Hi my name is Helle Samuelsen. I'm from Department of Anthropology, University of Copenhagen In this case study, I will take you to Burkina Faso, a land-locked West African country with a population of about 17 million. Burkina Faso is one of the poorest countries of the world, ranked as number 183 out of 186 countries at the United Nations Human Development Index. The government of Burkina Faso signed the Alma-Ata Declaration on Primary Health Care in 1978 and has since worked to increase the distribution of health care services in rural areas. Today, the maximum distance to a health center is about 15 kilometres. However, studies show that many of the public health facilities, which are government run, are under-utilized. The low use of public health facilities is paradoxical because the need for health care services is huge. Burkina Faso has one of the highest child mortality rates in the world: it is estimated to be 176 per 1000 (UNDP 2013). In other words, almost every fifth child will die before he or she reaches the age of five. Why is the public health care system under-utilized . The data for this case study was collected in three villages in the south-eastern part of the country. Most villagers here live from subsistence agriculture with remittances from migrants as another important source of income. In studies of health care seeking practices of rural populations, these five factors have been highlighted as important for an understanding of use and non-use of public health care facilities: Availability: Are health care facilities within geographical reach of the rural population? Accessibility: Does a sick person or a mother of a sick child have the means of transport to reach a health service facility? Cost (both direct and indirect costs): Can a household actually afford to seek treatment at a health facility and pay for the drugs? And can a family afford to miss a half day or full day of income in order to take a sick child to a health facility? Quality of care: Are the health staff trained well enough to provide the best possible treatment? And are the treatment procedures explained well enough for the patients so that they can follow the prescribed treatment? Delay: Does a sick person or a mother to a sick child seek professional help promptly - and does the sick person receive timely treatment when contacting a health facility? The Primary Health Care Centre in the rural areas of Burkina Faso is usually staffed with two nurses and an auxiliary midwife, and each center covers approximately 10 villages. The services offered at a health center include out-patient and ante-natal and post-natal care. There is also a small ward with a few beds for admitted patients and for maternity care. The standard procedure is that the patient is first examined by one of the nurses at the Primary Health Center, who writes the prescription on a small piece of paper; the patient then buys the medicines from a small pharmaceutical store selling the most essential drugs. Finally, the patient returns to the nurse for instructions about how to take the medicine, or the nurse gives the injection/s with the needle, syringe and medicine bought by the patient. The supply of drugs is usually sufficient, but the health care center has neither electricity or water and latrines, and the nearest hospital for referral is the district hospital of which there are 42 in the country. Vaccination is free in Burkina Faso and while the health centers are buzzing with activity at the scheduled vaccination days, they are surprisingly quiet at other days - taking the health care needs into account. All of the aforementioned factors are important for an understanding of the relatively low use of the government health facilities in these villages. In order to obtain a more in-depth understanding of why government health facilities may be under-utilized, we need to know a bit more about the local ethnography. In addition to the government health care center, our study identified a fairly large number of other people who offered some kind of health care services. The majority of these were herbalists who collect plants in the surrounding bush, prepare medicines and treat villagers who come for consultation. They are specialists in relation to specific symptoms or diseases. Another group of healers includes the bonesetters, who have specific skills in treating fractures. In addition, one person possessed specific knowledge about how to treat cases of sorcery, while another person was a diviner, who not only dealt with cases of sickness, but also with other kinds of misfortunes. The marabouts are those who, having attended Koran school and acquired skills in treating sickness, use quotations from the Koran as well as herbs and minerals as therapy. The therapeutic skills of these groups of healers are both technical and spiritual. The health care practices of these local healers are based on various types of indigenous knowledge traditions. At the market, young peddlers sell western pharmaceuticals and others sell herbal medicine. Furthermore, the local villagers themselves have an extensive knowledge about local plants used in herbal medicine and self-medication is widespread here as like in some other parts of the world. Thus, the health system in these villages comprises much more than the government health facilities. The fact that various knowledge traditions co-exist in a society is called medical pluralism. The primary health care center is thus not the only available health care facility and in cases of illness many villagers act very pragmatically by trying out various types of treatment simultaneously, which sometimes causes a delay before efficient treatment is reached. We discovered another important explanation of the under-utilization of the primary health care center in these villages, when we studied a number of monthly reports from the health centers. Here it became clear that malaria accounted for about 34% of all the cases attended. This is not necessarily surprising, but it was surprising that only very few people were diagnosed with heart problems, high blood pressure, diabetes and mental problems. This finding indicates that villagers mainly consult the government health facility with malaria related symptoms. Other symptoms and diseases are dealt with in other ways and through other types of consultations. In conclusion, by using ethnographic data and looking in detail at the health care seeking practices we can obtain a better understanding of why -- and in which cases - government health facilities are used and why these facilities are under-utilized in one of the poorest countries of the world.
