Health inequalities of children in sub-Saharan Africa from 1990 to 2010 : comparative analysis using data from Health and Demographic Surveys

Philosophiae Doctor - PhDThis study is based on the assumption that the under-five mortality rate, in recent decades, has declined, particularly in developing countries. However, all the social strata across many countries do not seem to benefit from this reduction of mortality - and mortality remains abnormally high among children especially those from underprivileged social strata. This research is, therefore, a holistic approach to analyse and quantify the inequalities of health among children under five in sub-Saharan Africa over the last two decades (1990-2010). The research sought to investigate the trend and determinants of health inequalities of under-five years (mortality and morbidity) in sub-Saharan Africa (SSA) from 1990 to 2010. An essential point has been devoted to the decomposition of effects and analysis of the contribution of the factors explaining these inequalities. The data used in the study come from Demographic and Heath Surveys (DHS) done between 1990 and 2015 in sub-Saharan Africa countries. In order to analyse the inequalities in trends of mortality and morbidity of children, different selected countries that have conducted at least three DHS during the 1990-2010 period. Several statistical methods were used for data analysis. There were four chapters which is prepared with an article style. For the first paper titled "Decomposing Inequalities in Under- Five Mortality in Selected African Countries", concentration index (CI) and Generalised Linear Model (GLM) with a logit link were used to analyse and measure under 5 mortality inequalities and the associated factors. This paper has been published in the Iranian Journal of Public Health. For the second paper titled "Determinants of Under-Five Mortality in Burkina Faso: A Concentration Dimension". The study used logistics regression and Oaxaca-Blinder decomposition method for the binary outcome to analyse data was involved. For data analysis of the third paper titled "Women Education, Health Inequalities in Under-Five Mortality in sub-Saharan Africa, 1990 – 2013", logistic regression and Bius's decomposition method were used to examine the effect of mother's education level on childhood mortality. In the fourth paper titled "Trends and Risk Factors for Childhood Diarrheal in sub-Saharan Countries (1990-2010): Assessing the Neighbourhood Inequalities", a multilevel logistic regression modelling was used to determine the fixed and random effects of the risk factors associated with the diarrheal morbidity. The work carried out during this on-going thesis helps to understand the magnitude of inequalities in under-five mortality in sub-Saharan countries. The findings showed that the contributing factors of inequalities of child mortality were birth order, maternal age, parity and household size. With regards to the relationship between mother's education level and inequalities in mortality of children under-five in sub-Saharan Africa, findings showed that children of mothers who did not attend school have a higher rate of death compared to those who had been to school. However, we have observed that the inequalities have narrowed over time. The results showed the risk factors of diarrheal morbidity varied from one country to another, but the main factors included: child's age, the size of the child at birth, the quality of the main floor material, mother's education and her occupation, type of toilet, and place of residence. In conclusion, the results of this study show that inequalities in under-five mortality are still important among different social strata in sub-Saharan Africa countries. It is then urgent to take actions to save the lives of children in disadvantaged social strata.National Research Foundatio

Trends and risk factors for childhood diarrhea in sub-Saharan countries (1990 2013): assessing the neighborhood inequalities

BACKGROUND: Diarrheal diseases are a major cause of child mortality and one of the main causes of medical consultation for children in sub-Saharan countries. This paper attempts to determine the risk factors and neighborhood inequalities of diarrheal morbidity among under-5 children in selected countries in sub- Saharan Africa over the period 1990 2013. DESIGN: Data used come from the Demographic and Health Survey (DHS) waves conducted in Burkina Faso (1992 93, 1998 99, 2003, and 2010), Mali (1995, 2001, 2016, and 2012), Nigeria (1990, 1999, 2003, 2008, and 2013), and Niger (1992, 1998, 2006, and 2012). Bivariate analysis was performed to assess the association between the dependent variable and each of the independent variables. Multilevel logistic regression modelling was used to determine the fixed and random effects of the risk factors associated with diarrheal morbidity. RESULTS: The findings showed that the proportion of diarrheal morbidity among under-5 children varied considerably across the cohorts of birth from 10 to 35%. There were large variations in the proportion of diarrheal morbidity across countries. The proportions of diarrheal morbidity were higher in Niger compared with Burkina Faso, Mali, and Nigeria. The risk factors of diarrheal morbidity varied from one country to another, but the main factors included the child's age, size of the child at birth, the quality of the main floor material, mother's education and her occupation, type of toilet, and place of residence. The analysis shows an increasing trend of diarrheal inequalities according to DHS rounds. In Burkina Faso, the value of the intraclass correlation coefficient (ICC) was 0.04 for 1993 DHS and 0.09 in 2010 DHS; in Mali, the ICC increased from 0.04 in 1995 to 0.16 in 2012; in Nigeria, the ICC increased from 0.13 in 1990 to 0.19 in 2013; and in Niger, the ICC increased from 0.07 in 1992 to 0.11 in 2012.IS

