Has the Gratuité policy reduced inequities in geographic access to antenatal care in Burkina Faso? Evidence from facility-based data from 2014 to 2022

BACKGROUND: Evidence shows that user fee exemption policies improve the use of maternal, newborn, and child health (MNCH) services. However, addressing the cost of care is only one barrier to accessing MNCH services. Poor geographic accessibility relating to distance is another. Our objective in this study was to assess the effect of a user fee exemption policy in Burkina Faso (Gratuité) on antenatal care (ANC) use, considering distance to health facilities. METHODS: We conducted a cross-sectional study with sub-analysis by intervention period to compare utilization of ANC services (outcome of interest) in pregnant women who used the service in the context of the Gratuité user fee exemption policy and those who did not, in Manga district, Burkina Faso. Dependent variables included were socio-demographic characteristics, obstetric history, and distance to the lower-level health facility (known as Centre de Santé et Promotion Sociale) in which care was sort. Univariate, bivariate, and multivariate analyses were performed across the entire population, within those who used ANC before the policy and after its inception. RESULTS: For women who used services before the Gratuité policy was introduced, those living 5-9 km were almost twice (OR = 1.94; 95% CI: 1.17-3.21) more likely to have their first ANC visit (ANC1) in the first trimester compared to those living 10 km from the nearest facility were almost twice (OR = 1.86; 95% CI: 1.14-3.05) and over twice (OR = 2.04; 95% CI: 1.20-3.48) more likely respectively to use ANC1 in the first trimester compared to those living within 5 km of the nearest health facility. Also, women living over 10 km from the nearest facility were 1.29 times (OR = 1.29; 95% CI: 1.00-1.66) more likely to have 4+ ANC than those living less than 5 km from the nearest health facility. CONCLUSIONS: Insofar as the financial barrier to ANC has been lifted and the geographical barrier reduced for the populations that live farther away from services through the Gratuité policy, then the Burkinabé government must make efforts to sustain the policy and ensure that benefits of the policy reach the targeted and its gains maximized

Stakeholder perceptions and experiences from the implementation of the Gratuité user fee exemption policy in Burkina Faso: a qualitative study.

BACKGROUND: In 2016, the Gratuité policy was initiated by the Government of Burkina Faso to remove user fees for maternal, newborn, and child Health (MNCH) services. Since its inception, there has not been any systematic capture of experiences of stakeholders as it relates to the policy. Our objective was to understand the perceptions and experiences of stakeholders regarding the implementation of the Gratuité policy. METHODS: We used key informant interviews (KIIs) and focus group discussions (FGDs) to engage national and sub-national stakeholders in the Centre and Hauts-Bassin regions. Participants included policymakers, civil servants, researchers, non-governmental organizations in charge of monitoring the policy, skilled health personnel, health facility managers, and women who used MNCH services before and after the policy implementation. Topic guides aided sessions, which were audio recorded and transcribed verbatim. A thematic analysis was used for data synthesis. RESULTS: There were five key themes emerging. First, majority of stakeholders have a positive perception of the Gratuité policy. Its implementation approach is deemed to have strengths including government leadership, multi-stakeholder involvement, robust internal capacity, and external monitoring. However, collateral shortage of financial and human resources, misuse of services, delays in reimbursement, political instability and health system shocks were highlighted as concerns that compromise the government's objective of achieving universal health coverage (UHC). However, many beneficiaries were satisfied at the point of use of MNHC services, though Gratuité did not always mean free to the service users. Broadly, there was consensus that the Gratuité policy has contributed to improvements in health-seeking behavior, access, and utilization of services, especially for children. However, the reported higher utilization is leading to some perceived increased workload and altered health worker attitude. CONCLUSIONS: There is a general perception that the Gratuité policy is achieving what it set out to do, which is to increase access to care by removing financial barriers. While stakeholders recognized the intention and value of the Gratuité policy, and many beneficiaries were satisfied at the point of use, inefficiencies in its implementation undermines progress. As the country moves towards the goal of realizing UHC, reliable investment in the Gratuité policy is needed

