, performance and job satisfaction of providers at rural, primary level facilities was sought to inform a research project in its early stages. The providers approached were those found to be delivering MNH care on the ground, and thus include auxiliary staff. Much of the previous work on motivation has focused on defined professional groups such as physicians and nurses. While attention has recently broadened to also include mid-level providers, the views of auxiliary health workers have seldom been explored. METHODS: In-depth interviews were the methodology of choice. An interview guideline was prepared with the involvement of Tanzanian psychologists, sociologists and health professionals to ensure the instrument was rooted in the socio-cultural setting of its application. Interviews were conducted with 25 MNH providers, 8 facility and district managers, and 2 policy-makers. RESULTS: Key sources of encouragement for all the types of respondents included community appreciation, perceived government and development partner support for MNH, and on-the-job learning. Discouragements were overwhelmingly financial in nature, but also included facility understaffing and the resulting workload, malfunction of the promotion system as well as health and safety, and security issues. Low-level cadres were found to be particularly discouraged. Difficulties and weaknesses in the management of rural facilities were revealed. Basic steps that could improve performance appeared to be overlooked. Motivation was generally referred to as being fair or low. However, all types of providers derived quite a strong degree of satisfaction, of an intrinsic nature, from their work. CONCLUSIONS: The influences on MNH provider motivation, performance and satisfaction were shown to be complex and to span different levels. Variations in the use of terms and concepts pertaining to motivation were found, and further clarification is needed. Intrinsic rewards play a role in continued provider willingness to exert an effort at work. In the critical area of MNH and the rural setting many providers, particularly auxiliary staff, felt poorly supported. The causes of discouragement were broadly divided into those requiring renewed policy attention and those which could be addressed by strengthening the skills of rural facility managers, enhancing the status of their role, and increasing the support they receive from higher levels of the health system. Given the increased reliance on staff with lower-levels of training in rural areas, the importance of the latter has never been greater.

Does recent contact with a health care provider make a difference in malaria knowledge?

Knowledge and practices with respect to malaria are aspects that need to be considered as part of effective malaria programs. We assessed and compared malaria practices and knowledge among those who had recently visited a health care provider and those who had not. A matched, population-based case-control study was conducted among 338 women between 15 and 45 years of age and caretakers of children ≤ 9 years of age in Nouna, Burkina Faso. Little difference was found in the reported responses between the cases and controls, which indicates that recent visits to health care providers may not have an effect on malaria risk or knowledge. Differences were noted in malaria practices, which could suggest that health care providers are consulted only after home treatments fail. Therefore, programs and policies targeted to health care providers aimed at improving the dissemination of information may be of some benefit.

Clinical diagnosis of malaria and the risk of chloroquine self-medication in rural health centres in Burkina Faso.

OBJECTIVE: To assess the quality of healthcare workers' performance with regard to malaria diagnosis and treatment and to assess patients' self-medication with chloroquine (CQ) before and after presentation at a health centre. METHODS: In the rainy season 2004, in five rural dispensaries in Burkina Faso, we observed 1101 general outpatient consultations and re-examined all these patients. CQ whole blood concentrations of confirmed malaria cases were measured before and after treatment. RESULTS: The clinical diagnosis based on fever and/or a history of fever had a sensitivity of 75% and a specificity of 41% when compared to confirmed malaria (defined as an axillary temperature of >/=37.5 degrees C and/or a history of fever and parasites of any density in the blood smear). Few febrile children under 5 years of age were assessed for other diseases than malaria such as pneumonia. No antimalarial was prescribed for 1.3% of patients with the clinical diagnosis malaria and for 24% of confirmed cases, while 2% received an antimalarial drug prescription without the corresponding clinical diagnosis. CQ was overdosed in 22% of the prescriptions. Before and 2 weeks after consultation, 25% and 46% respectively of the patients with confirmed malaria had potentially toxic CQ concentrations. CONCLUSION: As long as artemisinin-based combination therapy remains unavailable or unaffordable for most people in rural areas of Burkina Faso, self-medication with and prescription of CQ are likely to continue despite increasing resistance. Apart from considering more pragmatic first-line regimens for malaria treatment such as the combination of sulfadoxine-pyrimethamine with amodiaquine, more and better training on careful clinical management of febrile children including an appropriate consideration of other illnesses than malaria should be made available in the frame of the IMCI initiative in sub-Saharan Africa.

Clustering of childhood mortality in rural Burkina Faso.

BACKGROUND: Childhood mortality is a major public health problem in sub-Saharan Africa. For the implementation of efficient public health systems, knowledge of the spatial distribution of mortality is required. METHODS: Data from a demographic surveillance research project were analysed which comprised information obtained for about 30 000 individuals from 39 villages in northwest Burkina Faso (West Africa) in the period 1993--1998. Total childhood mortality rates were calculated and the geographical distribution of total childhood mortality was investigated. In addition, data from a cohort of 686 children sampled from 16/39 of the villages followed up during a randomized controlled trial in 1999 were also used to validate the results from the surveillance data. A spatial scan statistic was used to test for clusters of total childhood mortality in both space and time. RESULTS: Several statistically significant clusters of higher childhood mortality rates comprising different sets of villages were identified; one specific village was consistently identified in both study populations indicating non-random distribution of childhood mortality. Potential risk factors which were available in the database (ethnicity, religion, distance to nearest health centre) did not explain the spatial pattern. CONCLUSION: The findings indicate non-random clustering of total childhood mortality in the study area. The study may be regarded as a first step in prioritizing areas for follow-up public health efforts.

Measuring the local burden of disease. A study of years of life lost in sub-Saharan Africa.

BACKGROUND: An effective health policy necessitates a reliable characterization of the burden of disease (BOD) by cause. The Global Burden of Disease Study (GBDS) aims to deliver this information. For sub-Saharan Africa (SSA) in particular, the GBDS relies on extrapolations and expert guesses. Its results lack validation by locally measured epidemiological data. METHODS: This study presents locally measured BOD data for a health district in Burkina Faso and compares them to the results of the GBDS for SSA. As BOD indicator, standard years of life lost (age-weighted YLL, discounted with a discount rate of 3%) are used as proposed by the GBDS. To investigate the influence of different age and time preference weights on our results, the BOD pattern is again estimated using, first, YLL with no discounting and no age-weighting, and, second, mortality figures. RESULTS: Our data exhibit the same qualitative BOD pattern as the GBDS results regarding age and gender. We estimated that 53.9% of the BOD is carried by men, whereas the GBDS reported this share to be 53.2%. The ranking of diseases by BOD share, though, differs substantially. Malaria, diarrhoeal diseases and lower respiratory infections occupy the first three ranks in our study and in the GBDS, only differing in their respective order. Protein-energy malnutrition, bacterial meningitis and intestinal nematode infections occupy ranks 5, 6 and 7 in Nouna but ranks 15, 27 and 38 in the GBDS. The results are not sensitive to the different age and time preference weights used. Specifically, the choice of parameters matters less than the choice of indicator. CONCLUSIONS: Local health policy should rather be based on local BOD measurement instead of relying on extrapolations that might not represent the true BOD structure by cause.

Household strategies to cope with the economic costs of illness.

The authors examine the strategies rural households in Burkina Faso used to cope with the costs of illness in order to avert negative effects for household production and assets. They use information from 51 qualitative interviews, a household time allocation study and a household survey. Both surveys use the same sample of n = 566 households. The authors analyze these strategies along four dimensions: the type of behavior, the sequence in which strategies employed, the level at which strategies are negotiated, i.e. the household level, the non-household extended kin level or the community level, and finally the success of strategies in protecting household production and assets. A taxonomy of 11 distinct types of coping behavior is developed which have the effect of either avoiding costs by 'ignoring' disease, or of minimizing the impact of costs on the household once illness is perceived. Intra-household labor substitution was the main strategy to compensate for any labor lost to illness. However, labor substitution did not eliminate production losses in the majority of households struck with severe illness of a productive member. Only wealthy household were able to fully compensate labor losses by hiring labor or by investing in equipment to enhance productivity. Sales of livestock was the main strategy to cope with the financial costs of health care. None of the households studied fell into calamity. However, the households' ability to avert the loss of production and/or assets was very varied and depended on household size, composition and assets, on the type and duration of illness and on clustering of crises (e.g. several repetitive or simultaneous illnesses or concurrent seasonal stress). Coping with the costs of illness largely occurred at the level of the household. Inter-household transfers of resources played only a small role. The authors develop the concept of risk households and suggest several policies with the potential to strengthen the ability of households to cope with the economic costs of illness.

