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; 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.