BackgroundIf there is one universal recommendation to countries wanting to make progress towards Universal Health Coverage (UHC), it is to develop the learning capacities that will enable them to ‘find their own way’ – this is especially true for countries struggling with fragmented health financing systems. This paper explores results from a multi-country study whose main aim was to assess the extent to which UHC systems and processes at country level operate as ‘learning systems’.MethodThis study is part of a multi-year action-research project implemented by two communities of practice active in Africa. For this specific investigation, we adapted the concept of the learning organisation to so-called ‘UHC systems’. Our framework organises the assessment around 92 questions divided into blocks, sub-blocks and levels of learning, with a seven scale score in a standardised questionnaire developed during a protocol and methodology workshop attended by all the research teams. The study was implemented in six francophone African countries by national research teams involving researchers and cadres of the ministries involved in the UHC policy. Across the six countries, the questionnaire was administrated to 239 UHC actors. Data were analysed per country, per blocks and sub-blocks, by levels of learning and per question.ResultsThe study confirms the feasibility and relevance of adapting the learning organisation framework to UHC systems. All countries scored between 4 and 5 for all the sub-blocks of the learning system. The study and the validation workshops organised in the six countries indicate that the tool is particularly powerful to assess weaknesses within a specific country. However, some remarkable patterns also emerge from the cross-country analysis. Our respondents recognise the leadership developed at governmental level for UHC, but they also report some major weaknesses in the UHC system, especially the absence of a learning agenda and the limited use of data.ConclusionCountries will not progress towards UHC without strong learning systems. Our tool has allowed us to document the situation in six countries, create some awareness at country level and initiate a participatory action-oriented process.

Background: In Benin, malaria was the leading cause of hospital consultation for children less than 5 years old (47.2%), and for all patients not hospitalized (42.3%). Its incidence among those who attended a health facility was respectively 42.9% and 17%. To address this problem, the National Program for the Fight against Malaria undertook, in 2011, a mass campaign of distribution of Long-Lasting Insecticidal Nets (LLINs). In addition to this strategy, the program decided to implement Indoor Residual Spraying in 7 of the 9 municipalities of Atacora department, which is one of the most malaria endemic areas. The objective of this study was to see if adding the IRS to the LLINs (municipality of Kouandé) strategy is cost-effective, as compared to the LLINs-only strategy (municipality of Copargo), in highly malaria endemic areas.

The resolution of health problems at the community level requires firm political will on the part of governments and the effective participation of communities in co-management programs and health activities. The objective of this work is to study the role of Community Health Workers (CHWs) in solving health problems at the community level in Bénin and Togo, from 2009 to 2015. This is an evaluative study of the quasi-experimental type, with its variant "here elsewhere"; it was conducted in six health zones in Bénin and five health districts in Togo, ail randomly chosen from the list of districts and zones within the regions or departmental directions covered. The study involved 385 community health workers and 6150 heads of households. Female heads of households were predominant. The community health workers were predominantly male and their level of education was secondary school and up. Only level of education, marital status and the matrimonial régime of heads of households were not significantly correlated to their level of knowledge in both Bénin and Togo (p>5%). The heads of households had an acceptable knowledge of community health workers and their activities, but the subsequently expected favorable behavior towards health remained low. Thus, the role of CHWs in solving health problems was perceived as weak. For a visible impact of the actions of this new class of agents at the community level, a strong political will is needed from the countries in the implementation of World Health Organisation's recommendations on community health.

Background: The economic burden of malaria for households in the municipality of Kouandé and in the control and municipality of Copargo in Benin was assessed in two cross-sectional studies before and after the implementation of Indoor Residual Spraying (IRS).

Introduction : Au niveau international, une réflexion approfondie sur le rôle des agents de santé communautaire est en cours. L’objectif du travail est d’élaborer un modèle d’intégration des agents de santé communautaire dans le système national de santé. Méthode : L’étude s’est déroulée au Bénin et au Togo. Il s’agissait d’une enquête en grappe qui a concerné les agents de santé communautaire (ASC) au nombre de 385, 238 chefs de villages, 92 responsables de structures de santé sélectionnés par choix raisonné et 6 150 ménages choisis de façon probabiliste. L’analyse des forces, faiblesses, opportunités et menaces des interventions sous directive communautaire a contribué à l’élaboration du modèle. Résultats : Les documents de référence en santé communautaire existaient dans les deux pays. La quasi-totalité (98,4 %) des ASC avait déclaré, avoir reçu une formation avant le début de leur travail. Tous ont une motivation forte pour le travail qu’ils accomplissent. Quant aux chefs de ménage, seuls 31,3 % ont révélé participer à la sélection des ASC de leur localité. L’inexistence de lois reconnaissant le travail des ASC constitue une menace pour leur intégration dans le système de santé. Les principaux éléments proposés dans le modèle sont : l’élaboration du statut des ASC, la rémunération des ASC sur un budget géré par le district sanitaire et alimenté par plusieurs sources. Conclusion : Les ASC ne doivent pas être une alternative délivrant des soins de santé mais une entité à part entière du système national de santé.