Household costs of care in children under five attending primary care in Burkina Faso, Guinea, Mali and Niger: a cross-sectional study nested in the AIRE project

Introduction Out-of-pocket payments limit access to care in Africa. The Amélioration de l'Identification des détresses Respiratoires de l'Enfant/Improving Identification of Respiratory Distress in Children (AIRE) project evaluated the implementation of pulse oximetry within Integrated Management of Childhood Illness (IMCI) guidelines at primary health centres (PHCs) in Burkina Faso and Niger (with total exemption policies) and in Mali and Guinea (with partial exemption policies). We measured households’ out-of-pocket expenditures for treating children under 5 years of age and analysed the associated factors. Methods Between June 2021 and May 2022, all children under 5 years of age attending IMCI consultations, excluding simple non-respiratory cases, aged 2–59 months, were enrolled in the AIRE study with parental consent. Five non-severe cases and five severe cases (followed up over 14 days) per PHC were randomly selected every month. We collected medical and non-medical direct costs and indirect costs. We described the median costs and investigated the factors associated with medical direct costs (MDCs) using two-part models for countries with total exemption and a general linear model for those with partial exemption. Results Overall, 940 non-severe cases and 745 severe cases were selected. The median MDCs were US$0.0, US$7.1, US$5.0 and US$3.6 for non-severe cases and US$1.6, US$8.6, US$7.4 and US$14.4 for severe cases, in Burkina Faso, Guinea, Mali and Niger, respectively. Medicine expenditures were the main MDC items, accounting for 79% of costs for non-severe cases and 59% for severe cases. In all countries, disease severity and the unavailability of prescribed medicines at PHCs or referral hospital depots were associated with out-of-pocket payments and higher expenses. Conclusion With the exception of Burkina Faso, household out-of-pocket payments for children under five remain high despite free care policies, particularly for treating severe cases. This is mainly explained by medicines expenditures. Action is needed to identify efficient financing systems that ensure the regular and adequate supply of medicines in public health facilities and to support free healthcare policies.