Barriers to accessing and using primary and secondary healthcare among children under-five in the Koutiala health district of Mali.

BACKGROUND: A 2022 survey conducted in Koutiala suggested a modest increase in the mortality rate and low utilization of healthcare facilities among children under-five i.e., children less than five years old. This study aimed to identify and describe the barriers to accessing and using primary and secondary healthcare services for this population in Koutiala Health District. METHODS: A survey, including cross-sectional and retrospective components, was conducted. In the cross-sectional phase, data were gathered through interviews with caregivers of children under-five and medical personnel at community health centers (Centres de Santé Communautaire, CSComs), as well as with guardians of children under-five at the household level, to explore challenges in accessing healthcare. In the retrospective phase, referrals from CSComs to the reference health center (Centre de Santé de Reference, CSRef) in 2022 and 2023 were reviewed using patients registers at both levels. Data collection was conducted electronically using KoBo, and analyses were primarily descriptive, performed in R. RESULTS: A total of 460 caregivers were interviewed. Though over 96% of the caregivers were children's mothers, 86% required authorization to visit the hospital. Approximately 10% of patients did not receive care due to financial constraints or medication stockouts. At the household level, 60.9% of guardians said they would take an ill child to a CSCom as the first point of care, while 26.7% would opt for self-medication, and 12.4% for traditional medicine. Of 4667 patients referred from CSComs in 2022 and 2023, only 2744 (58.8%) reached the CSRef, indicating a referral failure rate greater than 41%. Referral completion varied by patient age. Healthcare staff cited transportation difficulties, financial constraints, social pressure, and long distances as key reasons for referral failure. CONCLUSIONS: Barriers to accessing care in Koutiala encompass issues with the healthcare delivery system (e.g., stock shortages, service fees, referral failure, distances to CSComs), patterns of service utilization (e.g., self-medication, traditional medicine) and sociocultural factors (e.g., household decision-making). The low referral completion rate is particularly concerning, as these children are high-risk for health deterioration and death and require urgent care. This may partially explain the elevated under-five mortality rate observed in the community.