Health Planning in Times of COVID-19 in Burkina Faso: The Role of Its National Strategic Pandemic Management Committee.

CONTEXT: Presenting the COVID-19 crisis as a pandemic misleadingly implies a certain homogeneity between the regions of the Globe in terms of their burden and reactions. However, from the outset of the crisis, countries presented different epidemiological realities and sometimes adopted divergent, even opposing measures. Curiously, the heterogeneity of responses persisted as scientific evidence accumulated about COVID-19 and the strategies for dealing with it. CASE STUDY: This commentary aims to recount the specific experience of Burkina Faso, and how it reoriented its initial biomedical response into a multisectoral strategy. Burkina Faso set up a committee specifically to examine the effects not only of the pandemic, but also of the control measures. This committee was mandated to decompartmentalize the lens through which the COVID-19 was dealt with. It entered into dialogue with a level of stakeholders often overlooked during national health crisis: communities. As a member of this "National Committee for Crisis Management of the Pandemic", one of the co-authors contributed to its orientations and has witnessed first-hand some of the challenges it faced. RECOMMENDATIONS: This experience suggests that the project of extricating the field of public health from medicine is advancing in Burkina Faso. In order to manage future crises more effectively and across different sectors, there is an urgent need to establish state structures and to strengthen public health systems. States need coordination units that have the legitimacy, authority and resources required to mobilize a variety of actors at the community, national and international levels.

Vaccination coverage in rural Burkina Faso under the effects of COVID-19: evidence from a panel study in eight districts.

BACKGROUND: Improving infant immunization completion and promoting equitable vaccination coverage are crucial to reducing global under-5 childhood mortality. Although there have been hypotheses that the impact of the COVID-19 pandemic would decrease the delivery of health services and immunization campaigns in low- and middle-income countries, the available evidence is still inconclusive. We conducted a study in rural Burkina Faso to assess changes in vaccination coverage during the pandemic. A secondary objective was to examine long-term trends in vaccination coverage throughout 2010-2021. METHODS: Using a quasi-experimental approach, we conducted three rounds of surveys (2019, 2020, 2021) in rural Burkina Faso that we pooled with two previous rounds of demographic and household surveys (2010, 2015) to assess trends in vaccination coverage. The study population comprised infants aged 0-13 months from a sample of 325 households randomly selected in eight districts (n = 736). We assessed vaccination coverage by directly observing the infants' vaccination booklet. Effects of the pandemic on infant vaccination completion were analyzed using multi-level logistic regression models with random intercepts at the household and district levels. RESULTS: A total of 736 child-year observations were included in the analysis. The proportion of children with age-appropriate complete vaccination was 69.76% in 2010, 55.38% in 2015, 50.47% in 2019-2020, and 64.75% in 2021. Analyses assessing changes in age-appropriate full-vaccination coverage before and during the pandemic show a significant increase (OR: 1.8, 95% CI: 1.14-2.85). Our models also confirmed the presence of heterogeneity in full vaccination between health administrative districts. The pandemic could have increased inequities in infant vaccination completion between these districts. The analyses suggest no disruption in age-appropriate full vaccination due to COVID-19. Our findings from our sensitivity analyses to examine trends since 2010 did not show any steady trends. CONCLUSION: Our findings in Burkina Faso do not support the predicted detrimental effects of COVID-19 on the immunization schedule for infants in low- and middle-income countries. Analyses comparing 2019 and 2021 show an improvement in age-appropriate full vaccination. Regardless of achieving and sustaining vaccination coverage levels in Burkina Faso, this should remain a priority for health systems and political agendas.

Towards a deeper understanding of male involvement in the prevention of mother to child transmission of HIV in the Bogodogo District of the Central Region of Burkina Faso.