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.

Recovery of recurrent health service costs through provincial health funds in Cameroon.

This article describes the Provincial Health Funds pioneered in two Provinces of Cameroon. These funds are non-profit associations and financed by the community through drug fees and--to a lesser extent--through fees for services. The financial objective of the Funds is the full coverage of both the costs of the drug supply and the recurrent non-salary costs of the entire public health services in the province. In addition the funds are channels for community participation in the management and improvement of health services. Following a discussion of the institutional and legal framework, the paper examines the cost recovery targets and the mark-up necessary to achieve them. Comparison is made with mark-up and prices of private for-profit pharmacies. In its third year of operation, the Fund currently covers 62% of recurrent health service costs, up from 22% in the first year. With increasing number of health centers joining the fund full coverage of recurrent costs is projected to occur at the earliest in year four of operations. The authors argue that the appropriate role of donor assistance is not only to finance investment but also to subsidize recurrent costs, until the fund has reached its optimal anticipated size, thus realizing economies of scale. While the final word on sustainability can only be said years after the funds have reached their final size, the consistent trend towards full cost recovery is encouraging.

Utilization of health care in an African urban area: results from a household survey in Ouagadougou, Burkina-Faso.

This study analysed the level of utilization of different kinds of health care providers, and its correlates, by people reporting an illness via a household health survey in a representative sample of 547 households (3667 persons) in the city of Ouagadougou, Burkina-Faso in 1989. More than one-fourth of the sample reported suffering from a health care problem in the 2-week period preceding the interview. Self care was the most frequently reported type of care received (55.6%). Bivariate analysis and logistic regression revealed that the principal determinants of the utilization of modern care givers were age, socio-economic level, illness characteristics (type, length, severity), and cost of care and transportation. In particular, we found that: (1) Even though the family remained the main provider of care in case of minor (mild and short) illnesses, it did not prevent modern health facilities from playing their curative role in case of serious illnesses. (2) Residential zone (central versus peripheral zone) was not significantly associated with health care choice, which was contrary to expectation. (3) On the other hand, socio-economic status strongly affected health-seeking behavior. (4) The travel pattern of the ill persons favored health carde facilities in the central zone. Taken together, the results of this study question the role of community health workers in the urban program of community health care which was in the process of being implemented at the time of the study. They suggest that the family, instead of the community health workers, should be seen as the provider of curative care for minor illnesses. Community health workers may have a more effective role in health education than in curative tasks.

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 role of research in a technical assistance agency: the case of the 'German Agency for Technical Co-operation'.

Technical assistance agencies have a sustainable impact on the health systems of the countries they are operating in. As well as policy-makers at the national level, technical assistance agencies see themselves confronted that their interventions should be based on evidence, usually meaning the results of research. This study has the aim to analyse role of research in the implementation of technical assistance. We sent a questionnaire to all health project managers of the 'German Agency for Technical Co-operation' and performed a qualitative case study in one of the health projects. Forty-seven of 80 (58.8%) of the questionnaires were completed and sent back. The managers considered publications of International Organisations (IOs), scientific articles and local research as most important for their work. The case study showed application problems in the daily work. Research use not only depends on the relevance of the data but also on analytical skills, linguistic barriers and technical access to research by the potential users. The role of knowledge and information management has to be clearly defined in an organisation of technical assistance. The specific needs at the different levels have to be analysed so that skills and resources can be allocated adequately.

Gender and willingness to pay for insecticides treated bed nets in a poor rural area in Tanzania.

