Effects of a free health insurance programme for the poor on health service utilisation and financial protection in Senegal.

INTRODUCTION: Implemented in 2013 in Senegal, the Programme National de Bourses de Sécurité Familiale (PNBSF) is a national cash transfer programme for poor households. Besides reducing household poverty and encouraging children's school attendance, an objective of the PNBSF is to expand health coverage by guaranteeing free enrolment in community-based health insurance (CBHI) schemes. In this paper, we provide the first assessment of the PNBSF free health insurance programme on health service utilisation and health-related financial protection. METHODS: We collected household-level and individual-level cross-sectional data on health insurance in 2019-2020 within the Niakhar Population Observatory in rural Senegal. We conducted a series of descriptive analyses to fully describe the application of the PNBSF programme in terms of health coverage. We then used multivariate logistic and Poisson regression models within an inverse probability weighting framework to estimate the effect of being registered in a CBHI through the PNBSF-as compared with having no health insurance or having voluntarily enrolled in a CBHI scheme-on a series of outcomes. RESULTS: With the exception of health facility deliveries, which were favoured by free health insurance, the PNBSF did not reduce the unmet need for healthcare or the health-related financial risk. It did not increase individuals' health service utilisation in case of health problems, did not increase the number of antenatal care visits and did not protect households against the risk of forgoing medical care and of catastrophic health expenditure. CONCLUSION: We found limited effects of the PNBSF free health insurance on health service utilisation and health-related financial protection, although these failures were not necessarily due to the provision of free health insurance per se. Our results point to both implementation failures and limited programme outcomes. Greater commitment from the state is needed, particularly through strategies to reduce barriers to accessing covered healthcare.

Heat waves and health risks in the northern part of Senegal: analysing the distribution of temperature-related diseases and associated risk factors.

The Sahelian zone of Senegal experienced heat waves in the previous decades, such as 2013, 2016 and 2018 that were characterised by temperatures exceeding 45°C for up to 3 successive days. The health impacts of these heat waves are not yet analysed in Senegal although their negative effects have been shown in many countries. This study analyses the health impacts of observed extreme temperatures in the Sahelian zone of the country, focusing on morbidity and mortality by combining data from station observation, climate model projections, and household survey to investigate heat wave detection, occurrence of climate-sensitive diseases and risk factors for exposure. To do this, a set of climatic (temperatures) and health (morbidity, mortality) data were collected for the months of April, May and June from 2009 to 2019. These data have been completed with 1246 households' surveys on risk factor exposure. Statistical methods were used to carry out univariate and bivariate analyses while cartographic techniques allowed mapping of the main climatic and health indicators. The results show an increase in temperatures compared to seasonal normal for the 1971-2000 reference period with threshold exceedances of the 90th percentiles (42°C) for the maxima and (27°C) the minima and higher temperatures during the months of May and June. From health perspective, it was noted an increase in cases of consultation in health facilities as well as a rise in declared morbidity by households especially in the departments of Kanel (17.7%), Ranérou (16.1 %), Matam (13.7%) and Bakel (13.7%). The heat waves of May 2013 were also associated with cases of death with a reported mortality (observed by medical staff) of 12.4% unequally distributed according to the departments with a higher number of deaths in Matam (25, 2%) and in Bakel (23.5%) than in Podor (8.4%) and Kanel (0.8%). The morbidity and mortality distribution according to gender shows that women (57%) were more affected than men (43%). These health risks have been associated with a number of factors including age, access to drinkable water, type of fuel, type of housing and construction materials, existence of fan and an air conditioner, and health history.The heat wave recurrence has led to a frequency in certain diseases sensitive to rising temperatures, which is increasingly a public health issue in the Sahelian zone of Senegal.

Reassessing the demand for community-based health insurance in rural Senegal: Geographic distance and awareness.

Limited access to information is one of the main health insurance market imperfections in developing countries. Differential access to information may determine individuals' awareness of health insurance schemes, thereby influencing their probability of enrollment. Relying on primary data collected in 2019-2020 in rural Senegal, we estimate the uptake of community-based health insurance using a Heckman-type model to correct for awareness-based sample selection bias. Besides showing that health insurance awareness is a precondition for effective enrollment in community-based health insurance schemes, we also bring new evidence on the roles which geographic factors and individual risk preference play in health insurance uptake by rural dwellers. We show that geographic distance prevents individuals from accessing information on health insurance schemes, and discourage those who are informed from enrolling, because of the additional distance they must travel to benefit from covered healthcare services. Results also show that individual risk preference influences health insurance uptake, but only when information barriers are taken into account. Overall, our results could help decision-makers better shape the universal health coverage roadmap, as policies to improve health insurance awareness differ substantially from policies to improve the features of health insurance schemes.

