Women’s decision-making power in a context of free reproductive healthcare and family planning in rural Burkina Faso

Abstract Background In 2016, the national user fee exemption policy for women and children under five was introduced in Burkina Faso. It covers most reproductive healthcare services for women including prenatal care, delivery, and postnatal care. In subsequent years, the policy was gradually extended to include family planning. While studies have shown that user fee abolition policies increase visits to health centers and improve access to reproductive healthcare and family planning, there are also indications that other barriers remain, notably women’s lack of decision-making power. The objective of the study is to investigate women’s decision-making power regarding access to reproductive health and family planning in a context of free healthcare in rural Burkina Faso. Methods A descriptive qualitative study was carried out in rural areas of the Cascades and Center-West regions. Qualitative data were collected using individual semi-structured interviews (n = 20 participants) and focus groups (n = 15 participants) with Burkinabe women of childbearing age, their husbands, and key informants in the community. Data was analyzed using thematic analysis. Results A conceptual framework describing women’s participation in the decision-making process was built from the analysis. Results show that the user fee exemption policy contributes to improving access to reproductive care and family planning by facilitating the negotiation processes between women and their families within households. However, social norms and gender inequalities still limit women’s decision-making power. Conclusion In light of these results, courses of action that go beyond the user fee exemption policy should be considered to improve women’s decision-making power in matters of health, particularly with regard to family planning. Interventions that involve men and community members may be necessary to challenge the social norms, which act as determinants of women’s health and empowerment.

Download Full-text

Scaling-Up Performance-Based Financing in Burkina Faso: From PBF to User Fees Exemption Strategic Purchasing

International Journal of Health Policy and Management ◽

10.34172/ijhpm.2020.209 ◽

2020 ◽

Author(s):

Mathieu Seppey ◽

Valéry Ridde ◽

Paul-André Somé

Keyword(s):

Burkina Faso ◽

Scale Up ◽

Scaling Up ◽

Healthcare Services ◽

Decision Makers ◽

Strategic Purchasing ◽

Performance Based Financing ◽

Fee Exemption ◽

Exemption Policy ◽

User Fee

Background: Numerous countries have undertaken performance-based financing (PBF) reforms to improve quality and quantity of healthcare services. However, only few reforms have successfully managed to achieve the different scale-up phases. In Burkina Faso, a pilot project was implemented, but was put on hold before being scaled. During the writing of this article, discussions to scale-up were still ongoing on a national strategic purchasing strategy within a government led user fee exemption policy. Methods: This study’s objective is to identify facilitators and barriers to scaling-up for that pilot, based on the World Health Organization’s (WHO’s) theoretical framework. Interviews were conducted in three health centres and in Ouagadougou to discuss the scale-up with different actors. The software QDA Miner© was used to help in the framework analysis. Results: The low involvement of some key stakeholders (mainly decision-makers) and the unstable context hindered ownership of the project, thus its priority on the political agenda. PBF reform therefore lost its momentum to the benefit of a user fee exemption policy. This latter program was seen to be more beneficial since it addressed access to healthcare services, in comparison to service quality, which was the PBF’s relative advantage. A scale-up of some PBF elements (eg, strategic purchasing tools) is however still in discussion in 2019, but would be integrated within the user fee exemption program. Increased costs during the PBF’s implementation gave the impression that the project was too costly and not scalable. The involvement of an important funding agency (World Bank, WB) also fed the impression of high costs, which demotivated the actors, especially decision-makers. Conclusion: Contextual factors remain central to the implementation of PBF, while their evaluation and mitigation have remained unclear. The participation of key actors in scaling-up operations and the use of social science as tools to better understand the context is therefore primordial.

