What were the challenges and needs before implementing routine pulse oximetry in IMCI consultations at primary health centres in West Africa? Baseline site assessment of the operational AIRE project, 2020

ABSTRACT Background Despite the Integrated Management of Childhood Illness (IMCI) implemented at primary health centres (PHC) level, under-5 mortality remains high in sub-Saharan Africa. To improve the diagnosis and management of severe hypoxaemia, the AIRE project implemented the systematic use of pulse oximeters (PO) into IMCI consultations in PHCs in Burkina Faso, Guinea, Mali and Niger. We described the intervention sites, and measure their capacity to offer IMCI-care prior to project implementation. Methods A cross-sectional quantitative survey was conducted in all the PHCs and their district hospital (DH) of the AIRE project from March to July 2020. Results Overall, 215 PHCs and 8 DH were surveyed. Almost all the PHCs were public structures mainly managed by nurses. The IMCI strategy was in force in all PHCs with at least one IMCI-trained agent in more than 99% of the PHCs. At baseline, PO was available in only 2/215 (1%) PHCs and 4/8 (50%) DH. Overall, 35/215 (16%) PHCs have functional ambulance for managing referrals to DH, including two with mobile oxygen. IMCI consultations were free-of-fees in Burkina Faso and Niger, but charged for in Guinea and Mali (from US$0.5 to US$1). All the DH had capacities to provide specialised paediatric care for children under-5 years of age, although the use of PO was not systematic. Oxygen was available at all DH except one. Parents of children requiring hospitalisation had to pay out of pocket costs ranging from US$1.7 to US$8.4 per day. Conclusions This study revealed the absence of POs at PHC level and their low use at hospital level, as well as difficulties in managing referral to hospital of severe cases and access to mobile oxygen. It has guided the reasoned choice of the AIRE research sites, and the upgrading of PHCs including IMCI training before the project implementation. Study registration number PACTR202206525204526 registered on 06/15/2022. • What is already known on this topic - Globally, the weakness of the healthcare system in West Africa had been demonstrated. - In our knowledge, it is the first study in these countries that aimed to assess the capacity of health facilities to provide health care to ill children under-five. Few studies have provided some indicators, such as human resources or accessibility challenges, but not a real assessment. • What this study adds This study describes the weakness of the healthcare system in the four countries where the AIRE project has been implemented (Burkina Faso, Guinea, Mali, Niger), with: - a shortage of skilled human resources in health, a lack of medical equipment, including Pulse Oximeters at primary healthcare centres, and their poor use at hospital level, and frequent shortages of essential medicines, - financial problems in benefiting from health services, despite the total and partial exemption policies in force, which were not being properly applied, - difficulties in organizing hospital transfers for severely ill children and the unavailability of oxygen during hospital transfers. • How this study might affect research, practice or policy The challenges identified through this study - guided the upgrading of sites before the AIRE project implementation, - raised awareness among health authorities of the many gaps in health systems that remain unresolved, especially the problem of hospital transfers and access to medical oxygen.