Use of health care among febrile children from urban poor households in Senegal: does the neighbourhood have an impact?

Urban malaria is considered a major public health problem in Africa. The malaria vector is well adapted in urban settings and autochthonous malaria has increased. Antimalarial treatments prescribed presumptively or after rapid diagnostic tests are also highly used in urban settings. Furthermore, health care strategies for urban malaria must comply with heterogeneous neighbourhood ecosystems where health-related risks and opportunities are spatially varied. This article aims to assess the capacity of the urban living environment to mitigate or increase individual or household vulnerabilities that influence the use of health services. The data are drawn from a survey on urban malaria conducted between 2008 and 2009. The study sample was selected using a two-stage randomized sampling. The questionnaire survey covered 2952 households that reported a case of fever episode in children below 10 years during the month before the survey.Self-medication is a widespread practice for children, particularly among the poorest households in Dakar. For rich households, self-medication for children is more a transitional practice enabling families to avoid opportunity costs related to visits to health facilities. For the poorest, it is a forced choice and often the only treatment option. However, the poor that live in well-equipped neighbourhoods inhabited by wealthy residents tend to behave as their rich neighbours. They grasp the opportunities provided by the area and adjust their behaviours accordingly. Though health care for children is strongly influenced by household socio-economic characteristics, neighbourhood resources (facilities and social networks) will promote health care among the poorest and reduce access inequalities. Without being a key factor, the neighbourhood of residence-when it provides resources-may be of some help to overcome the financial hurdle. Findings suggest that the neighbourhood (local setting) is a relevant scale for health programmes in African cities.

Evaluation of the effectiveness of malaria vector control measures in urban settings of Dakar by a specific anopheles salivary biomarker.

Standard entomological methods for evaluating the impact of vector control lack sensitivity in low-malaria-risk areas. The detection of human IgG specific to Anopheles gSG6-P1 salivary antigen reflects a direct measure of human-vector contact. This study aimed to assess the effectiveness of a range of vector control measures (VCMs) in urban settings by using this biomarker approach. The study was conducted from October to December 2008 on 2,774 residents of 45 districts of urban Dakar. IgG responses to gSG6-P1 and the use of malaria VCMs highly varied between districts. At the district level, specific IgG levels significantly increased with age and decreased with season and with VCM use. The use of insecticide-treated nets, by drastically reducing specific IgG levels, was by far the most efficient VCM regardless of age, season or exposure level to mosquito bites. The use of spray bombs was also associated with a significant reduction of specific IgG levels, whereas the use of mosquito coils or electric fans/air conditioning did not show a significant effect. Human IgG response to gSG6-P1 as biomarker of vector exposure represents a reliable alternative for accurately assessing the effectiveness of malaria VCM in low-malaria-risk areas. This biomarker tool could be especially relevant for malaria control monitoring and surveillance programmes in low-exposure/low-transmission settings.

Perceived malaria in the population of an urban setting: a skipped reality in Dakar, Senegal.

BACKGROUND: Urban malaria remains a public health problem. Dakar is located in a low endemic area. However, anti-malarial drugs consumption is reported to be high despite the decline of malaria announced by health authorities. The objective of the present study was to assess the burden of reported malaria attacks (RMAs) in 2008 and to describe care-seeking behaviours in the population of Dakar, Senegal. METHODS: In this cross-sectional study, 2,952 households selected from 50 sites were visited. In each household, a women and a child between two and 10 years old were interviewed about a malaria episode that occurred in 2008. The following information was recorded: age, education level, sex (for children), type of care seeking, method of diagnosis, use of anti-malarial treatment, place of medication purchase, bed net use, malaria-related deaths in the family, and perceptions of the frequency of mosquito bites. After a description of the variables in each subsample, a Pearson's chi-square test was used to compare proportions, and logistic regression was performed to identify the association between RMAs and other covariates. RESULTS: Among women, 31.8% reported a malaria attack in 2008; among children, the rate of malaria attacks reported by mothers or caretakers was 39.0%. With regard to care-seeking, 79.5% of women and 81.5% of children with a RMA had visited health facilities (HFs). Younger women and children under five years old were more likely to visit a HF (P<0.001). Presumptive diagnosis was the primary method that was used to identify malaria in HFs. For those who had visited a HF, the rate of anti-malarial treatment was 77% in women and 60% in children. Finally, 43.6% of women and 42.0% of children declared the use of bed nets. In a multivariate analysis, the malaria-related death of a relative and perceptions of mosquito bites were significantly associated with RMAs in women. In children, age was associated with RMAs. CONCLUSION: The frequent perceptions of the occurrence of malaria in the population were confirmed at the HF by the high presumptive diagnosis of health professionals. Despite the decline of malaria that has been announced by health authorities, the population will continue to complain of malaria and seek care directly at private pharmacies. This situation may sustain the circulation of anti-malarial drugs and increase the risk of an emergence of anti-malarial resistance.

