Determinants of unmet need for family planning in rural Burkina Faso: a multilevel logistic regression analysis

Background: Unmet need for family planning has implications for women and their families, such as unsafe abortion, physical abuse, and poor maternal health. Contraceptive knowledge has increased across low-income settings, yet unmet need remains high with little information on the factors explaining it. This study assessed factors associated with unmet need among pregnant women in rural Burkina Faso. Method: We collected data on pregnant women through a population-based survey conducted in 24 rural districts between October 2013 and March 2014. Multivariate multilevel logistic regression was used to assess the association between unmet need for family planning and a selection of relevant demand- and supply-side factors. Results: Of the 1309 pregnant women covered in the survey, 239 (18.26%) reported experiencing unmet need for family planning. Pregnant women with more than three living children [OR = 1.80; 95% CI (1.11–2.91)], those with a child younger than 1 year [OR = 1.75; 95% CI (1.04–2.97)], pregnant women whose partners disapproves contraceptive use [OR = 1.51; 95% CI (1.03–2.21)] and women who desired fewer children compared to their partners preferred number of children [OR = 1.907; 95% CI (1.361–2.672)] were significantly more likely to experience unmet need for family planning, while health staff training in family planning logistics management (OR = 0.46; 95% CI (0.24–0.73)] was associated with a lower probability of experiencing unmet need for family planning. Conclusion: Findings suggest the need to strengthen family planning interventions in Burkina Faso to ensure greater uptake of contraceptive use and thus reduce unmet need for family planning

The obstetric care subsidy policy in Burkina Faso: what are the effects after five years of implementation? Findings of a complex evaluation

Background Burkina Faso, like many low and middle income countries, has been taking a range of actions to address its poor maternal and neonatal health indicators. In 2006 the government introduced an innovative national subsidy scheme for deliveries and emergency obstetric care in public facilities. This article reports on a complex evaluation of this policy, carried out 5 years after its introduction, which examined its effects on utilisation, quality of care, equity and the health system as a whole, as well as its cost and sustainability. Methods The evaluation was carried out in six purposively selected districts, as well as at national level, using a case study approach. Data sources included: national and district routine and survey data, household interviews with women who had recently given birth, data extraction from hospital and medical records, and key informant and health worker interviews. Results The underlying secular trend of a 1 % annual increase in the facility-based delivery rate (1988-2010) was augmented by an additional 4 % annual increase from 2007 onwards (after the policy was introduced), especially in rural areas and amongst women from poor households. The absence of baseline quality of care data made it difficult to assess the impact of the policy on quality of care, but hospitals with the best level of implementation of the subsidy offered higher quality of care (as measured by health care near-misses), so there is no evidence of a negative impact on quality (as is often feared). Similarly, there is little evidence of unintended negative effects on untargeted services. Household payments for facility-based deliveries have reduced significantly, compared with payments before the policy, and the policy as a whole is affordable, costing about 2 % of total public health expenditure. Concerns include that the amounts paid by households are higher than the rates set by the policy, and also that 7 % of households still say that they cannot afford to pay. Wealthier women have higher utilisation of services, as before, and the policy of fully exempting indigents is not being put into practice. Conclusions These findings highlight the importance of maintaining the subsidy policy, given the evidence of positive outcomes, but they also point out areas where attention is needed to ensure the poor and most vulnerable population benefit fully from the policy.sch_iih16pub4332pub

Estimating the costs for the treatment of abortion complications in two public referral hospitals: a cross-sectional study in Ouagadougou, Burkina Faso

Treatment costs of induced abortion complications can consume a substantial amount of hospital resources. This use of hospitals scarce resources to treat induced abortion complications may affect hospitals’ capacities to deliver other health care services. In spite of the importance of studying the burden of the treatment of induced abortion complications, few studies have been conducted to document the costs of treating abortion complications in Burkina Faso. Our objective was to estimate the costs of six abortion complications including incomplete abortion, hemorrhage, shock, infection/sepsis, cervix or vagina laceration, and uterus perforation treated in two public referral hospital facilities in Ouagadougou and the cost saving of providing safe abortion care services

The long term economic impact of severe obstetric complications for women and their children in Burkina Faso

This study investigates the long term economic impact of severe obstetric complications for women and their children in Burkina Faso, focusing on measures of food security, expenditures and related quality of life measures. It uses a hospital based cohort, first visited in 2004/2005 and followed up four years later. This cohort of 1014 women consisted of two main groups of comparison: 677 women who had an uncomplicated delivery and 337 women who experienced a severe obstetric complication which would have almost certainly caused death had they not received hospital care (labelled a “near miss” event). To analyze the impact of such near miss events as well as the possible interaction with the pregnancy outcome, we compared household and individual level indicators between women without a near miss event and women with a near miss event who either had a live birth, a perinatal death or an early pregnancy loss. We used propensity score matching to remove initial selection bias. Although we found limited effects for the whole group of near miss women, the results indicated negative impacts: a) for near miss women with a live birth, on child development and education, on relatively expensive food consumption and on women’s quality of life; b) for near miss women with perinatal death, on relatively expensive foods consumption and children’s education and c) for near miss women who had an early pregnancy loss, on overall food security. Our results showed that severe obstetric complications have long lasting consequences for different groups of women and their children and highlighted the need for carefully targeted interventions

Delivery fee exemption and subsidy policies: how have they affected health staff? Findings from a four-country evaluation

Many countries, especially in Africa, have in recent years introduced fee exemptions or subsidies targeting deliveries and emergency obstetric care. A number of aspects of these policies have been studied but there are few studies which look at how staff have been affected and how they have responded. This article focuses on this question, comparing data from Benin, Burkina Faso, Mali and Morocco. It is nested in wider evaluation of the policies. The article analyses responses to a health worker survey, carried out in 2012 on 683 health staff (doctors, nurses, midwives and others such as auxiliaries) across the four countries. The survey focused on working hours, workloads, pay, motivation and perceptions of the policies, as well as reported changes in workload and remuneration over the period of policy introduction. Self-reported staff output ratios suggest that midwives are over-worked across all settings, but facility data presents lower estimates, making it hard to judge the adequacy of workforces. Staff are generally positive about the policies' effects on the health system (increasing supervised delivery rates, benefiting the poor, improving access to medicines and supplies and improving quality of care). In personal terms, staff in Mali and Burkina Faso report increased satisfaction with work as a result of the policies, while in Benin, there is little change and in Morocco a deterioration (which correlated with recommendations about extending exemption policies in future). Awareness of policies was high amongst staff but only a small minority had received any written guides or training on policy implementation. It is crucial that planned health financing changes engage with their implications for staffing - estimating whether specific cadres can absorb increase demand, for example, as well as how to engage them in the policy implementation such that their personal needs are met and their professionalism enhanced.sch_iihBertone, M. & Witter, S. 2015, The complex remuneration of Human Resources for Health in low income settings: policy implications and a research agenda for designing effective financial incentives, Human Resources for Health, vol. 13, no. 62. Boukhalfa, C., Abouchadi, S., Cunden, N., & Witter, S. 2014, Les rsultats de l'enqute des personnels de sant au Maroc, FEMHealth report, Aberdeen. http://www.abdn.ac.uk/femhealth/documents/Deliverables/Low_res/Overall_cost_and_effects_report_final_2015.pdf. Accessed 29/07/16 Campbell, O. & Graham, W. 2006, Strategies for reducing maternal mortality: getting on with what works, The Lancet, vol. Maternal Survival series, pp. 25-40. Carasso, B., Lagarde, M., Cheelo, C., Chansa, C., & Palmer, N. 2012, Health worker perspectives on user fee removal in Zambia, Human Resources for Health, vol. 10, no. 40. Cavallaro, F., Cresswell, J., Franca, G., Victora, C., Barros, A. & Ronsmans, C. 2013, Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa, Bulletin of the World Health Organisation, vol. 91, pp. 914-922D. Cresswell, J., Assarag, B., Meski, F., Filippi, V. & Ronsmans, C. 2015, Trends in health facility deliveries and caesarean sections by wealth quintile in Morocco between 1987 and 2012, Tropical Medicine & International Health, vol. 20, pp. 607-616. Dieleman, M., Toonen, J., Toure, H., & Martineau, T. 2006, The match between motivation and performance management of health sector workers in Mali, Human Resources for Health, vol. 4, no. 2. Direction Nationale de la Sant 2010, Bilan de la gratuit de la csarienne 2005 - 2009, Ministere de la Sant, Bamako. Goufodji, S. & et al. 2014, Rapport de synthse: l'valuation de la politique de gratuit de la csarienne dans cinq zones sanitaires, Bnin, FEMHealth. FEMHealth, Cotonou. http://www.abdn.ac.uk/femhealth/documents/Deliverables/Rapport_FP7_Sourou_Benin_310314_without_table_17_2.pdf. Accessed 29/07/16 Ilboudo, P., Ganaba, R., Cunden, N., & Witter, S. 2014, Les rsultats de l'enqute sur le personnel de sant, Burkina Faso, FEMHealth report, Aberdeen. http://www.abdn.ac.uk/femhealth/documents/Deliverables/Low_res/Rapport_HWIS_March_2014_final.pdf. Accessed 29/07/16 Kouanda, S. & et al. 20123, La charge de travail du personnel de sant face la gratuit des soins au Burkina Faso, Afrique contemporaine, vol. 243, pp. 104-105. Maestad, O., Torsvik, G., & Aakvik, A. 2010, Overworked? On the relationship between workload and health worker performance, Journal of Health Economics, vol. 29, p. 686-698. Marchal, B., Van Belle, S., De Brouwere, V. & Witter, S. 2013, Studying complex interventions - from theory to practice: designing the FEMHealth evaluation of fee exemption policies in West Africa and Morocco, BMC Health Services Research, vol. 13, no. 469. McCoy, D., Bennett, S., Witter, S., Pond, B., Baker, B., Gow, J., Chand, S., Ensor, T., & McPake, B. 2008, Salaries and incomes of health workers in sub-Saharan Africa, The Lancet, vol. 371, pp. 677-683. McPake, B., Witter S., Ensor, T., Fustukian, S., Newlands, D., & Martineau, T. 2013, Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources, Human Resources for Health, vol. 11, no. 1, p. 46. Meessen, B., Hercot, D., Noirhomme, M., Ridde, V., Tibouti, A., Tashobya, C., & et al. 2011, Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries, Health Policy and Planning, vol. Supplement 2, no. 26, p. ii16-ii29. Ministre de la Sant 2006, Stratgie nationale de subvention des accouchements et des soins obstetricaux et neonatals d'urgence au Burkina Faso, Direction de la Sant de la Famille, Ougadougou. Ministere de la sant 2008, Instauration de la gratuit de l'accouchement et la csarienne au niveau des hpitaux. Circulaire n 108. 11 Decembre 2008., Ministry of Health, Rabat. Richard, F., Witter S., & De Brouwere, V. 2008, Reducing financial barriers to access to obstetric care ITG Press, Antwerp. Shiffman, J. 2007, Generating political priority for maternal mortality reduction in five developing countries, American Journal of Public Health, vol. 97, no. 796, p. 803. Van Leberghe, W., Conceicao, C., Van Damme, W. & Ferrinho, P. 2002, When staff is underpaid: dealing with the individual coping strategies of health personnel, WHO Bulletin, vol. 80, no. 7, pp. 581-584. Walker, L. & Gilson, L. 2004, 'We are bitter but we are satisfied': nurses as street-level bureaucrats in South Africa, Social Science and Medicine, vol. 59, pp. 1251-1261. Witter, S. 2009, Service- and population-based exemptions: are these the way forward for equity and efficiency in health financing in low income countries?, Advances in Health Economics and Health Services Research, vol. 21, pp. 249-286. Witter, S. 2010, Mapping user fees for health care in low-income countries - evidence from a recent survey, HLSP Institute, London. Witter, S., Bertone, M., Wurie, H., Edem-Hotah, J., & Samai, M. 2014a, Health worker incentives post-conflict: survey report from Sierra Leone, ReBUILD. http://www.rebuildconsortium.com/media/1193/hwisreportslfinal.pdf. Accessed 29/07/16 Witter, S., Boukhalfa, C., Cresswell, J., Daou, Z., Filippi, V., Ganaba, R., Goufodji, S., Lange, I., & Richard, F. 2016, Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco, forthcoming with International Journal for Equity in Health. Witter, S., Boukhalfa, C., Filippi, V., & et al. 2014b, Cost and impact of policies to remove fees for obstetric care in Benin, Burkina Faso, Mali and Morocco, FEMHealth, Aberdeen. http://www.abdn.ac.uk/femhealth/documents/Deliverables/Low_res/Overall_cost_and_effects_report_final_2015.pdf. Accessed 29/07/16 Witter, S., Dieng, T., Mbengue, D., Moreira, I., & De Brouwere, V. 2010, The free delivery and caesarean policy in Senegal - how effective and cost-effective has it been?, Health Policy and Planning, vol. 25, no. 5, pp. 384-392. Witter, S., Kusi, A., & Aikins, M. 2007, Working practices and incomes of health workers: evidence from an evaluation of a delivery fee exemption scheme in Ghana, Human Resources for Health, vol. 5, no. 2. Witter, S., Wurie, H., & Bertone, M. 2015, The Free Health Care Initiative: how has it affected health workers in Sierra Leone?, Health Policy and Planning, vol. 3 (1), pp 1-9. World Health Organization 2015, Trends in maternal mortality: 1990 to 2015 Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division, WHO, Geneva.32pub4351pub

Household asset index score from principal component analysis in 2004/5.

<p>Household asset index score from principal component analysis in 2004/5.</p

2004/5 hospital event cost by near miss group and for the uncomplicated delivery group.

<p>2004/5 hospital event cost by near miss group and for the uncomplicated delivery group.</p

Preferences of healthcare workers for provider payment systems in The Gambia’s National Health Insurance Scheme

Abstract Background The Government of The Gambia introduced a national health insurance scheme (NHIS) in 2021 to promote universal health coverage (UHC). Provider payment systems (PPS) are strategic purchasing arrangements that can enhance provider performance, accountability, and efficiency in the NHIS. This study assessed healthcare workers’ (HCWs’) preferences for PPS across major service areas in the NHIS. Methods A facility-based cross-sectional study was conducted using a probability proportionate to size sampling technique to select an appropriate sample size. Health care workers were presented with options for PPS to choose from across major service areas. Descriptive statistics explored HCW socio-demographic and health service characteristics. Multinomial logistic regressions were used to assess the association between these characteristics and choices of PPS. Results The majority of HCW did not have insurance coverage, but more than 60% of them were willing to join and pay for the NHIS. Gender, professional cadre, facility level, and region influenced HCW’s preference for PPS across the major service areas. The preferred PPS varied among HCW depending on the service area, with capitation being the least preferred PPS across all service areas. Conclusion The National Health Insurance Authority (NHIA) needs to consider HCW’s preference for PPS and factors that influence their preferences when choosing various payment systems. Strategic purchasing decisions should consider the incentives these payment systems may create to align incentives to guide provider behaviour towards UHC. The findings of this study can inform policy and decision-makers on the right mix of PPS to spur provider performance and value for money in The Gambia’s NHIS