Ludovic Queuille

The national subsidy for deliveries and emergency obstetric care in Burkina Faso.

INTRODUCTION To reduce financial barriers to health care services presented by user fees, Burkina Faso adopted a policy to subsidize deliveries and emergency obstetric care for the period 2006-2015. Deliveries and caesarean sections are subsidized at 80%; women must pay the remainder. The worst-off are fully exempted. METHODS The aim of this article is to document this policys entire process using a health policy analytical framework. Qualitative data are drawn from individual interviews (n = 113 persons) and focus groups conducted with 344 persons in central government, three rural districts and one urban district. Quantitative data are taken from the national health information system in eight districts. RESULTS The policy was initiated in all districts concurrently, before all the technical instruments were ready. The subsidy is paid by the national budget (US

Evaluation of a knowledge transfer strategy from a user fee exemption program for vulnerable populations in Burkina Faso

60 million, including US

User fee exemptions and excessive household spending for normal delivery in Burkina Faso: the need for careful implementation

10 million for the worst-off). Information activities, implementation and evaluation support have been minimal because of insufficient funding. Health workers and lay people have not always had the same information, such that the policy has not been uniformly applied. Coping strategies have been noted among health workers and the population, but there has been no attempt to impede the policys implementation. At the time of the study, fixed-rate reimbursement for delivery (output-based) and overestimation of input costs were financially advantageous to health workers (bonuses) and management committees (hoarding). Very few of the worst-off have been exempted from payment because selection processes and criteria have not yet been defined and most health workers are unaware of this possibility. The upward trend in assisted deliveries since 2004 continued after the policys introduction. CONCLUSIONS This ambitious policy expresses a strong political commitment but has not been adequately supported by international partners. Despite relatively tight administrative controls, health workers have figured out how to take advantage of the system. Some of the policys instruments should be reviewed and clarified to improve its effectiveness.

Transversal analysis of public policies on user fees exemptions in six West African countries

As part of this special issue contributing to the development of knowledge on vulnerability and health in Africa, this article analyzes one example of a knowledge transfer strategy aimed at improving the use of research results that could help reduce the vulnerability of certain populations. In this case, since September 2008, the Non-Governmental Organization (NGO) Hilfe zur Selbsthilfe e.V. (HELP) has conducted a trial of subsidizing 100% of the costs of health care for vulnerable populations in two health districts of Burkina Faso. A scientific partnership was created to produce evidence on the intervention, and a knowledge transfer strategy was developed to promote the use of that evidence by stakeholders (decision-makers, people working in the health system, funding partners, etc.). The results showed that considerable efforts were invested in knowledge transfer activities and that these led to all types of use (instrumental, conceptual, persuasive). However, considerable variation in use was observed from one setting to another. This article presents some lessons to be drawn from this experience.

La charge de travail des agents de santé dans un contexte de gratuité des soins au Burkina Faso et au Niger

BackgroundIn 2006, the Parliament of Burkina Faso passed a policy to reduce the direct costs of obstetric services and neonatal care in the country’s health centres, aiming to lower the country’s high national maternal mortality and morbidity rates. Implementation was via a “partial exemption” covering 80% of the costs. In 2008 the German NGO HELP launched a pilot project in two health districts to eliminate the remaining 20% of user fees. Regardless of any exemptions, women giving birth in Burkina Faso’s health centres face additional expenses that often represent an additional barrier to accessing health services. We compared the total cost of giving birth in health centres offering partial exemption versus those with full exemption to assess the impact on additional out-of-pocket fees.MethodsA case–control study was performed to compare medical expenses. Case subjects were women who gave birth in 12 health centres located in the Dori and Sebba districts, where HELP provided full fee exemption for obstetric services and neonatal care. Controls were from six health centres in the neighbouring Djibo district where a partial fee exemption was in place. A random sample of approximately 50 women per health centre was selected for a total of 870 women.ResultsThere was an implementation gap regarding the full exemption for obstetric services and neonatal care. Only 1.1% of the sample from Sebba but 17.5% of the group from Dori had excessive spending on birth related costs, indicating that women who delivered in Sebba were much less exposed to excessive medical expenses than women from Dori. Additional out-of-pocket fees in the full exemption health districts took into account household ability to pay, with poorer women generally paying less.ConclusionsWe found that the elimination of fees for facility-based births benefits especially the poorest households. The existence of excessive spending related to direct costs of giving birth is of concern, making it urgent for the government to remove all direct fees for obstetric and neonatal care. However, the policy of completely abolishing user fees is insufficient; the implementation process must have a thorough monitoring system to reduce implementation gaps.