INTRODUCTION: Men can play crucial roles at each stage of HIV mother-to-child-transmission (MTCT) prevention. Low male involvement in preventative MTCT (PMTCT) in Burkina Faso is partially associated with increased MTCT rates in the country. Male involvement is at the intersection of individual experiences, social locations, organizational and systemic forces. It is crucial that PMTCT interventions are co-designed with all stakeholders, using approaches which account for such interconnected elements. This study, aims to provide a deeper understanding of male involvement using an intersectionality framework. METHODS: We used an intersectional theoretical approach as it positions male involvement at the intersection of social location, systemic forces, individual experiences, and dynamics within couples. We applied an interpretative qualitative description design. The study was performed at St-Camille's hospital in Ouagadougou, Burkina Faso. Our sample was theoretical to contrast for individual experiences and socioeconomic characteristics. Eligible women were identified via chart review and invited to participate with their male partners. We conducted individual semi-structured interviews with 12 couples. We performed a semantic thematic analysis using QDA Miner to identify themes and patterns among subjective perspectives, while accounting for variations between individuals. RESULTS: We interviewed 12 couples; 6 were serodiscordant. All women were HIV-positive. Participant ages ranged from 23 to 48 years. We found male involvement to be multidimensional and multifaceted, covering a large spectrum (from rejection to true partnership) and diverse involvement. Male involvement was limited by competing priorities, contradictory expectations, organizational opportunities and societal beliefs. We found interactions with caregivers impacted male involvement. CONCLUSION: This study contributed to enhancing our understanding of male involvement in PMTCT of HIV as a dynamic result of the interconnected individual, organizational and systemic experiences. Increasing male involvement will require implementation of coordinated interventions. Such interventions must strive to simultaneously integrate individual, organizational and systemic actions together.

Measurement of self-reported, facility-based labour and birth experiences: The Perinatal Experience Assessment Tool (PEAT).

Background: Women and their families make decisions on accessing perinatal care based on their experiences in the health care system and on the experience of others around them. Receiving supportive maternity care which demonstrates respect is an essential part of quality care. Globally, and in low- and middle-income countries in particular, women report receiving mistreatment and a lack of respect during labour, childbirth and the early postnatal period. These experiences, if negative, may influence choices around place of birth, thus hindering the scale-up of facility-based births. Methods: We conducted a focussed review of the literature between 2010 and 2019 to identify recent research addressing the assessment of women's experiences during childbirth in low- and middle-income country facilities. The World Health Organization (WHO) and White Ribbon Alliance themes and concepts of respectful maternity care served as a guide. Themes included disrespectful or abusive experiences such as verbal abuse or rudeness, abandonment, corruption, lack of privacy, failure to respect traditional practices, discrimination, and physical or sexual abuse. Experienced midwives in two low-resource countries contributed to the identification of appropriate indicators of respectful, non-abusive care, and eventual agreement as to which to include in an assessment tool monitoring women's experiences. Results: Our review of the literature identified 18 publications meeting pre-established criteria. This resulted in the eventual selection of 33 indicators of respectful care sub-grouped under 9 domains: 1) communication/verbal interaction, 2) supportive care, 3) physical abuse, 4) non-consented care, 5) non-confidential care/lack of privacy, 6) stigma and discrimination, 7) abandonment/neglect, 8) detention/inability to pay, and 9) health facility conditions. We converted these indicators into questions to be asked by an interviewer during a short interview following discharge to assess the childbirth experience. Conclusions: The Perinatal Experience Assessment Tool (PEAT) may be used to monitor or evaluate the experiences that women report after facility-based childbirth. It can be administered by trained, independent interviewers in the facility following discharge. The PEAT enables maternity leaders to assess the extent to which maternity services are conducted in a respectful, non-abusive manner and modify practices and procedures as feasible and appropriate.

Does abolishing user fees for family planning increase contraception use? An impact evaluation of the national policy in Burkina Faso.

