Shared and targeted barriers to care for skin-related neglected tropical diseases in two endemic communes of Benin: Toward a framework for resource allocation

Purpose

Skin-related neglected tropical diseases (skin-NTDs) persist across sub-Saharan Africa despite sustained control. Programme managers allocating scarce resources must decide whether barriers to care call for shared measures applied uniformly across districts or targeted responses tailored to each setting. We characterized the social, economic and cultural barriers to skin-NTD care in two contrasting endemic communes of Benin, tested for each barrier whether it is uniform or locally differentiated, and set out a preliminary framework for resource allocation that follows from this distinction.

Methods

Convergent mixed-methods study in Zagnanado and Allada, combining a household-based survey of 403 persons affected by a skin-NTD and members of their entourage with 60 semi-structured interviews. Each principal barrier was modelled by multivariable logistic regression with multidimensional adjustment for education, urbanicity, household size, occupation and sex, and tested across two sensitivity specifications. Reporting followed STROBE and COREQ.

Results

Treatment cost was reported by 84.6% of participants with no detectable between-commune difference (adjusted odds ratio [aOR] 0.72; P = 0.380). Limited access (26.4% versus 66.7%) and lack of infrastructure (10.0% versus 53.0%) were markedly concentrated in Zagnanado and persisted after adjustment (aOR 8.09 and 12.91; both P < 0.001), robust across three specifications of socioeconomic adjustment. Qualitative data linked these barriers to inability to pay upfront, peripheral health-system under-resourcing, and a local Fongbe nosology directing patients first to traditional or faith healers.

Conclusion

Cost behaves as a shared, high-burden barrier; structural deficits are locally concentrated. We propose a preliminary framework that classifies each barrier by its burden and between-setting variability, matching shared measures to shared barriers and targeted investment to locally concentrated ones. The framework is derived from two purposively selected communes and has not been externally validated; it is offered as a hypothesis for programme managers to test, not as a ready-to-use instrument.