OBJECTIVE: To examine socio-economic and malaria related differences between males and females that may cause gender differences in willingness to pay (WTP) for insecticide treated bed nets in a poor rural area. DESIGN: A two-week-interval (test re-test) cross-sectional study. SETTING: Kisarawe District in coastal Tanzania. SUBJECTS: Two hundred and fifty one males and two hundred dollars females were interviewed. RESULTS: Females had about 50% of the males' income. The monthly average income was about US dollars 10.50 for females and US dollars 20.20 for males. The proportion of respondents willing to pay for an ITN, for both males and females, declined as the ITN prices increased (P<0.05). The mean maximum WTP difference between men and women, between both rounds were not statistically significant (p>0.05). Male respondents reported a higher mean number of own underfives living in the household compared to women, the difference was not statistically significant (P>0.8). Willingness to pay for ITN was found to be independent of having an under five child with recent history of malaria. Among both males and females, there was an association between a recent experience with malaria episode and WTP, p=0.05 and p=0.02 respectively. Among females, the proportion of those willing to pay for another person, at the lowest ITN price, was significantly higher in those with under five children in their households than in those with no underfives. This was not the case among the male respondents as the association was not statistically significant. CONCLUSION: Contrary to expectations were was no statistically significant difference in WTP for an ITN between females and males. Further studies that link willingness and ability to pay are required in rural poor population, such studies may be valuable inputs to government policy on and planning of ITN interventions in the public and private sector.

Biomass smoke in Burkina Faso: what is the relationship between particulate matter, carbon monoxide, and kitchen characteristics?

In Burkina Faso where cooking with biomass is very common, little information exists regarding kitchen characteristics and their impact on air pollutant levels. The measurement of air pollutants such as respirable particulate matter (PM10), an important component of biomass smoke that has been linked to adverse health outcomes, can also pose challenges in terms of cost and the type of equipment needed. Carbon monoxide could potentially be a more economical and simpler measure of air pollution. The focus of this study was to first assess the association of kitchen characteristics with measured PM10 and CO levels and second, the relationship of PM10 with CO concentrations, across these different kitchen characteristics in households in Nouna, Burkina Faso. Twenty-four-hour concentrations of PM10 (area) were measured with portable monitors and CO (area and personal) estimated using color dosimeter tubes. Data on kitchen characteristics were collected through surveys. Most households used both wood and charcoal burned in three-stone and charcoal stoves. Mean outdoor kitchen PM10 levels were relatively high (774 µg/m(3), 95 % CI 329-1,218 µg/m(3)), but lower than indoor concentrations (Satterthwaite t value, -6.14; p < 0.0001). In multivariable analyses, outdoor kitchens were negatively associated with PM10 (OR = 0.06, 95 % CI 0.02-0.16, p value <0.0001) and CO (OR = 0.03, 95 % CI 0.01-0.11, p value <0.0001) concentrations. Strong area PM10 and area CO correlations were found with indoor kitchens (Spearman's r = 0.82, p < 0.0001), indoor stove use (Spearman's r = 0.82, p < 0.0001), and the presence of a smoker in the household (Spearman's r = 0.83, p < 0.0001). Weak correlations between area PM10 and personal CO levels were observed with three-stone (Spearman's r = 0.23, p = 0.008) and improved stoves (Spearman's r = 0.34, p = 0.003). This indicates that the extensive use of biomass fuels and multiple stove types for cooking still produce relatively high levels of exposure, even outdoors, suggesting that both fuel subsidies and stove improvement programs are likely necessary to address this problem. These findings also indicate that area CO color dosimeter tubes could be a useful measure of area PM10 concentrations when levels are influenced by strong emission sources or when used in indoors. The weaker correlation observed between area PM10 and personal CO levels suggests that area exposures are not as useful as proxies for personal exposures, which can vary widely from those recorded by stationary monitors.

Household risk factors for clinical malaria in a semi-urban area of Burkina Faso: a case-control study.

The risk of malaria can be influenced by the household environment. The range of these risks can be more diverse in semi-urban areas, which can include a mix of different housing styles and environments. This study examined the effect of different housing and household characteristics on malaria risk among 98 case and 185 control children in the semi-urban area of Nouna, Burkina Faso. Characteristics were assessed via questionnaires and direct inspection. Those characteristics associated with a decreased risk of malaria were floors constructed of earth bricks and running water in the neighbourhood. Electrification of the home and house age of <10 years were associated with an increased risk of malaria. The findings of this study suggest that modification of the household environment could be a feasible way to reduce the risk of malaria, particularly in semi-urban areas.