Background: Unmet needs for contraception constitute a major public health problem in sub-Saharan Africa. Several mechanisms have been tested to reduce the financial barrier and facilitate access to family planning services, with inconclusive results. Based on the positive impacts following the introduction of free health care for pregnant women, Burkina Faso decided to extend its national policy and abolished direct payment for family planning services. This study aims to evaluate the impact of this policy on contraceptive use and unmet needs for contraception among women of reproductive age (WRA) in Burkina Faso. Methods: This study uses two different study designs to examine the impact of a user fee removal policy on contraceptive use across a panel of 1400 households randomly selected across eight health districts. Data were collected using a standardized socio-demographic questionnaire at three different time points during the pilot and scale-up phases of the fee abolition program. The questionnaire was administered six months after the launch of the pilot fee abolition program in four health districts. For the remaining four health districts, the survey was conducted one year prior to and six months after the implementation of the program in those areas. All WRA in the households were eligible to participate. A cross-sectional study design was used to determine the association between knowledge of the fee abolition policy among WRA and actual use of contraceptives by WRA six months after the policy's implementation and across all eight districts. Additionally, a pre-post study with a non-randomized, reflexive control group was designed using repeated surveys in four health districts. Hierarchical logistic mixed effects models were adjusted for a set of time-variant individual variables; the impact was assessed by a difference-in-differences approach that compared pre-post changes in contraception use in women who knew about the new policy and those who did not. Results: Of the 1471 WRA surveyed six months after the removal of user fees for family planning services, 56% were aware of the policy's existence. Knowledge of the fee abolition policy was associated with a 46% increase probability of contraceptive use among WRA six months after the policy's implementation. Among the subset of the participants who were surveyed twice (n = 507), 65% knew about the fee removal policy six months after its introduction and constitute the intervention group. Pre-post changes in contraceptive use differed significantly between the intervention (n = 327) and control groups (n = 180). Removing user fees for family planning led to an 86% (95% confidence interval (CI) = 0.49, 1.31) increase in the likelihood of using contraception. In the study area, the policy reduced the prevalence of unmet needs for contraception by 13 percentage points. Conclusions: Removing user fees for family planning services is a promising strategy to increase access to, and reduce unmet needs for, contraception. A broader dissemination of the policy's existence will likely increase its impact on the overall population.

The Equity Tool for Valuing Global Health Partnerships.

Global health partnerships (GHPs) involve complex relationships between individuals and organizations, often joining partners from high-income and low- or middle-income countries around work that is carried out in the latter. Therefore, GHPs are situated in the context of global inequities and their underlying sociopolitical and historical causes, such as colonization. Equity is a core principle that should guide GHPs from start to end. How equity is embedded and nurtured throughout a partnership has remained a constant challenge. We have developed a user-friendly tool for valuing a GHP throughout its lifespan using an equity lens. The development of the EQT was informed by 5 distinct elements: a scoping review of scientific published peer-reviewed literature; an online survey and follow-up telephone interviews; workshops in Canada, Burkina Faso, and Vietnam; a critical interpretive synthesis; and a content validation exercise. Findings suggest GHPs generate experiences of equity or inequity yet provide little guidance on how to identify and respond to these experiences. The EQT can guide people involved in partnering to consider the equity implications of all their actions, from inception, through implementation and completion of a partnership. When used to guide reflective dialogue with a clear intention to advance equity in and through partnering, this tool offers a new approach to valuing global health partnerships. Global health practitioners, among others, can apply the EQT in their partnerships to learning together about how to cultivate equity in their unique contexts within what is becoming an increasingly diverse, vibrant, and responsive global health community.

Using experience to create evidence: a mixed methods process evaluation of the new free family planning policy in Burkina Faso.

BACKGROUND: In 2019, Burkina Faso was one of the first countries in Sub-Saharan Africa to introduce a free family planning (FP) policy. This process evaluation aims to identify obstacles and facilitators to its implementation, examine its coverage in the targeted population after six months, and investigate its influence on the perceived quality of FP services. METHODS: This process evaluation was conducted from November 2019 through March 2020 in the two regions of Burkina Faso where the new policy was introduced as a pilot. Mixed methods were used with a convergent design. Semi-directed interviews were conducted with the Ministry of Health (n = 3), healthcare workers (n = 10), and women aged 15-49 years (n = 10). Surveys were also administered to the female members of 696 households randomly selected from four health districts (n = 901). RESULTS: Implementation obstacles include insufficient communication, shortages of consumables and contraceptives, and delays in reimbursement from the government. The main facilitators were previous experience with free healthcare policies, good acceptability in the population, and support from local associations. Six months after its introduction, only 50% of the surveyed participants knew about the free FP policy. Higher education level, being sexually active or in a relationship, having recently seen a healthcare professional, and possession of a radio significantly increased the odds of knowing. Of the participants, 39% continued paying for FP services despite the new policy, mainly because of stock shortages forcing them to buy their contraceptive products elsewhere. Increased waiting time and shorter consultations were also reported. CONCLUSION: Six months after its introduction, the free FP policy still has gaps in its implementation, as women continue to spend money for FP services and have little knowledge of the policy, particularly in the Cascades region. While its use is reportedly increasing, addressing implementation issues could further improve women's access to contraception.