Push, pull, and push-back to land certification: regional dynamics in pilot certification projects in Côte d'Ivoire

Since 2000, many African countries have adopted land tenure reforms that aim at comprehensive land registration (or certification) and titling. Much work in political science and in the advocacy literature identifies recipients of land certificates or titles as 'programme beneficiaries', and political scientists have modelled titling programmes as a form of distributive politics. In practice, however, rural land registration programmes are often divisive and difficult to implement. This paper tackles the apparent puzzle of friction around rural land certification. We study Côte d'Ivoire's rocky history of land certification from 2004 to 2017 to identify political economy variables that may give rise to heterogeneous and even conflicting preferences around certification. Regional inequalities, social inequalities, and regional variation in pre-existing land tenure institutions are factors that help account for friction or even resistance around land titling, and thus the difficult politics that may arise around land tenure reform. Land certification is not a public good or a private good for everyone

Women's education and health inequalities in under-five mortality in selected sub-Saharan African countries, 1990–2015

The aim of the study was to analyse trends in the relationship between mother’s educational level and mortality of children under the year of five in Sub-Saharan Africa, from 1990 to 2015.Data used in this study came from different waves of Demographic and Health Surveys (DHS) of Sub-Saharan countries. Logistic regression and Buis’s decomposition method were used to explore the effect of mother’s educational level on the mortality of children under five years

Mothers' Preventive Health Care Practices and Children's Survival in Burkina Faso: Findings from Repeated Cross-sectional Household Surveys

The significant reduction in the level of child mortality in both developed and developing countries over recent decades has led to an improvement in children’s health. The implementation, monitoring, and evaluation of the health programs needed to reduce child mortality require determination and an understanding of the factors responsible for this reduction. This study investigated factors that have contributed to the recent improvement in the survival of children under five, focusing on the contribution of preventive health care in improving children's survival rates in Burkina Faso. The data used come from baseline and end-line surveys designed to evaluate the impact of performance-based financing (PBF) on health programs in Burkina Faso. Using time-series for health districts and child-level logistic regression models, we estimated the effect of preventive health care, as summarized by the changes in the composite coverage index (CCI), on under-five child survival of temporal trends and covariates at the household, maternal, and child levels. At the health district level, a unit increase in standardized CCI was associated with an improvement in under-five child survival after adjustment for survey period effects. The linear regression analysis showed that a standardized unit increase in CCI was associated with an increase in the percentage of children under five who survive. At the child level, the logistic regression showed that a skilled attendant at birth (SBA), wealth index, and mother's parity were associated with under-five children's survival, after adjustment for the survey period effects and a set of household, maternal, and child-level covariates. Preventive health care is important in improving under-five children's survival, whereas the effects of economic growth in Burkina Faso remain weak and inconsistent. Improved coverage of preventive health care interventions are likely to contribute to further reductions in under-five mortality in Burkina Faso

Factors associated with mothers’ health care‑seeking behaviours for childhood fever in Burkina Faso: Findings from repeated cross‑sectional household surveys

Fever is one of the most frequent reasons for paediatric consultations in Burkina Faso, but health careseeking behaviours and the factors associated with health care-seeking in the event of childhood fever are poorly documented. This study aims to analyse the health care-seeking behaviours and the factors associated with health care-seeking for childhood fever in Burkina Faso. This study used the data from the baseline and endline surveys conducted to evaluate the impact of the Performance-Based Financing program in Burkina Faso. Univariate and multivariate binary logistic regression analyses were used to identify the factors associated with appropriate healthcare-seeking for childhood fever. Odds ratios were estimated to assess the strength of associations and 95% confidence intervals (CIs) were used for significance tests. Data were cleaned, coded and analysed using Stata software version 16.1

Integration of postpartum care into child health and immunization services in Burkina Faso: Findings from a cross-sectional study