IgG responses to the gSG6-P1 salivary peptide for evaluating human exposure to Anopheles bites in urban areas of Dakar region, Sénégal.

BACKGROUND: Urban malaria can be a serious public health problem in Africa. Human-landing catches of mosquitoes, a standard entomological method to assess human exposure to malaria vector bites, can lack sensitivity in areas where exposure is low. A simple and highly sensitive tool could be a complementary indicator for evaluating malaria exposure in such epidemiological contexts. The human antibody response to the specific Anopheles gSG6-P1 salivary peptide have been described as an adequate tool biomarker for a reliable assessment of human exposure level to Anopheles bites. The aim of this study was to use this biomarker to evaluate the human exposure to Anopheles mosquito bites in urban settings of Dakar (Senegal), one of the largest cities in West Africa, where Anopheles biting rates and malaria transmission are supposed to be low. METHODS: One cross-sectional study concerning 1,010 (505 households) children (n = 505) and adults (n = 505) living in 16 districts of downtown Dakar and its suburbs was performed from October to December 2008. The IgG responses to gSG6-P1 peptide have been assessed and compared to entomological data obtained in or near the same district. RESULTS: Considerable individual variations in anti-gSG6-P1 IgG levels were observed between and within districts. In spite of this individual heterogeneity, the median level of specific IgG and the percentage of immune responders differed significantly between districts. A positive and significant association was observed between the exposure levels to Anopheles gambiae bites, estimated by classical entomological methods, and the median IgG levels or the percentage of immune responders measuring the contact between human populations and Anopheles mosquitoes. Interestingly, immunological parameters seemed to better discriminate the exposure level to Anopheles bites between different exposure groups of districts. CONCLUSIONS: Specific human IgG responses to gSG6-P1 peptide biomarker represent, at the population and individual levels, a credible new alternative tool to assess accurately the heterogeneity of exposure level to Anopheles bites and malaria risk in low urban transmission areas. The development of such biomarker tool would be particularly relevant for mapping and monitoring malaria risk and for measuring the efficiency of vector control strategies in these specific settings.

Asymptomatic carriage of plasmodium in urban Dakar: the risk of malaria should not be underestimated.

INTRODUCTION: The objective of this study was to measure the rate of asymptomatic carriage of plasmodium in the Dakar region two years after the implementation of new strategies in clinical malaria management. METHODOLOGY: Between October and December 2008, 2952 households selected in 50 sites of Dakar area, were visited for interviews and blood sampling. Giemsa-stained thick blood smears (TBS) were performed for microscopy in asymptomatic adult women and children aged 2 to 10 years. To ensure the quality of the microscopy, we performed a polymerase chain reaction (PCR) with real time qPCR in all positive TBS by microscopy and in a sample of negative TBS and filter paper blood spots. RESULTS: The analysis has concerned 2427 women and 2231 children. The mean age of the women was 35.6 years. The mean age of the children was 5.4 years. The parasite prevalence was 2.01% (49/2427) in women and 2.15% (48/2231) in children. Parasite prevalence varied from one study site to another, ranging from 0 to 7.41%. In multivariate analysis, reporting a malaria episode in 2008 was associated with plasmodium carriage (OR = 2.57, P = 0.002) in women; in children, a malaria episode (OR = 6.19, P<0.001) and a travel out of Dakar during last 3 months (OR = 2.27, P = 0.023) were associated with plasmodium carriage. Among the positive TBS, 95.8% (93/97) were positive by plasmodium PCR. Among the negative TBS, 13.9% (41/293) were positive by PCR. In blood spots, 15.2% (76/500) were positive by PCR. We estimated at 16.5% the parasite prevalence if PCR were performed in 4658 TBS. CONCLUSION: Parasite prevalence in Dakar area seemed to be higher than the rate found by microscopy. PCR may be the best tool for measuring plasmodium prevalence in the context of low transmission. Environmental conditions play a major role in the heterogeneity of parasite prevalence within sites.

Management of uncomplicated malaria in children under 13 years of age at a district hospital in Senegal: from official guidelines to usual practices.