Burkina Faso is one of the first countries in sub-Saharan Africa to remove user fees for family planning services. Introduced as a pilot in June 2019, this policy covers the main costs, including the contraceptives, for all women of reproductive age (15­49 years old). We conducted a study to find out how the implementation of this new policy was going. In particular, we wanted to know what might be limiting or facilitating the successful implementation of the policy in a rural community. Through interviews with health staff and women, we found that about half of the women did not even know that family planning was now free, even though it had been free for more than six months. In addition, there were problems in the supply chain, which meant that contraceptive methods may have become free, but they were no longer available. On the other hand, the new policy has been generally well received by the public: previous similar initiatives seem to have facilitated implementation, as have awareness campaigns conducted by non-governmental organizations. With this information, the new policy can be improved to further enhance women's access to contraceptive methods in rural Burkina Faso.

Change in childbearing intention, use of contraception, unwanted pregnancies, and related adverse events during the COVID-19 pandemic: Results from a panel study in rural Burkina Faso.

Evidence on how the COVID-19 pandemic has affected women's reproductive health remains scarce, particularly for low- and middle-income countries. Deleterious indirect effects seem likely, particularly on access to contraception and risk of unwanted pregnancies, but rigorous evaluations using quasi-experimental designs are lacking. Taking a diachronic perspective, we aimed to investigate the effects of the pandemic on four indicators of women's reproductive health: history of recent adverse events during pregnancy (past), use of contraception and unwanted pregnancies (present), and childbearing intentions (future). This study was conducted in four rural health districts of Burkina Faso: Banfora, Leo, Sindou and Tenado. Two rounds of household surveys (before and during the pandemic) were conducted in a panel of 696 households using standardized questionnaires. The households were selected using a stratified two-stage random sampling method. All women aged 15-49 years living in the household were eligible for the study. The same households were visited twice, in February 2020 and February 2021. The effects were estimated by fitting hierarchical regression models with fixed effects or random intercepts at the individual level. A total of 814 and 597 women reported being sexually active before and during the COVID-19 pandemic, respectively. The odds of not wanting (any more) children were two times higher during the pandemic than before (2.0, 95% CI [1.32-3.04]). Among those with childbearing intention, the average desired delay until the next pregnancy increased from 28.7 to 32.8 months. When comparing 2021 versus 2020, there was an increase in the adjusted odds ratio of contraception use (1.23, 95% CI [1.08-1.40]), unwanted pregnancies (2.07, 95% CI [1.01-4.25]), and self-reported history of miscarriages, abortions, or stillbirths in the previous 12 months (2.4, 95% CI [1.04-5.43]). Our findings in rural Burkina Faso do not support the predicted detrimental effects of COVID-19 on the use of family planning services in LMICs, but confirm that it negatively affects pregnancy intentions. Use of contraception increased significantly among women in the panel, but arguably not enough to avoid an increase in unwanted pregnancies.

Free healthcare for some, fee-paying for the rest: adaptive practices and ethical issues in rural communities in the district of Boulsa, Burkina Faso.

In Burkina Faso, in July 2016, user fees were removed at all public healthcare facilities, but only for children under 60 months of age and for "mothers", i.e. for reproductive care. This study was conducted in five rural communities in Boulsa District (Burkina Faso) (1) to understand the perceptions and practices of stakeholders regarding compliance with eligibility criteria for free care and (2) to explore the ethical tensions that may have resulted from this policy. Semi-directed individual interviews (n = 20) were conducted with healthcare personnel and mothers of young children. Interviews were recorded and transcribed, and a thematic content analysis was conducted. The study reveals the presence of practices to circumvent strict compliance with the eligibility criteria for free access. These include hiding the exact age of children over 60 months and using eligible persons for the benefit of others. These practices result from ethical and economic tensions experienced by the beneficiaries. They also raise dilemmas among healthcare providers, who have to enforce compliance with the eligibility criteria while realizing the households' deprivation. Informal adjustments are introduced at the community level to reconcile the healthcare providers' dissonance. Local reinvention mechanisms help in overcoming ethical tensions and in implementing the policy.

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.

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.