Download Full-text

The Experience of Ghana in Implementing a User Fee Exemption Policy to Provide Free Delivery Care

Reproductive Health Matters ◽

10.1016/s0968-8080(07)30325-x ◽

2007 ◽

Vol 15 (30) ◽

pp. 61-71 ◽

Cited By ~ 110

Author(s):

Sophie Witter ◽

Daniel Kojo Arhinful ◽

Anthony Kusi ◽

Sawudatu Zakariah-Akoto

Keyword(s):

Delivery Care ◽

Fee Exemption ◽

Exemption Policy ◽

User Fee

Download Full-text

Removing user fees to improve access to caesarean delivery: a quasi-experimental evaluation in western Africa

BMJ Global Health ◽

10.1136/bmjgh-2017-000558 ◽

2018 ◽

Vol 3 (1) ◽

pp. e000558 ◽

Cited By ~ 6

Author(s):

Marion Ravit ◽

Martine Audibert ◽

Valéry Ridde ◽

Myriam de Loenzien ◽

Clémence Schantz ◽

...

Keyword(s):

Neonatal Mortality ◽

Rural Areas ◽

Caesarean Delivery ◽

Positive Impact ◽

Demographic And Health Surveys ◽

Service Utilisation ◽

Fee Exemption ◽

Exemption Policy ◽

User Fee ◽

The Impact

IntroductionMali and Benin introduced a user fee exemption policy focused on caesarean sections in 2005 and 2009, respectively. The objective of this study is to assess the impact of this policy on service utilisation and neonatal outcomes. We focus specifically on whether the policy differentially impacts women by education level, zone of residence and wealth quintile of the household.MethodsWe use a difference-in-differences approach using two other western African countries with no fee exemption policies as the comparison group (Cameroon and Nigeria). Data were extracted from Demographic and Health Surveys over four periods between the early 1990s and the early 2000s. We assess the impact of the policy on three outcomes: caesarean delivery, facility-based delivery and neonatal mortality.ResultsWe analyse 99 800 childbirths. The free caesarean policy had a positive impact on caesarean section rates (adjusted OR=1.36 (95% CI 1.11 to 1.66; P≤0.01), particularly in non-educated women (adjusted OR=2.71; 95% CI 1.70 to 4.32; P≤0.001), those living in rural areas (adjusted OR=2.02; 95% CI 1.48 to 2.76; P≤0.001) and women in the middle-class wealth index (adjusted OR=3.88; 95% CI 1.77 to 4.72; P≤0.001). The policy contributes to the increase in the proportion of facility-based delivery (adjusted OR=1.68; 95% CI 1.48 to 1.89; P≤0.001) and may also contribute to the decrease of neonatal mortality (adjusted OR=0.70; 95% CI 0.58 to 0.85; P≤0.001).ConclusionThis study is the first to evaluate the impact of a user fee exemption policy focused on caesarean sections on maternal and child health outcomes with robust methods. It provides evidence that eliminating fees for caesareans benefits both women and neonates in sub-Saharan countries.

Download Full-text

Immediate and sustained effects of user fee exemption on healthcare utilization among children under five in Burkina Faso: A controlled interrupted time-series analysis

Social Science & Medicine ◽

10.1016/j.socscimed.2017.02.027 ◽

2017 ◽

Vol 179 ◽

pp. 27-35 ◽

Cited By ~ 20

Author(s):

David Zombré ◽

Manuela De Allegri ◽

Valéry Ridde

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Burkina Faso ◽

Healthcare Utilization ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Under Five ◽

Sustained Effects ◽

Fee Exemption ◽

User Fee

Download Full-text

Do Targeted User Fee Exemptions Reach the Ultra-Poor and Increase their Healthcare Utilisation? A Panel Study from Burkina Faso

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17186543 ◽

2020 ◽

Vol 17 (18) ◽

pp. 6543 ◽

Cited By ~ 1

Author(s):

Yvonne Beaugé ◽

Manuela De Allegri ◽

Samiratou Ouédraogo ◽

Emmanuel Bonnet ◽

Naasegnibe Kuunibe ◽

...

Keyword(s):

Panel Data ◽

Burkina Faso ◽

Healthcare Access ◽

Panel Study ◽

Healthcare Services ◽

Free Access ◽

Service Utilisation ◽

Data Set ◽

Fee Exemption ◽

User Fee

Background: A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of user fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of user fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of user fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diébougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (β = −0.07; 95% CI = −0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.

