Illness reporting and demand for medical care in rural Burkina Faso

This is the post-print version of the final paper published in Social Science & Medicine. The published article is available from the link below. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. Copyright @ 2010 Elsevier B.V.The issue of illness reporting in modelling demand for health care in low- and middle-income countries can be handled according to either of two conceptually-different constructs: (a) considering illness reporting behaviour as endogenous to demand; or (b) considering demand itself as the outcome of a sample selection phenomenon. In this paper, we take the second viewpoint and estimate the demand for medical care with an estimator that uses Heckman-type. Empirical estimates based on household survey data from rural Burkina Faso suggest that there are some implications of illness reporting behaviour for modelling the demand for medical care.German Science Foundatio

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

Linking weather data, satellite imagery and field observations to household food production and child undernutrition: an exploratory study in Burkina Faso

Worldwide, 50 million children under five are acutely malnourished, while 16 million amongst them suffer from severe wasting. Chronic malnutrition is more common and accounts for an estimated 159 million children, meaning that approximately 23.8% of all children under five worldwide are stunted. The proportion of stunted children has decreased worldwide between 1990 (39.6%) and 2014 (23.8%), but the progress has been unequal. While Asia as a whole reduced stunting by half (-47.0%) between 1990 and 2014, there are still 78 million stunted children in South Asia alone. Unlike Asia, the African continent has reduced stunting by just one quarter (24.0%). In contrast, the absolute number of stunted children in Africa has still increased, from 47 million in 1990, to 58 million in 2014. Under-nutrition is caused by a complex web of interdependent environmental/climatic, agricultural and socio-economic factors. Climate change has recently been identified as a major risk factor for childhood undernutrition. However, the scientific evidence base for this is weak. No study has so far simultaneously combined of the well-known drivers of undernutrition with climate change while being grounded in one population in one-time and in one location. Such studies are prerequisite for the relative attribution of the various risk factors, including climate chance, as causes of childhood undernutrition. In this exploratory study, methods from multiple sectors were applied to 20 randomly selected households in Bourasso in rural Burkina Faso, where more than 80% of the population are subsistence farmers, i.e. live off their fields. Well tested methods, such as household-level agricultural and nutritional surveys, anthropometric measurement of undernutrition with innovative methods, measuring household level-crop yields, were combined. This was done by participatory mapping of each household’s plots. Remote sensing algorithms were applied to RapidEye satellite scenes covering the study area in order to map the actual cultivated area and to derive qualitative harvest estimates for the surveyed micro-fields. Weather data were obtained from a research meteorological field station, about 20 km away from Bourasso. In addition to bringing field methods from different sectors together through the lens of a household, one further advanced method was integrated: The linkage between each household plot limits and their integration into the satellite scene making it possible to estimate crop yields at the plot level for each household and linking this to the nutritional status of that specific household. Thus the exploratory study produced the following results: High-resolution remote sensing data can assist studies on malnutrition in Burkina Faso; RapidEye is a promising data source in regard to the spatial resolution for micro-field assessments; The strong inter-annual variation of malnutrition is suggestive that climate is a casual factor in the absence of other explanatory factors (political unrest, price shocks of inputs, epidemics). Population-based studies replicating the described multi-sectoral toolbox should be upscaled to larger sample sizes and longer observational time series. This could contribute to generating crucial climate health impact functions, in this case for malnutrition

Annual Crop Yield Variation, Child Survival and Nutrition among Subsistence Farmers in Burkina Faso.

Whether year to year variation in crop yields affects the nutrition, health, and survival of subsistence farming populations is relevant to the understanding of the potential impacts of climate change. However, the empirical evidence is limited. We examined the association of child survival with inter-annual variation in food crop yield and middle-upper arm circumference (MUAC) in a subsistence farming population of rural Burkina Faso. The study was of 44,616 children < 5 years of age included in the Nouna Health and Demographic Surveillance System, 1992-2012, whose survival was analysed in relation to the food crop yield in the year of birth (which ranged from 65% to 120% of the period average) and, for a subset of 16,698 children, to MUAC, using shared frailty Cox proportional hazards models. Survival was appreciably worse in children born in years with low yield (fully adjusted hazard ratio of 1.11 (95% confidence interval: 1.02, 1.20) for a 90th to 10th centile decrease in annual crop yield) and in children with small MUAC (hazard ratio 2.72 (95% confidence interval: 2.15, 3.44) for a 90th to 10th centile decrease in MUAC). These results suggest an adverse impact of variations in crop yields which could increase under climate change