Experiences of intimate relationships, stigma, social support and treatment adherence among HIV-positive adolescents in Chiredzi district, Zimbabwe

This study explored experiences of intimate relationships, stigma, social support and treatment adherence among HIV-positive adolescents in Chiredzi district, Zimbabwe. The study adopted an interpretive qualitative methodology to explore the intricacies of living with HIV as an adolescent. Thirty (N = 30) adolescents aged between 13 and 19 years participated in this study. They were recruited while attending social support or during their routine visits to collect antiretrovirals. In-depth interviews were conducted to generate data. Adolescents were asked about their romantic lives and the difficulties they faced while living with HIV. Findings revealed that adolescents living with HIV (ALHIV) are confronted with stigma and discrimination. They also grapple with emotional issues such as dealing with disclosure. However, social support minimises the risk of harbouring suicidal thoughts. To the various challenges ALHIV face, most of them (particularly males) adopt several coping mechanisms. These include (but are not limited to) non-disclosure of their seropositive status to sexual partners, thereby risking reinfection and exposing their partners to HIV. Non-disclosure of seropositive status contributed to either poor antiretroviral therapy (ART) adherence or defaulting on HIV medication. A life-cycle approach to HIV prevention and management is crucial to mitigating the challenges faced by ALHIV because risks of HIV infection, challenges of access to HIV services and solutions to these challenges change at different stages of someone’s life. This scenario justifies the necessity of a holistic bio-psychosocial approach to managing HIV among adolescents, not only limited to the client, but also involving appropriate education programmes for the broader community

Effectiveness of the Gratuité user fee exemption policy on utilization and outcomes of maternal, newborn and child health services in conflict-affected districts of Burkina Faso from 2013 to 2018: a pre-post analysis

Abstract Background Evidence on effectiveness of user fee exemption policies targeting maternal, newborn, and child health (MNCH) services is limited for conflict-affected settings. In Burkina Faso, a country that has had its fair share of conflicts, user fee exemption policies have been piloted since 2008 and implemented along with a national government-led user fee reduction policy (‘SONU’: Soins Obstétricaux et Néonataux d'Urgence). In 2016, the government transitioned the entire country to a user fee exemption policy known as Gratuité. Our study objective was to assess the effect of the policy on the utilization and outcomes of MNCH services in conflict-affected districts of Burkina Faso. Methods We conducted a quasi-experimental study comparing four conflict-affected districts which had the user fee exemption pilot along with SONU before transitioning to Gratuité (comparator) with four other districts with similar characteristics, which had only SONU before transitioning (intervention). A difference-in-difference approach was initiated using data from 42 months before and 30 months after implementation. Specifically, we compared utilization rates for MNCH services, including antenatal care (ANC), facility delivery, postnatal care (PNC) and consultation for malaria. We reported the coefficient, including a 95% confidence interval (CI), p value, and the parallel trends test. Results Gratuité led to significant increases in rates of 6th day PNC visits for women (Coeff 0.15; 95% CI 0.01–0.29), new consultations in children < 1 year (Coeff 1.80; 95% CI 1.13–2.47, p < 0.001), new consultations in children 1–4 years (Coeff 0.81; 95% CI 0.50–1.13, p = 0.001), and uncomplicated malaria cases treated in children < 5 years (Coeff 0.59; 95% CI 0.44–0.73, p < 0.001). Other service utilization indicators investigated, including ANC1 and ANC5+ rates, did not show any statistically significant positive upward trend. Also, the rates of facility delivery, 6th hour and 6th week postnatal visits were found to have increased more in intervention areas compared to control areas, but these were not statistically significant. Conclusions Our study shows that, even in conflict-affected areas, the Gratuité policy significantly influences MNCH service utilization. There is a strong case for continued funding of the user fee exemption policy to ensure that gains are not reversed, especially if the conflict ceases to abate