Background: The Missed Opportunities for Maternal and Infant Health (MOMI) project, which aimed at upgrading maternal and infant postpartum care (PPC), implemented a package of interventions including the integration of maternal PPC in infant immunization services in 12 health facilities in Kaya Health district in Burkina Faso from 2013 to 2015. This paper assesses the coverage and the quality of combined mother-infant PPC in reproductive, maternal, newborn and child health services (RMNCH).Methods: We conducted a mixed methods study with cross-sectional surveys before and after the intervention in the Kaya health and demographic surveillance system. On the quantitative side, two household surveys were performed in 2012 (N = 757) and in 2014 (N = 754) among mothers within one year postpartum. The analysis examines the result of the intervention by the date of delivery at three key time points in the PPC schedule: the first 48 h, days 6–10 and during weeks 6–8 and beyond. On the qualitative side, in depth interviews, focus group discussions and observations were conducted in four health facilities in 2012 and 2015. They involved mothers in the postpartum period, facility and community health workers, and other stakeholders. We performed a descriptive analysis and a two-sample test of proportions of the quantitative data. The qualitative data were recorded, transcribed and analysed along the themes relevant for the intervention.Results: The findings show that the WHO guidelines, in terms of content and improvement of maternal PPC, were followed for physical examinations and consultations. They also show a significant increase in the coverage of maternal PPC services from 50% (372/752) before the intervention to 81% (544/672) one year after the start of the intervention. However, more women were assessed at days 6–10 than at later visits. Integration of maternal PPC was low, with little improvements in history taking and physical examination of mothers in immunization services. While health workers are polyvalent, difficulties in restructuring and organizing services hindered the integration.Conclusion: Unless a comprehensive strategy of integration within RMNCH services is implemented to address the primary health care challenges within the health system, integration will not yield the desired results

Awareness, treatment, control of hypertension and utilization of health care services following screening in the North-central region of Burkina Faso

Introduction: in Africa, a non-urban area is affected by hypertension. But in Burkina Faso, no study on factors associated with awareness, treatment and control of hypertension has not yet been published. The objectives of this report are to: (i) identify the factors associated with awareness, treatment, and control of hypertension in the adult population of Kaya health and demographic surveillance system (Kaya HDSS) and (ii) estimate health care services utilization by participant newly screened as hypertensive. Methods: a screening survey for hypertension was conducted on 1481 adults in Kaya HDSS in late 2012. Hypertensive individuals provided information relating to "awareness", "treatment" and "control" of their hypertension. After approximately two months, unaware hypertensive individuals were interviewed to know whether they had sought treatment. Results: during the screening survey, 123 individuals (9.4%) were identified as having hypertension. Among them, 33 (26.8%, 95% CI: 18.9-34.8) were aware of their condition, 25 (75.8%, 95% CI: 60.3-91.2) of them were receiving medication. Among those receiving treatment, 15 (60.0%, 95% CI: 39.4-80.6) had their blood pressure controlled. Semi-urban residence, presence of chronic diseases and physical inactivity were significantly associated with awareness of hypertension. Seventy two of the 90 participants who were classified as unaware were interviewed two months later. Out of them, 37 individuals had consulted a health worker and 28 received a diagnosis of hypertension. Conclusion: awareness was low but treatment and control of those who knew they were hypertensive were relatively high. These results could be used to improve management of hypertension in Burkina Faso

Reducing the Medical Cost of Deliveries in Burkina Faso Is Good for Everyone, Including the Poor

Since 2007, Burkina Faso has subsidized 80 % of the costs of child birth. Women are required to pay 20 % (900 F CFA = 1.4 Euros), except for the indigent, who are supposed to be exempted. The objective of the policy is to increase service utilization and reduce costs for households. We analyze the efficacy of the policy and the distribution of its benefits. The study was carried out in Ouargaye district. The analysis was based on two distinct cross-sectional household surveys, conducted before (2006; n = 1170) and after (2010; n = 905) the policy, of all women who had had a vaginal delivery in a public health centre. Medical expenses for delivery decreased from a median of 4,060 F CFA in 2006 to 900 F CFA in 2010 (p,0.001). There was pronounced contraction in the distribution of expenses and a reduction in interquartile range. Total expenses for delivery went from a median of 7,366 F CFA in 2006 to 4,750 F CFA in 2010 (p = 0.001). There was no exacerbation of the initial inequalities of the share in consumption after the policy. The distribution of benefits for medical expenses showed a progressive evolution. The greatest reduction in risk of excessive expenses was seen in women in the bottom quintile living less than 5 km from the health centres. Only 10 % of those in the poorest quintile were exempted. The subsidy policy was more effective in Burkina Faso than in other African countries. All categories of the population benefited from this policy, including the poorest. Yet despite the subsidy, women still carry a significant cost burden; half of them pay more than they should, and few indigents are fully exempted. Efforts must still be made to reach the indigent and to reduc