Nine misconceptions about free healthcare in sub-Saharan Africa

BackgroundWhile more and more West African countries are implementing public user fees exemption policies, there is still little knowledge available on this topic. The long time required for scientific production, combined with the needs of decision-makers, led to the creation in 2010 of a project to support implementers in aggregating knowledge on their experiences. This article presents a transversal analysis of user fees exemption policies implemented in Benin, Burkina Faso, Mali, Niger, Togo and Senegal.MethodsThis was a multiple case study with several embedded levels of analysis. The cases were public user fees exemption policies selected by the participants because of their instructive value. The data used in the countries were taken from documentary analysis, interviews and questionnaires. The transversal analysis was based on a framework for studying five implementation components and five actors’ attitudes usually encountered in these policies.ResultsThe analysis of the implementation components revealed: a majority of State financing; maintenance of centrally organized financing; a multiplicity of reimbursement methods; reimbursement delays and/or stock shortages; almost no implementation guides; a lack of support measures; communication plans that were rarely carried out, funded or renewed; health workers who were given general information but not details; poorly informed populations; almost no evaluation systems; ineffective and poorly funded coordination systems; low levels of community involvement; and incomplete referral-evacuation systems. With regard to actors’ attitudes, the analysis revealed: objectives that were appreciated by everyone; dissatisfaction with the implementation; specific tensions between healthcare providers and patients; overall satisfaction among patients, but still some problems; the perception that while the financial barrier has been removed, other barriers persist; occasionally a reorganization of practices, service rationing due to lack of reimbursement, and some overcharging or shifting of resources.ConclusionsThis transversal analysis confirms the need to assign a great deal of importance to the implementation of user fees exemption policies once these decisions have been taken. It also highlights some practices that suggest avenues of future research.

Health staff workload in a context of user fees exemption policy for health care in Burkina Faso and Niger

User fees exemption policy supported by NGOs in Burkina Faso and Niger resulted in a higher utilization of health services in primary health care facilities. We conducted a survey in 2 health districts in Burkina Faso and Niger in 2011. The study objective was to assess whether the higher utilization associated with the user fees exemption policy, may result in an overload for health staff at the front line in health facilities. The WHOs recommended WISN method was used to compute a ratio of actual/required staff using a comparative study with 4 control facilities and 4 intervention sites where the user fees exemption policy was provided by local NGOs in both countries. Overall, 8 primary health facilities both in Burkina Faso and Niger were involved. In Burkina Faso, the ratio was ≥1 in all facilities both control and intervention, i.e. a sufficient staff in facilities. In Niger, 3 out of the 4 intervention facilities in Keita district were found to have a ratio ≤1, i.e. understaffed. In the 4 control facilities, the staff was sufficient with a ratio ≥1. In Burkina Faso, the actual number of staff in facilities appeared enough to face the higher utilization of health services that may follow the user fees exemption policy supported by local NGOs unlike Niger where we found that the actual number of staff was insufficient to face a possible higher utilization resulting from the same policy in intervention facilities.

Améliorer l’accessibilité financière des soins de santé au Burkina Faso Une stratégie de recherche potentiellement favorable à l’utilisation des données probantes

As universal healthcare gains political momentum, there is a growing international consensus against charging user fees at the point of healthcare delivery. In 1994, South Africa launched the wave of new user fees abolition policies in Africa. In 2010, both the African Union and the UN Secretary General called for free healthcare at the point of service for children under five and pregnant women. However, dismantling a user fees policy that has been in place for over 30 years is no easy task. Not only does expanding free healthcare policies routinely lead to controversy that generally arises when public policies are badly planned, underfunded, and poorly implemented, but certain groups of actors also perceive this move as a threat. However, in most cases, the continued reluctance to make healthcare free in Africa is based not on strong evidence, but rather on misconceptions around the very notion of free care. In this paper, we address nine such misconceptions about free healthcare and provide recent evidence from Africa showing the benefit of eliminating user fees for patients. Our aim is to demonstrate that when free care is properly financed and implemented, which in itself is a major challenge, certain perceptions about the principle of free healthcare turn out to be misconceptions.

Determinants of non-medically indicated cesarean deliveries in Burkina Faso

User fees exemption policy supported by NGOs in Burkina Faso and Niger resulted in a higher utilization of health services in primary health care facilities. We conducted a survey in 2 health districts in Burkina Faso and Niger in 2011. The study objective was to assess whether the higher utilization associated with the user fees exemption policy, may result in an overload for health staff at the front line in health facilities. The WHOs recommended WISN method was used to compute a ratio of actual/required staff using a comparative study with 4 control facilities and 4 intervention sites where the user fees exemption policy was provided by local NGOs in both countries. Overall, 8 primary health facilities both in Burkina Faso and Niger were involved. In Burkina Faso, the ratio was ≥1 in all facilities both control and intervention, i.e. a sufficient staff in facilities. In Niger, 3 out of the 4 intervention facilities in Keita district were found to have a ratio ≤1, i.e. understaffed. In the 4 control facilities, the staff was sufficient with a ratio ≥1. In Burkina Faso, the actual number of staff in facilities appeared enough to face the higher utilization of health services that may follow the user fees exemption policy supported by local NGOs unlike Niger where we found that the actual number of staff was insufficient to face a possible higher utilization resulting from the same policy in intervention facilities.

La charge de travail des agents de santé dans un contexte de gratuité des soins au Burkina Faso et au Niger* Heath staff workload in a context of user fees exemption policy for health care in Burkina Faso and Niger

L’intervention subventionne le paiement des soins de santé des enfants de moins de cinq ans et des femmes enceintes dans deux districts du Burkina Faso. Une stratégie de recherches opérationnelles à multi-niveaux utilise des méthodes mixtes et associe l’analyse des effets à celle des processus. L’article propose une analyse des chances de succès de l’utilisation des données probantes. L’étude montre notamment qu’il faut associer chercheurs et décideurs le plus tôt possible et tout au long du processus, intéresser les intervenants aux activités de recherche et adapter la méthodologie en fonction des besoins des décideurs, de la rigueur scientifique et de la temporalité de la prise de décision.