Kadidiatou Kadio

Targeting the worst-off for free health care: A process evaluation in Burkina Faso

Effective mechanisms to exempt the indigent from user fees at health care facilities are rare in Africa. A State-led intervention (2004-2005) and two action research projects (2007-2010) were implemented in a health district in Burkina Faso to exempt the indigent from user fees. This article presents the results of the process evaluation of these three interventions. Individual and group interviews were organized with the key stakeholders (health staff, community members) to document the strengths and weaknesses of key components of the interventions (relevance and uptake of the intervention, worst-off selection and information, financial arrangements). Data was subjected to content analysis and thematic analysis. The results show that all three intervention processes can be improved. Community-based targeting was better accepted by the stakeholders than was the State-led intervention. The strengths of the community-based approach were in clearly defining the selection criteria, informing the waiver beneficiaries, using a participative process and using endogenous funding. A weakness was that using endogenous funding led to restrictive selection by the community. The community-based approach appears to be the most effective, but it needs to be improved and retested to generate more knowledge before scaling up.

Why do women pay more than they should? A mixed methods study of the implementation gap in a policy to subsidize the costs of deliveries in Burkina Faso

In 2007, Burkina Faso launched a public policy to subsidize 80% of the cost of normal deliveries. Although women are required to pay only the remaining 20%, i.e., 900F CFA (1.4 Euros), some qualitative evidence suggests they actually pay more. The aim of this study is to test and then (if confirmed) to understand the hypothesis that the amounts paid by women are more than the official fee, i.e., their 20% portion. A mixed method sequential explanatory design giving equal priority to both quantitative (n=883) and qualitative (n=50) methods was used in a rural health district of Ouargaye. Half (50%, median) of the women reported paying more than the official fee for a delivery. Health workers questioned the methodology of the study and the veracity of the womens reports. The three most plausible explanations for this payment disparity are: (i) the payments were for products used that were not part of the delivery kit covered by the official fee; (ii) the implementers had difficulty in understanding the policy; and (iii) there was improper conduct on the part of some health workers. Institutional design and organizational practices, as well as weak rule enforcement and organizational capacity, need to be considered more carefully to avoid an implementation gap in this public policy.

Challenges of scaling up and of knowledge transfer in an action research project in Burkina Faso to exempt the worst-off from health care user fees

BackgroundSystems to exempt the indigent from user fees have been put in place to prevent the worst-off from being excluded from health care services for lack of funds. Yet the implementation of these mechanisms is as rare as the operational research on this topic. This article analyzes an action research project aimed at finding an appropriate solution to make health care accessible to the indigent in a rural district of Burkina Faso.ResearchThis action research project was initiated in 2007 to study the feasibility and effectiveness of a community-based, participative and financially sustainable process for exempting the indigent from user fees. A interdisciplinary team of researchers from Burkina Faso and Canada was mobilized to document this action research project.Results and knowledge sharingThe action process was very well received. Indigent selection was effective and strengthened local solidarity, but coverage was reduced by the lack of local financial resources. Furthermore, the indigent have many other needs that cannot be addressed by exemption from user fees. Several knowledge transfer strategies were implemented to share research findings with residents and with local and national decision-makers.Partnership achievements and difficultiesUsing a mixed and interdisciplinary research approach was critical to grasping the complexity of this community-based process. The adoption of the process and the partnership with local decision-makers were very effective. Therefore, at the instigation of an NGO, four other districts in Burkina Faso and Niger reproduced this experiment. However, national decision-makers showed no interest in this action and still seem unconcerned about finding solutions that promote access to health care for the indigent.Lessons learnedThe lessons learned with regard to knowledge transfer and partnerships between researchers and associated decision-makers are: i) involve potential users of the research results from the research planning stage; ii) establish an ongoing partnership between researchers and users; iii) ensure that users can participate in certain research activities; iv) use a variety of strategies to disseminate results; and v) involve users in dissemination activities.

A spatial analysis of a community-based selection of indigents in Burkina Faso.

Over recent decades, Burkina Faso has improved the geographic accessibility of its health centres. However, patients are still required to pay point-of-service user fees, which excludes the most vulnerable from access to care. In 2010, 259 village committees in the Ouargaye district selected 2649 indigents to be exempted from user fees. The 26 health centre management committees that fund this exemption retained 1097 of those selected indigents. Spatial analysis showed that the management committees retained the indigents who were geographically closer to the health centres, in contrast to the selections of the village committees which were more diversified. Using village committees to select indigents would seem preferable to using management committees. It is not yet known whether the management committees’ selections were due to a desire to maximize the benefits of exemption by giving it to those most likely to use it, or to the fact that they did not personally know the indigents who were more geographically distant from them, or that some villages are not represented at the management committees.

