Direct and indirect household costs of care of children under 5 years old attending Integrated Management of Childhood Illness consultations at Primary Healthcare Centres in Burkina Faso, Guinea, Mali and Niger: a cross-sectional costing study nested in the longitudinal AIRE project 2021-2022

IntroductionOut-of-pocket payments persist, limiting access to care in Africa. The AIRE project evaluated the implementation of pulse oximetry integrated with Integrated Management of Childhood Illness (IMCI) at Primary Healthcare Centres (PHCs) in Burkina Faso and Niger (total exemption policy) and Mali and Guinea (partial exemption policy). We measured households out-of-pocket expenditures for care of children under-5 years and analyzed associated factors. MethodsBetween 06/2021-05/2022, five non-severe and five severe cases per PHC among children <5 years attending IMCI consultations (excluding simple non-respiratory cases) in four PHCs per participating country in the AIRE study were selected each month among the children included. Severe IMCI cases were followed-up at 14 days. We collected medical direct costs and non-medical direct and indirect costs. We describe median costs; factors associated with medical direct costs (MDC) were investigated in two-part models for countries with total exemption and general linear model in those with partial exemption. ResultsOf the 15,836 children overall, 940 non-severe cases and 745 severe cases were included. The median medical direct costs were USD 0.0, 7.1, 5.0 and 3.6 for non-severe cases, and 1.6, 8.6, 7.4 and 14.4 for severe cases, in Burkina Faso, Guinea, Mali and Niger, respectively. Medicine expenditures were the main MDC item, reaching 79% for non-severe cases and 59% in severe cases. In all countries, the disease severity and the unavailability of prescribed medicines at PHCs or hospital depots were associated to any out-of-pocket payment, and to higher amounts of expenses. ConclusionWith the exception of Burkina Faso and despite free care policies, household out-of-pocket payment remains high for children under-5, particularly for treating severe cases, mainly explained by medicines expenditures. Actions are needed to identify efficient financing systems to ensure regular and adequate delivery of medicines in public health facilities, and to support free healthcare policies. Key messagesO_LIWhat is already known on this topic? O_LIIn sub-Saharan Africa, various studies have shown that user fee total or partial exemption policies do not succeed in eliminating or significantly reducing healthcare costs borne by households. C_LIO_LIFew studies have explored household out-of-pocket expenditures for the care of children under 5 years in the West African context. C_LI C_LIO_LIWhat this study adds? O_LIDespite user-fee exemption policies, household out-of-pocket payment remains high for taking care of children under-5 at primary care and district hospital. C_LIO_LIMost expenditures were associated with purchasing medicines outside of primary healthcare centers and referral hospitals, which is likely the result of stock-outs in public facilities. C_LIO_LIBoth the probability of an out-of-pocket expenditure and its amount were associated with the severity of the disease. C_LI C_LIO_LIHow this study might affect research, practice or policy? O_LIOur study underlines the importance of further investigations to determine effective funding methods aimed at ensuring a regular and adequate supply of medicines in public healthcare facilities. C_LI C_LI CHEERS StatementThis study adheres to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).