"It Depends on What They Experience in Each Health Facility. Some Are Satisfied, Others Are Not." A MixedMethods Exploration of Health Workers' Attitudes Towards Performance-Based Financing in Burkina Faso.

BACKGROUND: Evidence emerging from qualitative studies suggests the existence of substantial variation in how health workers experience performance-based financing (PBF) within the same setting. To date, however, no study has quantified or systematically explored this within-setting heterogeneity. Considering that differences in health workers' affective reactions to PBF likely constitute an important element mediating the effectiveness of PBF in improving health service delivery, systematic and tangible information will be highly valuable to policy-makers and program managers who aim to maximize positive impacts of PBF. Our study aimed at contributing to filling this gap in knowledge by quantifying health workers' knowledge of, satisfaction with, and perceptions of PBF in Burkina Faso, and exploring factors associated with heterogeneity therein. METHODS: The study employed a post-intervention cross-sectional explanatory mixed methods study design with a dominant quantitative component - a structured survey to a total of 1314 health workers from 396 intervention health facilities - and a small and focused qualitative component - key informant interviews with 5 program managers - to triangulate and further elucidate the quantitative findings. Quantitative data were analyzed descriptively as well as using 3-level mixed-effects models. Qualitative data were analyzed in a largely deductive process along the quantitative variables and results. RESULTS: Health workers were on average moderately satisfied with PBF overall, with a slight tendency towards the positive and large variation between individuals. Two-thirds of health workers did not have adequate basic knowledge of key PBF elements. Perceived fairness of the performance evaluation process, of the bonus distribution process, and satisfaction with the individual financial bonuses varied dramatically between respondents. Factors associated with heterogeneity in knowledge, satisfaction, and fairness perceptions included responsibility at the facility, general work attitudes, management factors, and training in and length of exposure to PBF. CONCLUSION: Findings imply that investments into staff training on PBF and manager training on organizational change processes might be beneficial to positive staff attitudes towards PBF, which in turn would likely contribute to improving the effectiveness of PBF

How a supply-side intervention can help to increase caesarean section rates in Burkina Faso facilities-Evidence from an interrupted time-series analysis using routine health data.

OBJECTIVES: In Burkina Faso, only 2.1% of women give birth by caesarean section (CS). To improve the use of maternal health services during pregnancy and childbirth, many interventions were implemented during the 2010s including performance-based financing (PBF) and a free maternal health care policy (the gratuité). The objective of this study is to evaluate the impact of a supply-side intervention (PBF) combined with a demand-side intervention (gratuité) on institutional CS rates in Burkina Faso. METHODS: We used routine health data from all the public health facilities in 21 districts (10 that implemented PBF and 11 that did not) from January 2013 to September 2017. We analysed CS rates as the proportion of CS performed out of all facility-based deliveries (FBD) that occurred in the district. We performed an interrupted time series (ITS) analysis to evaluate the impact of PBF alone and then in conjunction with the gratuité on institutional CS rates. RESULTS: CS rates in Burkina Faso increased slightly between January 2013 and September 2017 in all districts. After the introduction of PBF, the increase of CS rates was higher in intervention than in non-intervention districts. However, after the introduction of the gratuité, CS rates decreased in all districts, independently of the PBF intervention. CONCLUSION: In 2017, despite high FBD rates in Burkina Faso as well as the PBF intervention and the gratuité, less than 3% of women who gave birth in a health facility did so by CS. Our study shows that the positive PBF effects were not sustained in a context of user fee exemption

Patterns of healthcare seeking among people reporting chronic conditions in rural sub-Saharan Africa: findings from a population-based study in Burkina Faso.