Using community wealth ranking to identify the poor for subsidies: a case study of community-based health insurance in Nouna, Burkina Faso.

Access to health-care is low in developing countries. Poor people are less likely to seek care than those who are better off. Community-based health insurance (CBI) aims to improve healthcare utilisation by removing financial barriers, unfortunately CBI has been less effective in securing equity than expected. Poor people, who probably require greater protection from catastrophic health expenses, are less likely to enrol in such schemes. Therefore, it is important to implement targeted interventions so that the most in need are not left out. CBI has been offered to a district in Burkina Faso, comprising 7762 households in 41 villages and the district capital of Nouna since 2004. Community wealth ranking (CWR) was used in 2007 to identify the poorest quintile of households who were subsequently offered insurance at half the usual premium rate. The CWR is easy to implement and requires minimal resources such as interviews with local informants. As used in this study, the agreement between the key informants was more (37.5%) in the villages than in Nouna town (27.3%). CBI management unit only received nine complaints from villagers who considered that some households had been wrongly identified. Among the poorest, the annual enrolment increased from 18 households (1.1%) in 2006 to 186 (11.1%) in 2007 after subsidies. CWR is an alternative methodology to identify poor households and was found to be more cost and time efficient compared to other methods. It could be successfully replicated in low-income countries with similar contexts. Moreover, targeted subsidies had a positive impact on enrolment.

Effectiveness of a community intervention on malaria in rural Tanzania - a randomised controlled trial.

BACKGROUND: Malaria infections are a major public health problem in Africa and prompt treatment is one way of controlling the disease and saving lives. METHODS: This cluster-randomised controlled community intervention conducted in 2003-2005 aimed at improving early malaria case management in under five children. Health workers were trained to train community-based women groups in recognizing malaria symptoms, providing first-line treatment for uncomplicated malaria and referring severe cases. Evaluation was through a pre- (2004) and a post-intervention survey (2005). Anaemia prevalence was the primary outcome. RESULTS: 1715 children aged 6-59 months were included in the pre-intervention survey and 2169 in the post-intervention survey. The prevalence of anaemia decreased significantly from 37% [95% CI 34.7-39.3] to 0.5% [95% CI 0.2-0.7] after the intervention (p<0.001); slightly more in the intervention (from 43.9% to 0.8%) than in the control (30.8% to 0.17%) group (p=0.038). Fever and reported fever decreased significantly and the mean body weight of the children increased significantly over the study period in both control and intervention groups. CONCLUSION: The decrease in anaemia was significantly associated with the intervention, whereas the fever and body weight trends might be explained by other malaria control activities or seasonal/climate effects in the area. The community intervention was shown to be feasible in the study context.

Using modelling to assess the risk of malarial infection during the dry season, on a local scale in an endemic area of rural Burkina Faso.

Mathematical modelling has been used to assess the level of malarial transmission, during the dry season, in Nouna province, in north-western Burkina Faso. The data used were collected, at four sites (one semi-urban and three rural), from 867 children aged 6-60 months who were randomly selected. Almost all of the children (850) completed the follow-up, which involved the active detection of malaria (i.e. febrile, smear-positive malarial infection) throughout a single dry season (December 2003-May 2004). Light traps were used to sample the local populations of Anopheles vectors, in order to estimate the daily biting rate. The mathematical model was then used to simulate the incidence of malaria, which was compared with the observed incidence. At all four study sites, new cases of malaria were observed throughout the dry season, although the level of transmission was low. The monthly incidence of malaria estimated using the mathematical model was very close to the observed incidence. The fit was sensitive to daily mosquito survival and daily human parasite clearance. In Nouna province, effective interventions to prevent malaria should not be confined to the rainy season but must continue throughout the year. The focus should be on the clearance of parasitaemias, by the use of effective drugs, and on decreasing vector survival, by the use of vector-control methods.