Druetz Thomas, Fregonese Federica, Bado Aristide, Millogo Tieba, Kouanda Seni, Diabaté Souleymane, Haddad Slim
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.
University of Montreal Hospital Research Centre, 850 rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.
PLoS One. 2015 Oct 26;10(10):e0141306. doi: 10.1371/journal.pone.0141306. eCollection 2015.
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.
To assess the effects of concurrent implementation of CCMm and user fees abolition on treatment-seeking practices for febrile children.
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.
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).
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.
布基纳法索于2010年开始在全国范围内开展疟疾社区病例管理（CCMm）。2011年，一些地区取消了五岁以下儿童在卫生中心的就诊费用。
评估同时实施CCMm和取消就诊费用对发热儿童寻求治疗行为的影响。
这是一项在卡亚区（CCMm加上取消就诊费用）和佐尔戈区（仅CCMm）进行的自然实验。收集了研究区域内所有八个农村卫生中心2005年至2014年疟疾就诊的登记数据。在2011年和2012年疟疾传播季节，对1035个随机选择的农村家庭进行了年度家庭调查。对登记数据拟合中断时间序列模型，对调查数据拟合Fine和Gray竞争风险模型。
卡亚区取消就诊费用显著增加了符合条件的疟疾儿童对卫生中心的利用（截距变化的发病率比=2.1，p<0.001）。2011年在卡亚区，当照顾者知道服务免费时，发热儿童使用卫生中心的可能性高出三倍，而使用社区卫生工作者服务的可能性低三倍。在2012年的421名发热儿童中，卡亚区儿童前往卫生中心就诊前的延迟时间明显短于佐尔戈区（1.46天对1.79天，p<0.05）。距离卫生中心<2.5公里或<5公里的家庭中，发热第一天前往卫生中心就诊的可能性在卡亚区分别比佐尔戈区高出两倍和三倍（p<0.001）。
取消就诊费用减少了居住在卫生中心附近的发热儿童的就诊延迟。它还增加了疟疾儿童对卫生中心的需求和利用。同时，对社区卫生工作者服务的需求减少。应协调取消就诊费用和CCMm，以最大限度地提高农村地区及时获得治疗的机会。