OBJECTIVE: Non-communicable diseases are rapidly becoming one of the leading causes of morbidity and mortality in sub-Saharan Africa. Yet, little is known about patterns of healthcare seeking among people with chronic conditions in these settings. We aimed to explore determinants of healthcare seeking among people who reported at least one chronic condition in rural Burkina Faso. METHODS: Data were drawn from a cross-sectional population-based survey conducted across 24 districts on 52 562 individuals from March to June 2017. We used multinomial logistic regression to assess factors associated with seeking care at a formal provider (facility-based care) or at an informal provider (home and traditional treatment) compared to no care. RESULTS: 1124 individuals (2% of all respondents) reported at least one chronic condition. Among those, 22.8% reported formal care use, 10.6% informal care use, and 66.6% no care. The presence of other household members reporting a chronic condition (RRR = 0.57, 95%-CI [0.39, 0.82]) was negatively associated with seeking formal care. Wealthier households (RRR = 2.14, 95%-CI [1.26, 3.64]), perceived illness severity (RRR = 3.23, 95%-CI [2.22, 4.70]) and suffering from major chronic conditions (RRR = 1.54, 95%-CI [1.13, 2.11]) were positively associated with seeking formal care. CONCLUSION: Only a minority of individuals with chronic conditions sought formal care, with important differences due to socio-economic status. Policies and interventions aimed at increasing the availability and affordability of services for early detection and management in peripheral settings should be prioritised

How a supply‐side intervention can help to increase caesarean section rates in Burkina Faso facilities—Evidence from an interrupted time‐series analysis using routine health data

Objectives: In Burkina Faso, only 2.1% of women give birth by caesarean section (CS). To improve the use of maternal health services during pregnancy and childbirth, many interventions were implemented during the 2010s including performance-based financing (PBF) and a free maternal health care policy (the gratuité). The objective of this study is to evaluate the impact of a supply-side intervention (PBF) combined with a demand-side intervention (gratuité) on institutional CS rates in Burkina Faso. Methods: We used routine health data from all the public health facilities in 21 districts (10 that implemented PBF and 11 that did not) from January 2013 to September 2017. We analysed CS rates as the proportion of CS performed out of all facility-based deliveries (FBD) that occurred in the district. We performed an interrupted time series (ITS) analysis to evaluate the impact of PBF alone and then in conjunction with the gratuité on institutional CS rates. Results: CS rates in Burkina Faso increased slightly between January 2013 and September 2017 in all districts. After the introduction of PBF, the increase of CS rates was higher in intervention than in non-intervention districts. However, after the introduction of the gratuité, CS rates decreased in all districts, independently of the PBF intervention. Conclusion: In 2017, despite high FBD rates in Burkina Faso as well as the PBF intervention and the gratuité, less than 3% of women who gave birth in a health facility did so by CS. Our study shows that the positive PBF effects were not sustained in a context of user fee exemption

Disk galaxies are self-similar: the universality of the HI-to-Halo mass ratio for isolated disks

Observed scaling relations in galaxies between baryons and dark matter global properties are key to shed light on the process of galaxy formation and on the nature of dark matter. Here, we study the scaling relation between the neutral hydrogen (HI) and dark matter mass in isolated rotationally-supported disk galaxies at low redshift. We first show that state-of-the-art galaxy formation simulations predict that the HI-to-dark halo mass ratio decreases with stellar mass for the most massive disk galaxies. We then infer dark matter halo masses from high-quality rotation curve data for isolated disk galaxies in the local Universe, and report on the actual universality of the HI-to-dark halo mass ratio for these observed galaxies. This scaling relation holds for disks spanning a range of 4 orders of magnitude in stellar mass and 3 orders of magnitude in surface brightness. Accounting for the diversity of rotation curve shapes in our observational fits decreases the scatter of the HI-to-dark halo mass ratio while keeping it constant. This finding extends the previously reported discrepancy for the stellar-to-halo mass relation of massive disk galaxies within galaxy formation simulations to the realm of neutral atomic gas. Our result reveals that isolated galaxies with regularly rotating extended HI disks are surprisingly self-similar up to high masses, which hints at mass-independent self-regulation mechanisms that have yet to be fully understood.Comment: 14 pages, 4 figures. Accepted for publication in ApJ

How a supply‐side intervention can help to increase caesarean section rates in Burkina Faso facilities—Evidence from an interrupted time‐series analysis using routine health data

