Is the process for selecting indigents to receive free care in Burkina Faso equitable?
An article published in BMC Public Health 2014 , november 7th 2014.
Authors: Nicole Atchessi, Valéry Ridde, Maria-Victoria Zunzunégui .
Abstract:
Background: In Burkina Faso, patients are required to pay for healthcare. This constitutes a barrier to access for indigents, who are the most disadvantaged. User fee exemption systems have been created to facilitate their access. A community-based initiative was thus implemented in a rural region of Burkina Faso to select the worst-off and exempt them from user fees. The final selection was not based on pre-defined criteria, but rather on community members’ tacit knowledge of the villagers. The objective of this study was to analyze the equitable nature of this community-based selection process.
Method: Based on a cross-sectional study carried out in 2010, we surveyed 1,687 indigents. The variables collected were those that determine healthcare use according to the Andersen-Newman model (1969): sociodemographic variables; income; occupation; access to financial, food or instrumental assistance; presence of chronic illness; and disabilities related to vision, muscle strength, or mobility. Bivariate analyses and logistic regression were performed.
Results: User fee exemptions were given mainly to indigents who were widowed (OR = 1.40; CI 95% [1.10–1.78]), had no financial assistance from their household for healthcare (OR = 1.58; CI 95% [1.26–1.97], lived alone (OR = 1.28; CI 95% [1.01–1.63]), lived with their spouses, (OR = 2.00; CI 95% [1.35-2.96], had vision impairments (OR = 1.45; CI 95% [1.14–1.84]), or had poor muscle strength and good mobility (OR = 1.73; CI 95% [1.28–2.33]). The indigent selection was not determined by household income, self-reported chronic illness, or previous use of services.
Conclusion: The community selection process took into account factors related to social vulnerability and functional limitations. However, we cannot affirm that the selection process was perfectly equitable, as it was very restrictive due to the limited budget available and the State’s lack of engagement in this matter. Exemption processes should be temporary solutions, and the State should make a commitment to move toward universal healthcare coverage.
Full article:
Other research axis
Axes de recherche et d'intervention
Other research axis
Fight Against Malaria
This axis aims to assess the national policy in the fight against malaria and its interaction with interventions aiming to exempt payment of healthcare for children under the age of five (in some districts). A population survey in 2013 will assess the effects of these interventions on the health status of children less than five years of age.
Publications to come
Insurance and Poverty
For many years, the government of Burkina Faso has shown interest in establishing universal health coverage including national health insurance. This research axis aims to support this change by namely evaluating public support concepts underlying the implementation of compulsory coverage and examining the policies that have been formulated and implemented specifically for those in need.
Publications to come
Funding Based on the Results and Equity
The Ministry of Health has established an incentive system in early 2014 regarding the funding of health facilities based on their performance in 15 districts of the country. They added an equity section to this process to organize a community targeting system of the poor individuals in these districts to offer a free healthcare component. This research axis aims to participate in the evaluation of this intervention and more specifically in its emergence, establishment, implementation and its potential for improvement.
Publications to come
Maternal Health
The national policy of price subsidy of birth deliveries has contributed to the increase in maternal health services. However, the removal of financial barriers can also cause an unnecessary recourse to caesarean sections. This axis aims to assess whether this has been the case and to assist health professionals in their training so as to better target the needs of pregnant women. The use of mobile phone technology will be considered in interventions that will be implemented.
Publications to come
Trauma research axis
Axes de recherche et d'intervention
Developing a System to Monitor Road Accidents in Ouagadougou to Reduce Accident Burden
Traffic accidents have become a worldwide public health issue since the late 20th century. Today, they cause as many victims as major pandemics such as malaria and tuberculosis, and are the leading cause of death in the world in people between 10 and 45 years old. In Africa, death by road accident is the 5th leading cause of death, while it is in the 10th place worldwide (WHO, 2013). Burkina Faso and its capital Ouagadougou are experiencing this new public health burden. The number of accidents with injuries is increasing every year.
One of the research questions in the Trauma axis of the equity program is to know where the road accidents with injury are most frequent in Ouagadougou so as to identify and understand the spatial differentiation of this burden as well as to define the victims’ profile. How are they supported by first aid and hospital emergency services? How are victims being monitored by physicians? What are the economic consequences for these people?
The overall objective of this research’s axis is to understand the needs of vulnerable road users in order to fight against this burden. Several surveys will be undertaken to achieve this and will form the basis in the process of defining a community intervention that will aim to reduce the vulnerability of populations most at risk.
Publication (french)
Research and community-based interventions for health equity in Burkina Faso
Axis of research and intervention
Research and community-based interventions for health equity in Burkina Faso
This program takes place in Burkina Faso, given that the country is at the end of the classification of the Human Development Index – measured under the United Nations Program for Development (2010) – and its indicators of health and equity health are alarming. This suggests that the objectives of the Millennium Development Goals will not be achieved in 2015. However, the Commission on Social Determinants of Health of the World Health Organization (WHO), the World Bank and the Countdown to 2015 Core Group have provided an overview of theoretically effective interventions to improve health equity. In addition, a recent review shows that nearly 90% of interventions that follow a participatory and community process have beneficial effects on the population. However, if the content of these interventions is described in international reports, the conditions for their implementation and their effectiveness in natural experiments are still very poorly understood. Several meta-analyses show that the potential effectiveness of interventions is subjected to multiple reduction factors often exceeding 50%. This is especially true in Africa, where there is very little research on the subject. Furthermore, according to WHO, these interventions are rarely carried out in Burkina Faso.
The aim of the program is to document the effectiveness and the procedures of promising community-based interventions to improve health equity in the context of one of the world’s poorest countries. The primary objective is to evaluate community-based interventions that are currently underway in the health district of Kaya and that have been selected by the program’s stakeholders (researchers, practitioners, policy makers, communities) in a preliminary participatory planning process. The aim would be to provide evidence of their effectiveness regarding health equity. The second objective would be to articulate, implement and evaluate the best practices of community interventions favoring equity, based on the work and results of experiments using a participatory approach. It will also be important to take action and conduct research in accordance with ethical principles and negotiated partnership approaches with stakeholders, while having due regard to the application of the knowledge produced.
Evaluative research will be undertaken both on community interventions that are underway as well as on those created within the program. This project comprises several scientific assets that favor socially and scientifically relevant knowledge including:
- Intervention heterogeneity (nutrition, malaria, financial protection, family planning, etc.);
- Intervention temporality (before 2012, during the program);
- Variety of assessment type (impact, equity, process, sustainability, scalability);
- Variety of methods of assessment (quantitative, qualitative, mixed);
- Existence of a research infrastructure with exceptional population data for the region (demographic surveillance system with a panel of 50,000 people since 2007)
This program is also an opportunity to experience and evaluate the best research practices and potential interventions that could favor equity. These new practices will allow to meet the needs of knowledge in the following areas:
- Practice of collaborative research (North/South partnerships and relationships between researchers, stakeholders, policy makers, and community partnership);
- Development and evaluation of a code of ethics;
- Knowledge application through the implementation and evaluation of a strategy for knowledge brokering;
- Identification of new community-based interventions aimed to improve health equity.
Finally, this project will advance the state of knowledge regarding three methodological developments:
- The use of geographic information systems for health equity;
- The use of a realistic approach in terms of evaluation;
- The analysis of the impact of profits using a method allowing to evaluate the effects of an intervention without resorting to external standards of success
The interdisciplinary aspect of this program is guaranteed through the mobilization of researchers from different disciplines (anthropology, social sciences, geography) and experts in complementary fields (public health, evaluation, knowledge transfer, nutrition).
Publications: