Illness reporting and demand for medical care in rural Burkina Faso

This is the post-print version of the final paper published in Social Science & Medicine. The published article is available from the link below. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. Copyright @ 2010 Elsevier B.V.The issue of illness reporting in modelling demand for health care in low- and middle-income countries can be handled according to either of two conceptually-different constructs: (a) considering illness reporting behaviour as endogenous to demand; or (b) considering demand itself as the outcome of a sample selection phenomenon. In this paper, we take the second viewpoint and estimate the demand for medical care with an estimator that uses Heckman-type. Empirical estimates based on household survey data from rural Burkina Faso suggest that there are some implications of illness reporting behaviour for modelling the demand for medical care.German Science Foundatio

“It’s not easy to acknowledge that I’m ill”: a qualitative investigation into the health seeking behavior of rural Palestinian women

Background: This qualitative study sets to fill a gap in knowledge by exploring the health seeking behaviour of rural women living in the occupied Palestinian territories (oPt). The existing literature on the oPt has so far focused on unravelling the country’s epidemiological and health system profile, but has largely neglected the assessment of factors shaping people’s decisions on health care use. Methods: Based on a conceptual framework rooted in the Anderson behavioural model, we conducted 30 semi-structured interviews with purposely selected women and seven key informant interviews in three purposely selected villages in Ramallah district. Results: Our findings indicate that women delay seeking professional care, use self-prescribed medications and home treatment, and do not use preventive and educational health services. Their health seeking behaviour is the result of the interplay of several factors: their gendered socio-cultural role; their health beliefs; financial affordability and geographical accessibility; their perceptions of the quality of care; and their perceived health needs. Conclusions: Findings are discussed in the light of their policy implications, suggesting that adequate health policy planning ought to take into considerations socio-cultural dimensions beyond those directly pertinent to the health care system

Evaluating performance-based financing in low-income and middle-income countries: the need to look beyond average effect.

Over the last decade, performance-based financing (PBF) has gained momentum as a health financing innovation, which combines linking healthcare payments to performance with increased provider autonomy and supervision. 1 2 The combination of these elements is expected to boost supply-side efforts towards increasing quantity and quality of service provision, triggering a demand-side response towards improved service utilisation.1 3 4 A recent paper by Paul et al has critically questioned the widespread introduction of PBF in light of the limited available evidence on its effectiveness.5 The response to this paper has been varied, with authors advancing arguments for and against PBF. Some African PBF implementers have claimed that PBF is an evolving strategy with potential benefits on health systems despite its existing challenges. 6 Others have drawn attention to the unintended consequences of PBF7 or to the need to assess the economic value of such an approach.8 Beyond their diverse arguments, however, most authors have concurred with Paul et al5 on the limited scope of currently available evidence and have postulated the need to better assess how PBF works under different contextual constraints within and across settings.9 10 Our commentary positions itself against this background, acknowledges the limited scope of current evidence on PBF, and explicitly argues in favour of devoting more effort to unravel heterogeneity across and within settings. Our argument is based on the recognition that by virtue of how impact evaluations are designed, the focus has been on the average effect, which masks important heterogeneity across settings, providers and users.11-13 To date, only a handful of studies have assessed heterogeneity of PBF effects across population subgroups4 14 15 or across health providers.16-18 Similarly, little attention has been devoted to understanding which factors can explain heterogeneity in the response to PBF or why PBF stimulates changes in some instances, but not in others.3 4 10 In light of the above, we call for more systematic analyses of heterogeneity, defined in relation to both the need to report differential effects and the need to understand what drives or explains such differential effects within and across settings. We first define and outline potential sources of heterogeneity and then offer initial guidance on how to measure and understand heterogeneity

How much does it cost to combine supply-side and demand-side RBF approaches in a single intervention? Full cost analysis of the Results Based Financing for Maternal and Newborn Health Initiative in Malawi

Objective: To estimate the economic cost associated with implementing the Results Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative in Malawi. No specific hypotheses were formulated ex-ante. Setting: Primary and secondary delivery facilities in rural Malawi. Participants: Not applicable. The study relied almost exclusively on secondary financial data. Intervention: The RBF4MNH Initiative was a results-based financing (RBF) intervention including both a demand and a supply-side component. Primary and secondary outcome measures: Cost per potential and for actual beneficiaries. Results: The overall economic cost of the Initiative during 2011-2016 amounted to €12 786 924, equivalent to €24.17 per pregnant woman residing in the intervention districts. The supply side activity cluster absorbed over 40% of all resources, half of which were spent on infrastructure upgrading and equipment supply, and 10% on incentives. Costs for the demand side activity cluster and for verification were equivalent to 14% and 6%, respectively of the Initiative overall cost. Conclusion: Carefully tracing resource consumption across all activities, our study suggests that the full economic cost of implementing RBF interventions may be higher than what was previously reported in published cost-effectiveness studies. More research is urgently needed to carefully trace the costs of implementing RBF and similar health financing innovations, in order to inform decision-making in low-income and middle-income countries around scaling up RBF approaches

A scoping review on determinants of unmet need for family planning among women of reproductive age in low and middle income countries

Background: Poor access and low contraceptive prevalence are common to many Low- and Middle-Income Countries (LMICs). Unmet need for family planning (FP), defined as the proportion of women wishing to limit or postpone child birth, but not using contraception, has been central to reproductive health efforts for decades and still remains relevant for most policy makers and FP programs in LMICs. There is still a lag in contraceptive uptake across regions resulting in high unmet need due to various socioeconomic and cultural factors. In this mixed method scoping review we analyzed quantitative, qualitative and mixed method studies to summarize those factors influencing unmet need among women in LMICs. Methods: We conducted our scoping review by employing mixed method approach. We included studies applying quantitative and qualitative methods retrieved from online data bases (PubMed, JSTOR, and Google Scholar). We also reviewed the indexes of journals specific to the field of reproductive health by using a set of keywords related to unmet contraception need, and non-contraception use in LMICs. Results: We retrieved 283 articles and retained 34 articles meeting our inclusion criteria. Of these, 26 were quantitative studies and 8 qualitative studies. We found unmet need for FP to range between 20 % and 58 % in most studies. Woman’s age was negatively associated with total unmet need for FP, meaning as women get older the unmet need for FP decreases. The number of children was found to be a positively associated determinant for a woman’s total unmet need. Also, woman’s level of education was negatively associated – as a woman’s education improves, her total unmet need decreases. Frequently reported reasons for non-contraception use were opposition from husband or husbands fear of infidelity, as well as woman’s fear of side effects or other health concerns related to contraceptive methods. Conclusion: Factors associated with unmet need for FP and non-contraception use were common across different LMIC settings. This suggests that women in LMICs face similar barriers to FP and that it is still necessary for reproductive health programs to identify FP interventions that more specifically tackle unmet need

How does performance-based financing affect health workers' intrinsic motivation? A Self-Determination Theory-based mixed-methods study in Malawi.

"Intrinsic motivation crowding out", the erosion of high-quality, sustainable motivation through the introduction of financial incentives, is one of the most frequently discussed but yet little researched potential unfavorable consequence of Performance-based Financing (PBF). We used the opportunity of the introduction of PBF in Malawi to investigate whether and how PBF affected intrinsic motivation, using a mixed-methods research design theoretically grounded in Self-Determination Theory (SDT). The quantitative component served to estimate the impact of PBF on intrinsic motivation, relying on a controlled pre- and post-test design, with data collected from health workers in 23 intervention and 10 comparison facilities before (March/April 2013; n = 70) and approximately two years after (June/July 2015; n = 71) the start of the intervention. The qualitative component, relying on in-depth interviews with health workers in selected intervention facilities one (April 2014; n = 21) and two (September 2015; n = 20) years after the start of PBF, served to understand how PBF did or did not bring about change in intrinsic motivation. Specifically, it allowed us to examine how the various motivation-relevant elements and consequences of PBF impacted health workers' basic psychological needs for autonomy, competence, and relatedness, which SDT postulates as central to intrinsic motivation. Our results suggest that PBF did not affect health workers' overall intrinsic motivation levels, with the intervention having had both positive and negative effects on psychological needs satisfaction. To maximize positive PBF effects on intrinsic motivation, our results underline the potential value of explicit strategies to mitigate unintended negative impact of unavoidable design, implementation, and contextual challenges, for instance by building autonomy support activities into PBF designs

Do community-based health insurance schemes fulfil the promise of equity? A study from Burkina Faso

Objective: To examine whether the community-based health insurance (CBHI) scheme in Burkina Faso has been effective in providing equitable healthcare access to poor individuals, women, children and those living far from health facilities. Methods: We used the Nouna Health District Household Survey to collect panel data on 990 households during 2004?08. By applying a series of random effects regressions and using concentration curves, we first studied determinants of CBHI enrolment and then assessed differences in healthcare utilization between members and non-members. We studied differences with regard to rich and poor, men and women, children and adults and those living far vs those living close to health facilities. Findings: With regard to enrolment, we found that poor (odds ratio [OR] = 0.274) and children (OR = 0.456) were less likely to enrol while gender and distance were not significantly correlated to enrolment. In terms of utilization, poor (coefficient = 0.349), women (coefficient = 0.131) and children (coefficient = 0.190) with CBHI had higher utilization than the group without CBHI. We also found that there was no significant difference in utilization between members and non-members if they were living far from health facilities. Conclusion: The CBHI scheme in this case was only partially successful in achieving the equity objectives. This study advises policy makers in Burkina Faso and elsewhere, who see CBHI schemes as a silver bullet to achieve universal health coverage, to be mindful of the chronically low enrolment rates and more importantly the lack of equity across the various groups that this study has highlighted

Step-wedge cluster-randomised community-based trials: An application to the study of the impact of community health insurance

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.BACKGROUND: We describe a step-wedge cluster-randomised community-based trial which has been conducted since 2003 to accompany the implementation of a community health insurance (CHI) scheme in West Africa. The trial aims at overcoming the paucity of evidence-based information on the impact of CHI. Impact is defined in terms of changes in health service utilisation and household protection against the cost of illness. Our exclusive focus on the description and discussion of the methods is justified by the fact that the study relies on a methodology previously applied in the field of disease control, but never in the field of health financing. METHODS: First, we clarify how clusters were defined both in respect of statistical considerations and of local geographical and socio-cultural concerns. Second, we illustrate how households within clusters were sampled. Third, we expound the data collection process and the survey instruments. Finally, we outline the statistical tools to be applied to estimate the impact of CHI. CONCLUSION: We discuss all design choices both in relation to methodological considerations and to specific ethical and organisational concerns faced in the field. On the basis of the appraisal of our experience, we postulate that conducting relatively sophisticated trials (such as our step-wedge cluster-randomised community-based trial) aimed at generating sound public health evidence, is both feasible and valuable also in low income settings. Our work shows that if accurately designed in conjunction with local health authorities, such trials have the potential to generate sound scientific evidence and do not hinder, but at times even facilitate, the implementation of complex health interventions such as CHI

The Great Failure of Malaria Control in Africa: A District Perspective from Burkina Faso

Too many African children are dying from a disease for which we have effective and cost-effective prevention and treatment options, say the authors