Abstract
BACKGROUND: Under-five mortality remains high in West Africa, where sick children are expected to first attend the primary health care before being referred to a hospital if necessary. However, little is known about how families navigate between home and higher levels of care to meet their children's health needs, despite multiple known barriers (including social, financial, and geographical accessibility). We analysed the care pathways of children aged 0-5 years before they presented to the district hospital with a serious illness and the determinants of these care pathways in four West African countries. METHODS: From May to August 2022, we conducted a cross-sectional study over a one-month data collection in seven district hospitals participating in the AIRE project aimed to introduce pulse oximetry at primary health care level in Burkina Faso, Guinea, Mali, and Niger. All children aged 0-5 years, classified as severe or priority cases by clinicians at referral district hospitals were included after parental consent. Data about care pathways since the onset of their disease were collected from caregivers, and the Levesque framework was used to analyse the accessibility issues. RESULTS: A total of 861 severely ill children were included, with 33% being neonates: 20.3% in Burkina Faso, 9.2% in Guinea, 9.5% in Mali, and 61% in Niger. In Burkina Faso and Niger, most children followed the recommended care pathway and first visited a primary health centre before arriving at the hospital, with 81.1% and 73.3% of children, respectively. However, they were only 51.2% in Mali and 13.9% in Guinea. Using alternative pathways was common, particularly in Guinea, where 30.4% of children first consulted a pharmacist, and Mali, where 25.6% consulted a traditional medicine practitioner. Overall, primary care was perceived to be more geographically accessible and less expensive, but parents were much less convinced that it could improve their child's health compared to hospital care. CONCLUSION: The recommended pathway is largely adhered to, yet parallel pathways require attention, notably in Guinea and Mali. A better understanding of healthcare-seeking behaviours can help remove barriers to care, improving the likelihood that a sick child will receive optimal care.