Introduction Out-of-pocket payments persist, limiting access to care in Africa. The AIRE project evaluated the implementation of pulse oximetry integrated with Integrated Management of Childhood Illness (IMCI) at Primary Healthcare Centres (PHCs) in Burkina Faso and Niger (total exemption policy) and Mali and Guinea (partial exemption policy). We measured households out-of-pocket expenditures for care of children under-5 years and analyzed associated factors. Methods Between 06/2021-05/2022, five non-severe and five severe cases per PHC among children <5 years attending IMCI consultations (excluding simple non-respiratory cases) in four PHCs per participating country in the AIRE study were selected each month among the children included. Severe IMCI cases were followed-up at 14 days. We collected medical direct costs and non-medical direct and indirect costs. We describe median costs; factors associated with medical direct costs (MDC) were investigated in two-part models for countries with total exemption and general linear model in those with partial exemption. Results Of the 15,836 children overall, 940 non-severe cases and 745 severe cases were included. The median medical direct costs were USD 0.0, 7.1, 5.0 and 3.6 for non-severe cases, and 1.6, 8.6, 7.4 and 14.4 for severe cases, in Burkina Faso, Guinea, Mali and Niger, respectively. Medicine expenditures were the main MDC item, reaching 79% for non-severe cases and 59% in severe cases. In all countries, the disease severity and the unavailability of prescribed medicines at PHCs or hospital depots were associated to any out-of-pocket payment, and to higher amounts of expenses. Conclusion With the exception of Burkina Faso and despite free care policies, household out-of-pocket payment remains high for children under-5, particularly for treating severe cases, mainly explained by medicines expenditures. Actions are needed to identify efficient financing systems to ensure regular and adequate delivery of medicines in public health facilities, and to support free healthcare policies.

The authors have declared no competing interest.

PACTR202206525204526

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08982-4

The AIRE project is funded by UNITAID, with in-kind support from Inserm and IRD. UNITAID was not involved in the design of the study, the collection, analysis and interpretation of the data, nor in the writing of the manuscript.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

- The WHO Ethics Review Committee (WHO-ERC) gave ethical approval for this work (ERC.0003364) - The Inserm Institutional Evaluation Ethics Committee (IEEC) gave ethical approval for this work (Inserm IEEC 20-720). - The "Comite d Ethique pour la Recherche en Sante (CERS), of Burkina Faso gave ethical approval for this work (2020-4-070). - The "Comite National d Ethique pour la Recherche en Sante (CNERS)", of Guinea gave ethical approval for this work (169/CNERS/21). - The "Comite National d Ethique pour la Sante et les Sciences de la vie (CNESS)", of Mali gave ethical approval for this work (127/MSDS-CNESS). - The "Comite National d Ethique pour la Recherche en Sante (CNERS)", of Niger gave ethical approval for this work (67/2020/CNERS).

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All data produced in the present study are available upon reasonable request to the authors