Objectives: In Burkina Faso, only 2.1% of women give birth by caesarean section (CS). To improve the use of maternal health services during pregnancy and childbirth, many interventions were implemented during the 2010s including performance‐based financing (PBF) and a free maternal health care policy (the gratuité). The objective of this study is to evaluate the impact of a supply‐side intervention (PBF) combined with a demand‐side intervention (gratuité) on institutional CS rates in Burkina Faso. Methods: We used routine health data from all the public health facilities in 21 districts (10 that implemented PBF and 11 that did not) from January 2013 to September 2017. We analysed CS rates as the proportion of CS performed out of all facility‐based deliveries (FBD) that occurred in the district. We performed an interrupted time series (ITS) analysis to evaluate the impact of PBF alone and then in conjunction with the gratuité on institutional CS rates. Results: CS rates in Burkina Faso increased slightly between January 2013 and September 2017 in all districts. After the introduction of PBF, the increase of CS rates was higher in intervention than in non‐intervention districts. However, after the introduction of the gratuité, CS rates decreased in all districts, independently of the PBF intervention. Conclusion: In 2017, despite high FBD rates in Burkina Faso as well as the PBF intervention and the gratuité, less than 3% of women who gave birth in a health facility did so by CS. Our study shows that the positive PBF effects were not sustained in a context of user fee exemption

How much does community-based targeting of the ultra-poor in the health sector cost? Novel evidence from Burkina Faso

Background: Targeting efforts aimed at increasing access to care for the poorest by reducing to a minimum or completely eliminating payments at point of use are increasingly being adopted across low and middle income countries, within the framework of Universal Health Coverage policies. No evidence, however, is available on the real cost of designing and implementing these efforts. Our study aimed to fill this gap in knowledge through the systematic assessment of both the financial and economic costs associated with designing and implementing a pro-poor community-based targeting intervention across eight districts in rural Burkina Faso. Methods: We conducted a partial retrospective economic evaluation (i.e. estimating costs, but not benefits) associated with the abovementioned targeting intervention. We adopted a health system perspective, including all costs incurred by the government and its development partners as well as costs incurred by the community when working as volunteers on behalf of government structures. To trace both financial and economic costs, we combined Activity-Based Costing with Resource Consumption Accounting. To this purpose, we consulted and extracted information from all relevant design/implementation documents and conducted additional key informant structured interviews to assess the resource consumption that was not valued in the documents. Results: For the entire community-based targeting intervention, we estimated a financial cost of USD 587,510 and an economic cost of USD 1,213,447. The difference was driven primarily by the value of the time contributed by the community. Communities carried the main economic burden. With a total of 102,609 ultra-poor identified, the financial cost and the economic cost per ultra-poor person were respectively USD 5,73 and USD 11,83. Conclusion: The study is first of its kind to accurately trace the financial and economic costs of a community-based targeting intervention aiming to identify the ultra-poor. The financial costs amounted to USD 5,73 and the economic costs to USD 11,83 per ultra-poor person identified. The financial costs of almost USD 6 represents 21% of the per capita government expenditure on health

No impact of performance-based financing on the availability of essential medicines in Burkina Faso: A mixed-methods study

Access to safe, effective, and affordable essential medicines (EM) is critical to quality health services and as such has played a key role in innovative health system strengthening approaches such as Performance-based Financing (PBF). Available literature indicates that PBF can improve EM availability, but has not done so consistently in the past. Qualitative explorations of the reasons are yet scarce. We contribute to expanding the literature by estimating the impact of PBF on EM availability and stockout in Burkina Faso and investigating mechanisms of and barriers to change. The study used an explanatory mixed methods design. The quantitative study component followed a quasi-experimental design (difference-in-differences), comparing how EM availability and stockout had changed three years after implementation in 12 PBF and in 12 control districts. Qualitative data was collected from purposely selected policy and implementation stakeholders at all levels of the health system and community, using in-depth interviews and focus group discussions, and explored using deductive coding and thematic analysis. We found no impact of PBF on EM availability and stockouts in the quantitative data. Qualitative narratives converge in that EM supply had increased as a result of PBF, albeit not fully satisfactorily and sustainably so. Reasons include persisting contextual challenges, most importantly a public medicine procurement monopoly; design challenges, specifically a disconnect and disbalance in incentive levels between service provision and service quality indicators; implementation challenges including payment delays, issues around performance verification, and insufficient implementation of activities to strengthen stock management skills; and concurrently implemented policies, most importantly a national user fee exemption for children and pregnant women half way through the impact evaluation period. The case of PBF and EM availability in Burkina Faso illustrates the difficulty of incentivizing and effecting holistic change in EM availability in the presence of strong contextual constraints and powerful concurrent policies.</jats:p

Why did performance-based financing in Burkina Faso fail to achieve the intended equity effects? A process tracing study

