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Abstract: The primary aim of Mutual Health Organizations (MHOs) is the financial protection of their members. However, given their community-based, participative and voluntary nature, it is conceivable that MHOs, as social organizations, would affect social dynamics. In an exploratory study in Benin, we studied social dynamics related to mutual aid, relationships of trust, and empowerment. Four MHOs, as contrasted cases, were selected from among the 11 in the region. Focus groups (n = 20) and individual interviews (n = 29) were conducted with members, non-members, and elected leaders of the four MHOs, and with professionals from the health facilities concerned. We carried out a qualitative thematic analysis of the content. Mutual aid practices, which pre-date MHOs, can be mobilized to promote MHO membership. Mutual aid practices are based on relationships of trust. The primary reason for joining an MHO is to improve financial accessibility to health services. Non-members see that members have a strong sense of empowerment in this regard, based on a high level of trust in MHOs and their elected leaders, even if their trust in health professionals is not as strong. Non-members share these feelings of confidence in MHOs and their leadership, although they trust health professionals somewhat less than do the members. The MHOs’ low penetration rate therefore cannot be explained by lack of trust, as this study shows that, even with some distrust of the professionals, the overall level of trust in MHOs is high and MHOs and their leaders function as intermediaries with health professionals. Other explanatory factors are the lack of information available to villagers and, most especially, the problems they face in being able to pay the MHO premiums. [Copyright &y& Elsevier]

Summary: Based on a qualitative study contrasting a gender-relationally restrictive socio-cultural setting with a rather liberal one, we explain how social norms shape resource negotiation for women seeking modern healthcare. A system of “protection and dependency” covers them in principle for obviously serious illness, as far as household resources permit. In both settings, however, women must have “well behaved” and justify less-obvious needs in an unequal bargaining process with ambivalent recourse opportunities. Consequently, women may suffer delays in or exclusion from healthcare. Moreover, their self-esteem may lower and the domestic power imbalance may increase. The results suggest sectoral and sector-crosscutting solutions. [Copyright &y& Elsevier]

Many African countries have introduced cost recovery mechanisms based on the sale of drugs and measures aimed at improving drug supply. This study compares prescribing and selling practices in Mali, in 3 cities where the public sector contributes differentially to the supply of drugs on the market. Multilevel models are used to analyse the content and cost of 700 medication transactions observed in 14 private and public legal points of sale.Results show that the objective of improving access to drugs seems to have been achieved in the sites studied. Costs of prescriptions were lower where public health services had been revitalized. Affordable generic drugs were accessible and widely used, even in the private sector. However, measures intended to rationalize the prescription and delivery of drugs did not always have the desired effect. While agents in the public sector tended to prescribe fewer antibiotics, injectables, or brand-name drugs, the data confirm the virtual absence of advice concerning the use or the side effects of the drugs in both public and private sectors. In addition, data supported the notion that the public and private sectors are closely intertwined. Notably, availability of drugs in the public sector contributed to diminishing the prices charged in the private sector. Similarly, the use that agents in the public sector made of the opportunities afforded by the presence of the private pharmaceutical sector provided another illustration of interrelatedness. Finally, the data showed that the presence of a private sector, which has not been affected by measures aimed at rationalizing prescription and sales practices, limits the effects of measures implemented in the public sector. More assertive policies, based on strategies encompassing actors in the private sector, are needed to increase the safety and effectiveness of prescription and sales practices. [Copyright &y& Elsevier]

Presents information on a study conducted which assessed the quality of primary health care (PHC) services in Guinea. Methodology used to conduct the study; In-depth look at the physician-patient relationship; Reference made to strategies used to revitalize PHC services; Information on the components of health care.

The use of community health workers to administer prompt treatments is gaining popularity in most sub-Saharan African countries. Their performance is a key challenge because it varies considerably, depending on the context, while being closely associated with the effectiveness of case management strategies. What determines community health workers' performance is still under debate. Based on a realist perspective, a systematic review recently hypothesized that several mechanisms are associated with good performance and successful community interventions. In order to empirically investigate this hypothesis and confront it with the reality, we conducted a study in Burkina Faso, where in 2010 health authorities have implemented a national program introducing community case management of malaria. The objective was to assess the presence of the mechanisms in community health workers, and explore the influence of contextual factors. In 2012, we conducted semi-structured interviews with 35 community health workers from a study area established in two similar health districts (Kaya and Zorgho). Results suggest that they perceive most of the mechanisms, except the sense of being valued by the health system and accountability to village members. Analysis shows that drug stock-outs and past experiences of community health workers simultaneously influence the presence of several mechanisms. The lack of integration between governmental and non-governmental interventions and the overall socio-economic deprivation, were also identified as influencing the mechanisms' presence. By focusing on community health workers' agency, this study puts the influence of the context back at the core of the performance debate and raises the question of their ability to perform well in scaled-up anti-malaria programs. [ABSTRACT FROM AUTHOR]

