The evaluation of an experiment in healthcare user fees exemption for vulnerable groups in Burkina Faso

Introduction: The African Union and United Nations agencies requested that children under five years and pregnant women be exempt from healthcare payment at the point of service. Indeed, this payment method is a financial barrier to healthcare access that the most vulnerable populations cannot overcome. Since Burkina Faso had not yet implemented such a policy, an experiment was undertaken starting in 2008 in two districts of the Sahel region in order to produce evidence. Methods: A research programme was organised in order to evaluate the effectiveness, equity, processes, costs and social effects of this experiment. Twelve studies were undertaken that used a concurrent mixed method design with data collected from individuals, households, health centres and villages. Results: The experiment was integrated into the health system and was fully appreciated by all. The third-party payer system was effective. Pregnant women and children under the age of five years had faster and broader access to the health system. The poorest among them substantially benefited from the intervention. The quality of care was sustained and costs were controlled. Conclusion: Since equity is a priority for the government and its financial partners, the research results suggest that exemption should be extended to the national level and that measures should be organised to break down the geographic barrier.Introduction : L’Union Africaine et les agences des Nations Unies réclament que les enfants de moins de cinq ans et les femmes enceintes soient exemptés du paiement des soins au point de service. En effet, cette modalité de paiement impose une barrière financière à l’accès aux soins que les plus vulnérables ne peuvent surmonter. Puisque le Burkina Faso ne s’est pas encore engagé dans une telle politique, une expérimentation a été mise en œuvre depuis 2008 dans deux districts du Sahel afin de produire des preuves sur cette stratégie. Méthodes : Un programme de recherches a été organisé afin d’évaluer l’efficacité, l’équité, les processus, les coûts et les effets sociaux de cette expérimentation. Douze études ont été entreprises en ayant recours à un devis mixte concomitant usant de données collectées auprès des individus, des ménages, des centres de santé et des villages. Résultats : L’expérimentation s’est intégrée au système de santé et a été bien appréciée par tous. Le système de tiers-payeur a été efficace. Les femmes enceintes et les enfants de moins de cinq ont eu recours plus rapidement et de manière plus importante au système de santé. Les plus pauvres d’entre eux ont bénéficié substantiellement de l’intervention. La qualité des soins s’est maintenue et les coûts ont été maîtrisés. Conclusion : Si l’équité est une priorité pour le gouvernement et ses partenaires financiers, les résultats des recherches suggèrent une extension de l’exemption à l’échelle nationale et l’organisation de mesures pour s’attaquer à la barrière géographique.Introducción: La Unión Africana y la agencia de las Naciones Unidas demandaron que los niños menores de cinco años y las mujeres embarazadas estuvieran exentos del pago por la atención de salud en los centros de atención. De hecho, esta modalidad de pago supone una barrera financiera para el acceso a la asistencia médica que los más vulnerables no pueden superar. Dado que Burkina Faso aun no ha implementado una política de este tipo, en el 2008 y con el objetivo de generar evidencia, se llevó a cabo un estudio experimental en dos distritos de Sahel. Métodos: Se estableció un programa de estudios con el fin de evaluar la eficacia, la equidad,  los procesos, los costos y los efectos sociales del estudio experimental. Se realizaron doce estudios utilizando diseños de métodos mixtos con los datos obtenidos de individuos, viviendas, centros de salud y municipalidades. Resultados: El estudio se integró en el sistema de salud y mereció la aprobación general. El sistema del pago a través de terceros demostró ser eficaz.  Las mujeres embarazadas y niños menores de cinco años utilizaron con mayor rapidez y de manera significativa el sistema de salud. La población con menores ingresos se beneficio considerablemente de la intervención. La calidad de la atención y los costos permanecieron controlados. Conclusión: Si la equidad es una prioridad para el gobierno y para sus socios financieros, los resultados de la evaluación sugieren la ampliación de la exención a escala nacional así como la adopción de medidas para enfrentar la barrera geográfica

The evaluation of an experiment in healthcare user fees exemption for vulnerable groups in Burkina Faso