A community-based approach to indigent selection is difficult to organize in a formal neighbourhood in Ouagadougou, Burkina Faso: a mixed methods exploratory study

BackgroundIn most African countries, indigents treated at public health centres are supposed to be exempted from user fees. In Africa, most of the available knowledge has to do with targeting processes in rural areas, and little is known about how to select the worst-off in an urban area. In rural communities of Burkina Faso, trials of participatory community-based selection of indigents have been effective. However, the process for selecting indigents in urban areas is not yet clear.MethodsThis study evaluates a community-funded participatory indigent selection process in both a formal (loti) and an informal (non-loti) neighbourhood in the urban setting of Burkina Faso’s capital. This was an exploratory study to evaluate the processes and effectiveness of participatory targeting. We conducted individual interviews (n = 26) and analyzed secondary qualitative data (eight focus groups, 16 individual interviews). We also used the results of a socioeconomic survey (carried out by the Ouaga HDSS in 2011) of all the households established in the areas, including those of selected indigents.ResultsThe coverage of indigent targeting was very low: 0.33% (loti) and 0.22% (non loti). In the non loti neighbourhood, the level of poverty among people selected was higher than the mean level of the poor who were not selected. Some indigents selected in the loti neighbourhood were not among the worst-off. The process was difficult to organize in the loti neighbourhood; people knew each other less well and were not very available, and there were cases of collusion. The process worked well in the non loti neighbourhood.ConclusionsThis intervention research provides new evidence about the feasibility of a community-based selection process in an urban setting in Africa by comparing two different urban settings. The participatory community-based selection process appeared to be suitable for the non loti neighbourhood, but other targeting strategies need to be found for loti areas. Specific budgets need to be allocated to increase the coverage of indigent targeting.Additional non-English language abstract: FrenchContexteDans la plupart des pays d’Afrique, les indigents doivent être exemptés du paiement des soins dans les centres de santé publics. En Afrique, la plupart des connaissances disponibles concernent les processus de ciblage realisés en milieu rural, mais très peu de données probantes concernent ces processus en milieu urbain. Des expériences de sélection communautaire participative ont été testées avec efficacité en milieu rural au Burkina Faso. Cependant, on ne sait pas encore comment sélectionner les indigents en milieu urbain.MéthodesL’étude vise à évaluer une sélection communautaire des indigents financée par la communauté dans un quartier loti et un quartier non loti du milieu urbain de la capitale du Burkina Faso. Il s’agit d’une recherche exploratoire d’évaluation des processus et de l’efficacité du ciblage participatif. Des entrevues individuelles (n = 26) et une analyse de données qualitatives secondaires (8 focus groups, 16 entrevues individuelles) ont été réalisées. Nous avons également utilisé une enquête socio-économique réalisée auprès de tous les ménages des quartiers concernés par l’Observatoire de Population de Ouagadougou en 2011, y compris auprès des ménages des indigents sélectionnés.RésultatsLa couverture du ciblage des indigents est très faible, soit 0,33% (loti) et 0,22% (non loti). Les personnes sélectionnées dans le quartier non loti sont plus pauvres que la moyenne des pauvres non sélectionnés. Une partie des indigents sélectionnés dans le quartier loti ne sont pas parmi les plus pauvres. Le processus a été difficile à organiser dans le quartier loti, où les personnes se connaissent moins, sont peu disponibles, et des cas de collusion ont été rencontrés. Le processus s’est bien déroulé en quartier non loti.ConclusionsCette recherche interventionnelle génère de nouvelles connaissances sur la faisabilité d’un processus participatif de ciblage en milieu urbain en Afrique en comparant deux milieux. Le processus communautaire participatif semble adapté au quartier non loti en milieu urbain mais d’autres solutions de ciblage doivent être trouvées en quartier loti. Des budgets spécifiques doivent être alloués pour augmenter la couverture du ciblage des indigents.

Endorsement of universal health coverage financial principles in Burkina Faso

In West Africa, health system funding rarely involves cross-subsidization among population segments. In some countries, a few community-based or professional health insurance programs are present, but coverage is very low. The financial principles underlying universal health coverage (UHC) sustainability and solidarity are threefold: 1) anticipation of potential health risks; 2) risk sharing and; 3) socio-economic status solidarity. In Burkina Faso, where decision-makers are favorable to national health insurance, we measured endorsement of these principles and discerned which management configurations would achieve the greatest adherence. We used a sequential exploratory design. In a qualitative step (9 interviews, 12 focus groups), we adapted an instrument proposed by Goudge et al. (2012) to the local context and addressed desirability bias. Then, in a quantitative step (1255 respondents from the general population), we measured endorsement. Thematic analysis (qualitative) and logistic regressions (quantitative) were used. High levels of endorsement were found for each principle. Actual practices showed that anticipation and risk sharing were not only intentions. Preferences were given to solidarity between socio-economic status (SES) levels and progressivity. Although respondents seemed to prefer the national level for implementation, their current solidarity practices were mainly focused on close family. Thus, contribution levels should be set so that the entire family benefits from healthcare. Some critical conditions must be met to make UHC financial principles a reality through health insurance in Burkina Faso: trust, fair and mandatory contributions, and education.