With solid evidence that free healthcare increases the utilization of health services, Burkina Faso recently exempted all children under five and pregnant women from direct payment at health facilities. However, there is little insight into the capacity to maintain the gains attributable to free healthcare under routine conditions of implementation at the national scale. In particular, the repercussions of its interruption are unknown. The objective is to assess the effects of a sequence of natural interventions including the introduction, interruption and reintroduction of free healthcare on health-seeking practices and utilization of healthcare facilities by children under five. This is an embedded mixed methods study conducted in Kaya district, Burkina Faso. The quantitative component is based on a reversal longitudinal design. Pooled interrupted time-series analysis was performed to assess changes in the monthly number of visits from January 2005 to March 2015. Qualitative data were collected through in-depth interviews with health personnel and mothers to better understand the quantitative results. The results show that visits to health centres dropped immediately and significantly when free healthcare was interrupted (−146, CI 95% [-255; −37]). They increased again when free healthcare was reintroduced (+89, CI 95% [-11; 187]). Both urban and rural centres were affected. Self-medication and visits to traditional healers were reported more frequently during the withdrawal of free healthcare, and tensions between the population and health personnel increased. Implementation problems other than insufficient funding limited the coverage or intensity of free healthcare. While removing user fees could potentially improve mothers and children's health in Burkina Faso, this study shows that demand for healthcare remains highly sensitive to price changes. Gains in utilization attributable to free healthcare may vanish rapidly if user fees are reintroduced. It is essential to support an effective and sustainable implementation of this ambitious initiative. [ABSTRACT FROM AUTHOR]

Abstract: Background: Alcohol consumption in India is disproportionately higher among poorer and socially marginalised groups, notably Scheduled Tribes (STs). We lack an understanding of STs own views with regard to alcohol, which is important for implementing appropriate interventions. Methods: This study was undertaken with the Paniyas (a previously enslaved ST) in a rural community in Kerala, South India. The study, nested in a participatory poverty and health assessment (PPHA). PPHA aims to enable marginalized groups to define, describe, analyze, and express their own perceptions through a combination of qualitative methods and participatory approaches (e.g. participatory mapping and ranking exercises). We worked with 5 Paniya colonies between January and June 2008. Results: Alcohol is viewed as a problem among the Paniyas who reported that consumption is increasing, notably among younger men. Alcohol is easily available in licensed shops and is produced illicitly in some colonies. There is evidence that local employers are using alcohol to attract Paniyas for work. Male alcohol consumption is associated with a range of social and economic consequences that are rooted in historical oppression and social discrimination. Conclusion: Future research should examine the views of alcohol use among a variety of marginalised groups in developing countries and the different policy options available for these populations. In addition, there is a need for studies that untangle the potential linkages between both historical and current exploitation of marginalized populations and alcohol use. [Copyright &y& Elsevier]

In Quebec (Canada), the utilization of dental care services varies greatly from one social class to another: whereas the well-to-do visit the dentist often for check-ups, those most in need demonstrate a “wait-and-see” attitude. The objective of our research was to describe the dental care pathway of the underprivileged when confronted with symptoms, and to understand how this pathway might be interrupted and possibly lead to tooth extractions. We arranged 16 one-on-one interviews with adult Montrealers who had experienced a dental problem during the 12 months preceding the interview. These participants, 9 women and 7 men aged between 30 and 48, lived in great poverty: all were welfare recipients, and as such, enjoyed the benefits of a government programme that entitled them to free basic dental care. During the interviews, the interviewers asked the participants to describe their latest dental problem and their subsequent behaviour.The dental care pathway of our participants was characterized by a strategy of adapting to the symptoms. This process of adapting, which can last several months, is essentially an individual process in which the individuals often resort to self-medication to soothe their pain. They decide to visit a dentist when the pain is too great and self-medication is no longer effective. Once this decision is made, their dental care pathway may nevertheless be interrupted in two ways: first, in the failure to find a dentist, and second, later, in the failure to complete treatments that are not covered by the welfare program, such as endodontic treatment. The fragmented character of these dental care pathways refers us to two features of accessibility: financial accessibility and acceptability. With regard to financial accessibility, our study shows that the public coverage intended for welfare recipients presents major gaps. As for acceptability, our participants are strongly critical of the dental profession, and develop a culture of rejection of it. [Copyright &y& Elsevier]