In recent years, performance-based financing (PBF) has attracted attention as a means of reforming provider payment mechanisms in low- and middle-income countries. Particularly in combination with demand-side interventions, PBF has been assumed to benefit also the most vulnerable and disadvantaged groups. However, impact evaluations have often found this not to be the case. In Burkina Faso, PBF was coupled with specific equity measures to enhance healthcare utilization among the ultra-poor, but failed to produce the expected effects. Our study used the process tracing methodology to unravel the reasons for the lack of impact produced by the equity measures. We relied on published evidence, secondary data analysis, and findings from a qualitative study to support or invalidate the hypothesized causal mechanism, that is the reconstructed theory of change of the equity measures. Our findings show how various contextual, design, and implementation challenges hindered the causal mechanism from unfolding as planned. These included issues with the identification and exemption of the ultra-poor on the demand side, and with financial issues and considerations on the supply side. In broader terms, our findings underline the difficulty in improving access to care for the ultra-poor, given the multifaceted and complex nature of barriers to care the most vulnerable face. From a methodological point of view, our study demonstrates the value and applicability of process tracing in complementing other forms of evaluation for complex interventions in global health

Adsorption et transport d'un composé organique volatil dans un sol hygroscopique (Application aux pesticides dans un sol aride)

L'objectif de ce travail est d'analyser et de modéliser le transport d'un polluant dans la couche superficielle non saturée du sol. On se limite aux sols hygroscopiques pour lesquels les constituants de la phase liquide (eau+polluant) sont fortement liés à la phase solide. Les transferts de matière s'opèrent en phase liquide et gazeuse avec prise en compte du changement de phase liquide-gaz. Grâce à un dispositif original, on analyse tout d'abord les isothermes de désorption de l'eau, de l'heptane, du trichloréthylène (TCE) et du mélange eau+TCE dans deux sols ; l'un contenant de l'argile et de la matière organique ; l'autre, en provenance du Burkina Faso (BF) présente des proportions moindres de ces constituants. Le changement de phase liquide-gaz du TCE a fait l'objet d'une étude expérimentale dans le cas du sol du BF avec différentes conditions expérimentales en température et pression. L'ensemble des travaux bibliographiques et expérimentaux ont conduit à la proposition d'un modèle mathématique. La validation du modèle a porté sur le transfert d'eau seule par comparaison avec des expériences de transfert sur des colonnes de sol. Ce modèle traduit particulièrement bien le flux d'eau à la surface et l'évolution des profils de teneur en eau. Ce modèle peut être utilisé dans l'état actuel pour décrire les transferts d'eau à l'interface sol-atmosphère en zone aride. Dans une deuxième partie, on examine le transfert du TCE dans la couche superficielle. Des études de sensibilité ont été menées sur l'épaisseur de la couche, la teneur en eau, la concentration initiale du TCE, la constante de Henry et du coefficient de changement de phase. Cette étude met en évidence l'importance des différents paramètres sur les transferts d'un composé organique volatil indiquant ainsi qu'il est nécessaire de mener parallèlement des expériences en laboratoire et in situ.The objective of this work is to analyze and model the transport of a pollutant in the surface layer of unsaturated soil. We are particularly interested to hygroscopic soils where components of the liquid phase are strongly linked to the solid phase. Mass transfer occurring in the liquid phase and gas, taking into account the change of phase liquid-gas. Using an original apparatus, we analyze first the isothermal desorption of water, heptane, trichlorethylene (TCE) and the mixture water + TCE in two soils; one containing clay and organic matter, the other, from Burkina Faso (BF), has lower proportions of these constituents. The phase change liquid-gas of TEC has been experimentally studied in the soil of Burkina with different experimental conditions in temperature and pressure. All the bibliographic and experimental works led us to propose a mathematical model. The validation of the model has focused on the transfer of water only by comparison with transfer experiments on soil columns. This model reflects particularly well the flow of water to the surface and changing profiles of water content in columns. This model is also well suited to describe the water transfer at the interface soil-atmosphere in arid zone. In a second part, we examine the transfer of TCE in the surface layer. Sensitivity studies were conducted on thick layer of soil, water content, the initial concentration of TCE, the Henry constant and the coefficient of phase change. This study highlights the importance of different parameters on the transfer of a volatile organic compound showing that it is necessary to conduct parallel investigations in the laboratory and in situ.MONTPELLIER-BU Sciences (341722106) / SudocSudocFranceBurkina FasoFRB