Abolishing Fees at Health Centers in the Context of Community Case Management of Malaria: What Effects on Treatment-Seeking Practices for Febrile Children in Rural Burkina Faso?
BACKGROUND
Burkina Faso started nationwide community case management of malaria (CCMm) in 2010. In 2011, health center user fees for children under five were abolished in some districts.


OBJECTIVE
To assess the effects of concurrent implementation of CCMm and user fees abolition on treatment-seeking practices for febrile children.


METHODS
This is a natural experiment conducted in the districts of Kaya (CCMm plus user fees abolition) and Zorgho (CCMm only). Registry data from 2005 to 2014 on visits for malaria were collected from all eight rural health centers in the study area. Annual household surveys were administered during malaria transmission season in 2011 and 2012 in 1,035 randomly selected rural households. Interrupted time series models were fitted for registry data and Fine and Gray's competing risks models for survey data.


RESULTS
User fees abolition in Kaya significantly increased health center use by eligible children with malaria (incidence rate ratio for intercept change = 2.1, p <0.001). In 2011, in Kaya, likelihood of health center use for febrile children was three times higher and CHW use three times lower when caregivers knew services were free. Among the 421 children with fever in 2012, the delay before visiting a health center was significantly shorter in Kaya than in Zorgho (1.46 versus 1.79 days, p <0.05). Likelihood of visiting a health center on the first day of fever among households <2.5 km or <5 km from a health center was two and three times higher in Kaya than in Zorgho, respectively (p <0.001).


CONCLUSIONS
User fees abolition reduced visit delay for febrile children living close to health centers. It also increased demand for and use of health center for children with malaria. Concurrently, demand for CHWs' services diminished. User fees abolition and CCMm should be coordinated to maximize prompt access to treatment in rural areas.
School of Public Health, University of Montreal, 7101 avenue du Parc, Montréal, Québec, H3N 1X9, Canada; University of Montreal Hospital Research Centre, 850 rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.
Thomas
T
Druetz
University of Montreal Hospital Research Centre, 850 rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.
Federica
F
Fregonese
Biomedical and Public Health Department, Institut de Recherche en Sciences de la Santé, Ouagadougou 03 BP 7192, Burkina Faso.
Aristide
A
Bado
Biomedical and Public Health Department, Institut de Recherche en Sciences de la Santé, Ouagadougou 03 BP 7192, Burkina Faso.
Tieba
T
Millogo
Biomedical and Public Health Department, Institut de Recherche en Sciences de la Santé, Ouagadougou 03 BP 7192, Burkina Faso.
Seni
S
Kouanda
Laval University Medical Research Center (CHUQ), Saint-Sacrement Hospital, 1050, chemin Sainte-Foy, Québec, Québec, G1S 4L8, Canada.
Souleymane
S
Diabaté
Laval University Medical Research Center (CHUQ), Saint-Sacrement Hospital, 1050, chemin Sainte-Foy, Québec, Québec, G1S 4L8, Canada; Faculty of Medicine, Laval University, 1050 avenue de la Médecine, Québec, Québec, G1V 0A6, Canada.
Slim
S
Haddad
D000293:Adolescent; D000962:Antimalarials / Q000627:therapeutic use; D002050:Burkina Faso; D019090:Case Management / Q000191:economics* / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D005249:Fees and Charges; D005260:Female; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008288:Malaria / Q000188:drug therapy*; D008297:Male; D012424:Rural Population
D000962:Antimalarials