Introduction: The African Union and United Nations agencies requested that children under five years and pregnant women be exempt from healthcare payment at the point of service. Indeed, this payment method is a financial barrier to healthcare access that the most vulnerable populations cannot overcome. Since Burkina Faso had not yet implemented such a policy, an experiment was undertaken starting in 2008 in two districts of the Sahel region in order to produce evidence. Methods: A research programme was organised in order to evaluate the effectiveness, equity, processes, costs and social effects of this experiment. Twelve studies were undertaken that used a concurrent mixed method design with data collected from individuals, households, health centres and villages. Results: The experiment was integrated into the health system and was fully appreciated by all. The third-party payer system was effective. Pregnant women and children under the age of five years had faster and broader access to the health system. The poorest among them substantially benefited from the intervention. The quality of care was sustained and costs were controlled. Conclusion: Since equity is a priority for the government and its financial partners, the research results suggest that exemption should be extended to the national level and that measures should be organised to break down the geographic barrier.Introduction : L’Union Africaine et les agences des Nations Unies réclament que les enfants de moins de cinq ans et les femmes enceintes soient exemptés du paiement des soins au point de service. En effet, cette modalité de paiement impose une barrière financière à l’accès aux soins que les plus vulnérables ne peuvent surmonter. Puisque le Burkina Faso ne s’est pas encore engagé dans une telle politique, une expérimentation a été mise en œuvre depuis 2008 dans deux districts du Sahel afin de produire des preuves sur cette stratégie. Méthodes : Un programme de recherches a été organisé afin d’évaluer l’efficacité, l’équité, les processus, les coûts et les effets sociaux de cette expérimentation. Douze études ont été entreprises en ayant recours à un devis mixte concomitant usant de données collectées auprès des individus, des ménages, des centres de santé et des villages. Résultats : L’expérimentation s’est intégrée au système de santé et a été bien appréciée par tous. Le système de tiers-payeur a été efficace. Les femmes enceintes et les enfants de moins de cinq ont eu recours plus rapidement et de manière plus importante au système de santé. Les plus pauvres d’entre eux ont bénéficié substantiellement de l’intervention. La qualité des soins s’est maintenue et les coûts ont été maîtrisés. Conclusion : Si l’équité est une priorité pour le gouvernement et ses partenaires financiers, les résultats des recherches suggèrent une extension de l’exemption à l’échelle nationale et l’organisation de mesures pour s’attaquer à la barrière géographique.Introducción: La Unión Africana y la agencia de las Naciones Unidas demandaron que los niños menores de cinco años y las mujeres embarazadas estuvieran exentos del pago por la atención de salud en los centros de atención. De hecho, esta modalidad de pago supone una barrera financiera para el acceso a la asistencia médica que los más vulnerables no pueden superar. Dado que Burkina Faso aun no ha implementado una política de este tipo, en el 2008 y con el objetivo de generar evidencia, se llevó a cabo un estudio experimental en dos distritos de Sahel. Métodos: Se estableció un programa de estudios con el fin de evaluar la eficacia, la equidad,  los procesos, los costos y los efectos sociales del estudio experimental. Se realizaron doce estudios utilizando diseños de métodos mixtos con los datos obtenidos de individuos, viviendas, centros de salud y municipalidades. Resultados: El estudio se integró en el sistema de salud y mereció la aprobación general. El sistema del pago a través de terceros demostró ser eficaz.  Las mujeres embarazadas y niños menores de cinco años utilizaron con mayor rapidez y de manera significativa el sistema de salud. La población con menores ingresos se beneficio considerablemente de la intervención. La calidad de la atención y los costos permanecieron controlados. Conclusión: Si la equidad es una prioridad para el gobierno y para sus socios financieros, los resultados de la evaluación sugieren la ampliación de la exención a escala nacional así como la adopción de medidas para enfrentar la barrera geográfica

Relevance of a Toll-Free Call Service Using an Interactive Voice Server to Strengthen Health System Governance and Responsiveness in Burkina Faso

Background: In Africa, health systems are poorly accessible, inequitable, and unresponsive. People rarely have either the confidence or the opportunity to express their opinions. In Burkina Faso, there is a political will to improve governance and responsiveness to create a more relevant and equitable health system. Given their development in Africa, information and communication technologies (ICTs) offer opportunities in this area.Methods: This article presents the results of an evaluation of a toll-free call service coupled with an interactive voice server (TF-IVS) tested in Ouagadougou, Burkina Faso, to assess its relevance for improving health systems governance. The approach consisted of a 2-phased action research project to test 2 technologies: recorded messages and touch keypad. Using a concurrent mixed approach, we assessed the technological, social, and instrumental relevance of the service. Results: The call service is available everywhere, 24 hours per day, seven days per week. The equipment and its physical location were not adequately protected against technological hazards. Of the 278 days of operation, 49 were non-functional. In 8 months, there were 13 877 calls, which demonstrated the popularity of ICTs and the ease of access to telephone networks and mobile technologies. The TF-IVS was free, anonymous, and multilingual, which fostered the expression of public opinion. However, cultural context (religion, ethnic culture) and fear of reprisals may have had a negative influence. In the end, questions remained regarding people’s capacity to use this innovative service. In the first trial, 49% of callers recorded their message and in the second, 48%. Touch key technology appeared more relevant for automated and real-time data collection and analysis, but there was no comprehensive strategy for translating the information collected into a response from healthcare actors or the government.Conclusion: This study showed the relevance and feasibility of implementing a TF-IVS to strengthen health system responsiveness in one of the world’s poorest countries. Public opinion expressed through data collected in real-time is helpful for improving system responsiveness to meet care needs and enhance equity. However, the strategy for developing this tool must take into account the implementation context and the activities needed to influence the mechanisms of social responsibility (eg, information provision, citizen action, and state response)

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Nine misconceptions about free healthcare in sub- Saharan Africa Nine misconceptions about free healthcare in sub-Saharan Africa

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

Nine misconceptions about free healthcare in sub- Saharan Africa Nine misconceptions about free healthcare in sub-Saharan Africa

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