Step-wedge cluster-randomised community-based trials: An application to the study of the impact of community health insurance

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.BACKGROUND: We describe a step-wedge cluster-randomised community-based trial which has been conducted since 2003 to accompany the implementation of a community health insurance (CHI) scheme in West Africa. The trial aims at overcoming the paucity of evidence-based information on the impact of CHI. Impact is defined in terms of changes in health service utilisation and household protection against the cost of illness. Our exclusive focus on the description and discussion of the methods is justified by the fact that the study relies on a methodology previously applied in the field of disease control, but never in the field of health financing. METHODS: First, we clarify how clusters were defined both in respect of statistical considerations and of local geographical and socio-cultural concerns. Second, we illustrate how households within clusters were sampled. Third, we expound the data collection process and the survey instruments. Finally, we outline the statistical tools to be applied to estimate the impact of CHI. CONCLUSION: We discuss all design choices both in relation to methodological considerations and to specific ethical and organisational concerns faced in the field. On the basis of the appraisal of our experience, we postulate that conducting relatively sophisticated trials (such as our step-wedge cluster-randomised community-based trial) aimed at generating sound public health evidence, is both feasible and valuable also in low income settings. Our work shows that if accurately designed in conjunction with local health authorities, such trials have the potential to generate sound scientific evidence and do not hinder, but at times even facilitate, the implementation of complex health interventions such as CHI

Exploring the use of a general equilibrium method to assess the value of a malaria vaccine: an application to Ghana

BACKGROUND: Malaria is an important health and economic burden in sub-Saharan Africa. Conventional economic evaluations typically consider only direct costs to the healthcare system and government budgets. This paper quantifies the potential impact of malaria vaccination on the wider economy, using Ghana as an example METHODS: We used a computable general equilibrium model of the Ghanaian economy to estimate the macroeconomic impact of malaria vaccination in children under the age of five, with a vaccine efficacy of 50% against clinical malaria and 20% against malaria mortality. The model considered changes in demography and labor productivity, and projected gross domestic product (GDP) over a time frame of 30 years. Vaccine coverage ranging from 20% to 100% was compared with a baseline with no vaccination. RESULTS: Malaria vaccination with 100% coverage was projected to increase the GDP of Ghana over 30 years by US$6.93 billion (in 2015 prices) above the baseline without vaccination, equivalent to an increase in annual GDP growth of 0.5%. Projected GDP per capita would increase in the first year due to immediate reductions in time lost from work by adults caring for children with malaria, then decrease for several years as reductions in child mortality increase the number of dependent children, then show a sustained increase after Year 11 due to long-term productivity improvements in adults resulting from fewer malaria episodes in childhood. CONCLUSION: Investing in improving childhood health by vaccinating against malaria could result in substantial long-term macroeconomic benefits when these children enter the workforce as adults. These macroeconomic benefits are not captured by conventional economic evaluations and constitute an important potential benefit of vaccination

Efficacy of Bacillus thuringiensis var. israelensis against malaria mosquitoes in northwestern Burkina Faso

Background: In Sub Saharan Africa malaria remains one of the major health problems and its control represents an important public health measure. Integrated malaria control comprises the use of impregnated mosquito nets and indoor residual spraying. The use of drugs to treat patients can create additional pressure on the equation of malaria transmission. Vector control may target the adult mosquitoes or their aquatic larval stages. Biological larvicides such as Bacillus thuringiensis israelensis (Bti) represent a promising approach to support malaria control programs by creating additional pressure on the equation of malaria transmission. Methods: In this study we examined the efficacy of a water-dispersible granule formulation (WDG) of the biological larvicide Bti (VectoBac®) against wild Anopheles spp. larvae. Different concentrations of the larvicide were tested in standardized plastic tubs in the field against untreated controls. In weekly intervals tubs were treated with fixed concentrations of larvicide and the percentage reduction of larvae and pupae was calculated. Results: All used concentrations successfully killed 100 percent of the larvae within 24 hours, while the higher concentrations showed a slightly prolonged residual effect. Natural reconolization of larvae took place after two and three days respectively, late instar larvae were not found before 5 days after treatment. For the higher concentrations, up to three days no new larvae were found, implicating that the residual effect of WDG in tropical conditions is approximately one to two days. The overall pupae reduction in treated tubs was 98.5%. Conclusions: Biological larviciding with Bti can be a promising, additional tool in the fight against malaria in Africa. Environmental particularities in tropical Africa, first and foremost the rapid development of mosquitoes from oviposition to imago have to be taken into account before implementing such counter measures in national or international vector control programs. Nonetheless biological larviciding seems to be an appropriate measure for selected conditions, offering a significant contribution to the future of malaria control

