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Mariamawit Negatou,1 Mady Ouedraogo,2 Philippe Donnen,3 Elisabeth Paul,3 Sekou Samadoulougou,4,5,* Fati Kirakoya-Samadoulougou1,* 1Centre de Recherche en Epidémiologie, Biostatistiques et Recherche Clinique, École de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique; 2Institut National de la Statistique et de la Démographie (INSD), Ouagadougou, Burkina Faso; 3Centre de Recherche en Politiques et Systèmes de Santé – Santé Internationale, École de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique; 4Centre for Research on Planning and Development (CRAD), Laval University, Quebec City, Quebec, G1V 0A6, Canada; 5Evaluation Platform on Obesity Prevention, Quebec Heart and Lung Institute, Quebec City, Quebec, G1V 4G5, Canada*These authors contributed equally to this workCorrespondence: Mariamawit NegatouCentre de Recherche en Épidémiologie, Biostatistique et Recherche Clinique, École de Santé Publique, Université Libre de Bruxelles, Bruxelles, BelgiqueTel +251911747363Email mariamawitbrouk@gmail.comBackground: In 2016, a free healthcare policy (FHP) was implemented in Burkina Faso for children under the age of five. In our study, we aimed to determine the prevalence of care-seeking for a fever in children under the age of five before and after the implementation of the FHP and to analyze the determinants of not seeking care under the FHP.Methods: The data of three nationally representative surveys were used to evaluate the trends of the prevalence of care-seeking. We performed a modified Poisson regression using a generalized estimating equation to determine the factors associated with not seeking care.Results: The prevalence for care seeking increased from 57.5% (95% CI, 54.2– 60.8) in 2014 to 72.3% (95% CI, 68.1– 76.2) in 2017. Children from the poor quintile were less likely to seek care when compared to children from the poorest quintile (prevalence ratio (PR) = 0.7 (95% CI, 0.5– 0.9)). Caregivers who did not have messages regarding malaria in the past six months were more likely not to seek care (PR = 0.8 (95% CI, 0.7– 0.9)). Caregivers of children aged 36– 59 months were more likely not to seek care compared to those aged < 12 months (PR = 1.6 (95% CI, 1.2– 2.1)). Children from the Boucle du Mouhoun region (PR = 1.9 (95% CI, 1.2– 3.2)) and the Centre-Est region (PR = 1.9 (95% CI, 1.2– 3.0)) were more likely not to seek care compared to children from the Sud Ouest region.Conclusion: Our study showed an increase in the prevalence of care-seeking after the implementation of the FHP. Even if this is encouraging, these findings highlight the critical importance of non-financial barriers to care-seeking. Maintaining FHP and tackling the barriers should be considered by policy makers to increase care-seeking.Keywords: fever, free healthcare policy, care-seeking, children under-five, Burkina Faso

Background In 2010, the government of Sierra Leone implemented the Free Health Care Initiative (FHCI) in the country with the objective of reducing the high maternal, infant, and child mortality rates and improving general health indicators. The objective of this study was to assess the trends in the prevalence of health care-seeking and to identify the determinants of healthcare service utilization by caregivers of children younger than five years. Methods The analysis of health-care-seeking behavior was done using data from four populationbased surveys in Sierra Leone before (2008) and after (2013, 2016, 2019) the FHCI was implemented. Care-seeking behavior was assessed with regard to caregivers seeking care for children under-five in the two weeks prior to each survey. We compared the percentages of healthcare-seeking behavior change and identify factors associated with healthcareseeking using a modified Poisson regression model with generalized estimating equations. Results In 2008, a total of 1208 children with fever were recorded, compared with 2823 children in 2013, 1633 in 2016, and 1464 in 2019. Care-seeking for children with fever was lowest in 2008 (51%; 95% CI (46.4-55.5)) than in 2013 (71.5%; 95% CI (68.4-74.5)), 2016 (70.3%; 95% CI (66.6-73.8)), and 2019 (74.6%; 95% CI (71.6-77.3)) (p < 0.001). Care-seeking in 2013, 2016 and 2019 was at least 1.4 time higher than in 2008 (p < 0.001) after adjusting for mother's age, wealth, religion, education level, household head and the child's age. Careseeking was lowest for children older than 12 months, mothers older than 35 years, children living in the poorest households, and in the northern region. A trend was observed for the sex of the household head. The level of care-seeking was lowest when the household head was a man. Conclusions The increase in healthcare-seeking for children under-five with fever followed the introduction of the FHCI in Sierra Leone. Care-seeking for fever varied by the child's age, caregiver's age, household wealth, the sex ...