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

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.

Applying the Realist Evaluation Approach to the Complex Process of Policy Implementation—The Case of the User Fee Exemption Policy for Cesarean Section in Benin

Realist evaluation is making inroads in the field of health policy and systems research to a large extent because of its good fit with complex issues. Until now, most realist studies focused on evaluating interventions or projects related to health care delivery, organization of health services, education, management, and leadership of health workers in high income countries. With this paper, we apply the realist approach to the study of national health policy implementation in a low resource country. We use the case of the user fee exemption policy for cesarean section in Benin, which we followed up from 2009 to 2018. We report on how realist evaluation can be applied for policy implementation research. We illustrate how we developed the initial programme theory—the starting point of any realist evaluation -, how we designed the study and data collection tools, and how we analyzed the data. For each step, we present current good practices, how we adapted them when needed, the challenges and the lessons learned. We report also on how the dynamic interactions between the central level (the national implementing agency) and the peripheral level (an implementing hospital) shaped the policy implementation. We found that at central level, availability of resources for a given policy is constantly challenged in the competitive national resource allocation arena. Key factors include the political power and the legitimacy of the group supporting the policy. These are influenced by the policy implementation structure, how the actual outputs of the implementation align with promises of the group supporting the policy and consequently how these outputs, the policy and its promoters are perceived by the community. We found that the service providers are key to the implementation, and that they are constrained or influenced by the dependability of the funding, their autonomy, their personal background, and the accountability arrangements. This study can inform the design and implementation of national health policies that involve interactions between central and operational level in other low-income countries.

The Use of Geographic Information Systems in the Development of a User-Pay Stormwater Utility in the Mimico Creek Watershed

User fee systems are becoming increasingly popular at local levels of government. By shifting the burden from a tax and spend, to user-pay delivery of services, local governments are able to provide and manage local services with greater efficiency and accountability. A stormwater utility concept has been created for dealing with the often-expensive construction, maintenance, upgrading, and management of storm sewers and associated infrastructure. By examining the various user-pay systems for stormwater management, local governments and researchers can make a more informed decision on whether or not it is an appropriate method to raise revenues. The collection of fees is not based on consumption, as in many other public utilities, but on the property owner's contribution to the problem. Therefore, any user-pay stormwater utility must be easily understood and defensible to the general public. As well, the utility creation, administration, and management process can be aided by the use of a Geographic Information System (GIS). Data can be easily collected, stored, and analyzed, as well as be displayed in a way that is easy to understand, not only by the managers and analysts, but by the general public as well.

The Use of Geographic Information Systems in the Development of a User-Pay Stormwater Utility in the Mimico Creek Watershed

User fee systems are becoming increasingly popular at local levels of government. By shifting the burden from a tax and spend, to user-pay delivery of services, local governments are able to provide and manage local services with greater efficiency and accountability. A stormwater utility concept has been created for dealing with the often-expensive construction, maintenance, upgrading, and management of storm sewers and associated infrastructure. By examining the various user-pay systems for stormwater management, local governments and researchers can make a more informed decision on whether or not it is an appropriate method to raise revenues. The collection of fees is not based on consumption, as in many other public utilities, but on the property owner's contribution to the problem. Therefore, any user-pay stormwater utility must be easily understood and defensible to the general public. As well, the utility creation, administration, and management process can be aided by the use of a Geographic Information System (GIS). Data can be easily collected, stored, and analyzed, as well as be displayed in a way that is easy to understand, not only by the managers and analysts, but by the general public as well.

The Utilization of User Fees to Subsidize Greenhouse and Growth Chamber Facilities at Public and Land Grant Universities

Greenhouse and growth chamber operating and maintenance costs continue to escalate while budgets remain stagnant. As a result, many universities struggle to find the necessary funds for the maintenance, repair, and replacement of basic research infrastructure needs. A survey was conducted to develop an understanding of how user fee systems contribute to funding stability, and how they are designed and managed in support of greenhouse and growth chamber facilities at colleges of agriculture throughout the United States. Where user fees have been implemented, the majority of greenhouse and growth chamber facilities are managed centrally, and are administered by agricultural experiment station (AES) directors or facility managers. Regardless of the administrative authority, most systems use an advisory committee to set fee schedules and determine policies. The majority of user fees are allocated back to the specific facility, with the majority of funds in general used to help pay for indirect expenses. The findings also indicate that user fees make more efficient use of space by providing faculty with a financial incentive to minimize their project area and to conduct experiments quickly.

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

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.

User fee policies and women’s empowerment: a systematic scoping review

Background Over the past decade, an increasing number of low- and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage. Despite the large number of studies (including meta-analyses and systematic reviews) that have shown this strategy’s positive effects impact on health-related indicators, the repercussions on women’s empowerment or gender equality has been overlooked in the literature. The aim of this study is to systematically review the evidence on the association between user fee policies in low- and middle-income countries and women’s empowerment. Methods A systematic scoping review was conducted. Two reviewers conducted the database search in six health-focused databases (Pubmed, CAB Abstracts, Embase, Medline, Global Health, EBM Reviews) using English key words. The database search was conducted on February 20, 2020, with no publication date limitation. Qualitative analysis of the included articles was conducted using a thematic analysis approach. The material was organized based on the Gender at Work analytical framework. Results Out of the 206 initial records, nine articles were included in the review. The study settings include three low-income countries (Burkina Faso, Mali, Sierra Leone) and two lower-middle countries (Kenya, India). Four of them examine a direct association between user fee policies and women’s empowerment, while the others address this issue indirectly —mostly by examining gender equality or women’s decision-making in the context of free healthcare. The evidence suggests that user fee removal contributes to improving women’s capability to make health decisions through different mechanisms, but that the impact is limited. In the context of free healthcare, women’s healthcare decision-making power remains undermined because of social norms that are prevalent in the household, the community and the healthcare centers. In addition, women continue to endure limited access to and control over resources (mainly education, information and economic resources). Conclusion User fee removal policies alone are not enough to improve women’s healthcare decision-making power. Comprehensive and multi-sectoral approaches are needed to bring sustainable change regarding women’s empowerment. A focus on “gender equitable access to healthcare” is needed to reconcile women’s empowerment and the efforts to achieve universal health coverage.

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

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.