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- Analyse the utilisation of the different structures of the child health care system and describe possible differences in their use from that of their intended mission;
- Analyse existing relationships between these different structures, especially between the hospital and "peripheral" structures;
- Study perceptions of the roles of these different structures by : health professionals on the one hand, clients (families of children) on the other hand.
- The main results of the epidemiological and anthropological studies carried out in Algeria, Morocco and Togo are summarised here. The results converge and in the three countries, comparable problems in health seeking and in functioning of health services were noted.
- Health seeking behaviours of these populations for their children (primarily infants in all the countries) shows certain characteristics that are cause for concern :
- the high frequency of self-referrals to hospitals;
- a certain number of "false emergencies";
- a long delay between first symptoms and the consultation;
- a high frequency of self-medication at home;
- frequent absence of the mother during the consultation in Algeria;
- appointments given for consultation not kept by families;
- highest frequency of consultations, considered by supervisors as not justified for that level of health care, at the university hospital level;
- differential health seeking by sex, with recourse to emergency services more frequent for boys than for girls.
- The frequency of consultations with tradipractitioners appears low. Thus, in Togo, the percentage of families who say they consulted a tradipractioner is 6% for the first consultation and 8% for the third, in cases of multiple consultations for the same problem. In Algeria it is 5.1%. While recourse to tradipractitioners appears infrequent, use of traditional medicinal substances seems to be more widespread. In Togo, during interviews in the anthropological study, 69% of families said they used infusions and medicinal plants.
- Problems in the functioning of health services are numerous :
- a problem of multiple entryways into services and an absence of triage;
- long waiting times : more than one hour in emergency services in 12% of cases in Algeria; more than two hours in 14% cases in Togo;
- incomplete care and lack of dialogue. For example, one may note the high frequency of missed opportunities to vaccinate during curative consultations in Algeria (only 3% of cases got needed vaccinations); the short contact time between caregivers and the family in health centres in Morocco : average time was reckoned to be 3 minutes;
- an absence of feedback in case of referral : in only 18% of cases in Algeria.
- In France, the research was not carried out in as much detail due to lack of financing. Nevertheless, in a geographical zone in the North of Paris, it was possible to note dysfunctions quite similar to those observed in the Southern countries, in particular, a high percentage of self-referrals to hospital and the use of emergency services as the primary care level.
- Ultimately, the summary of these results leads to the conclusion that, rather than a problem of inappropriate use of health services by users, there is a problem of late use of these services. Delays are long between the appearance of symptoms and recourse to modern medicine, the hospital is often reached belatedly after complex therapeutic itineraries, with consultations likely taking place under emergency conditions, and lethality may be high in case of hospitalisation. However, one cannot say that families of the children do not understand how the health system functions. Indeed, if one looks at the reasons given for choosing the place of consultation, it is apparent that families know how to adapt their choice according to the sickness of the child, the type of facility and the expected benefits (distance, care, technical quality). Health professionals themselves recognise this fact. Thus in Algeria, the supervisors of the epidemiological study estimated that, largely, the families'choices of care facility were appropriate in 91% of cases. What is more, these families demonstrate a sort of "basic confidence" in modern medicine. Accordingly, in Togo "medical quality" is cited first among reasons for choosing care facilities. The percentage of patients leaving hospital without medical consent is low, recourse to tradipractitioners appears of only moderate importance, although the products of popular and traditional medicine appear to be more utilised. It is probable that what discourages families, and what is principally behind belated consulting, are the unfriendly reception and problems of communication with care givers in the public health services. These problems appear more important than financial problems that are rarely mentioned except in Togo, a country in which the high cost of care and drugs doubtless plays a role in self-medication and belated consultations in health care facilities.
- In Togo, it is primarily public services that are criticised, sometimes almost violently, by users who complain of "insolence", even "insults" on the part of health personnel, of deplorable hygienic conditions and of a chronic lack of material, human and financial resources. Under these conditions, there could be a strong temptation to have preferential recourse to tradipractitioners, who, as we have noted from the Togo study, put an emphasis on properly welcoming patients. In addition, they play a social role and consider a sick child, its illness and the family in a global perspective. They do not deny the therapeutic role of parents, and even encourage them in this direction, and they are ready to negotiate on the cost of services rendered. Nonetheless, with improvement, basic health services could efficiently provide a first level of patient contact, because they are in fact used. For example, in Algeria consultations in small health care dispensaries and health centres represent 39% of all consultations.
- Improvement is therefore more to be looked for among health care providers than among family behaviours, and information campaigns for the population on how patients should use health services would doubtless be largely unproductive. But health education activities are what health professionals in Togo are asking for, refusing completely to call into question their own behaviours. A reading of passages from interviews with families in Algeria demonstrates convincingly the need for training of care givers in the reception of and communication with patients, but also about the role families play when faced with the illness of their children. Indeed, in the interviews with Algerian families, the active role of parents faced with a child's illness is quite apparent, while in the same country, health professionals, in interviews in the anthropological study, deny any important role for families in the treatment of children. Rather, their primary preoccupation is with the organisation of activities and the resources available in health facilities, and they express frustration with families of sick children when they do not use these facilities according to the expectations of the personnel.
- It is these kinds of research results that lead logically to the refinement of training tools for health professionals, using especially findings from the anthropological research. This has been undertaken in a later phase of the research project (see the section on "follow-up" below).
- At the same time, other frustrations of health professionals should also be taken into account. It is doubtful that changes in their behaviour related to the manner they receive and communication with families will be possible without accompanying improvements in technical aspects of their work environment. This comes out clearly in interviews in Algeria showing the extent to which personnel suffer from lack of resources, especially at the level of primary care structures, which have acquired a highly negative image. The professionals'experiences with the lack of modern technical resources is well described by the Algerian sociologist when he notes "medicine as it is dreamed about and learned during medical education undergoes a process of distortion when it comes into contact with social reality".
- Finally, the results of this research overturn the culturalist idea that a certain user mentality is responsible for the poor functioning of health services. Rather, they emphasise the responsibility of State governments by showing the need to train health personnel so that they may better understand the cognitive and social organisation of societies in which they practise medicine. This is rarely discussed at the international level, where more often the tendency is to assert that certain ways of thinking are obstacles to development. In fact, it appears that when services are of good quality, there is no reason why people will not use them. Under the term "quality" one must include both technical aspects of care as well as the ability to relate and communicate with service users.


- This research program financed by STD2 was carried out with considerable difficulties because of grave social and political problems in two of the countries beginning in 1992 (Algeria and Togo). It was continued and completed by an operational phase made possible by an STD3 grant. This enabled :
- the completion of data gathering in the first phase of research in the Congo, a country which was not included in financing under STD2, but which had support from the French National Institute for Health and Medical Research (INSERM) and the French Ministry of Co-operation;
- the continuation of analysis of epidemiological and anthropological data gathered during the first phase;
- the development of specific research projects on topics identified during the first phase of the research : the use of medicinal drugs by children in Togo, emergencies, therapeutic itineraries and behaviour of health personnel in Morocco;
- the development of training activities and of applied research;
- the organisation of progress workshops.
- Training activities have taken place mainly in Algeria and have consisted in the preparation of innovative teaching methods using results from the anthropological study (contents of interviews with families on health seeking behaviour for children) among health professionals during their initial training (nurses) or in the context of continuing education for interns and residents in hospital departments. In Morocco, activities were carried out at the level of health centres and diagnostic centres to improve the rate of use of curative consultations and to decrease the percentage of "unjustified" emergencies and self-referrals.
- Finally, the total research project (1st and 2nd phase financed by STD2 and STD3) resulted in the strengthening of local research potentials and the creation of local multidisciplinary teams. Moreover, it made possible the obtaining (by physicians and by medical assistants) of several Masters theses in public health, a French University Diploma and a Special Studies Diploma in paediatrics. Future collaboration is envisaged : the extension of training activities to the Congo and Togo, the development of a project on the use of medicinal drugs in the Congo and Togo, activities at the health services level in all the countries, with the inclusion of research results from this research project in already existing programmes, as is presently the case with the National Health Development Plan in the Congo.
- In conclusion, it should be emphasised that one of the primary merits of this research program lies in the local mastery by a local team of the entire process of a research project that had been requested by the country, or one of its neighbours, in the first place. Each country used its results from the descriptive phase of the research to orient the operational phase of the in-depth research, sometimes through a complex process of negotiation between what was a priority and what is feasible. Some of the results presented here were already known in the international literature; for example, the frequency of self-referral at the level of central hospitals, the existence of false emergencies or problems of triage in health centres. What is interesting in this research program is that the teams took over ownership of these results and made them into a local reality that made it possible for them, among other things, to convince local officials of their importance. This ownership of a problem by local teams is doubtless largely linked to the enthusiasm engendered by associating both an epidemiological and a qualitative approach.
- This research was undertaken in four different countries : Algeria, France, Morocco and Togo. It covered four main subject areas :
- a review and analysis of child health protection legislation;
- a general survey of socio-economic and demographic characteristics of the research area;
- an epidemiological study of ambulatory care cases and hospitalisation, in a sample of all types of health care facilities in the zones studied;
- an anthropological study of use and perception of health systems, using semi-structured interviews in families and among health professionals.
- This approach creates an interface between epidemiological, socio-economic, cultural and behavioural information. It encourages the formation of multidisciplinary research groups and reinforces research units in the countries.


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Centre International de l'Enfance et de la Famille
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