Utilization of community health workers for malaria treatment: results from a three-year panel study in the districts of Kaya and Zorgho, Burkina Faso.

BACKGROUND: Malaria is holo-endemic in Burkina Faso and causes approximately 40,000 deaths every year. In 2010, health authorities scaled up community case management of malaria with artemisinin-based combination therapy. Previous trials and pilot project evaluations have shown that this strategy may be feasible, acceptable, and effective under controlled implementation conditions. However, little is known about its effectiveness or feasibility/acceptability under real-world conditions of implementation at national scale.

METHODS: A panel study was conducted in two health districts of Burkina Faso, Kaya and Zorgho. Three rounds of surveys were conducted during the peak malaria-transmission season (in August 2011, 2012 and 2013) in a panel of 2,232 randomly selected households. All sickness episodes in children under five and associated health-seeking practices were documented. Community health worker (CHW) treatment coverage was evaluated and the determinants of consulting a CHW were analysed using multi-level logistic regression.

RESULTS: In urban areas, less than 1% of sick children consulted a CHW, compared to 1%-9% in rural areas. Gaps remained between intentions and actual practices in treatment-seeking behaviour. In 2013, the most frequent reasons for not consulting the CHW were: the fact of not knowing him/her (78% in urban areas; 33% in rural areas); preferring the health centre (23% and 45%, respectively); and drug stock-outs (2% and 12%, respectively). The odds of visiting a CHW in rural areas significantly increased with the distance to the nearest health centre and if the household had been visited by a CHW during the previous three months.

CONCLUSIONS: This study shows that CHWs are rarely used in Burkina Faso to treat malaria in children. Issues of implementation fidelity, a lack of adaptation to the local context and problems of acceptability/feasibility might have undermined the effectiveness of community case management of malaria. While some suggest extending this strategy in urban areas, total absence of CHW services uptake in these areas suggest that caution is required. Even in rural areas, treatment coverage by CHWs was considerably less than that reported by previous trials and pilot projects. This study confirms the necessity of evaluating public health interventions under real-world conditions of implementation.