Download Full-text

Evaluation of a knowledge transfer strategy from a user fee exemption program for vulnerable populations in Burkina Faso

Global Health Promotion ◽

10.1177/1757975912462416 ◽

2013 ◽

Vol 20 (1_suppl) ◽

pp. 70-79 ◽

Cited By ~ 24

Author(s):

Christian Dagenais ◽

Ludovic Queuille ◽

Valéry Ridde

Keyword(s):

Health Care ◽

Knowledge Transfer ◽

Burkina Faso ◽

Vulnerable Populations ◽

Decision Makers ◽

Special Issue ◽

Governmental Organization ◽

Fee Exemption ◽

User Fee ◽

Health Districts

As part of this special issue contributing to the development of knowledge on vulnerability and health in Africa, this article analyzes one example of a knowledge transfer strategy aimed at improving the use of research results that could help reduce the vulnerability of certain populations. In this case, since September 2008, the Non-Governmental Organization (NGO) Hilfe zur Selbsthilfe e.V. (HELP) has conducted a trial of subsidizing 100% of the costs of health care for vulnerable populations in two health districts of Burkina Faso. A scientific partnership was created to produce evidence on the intervention, and a knowledge transfer strategy was developed to promote the use of that evidence by stakeholders (decision-makers, people working in the health system, funding partners, etc.). The results showed that considerable efforts were invested in knowledge transfer activities and that these led to all types of use (instrumental, conceptual, persuasive). However, considerable variation in use was observed from one setting to another. This article presents some lessons to be drawn from this experience.

Download Full-text

Effect of delivery care user fee exemption policy on institutional maternal deaths in the central and volta regions of Ghana

Ghana Medical Journal ◽

10.4314/gmj.v41i3.55278 ◽

2010 ◽

Vol 41 (3) ◽

Cited By ~ 2

Author(s):

W.K Bosu ◽

J Bell ◽

M Armar-klemesu ◽

J Tornui

Keyword(s):

Delivery Care ◽

Maternal Deaths ◽

Fee Exemption ◽

Exemption Policy ◽

User Fee

Download Full-text

Birth spacing and informed family planning choices after childbirth in Burkina Faso and the Democratic Republic of Congo: Participatory action research to design and evaluate a decision-making tool for providers and their clients

Patient Education and Counseling ◽

10.1016/j.pec.2018.05.004 ◽

2018 ◽

Vol 101 (10) ◽

pp. 1871-1875 ◽

Cited By ~ 3

Author(s):

Nguyen Toan Tran ◽

Wambi Maurice M. Yameogo ◽

Félicité Langwana ◽

Seni Kouanda ◽

Blandine Thieba ◽

...

Keyword(s):

Decision Making ◽

Family Planning ◽

Action Research ◽

Burkina Faso ◽

Participatory Action Research ◽

Democratic Republic ◽

Democratic Republic Of Congo ◽

Birth Spacing ◽

Participatory Action ◽

Decision Making Tool

Download Full-text

Opening the ‘implementation black-box’ of the user fee exemption policy for caesarean section in Benin: a realist evaluation

Health Policy and Planning ◽

10.1093/heapol/czz146 ◽

2019 ◽

Vol 35 (2) ◽

pp. 153-166 ◽

Cited By ~ 2

Author(s):

Jean-Paul Dossou ◽

Vincent De Brouwere ◽

Sara Van Belle ◽

Bruno Marchal

Keyword(s):

Caesarean Section ◽

Financial Incentives ◽

Realist Evaluation ◽

Health Coverage ◽

Programme Theory ◽

Financial Flows ◽

Causal Pathways ◽

Fee Exemption ◽

Exemption Policy ◽

User Fee

Abstract To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low- and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. We selected two hospitals with contrastive outcomes. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We identified two main causal pathways. First, in the state-owned hospital, which has a public-oriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor. We found that trust, perceived coercion, adherence to policy goals, perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes. Compliance with the policy depended on enforcement by hierarchical authority and bottom-up pressure. Persuasion depended on the alignment of the policy with personal and organizational values. Incentives may determine the adoption if they influence the local stakeholder’s revenue are trustworthy and perceived as fairly allocated. Failure to anticipate the differential responses of implementers will prevent the proper implementation of user fee exemption policies and similar universal health coverage reforms.

Download Full-text