BACKGROUND: To be effective, national malaria guidelines must be properly followed. This study evaluated nurses' practices in the management of uncomplicated malaria cases at a District Hospital. Its objective was to identify the reasons for discrepancies between official guidelines and usual practices. METHODS: This study took place at Oussouye hospital, south-western Senegal. Blood smears were available for biological diagnosis in patients aged more than five years while the Integrated Management of Childhood Illness recommended treating fevers presumptively in children under five. First line anti-malarial was Amodiaquine plus sulphadoxine-pyrimethamine (AQ+SP) bi-therapy. Hospital records of children under 13 years of age seen between 2004 and 2005 were reviewed. RESULTS: Among children treated with anti-malarials, 74% (2, 063/2, 789) received AQ+SP. However, only 22% (406/1, 879) of febrile children and 19% (429/2, 198) of children diagnosed with malaria got a blood smear. Moreover, an anti-malarial was prescribed for 80% (377/474) of children with a negative blood smear. CONCLUSIONS: The transition from chloroquine to AQ+SP was well followed. Nonetheless, blood smear use was very low and many over-prescriptions were reported. Reasons for discrepancies between guidelines and practices can be classified in three main categories: ambiguous guidelines, health system's dysfunctions and nurses' own considerations. Aside from the strengthening of the public health system, in order to guarantee practices complying with guidelines, training content should be more adapted to nurses' own considerations.

Self-reported data: a major tool to assess compliance with anti-malarial combination therapy among children in Senegal.

BACKGROUND: Although there are many methods available for measuring compliance, there is no formal gold standard. Different techniques used to measure compliance were compared among children treated by the anti-malarial amodiaquine/sulphadoxine-pyrimethamine (AQ/SP) combination therapy, in use in Senegal between 2004 and 2006. METHODS: The study was carried out in 2004, in five health centres located in the Thies region (Senegal). Children who had AQ/SP prescribed for three and one day respectively at the health centre were recruited. The day following the theoretical last intake of AQ, venous blood, and urine samples were collected for anti-malarial drugs dosage. Caregivers and children above five years were interviewed concerning children's drug intake. RESULTS: Among the children, 64.7% adhered to 80% of the prescribed dose and only 37.7% were strict full adherent to the prescription. There was 72.7% agreement between self-reported data and blood drug dosage for amodiaquine treatment. Concerning SP, results found that blood dosages were 91.4% concordant with urine tests and 90% with self-reported data based on questionnaires. CONCLUSION: Self-reported data could provide useful quantitative information on drug intake and administration. Under strict methodological conditions this method, easy to implement, can be used to describe patients' behaviors and their use of new anti-malarial treatment. Self-reported data is a major tool for assessing compliance in resource poor countries. Blood and urine drug dosages provide qualitative results that confirm any drug intake. Urine assays for SP could be useful to obtain public health data, for example on chemoprophylaxis among pregnant women.

Factors related to compliance to anti-malarial drug combination: example of amodiaquine/sulphadoxine-pyrimethamine among children in rural Senegal.

BACKGROUND: The introduction of new anti-malarial treatment that is effective, but more expensive, raises questions about whether the high level of effectiveness observed in clinical trials can be found in a context of family use. The objective of this study was to determine the factors related to adherence, when using the amodiaquine/sulphadoxine-pyrimethamine (AQ/SP) association, a transitory strategy before ACT implementation in Senegal. METHODS: The study was conducted in five rural dispensaries. Children, between two and 10 years of age, who presented mild malaria were recruited at the time of the consultation and were prescribed AQ/SP. The child's primary caretaker was questioned at home on D3 about treatment compliance and factors that could have influenced his or her adherence to treatment. A logistic regression model was used for the analyses. RESULTS: The study sample included 289 children. The adherence rate was 64.7%. Two risks factors for non-adherence were identified: the children's age (8-10 years) (ORa = 3.07 [1.49-6.29]; p = 0.004); and the profession of the head of household (retailer/employee versus farmer) (ORa = 2.71 [1.34-5.48]; p = 0.006). Previously seeking care (ORa = 0.28 [0.105-0.736], p=0.001] satisfaction with received information (ORa = 0.45 [0.24-0.84]; p = 0.013), and the quality of history taking (ORa = 0.38 [0.21-0.69]; p = 0.001) were significantly associated with good compliance. CONCLUSION: The results of the study show the importance of information and communication between caregivers and health center staff. The experience gained from this therapeutic transition emphasizes the importance of information given to the patients at the time of the consultation and drug delivery in order to improve drug use and thus prevent the emergence of rapid drug resistance.

Health-seeking behaviour for childhood malaria: household dynamics in rural Senegal.

Research on health care behaviour in sub-Saharan Africa usually considers the mother as the reference in the household when a child is sick. The study of health care management within the family is a key issue for understanding therapeutic rationales. This study was conducted in the region of Fatick in Senegal among 902 children with malaria-related fever. The data were taken from a retrospective quantitative survey conducted in all compounds of the DSS (Demographic Surveillance Site) of Niakhar. The results show that child care-taking is fundamentally a collective process: in 70.9% of out-of-home resorts, the treatment decision was collective. The health care process of 68.1% of morbid episodes involved several individuals. The involvement of the mother, the father and other relatives in the collective management of health care followed different logics. Each care-giver had a specific and complementary function depending on gender norms, intergenerational relations and characteristics of the family unit. Family management of illness aims at optimizing financial and human resources given the economic, logistical and social constraints on health care. Nevertheless, collective management also favoured home-based care, prevented good treatment compliance and delayed the resort to health facilities. These results suggest that health education campaigns should focus on an early involvement of fathers in health care-giving and also on the strengthening of the autonomy of mothers. Mothers' empowerment should give women more autonomy in their child's treatment choice. Lastly, there is a need to develop community health facilities and establish shared funding at the community level.

Adherence and effectiveness of drug combination in curative treatment among children suffering uncomplicated malaria in rural Senegal.

Increased Plasmodium falciparum resistance to chloroquine has prompted national malaria programs to develop new policies in several African countries. Less than a year after the introduction of amodiaquine/sulfadoxine-pyrimethamine (AQ/SP) as first-line treatment in Senegal, we examined adherence rates to therapy and its efficacy among children. The study was conducted in five dispensaries in rural Senegal. Children aged 2-10 years with a presumptive diagnosis of malaria were prescribed AQ/SP. Thick blood film analyses were carried out on days 0, 3, 7, 14 and 28. Blood and urine samples were collected on day 3 for drug level measurements. The principal caregivers were questioned on treatment adherence. Among the 289 recruited children, 144 had a parasitemia >2500/microl. The results demonstrated markedly good efficacy for the treatment, as no detectable parasitemia was observed on day 28 for 97.9% of the children. However, we noticed that 35.3% of children did not comply with the recommended doses and 62.3% did not exactly adhere to the drug schedule. Despite the good efficacy of the drugs, adherence to the therapeutic scheme was poor. Strategies to promote patient adherence would improve drug performance and thus might help to prevent the rapid emergence of drug resistance.

Antimalarial drug use in general populations of tropical Africa.

BACKGROUND: The burden of Plasmodium falciparum malaria has worsened because of the emergence of chloroquine resistance. Antimalarial drug use and drug pressure are critical factors contributing to the selection and spread of resistance. The present study explores the geographical, socio-economic and behavioural factors associated with the use of antimalarial drugs in Africa. METHODS: The presence of chloroquine (CQ), pyrimethamine (PYR) and other antimalarial drugs has been evaluated by immuno-capture and high-performance liquid chromatography in the urine samples of 3,052 children (2-9 y), randomly drawn in 2003 from the general populations at 30 sites in Senegal (10), Burkina-Faso (10) and Cameroon (10). Questionnaires have been administered to the parents of sampled children and to a random sample of households in each site. The presence of CQ in urine was analysed as dependent variable according to individual and site characteristics using a random - effect logistic regression model to take into account the interdependency of observations made within the same site. RESULTS: According to the sites, the prevalence rates of CQ and PYR ranged from 9% to 91% and from 0% to 21%, respectively. In multivariate analysis, the presence of CQ in urine was significantly associated with a history of fever during the three days preceding urine sampling (OR = 1.22, p = 0.043), socio-economic level of the population of the sites (OR = 2.74, p = 0.029), age (2-5 y = reference level; 6-9 y OR = 0.76, p = 0.002), prevalence of anti-circumsporozoite protein (CSP) antibodies (low prevalence: reference level; intermediate level OR = 2.47, p = 0.023), proportion of inhabitants who lived in another site one year before (OR = 2.53, p = 0.003), and duration to reach the nearest tarmacked road (duration less than one hour = reference level, duration equal to or more than one hour OR = 0.49, p = 0.019). CONCLUSION: Antimalarial drug pressure varied considerably from one site to another. It was significantly higher in areas with intermediate malaria transmission level and in the most accessible sites. Thus, P. falciparum strains arriving in cross-road sites or in areas with intermediate malaria transmission are exposed to higher drug pressure, which could favour the selection and the spread of drug resistance.