Health coping strategies of the people vulnerable to climate change in a resource-poor rural setting in Bangladesh

BACKGROUND: Among the many challenges faced by the people of Bangladesh, the effects of climate change are discernibly threatening, impacting on human settlement, agricultural production, economic development, and human health. Bangladesh is a low-income country with limited resources; its vulnerability to climate change has influenced individuals to seek out health coping strategies. The objectives of the study were to explore the different strategies/measures people employ to cope with climate sensitive diseases and sickness. METHODS: A cross-sectional study was conducted among 450 households from Rajshahi and Khulna districts of Bangladesh selected through multi-stage sampling techniques, using a semi-structured questionnaire supplemented by 12 focus group discussions and 15 key informant interviews. RESULTS: Respondents applied 22 types of primary health coping strategies to prevent climate related diseases and sickness. To cope with health problems, 80.8% used personal treatment experiences and 99.3% sought any treatments available at village level. The percentage of respondents that visited unqualified health providers to cope with climate induced health problems was quite high, namely 92.7% visited village doctors, 75.9% drug stores, and 67.3% self-medicated. Ninety per cent of the respondents took treatment from unqualified providers as their first choice. Public health facilities were the first choice of treatment for only 11.0% of respondents. On average, every household spent Bangladesh Currency Taka 9,323 per year for the treatment of climate sensitive diseases and sickness. Only 46% of health expenditure was managed from their savings. The rest, 54% expenditure, was supported by using 24 different sources, such as social capital and the selling of family assets. The rate of out-of-pocket payment was almost 100%. CONCLUSION: People are concerned about climate induced diseases and sickness and sought preventive as well as curative measures to cope with health problems. The most common and widely used climate health coping strategies among the respondents included self-medicating and seeking the health service of unqualified private health care providers. Per family spending to cope with such health problems is expensive and completely based on out of pocket payment. There is no fund pooling, community funding or health insurance program in rural areas to support the health coping of the people. Policies are needed to reduce out-of-pocket payment, to improve the quality of the unqualified providers and to extend public health services at rural areas and support climate related health coping. Collection of such knowledge on climate related health coping strategies can allow researchers to study any specific issue on health coping, and policy makers to initiate effective climate related health coping strategies for climate vulnerable people

Human health as a motivator for climate change mitigation: results from four European high-income countries

Invoking health benefits to promote climate-friendly household behavior has three unique advantages: (i) health co-benefits accrue directly to the acting individual, they are “private goods” rather than public ones; (ii) the evidence base for, and magnitude of health co-benefits is well-established; and (iii) the idea of a healthy life-style is well-engrained in public discourse, much more so than that of a climate-friendly life-style. In previous research, assessing the influence of information on health effects on people's motivation to adopt mitigation actions, health co-benefits for the individual were typically confounded with collective health co-benefits, for example from pollution reduction. The present research aims to overcome this limitation by providing information on individual health co-benefits that are unconditional on the actions of others (direct health co-benefits). We report effects of this kind of health information on stated willingness to adopt mitigation actions as well as on simulation-based carbon emission reductions in a pre-registered experimental setting among 308 households in 4 mid-size case-study cities in 4 European high-income countries: France, Germany, Norway and Sweden. For each mitigation action from the sectors food, housing, and mobility, half of the sample received the amount of CO2equivalents (CO2-eq) saved and the financial costs or savings the respective action generated. The other half additionally received information on direct health co-benefits, where applicable. For households receiving information on direct health co-benefits, we find a higher mean willingness to adopt food and housing actions, and a greater proportion very willing to adopt one or more mitigation actions (OR 1.86, 95% CI 1.1, 3.12); and a greater simulated reduction in overall carbon footprint: difference in percent reduction -2.70%, (95% CI -5.34, -0.04) overall and -4.45%, (95% CI -8.26, -0.64) for food. Our study is the first to show that providing information on strictly unconditional, individual health co-benefits can motivate households in high-income countries to adopt mitigation actions