Utilisation inappropriée des médicaments chez des personnes âgées avec des multimorbidités : traceur utile pour l’analyse du système de soins au Burkina Faso

Inappropriate use of medication which occurs from the care of the persons with multimorbidity is recognized as a public health issue for the northern countries. This is stressed by the ageing of their population. In sub-Saharan Africa and more specifically in Burkina Faso, the care of the people with multimorbidity, in particular at the older adults, still seems little taken into account in the health care systems organization. This system is still health problems-centered and acute diseases- centered. The aim of this thesis was to analysis the health care system by a tracer «Inappropriate use of medication in older adults with multimorbidity». The three questions of research were 1) what are the characteristics of the older adults with multimorbidity which could influence the inappropriate use of medication? 2) What are the characteristics of the health care system which influence the care of older adults with multimorbidity? 3) How the characteristics of health care system influence the care of older adults with multimorbidity? The research was carried out at Bobo-Dioulasso in Burkina Faso. We conducted an analysis based-system centered on the care of older adults with multimorbidity. For their care, the older adults are in interaction with the care providers, the organization of health facilities and the social-family network. This system was analyzed through different methods using various sources of data. This analysis had for starting point the older adults at home. This first step was carried out in 2012. This first step consisted of a household survey to understand health problems (chronic diseases) and the problems of the older adults care (potentially inappropriate medication). In a second step (2013-2014), we carried out, in a logical way, sub-studies in the health facilities 1) the health care system dysfunctions, 2) the factors of heath care organization associated with the inappropriate use of medication according to the older adult’s perspective and 3) the reasons of the inappropriate use of medication during the care of older adults. Our sample was constituted by older adults with a mean age of 69 years. Among the older adults, 55.3% were men, 54.1% illiteracy 58.7%, married, 58% without retirement incomes and 59.1% having already used a health facility during the last six months. We found older adults with polypharmacy (39%), multimorbidity (65 %), having used at least one inappropriate medication (59%), having used the formal and informal care (self-medication by informal market, the traditional medication) for the same episode of disease. These older adults were affected by the following main chronic diseases: arterial hypertension (82.3%), malnutrition (39.2%), visual impairment (28.3%), and diabetes mellitus (26.5%). About their care, our research showed an acute management of the chronic diseases, a lack of coordination with others care providers in the private and traditional sector, a weak implementation of the activities of information, educational and communication to strengthen patients empowerment, a weakness in the in-house training of the care providers, an insufficiency of the teamwork, a lack of standards and protocols for the care of the older adults with multimorbidity. The main prescribers of inappropriate medication were the paramedical in the first line. The characteristics of care providers who can contribute to explain the use of the inappropriate medication are: their missing work, their initial training, the lack of their work follow-up (assessment), their relation with the older adult during the consultation (paternalist), their low feeling of non-accountability to the patients and to their peers. To improve the use of inappropriate medication at the older adults with multimorbidity, we propose track at various levels and by priority, which should bring a profit beyond this target group. At macro level, the current dynamic in Burkina Faso about the development of an universal health insurance (UHI) and as well as the discussions about the financing based-result (FBR) could be taken as opportunities. In the first place, the identification of a basket of care for the UHI is an opportunity to include the necessary services for the rational care of the older adults with multimorbidity. Secondly, the inclusion of the private care providers in the system of UHI could allow the improvement of the health care system compartmentalization. Thirdly, the opportunity offered by the UHI and the FBR to include private and public care providers in the care is a track to introduce a process of accreditation for these providers in the rational prescription. Fourthly, to support this rational care, the implementation of consensus experts' committee could allow the producing of pharmaceutical and therapeutic directives centered on the care of the older adults with multimorbidity. This committee can be constituted by the experts of the learned societies and by the general practitioners of hospitals. At meso level: in the first place, a committee of regional experts constituted by specialists and general practitioners of hospitals can design therapeutic and pharmaceutical protocols and insure their application for the care of older adults with multimorbidity. This committee offers an opportunity to work on the conception of a medical record in hospitals. Secondly, the implementation of this committee is an opportunity to ensure the in-house training of the care providers. This in-house training could join the logic of the accreditation of the care providers in the rational prescription. At micro level: in the first place, the implementation of the pharmaceutical and therapeutic committees in the district hospitals could allow a rational prescription for the older adults with multimorbidity. These committees can consist of doctors, pharmacists, nurses and of social workers. Secondly, these committees can promote the use of the therapeutic and pharmaceutical protocols, the test of a medical shared tool (medical record). Thirdly these committees can be an opportunity to develop a local multidisciplinary team of care, to think about forms of information, educational and communication to strengthen patient’s empowerment and to define the role of a home-care coordinator.