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BackgroundThe community case management of malaria (CCMm) is now an established route for distribution of artemisinin-based combination therapy (ACT) in rural areas, but the feasibility and acceptability of the approach through community medicine distributors (CMD) in urban areas has not been explored. It is estimated that in 15 years time 50% of the African population will live in urban areas and transmission of the malaria parasite occurs in these densely populated areas.MethodsPre- and post-implementation studies were conducted in five African cities: Ghana, Burkina Faso, Ethiopia and Malawi. CMDs were trained to educate caregivers, diagnose and treat malaria cases in < 5-year olds with ACT. Household surveys, focus group discussions and in-depth interviews were used to evaluate impact.ResultsQualitative findings: In all sites, interviews revealed that caregivers' knowledge of malaria signs and symptoms improved after the intervention. Preference for CMDs as preferred providers for malaria increased in all sites.Quantitative findings: 9001 children with an episode of fever were treated by 199 CMDs in the five study sites. Results from the CHWs registers show that of these, 6974 were treated with an ACT and 6933 (99%) were prescribed the correct dose for their age. Fifty-four percent of the 3,025 children for which information about the promptness of treatment was available were treated within 24 hours from the onset of symptoms.From the household survey 3700 children were identified who had an episode of fever during the preceding two weeks. 1480 (40%) of them sought treatment from a CMD and 1213 of them (82%) had received an ACT. Of these, 1123 (92.6%) were administered the ACT for the correct number of doses and days; 773 of the 1118 (69.1%) children for which information about the promptness of treatment was available were treated within 24 hours from onset of symptoms, and 768 (68.7%) were treated promptly and correctly.ConclusionsThe concept of CCMm in an urban environment was positive, and caregivers were generally satisfied with the services. Quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm. Urban CCMm is feasible, but it struggles against other sources of established healthcare providers. Innovation is required by everyone to make it viable.

Background: Home Management of Malaria (HMM) is one of the key strategies to reduce the burden of malaria for vulnerable population in endemic countries. It is based on the evidence that well-trained communities health workers can provide prompt and adequate care to patients close to their homes. The strategy has been shown to reduce malaria mortality and severe morbidity and has been adopted by the World Health Organization as a cornerstone of malaria control in Africa. However, the potential fall-out of this community-based strategy on the work burden at the peripheral health facilities level has never been investigated.

Hepatitis B virus (HBV) infection is a critical global health problem. The World Health Organization (WHO) has recently developed a global elimination strategy for HBV infection. Increasing access to screening, liver assessment, and antiviral treatment are crucial steps in achieving this goal. Little is known, however, about obstacles to linkage to care in low- and middle-income countries. Using a grounded theory approach, this qualitative study sought to characterize the diagnostic itineraries of people with chronic HBV infection in Burkina Faso, a west African country with high HBV prevalence, to identify barriers to linkage from screening to specialist care with hepatic assessment (alanine transaminase and hepatitis B e antigen or HBV DNA). We conducted 80 semistructured interviews with chronically infected people, their families, medical personnel, and traditional practitioners, and participant observation of HBV diagnostic announcements and consultations. Of 30 individuals diagnosed with chronic viral hepatitis, 18 inadvertently discovered their status through blood screening and 12 actively sought diagnosis for their symptoms. Only a quarter (8/30) were linked to care. Barriers included: 1) patients' ability to pay for testing and treatment; 2) a formal health system lacking trained personnel, diagnostic infrastructures, and other resources; 3) patients' familial and social networks that discouraged access to testing and HBV knowledge; 4) a well-developed demand for and provisioning of traditional medicine for hepatitis; and 5) a weak global politics around HBV. More training for medical personnel would improve linkage to care in sub-Saharan Africa. Developing effective communications between medical workers and patients should be a major priority in this elimination strategy.

This comparative study explores incertitude about hepatitis B (HBV) and its implications for childhood vaccination in Bangui, Central African Republic, and the Cascades region, Burkina Faso. Anthropological approaches to vaccination, which counter stereotypes of "ignorant" publics needing education to accept vaccination, excavate alternative ways of knowing about illness and vaccination. We build on these approaches, evaluating different kinds of incertitude (ambiguity, uncertainty, ignorance) about infancy, HBV, health protection, and vaccination. Using interviews and participant observation, we find that Bangui and Cascades publics framed their incertitude differently through stories of infancy, illness, and protection. We locate different forms of incertitude within their historical contexts to illuminate why vaccination practices differ in the Cascades region and Bangui. A more nuanced approach to incomplete knowledge, situated in political, economic, and social histories of the state and vaccination, can contribute to more appropriate global health strategies to improve HBV prevention.