Effects of terrorist attacks on access to maternal healthcare services: a national longitudinal study in Burkina Faso.

INTRODUCTION: Most of the literature on terrorist attacks' health impacts has focused on direct victims rather than on distal consequences in the overall population. There is limited knowledge on how terrorist attacks can be detrimental to access to healthcare services. The objective of this study is to assess the impact of terrorist attacks on the utilisation of maternal healthcare services by examining the case of Burkina Faso. METHODS: This longitudinal quasi-experimental study uses multiple interrupted time series analysis. Utilisation of healthcare services data was extracted from the National Health Information System in Burkina Faso. Data span the period of January 2013-December 2018 and include all public primary healthcare centres and district hospitals. Terrorist attack data were extracted from the Armed Conflict Location and Event Data project. Negative binomial regression models were fitted with fixed effects to isolate the immediate and long-term effects of terrorist attacks on three outcomes (antenatal care visits, of facility deliveries and of cesarean sections). RESULTS: During the next month of an attack, the incidence of assisted deliveries in healthcare facilities is significantly reduced by 3.8% (95% CI 1.3 to 6.3). Multiple attacks have immediate effects more pronounced than single attacks. Longitudinal analysis show that the incremental number of terrorist attacks is associated with a decrease of the three outcomes. For every additional attack in a commune, the incidence of cesarean sections is reduced by 7.7% (95% CI 4.7 to 10.7) while, for assisted deliveries, it is reduced by 2.5% (95% CI 1.9 to 3.1) and, for antenatal care visits, by 1.8% (95% CI 1.2 to 2.5). CONCLUSION: Terrorist attacks constitute a new barrier to access of maternal healthcare in Burkina Faso. The exponential increase in terrorist activities in West Africa is expected to have negative effects on maternal health in the entire region.

Longitudinal analysis of the capacities of community health workers mobilized for seasonal malaria chemoprevention in Burkina Faso.

BACKGROUND: Seasonal malaria chemoprevention (SMC) relies on community health workers to distribute drugs. This study assessed: (1) the capacity of community-based distributors (CBDs) at the start and end of a campaign and from one campaign to another after training or refresher courses before each round; (2) to what extent CBDs' experience over several campaigns contributed to measurable increase in their capacities; and (3) to what extent the training and experience of committed CBDs helped the less productive to catch up. METHODS: A longitudinal analysis was conducted in one Burkina Faso health district during the 2017 and 2018 campaigns. A panel including all CBDs was created. Their capacities were observed after: (1) initial training for the 2017 season; (2) refresher training for that year's fourth round; and (3) initial training for the 2018 season. All were invited to complete a questionnaire at the end of training with 27 multiple-choice questions on their main tasks. Observers noted content coverage and conditions under which training sessions were conducted. RESULTS: The 612 CBDs showed, on average, high understanding of their tasks from the start of the annual campaigns. Tasks related to communicating with parents and reporting were best mastered. Their capacities grew from round to round and campaign to campaign, after most had undergone training and been supervised by head nurses. The greatest progress was in the technical components, considered more complex, which involved selecting eligible children, choosing the correct drug packet, and referring children to health professionals. Retaining CBDs from one round to the next benefited everyone, whatever their starting level. Groups that initially obtained the lowest scores (women, illiterates, youngest/oldest) progressed the most. CONCLUSION: These results confirm the potential of using CBDs under routine programme implementation. Mandating CBDs with targeted tasks is a functional model, as they achieve mastery in this context where investments are made in training and supervision. Losing this specificity by extending CBDs' mandates beyond SMC could have undesirable consequences. The added value of retaining committed CBDs is high. It is suggested that motivation and commitment be considered in recruitment, and that a supportive climate be created to foster retention.

Analysis of the quality of seasonal malaria chemoprevention provided by community health Workers in Boulsa health district, Burkina Faso.

BACKGROUND: Since 2014, the Burkina Faso government has made Seasonal Malaria Chemoprevention (SMC) a priority in its strategic plan to fight against malaria among children aged from 3 to 59 months. Very few studies have examined the care provided by community health workers in the framework of this strategy. The purpose of this study was to evaluate the level of quality of care provided by the latter. METHODS: This was a mixed study. The quantitative component consisted of a non-participant observation of community health workers during the administration of care. The qualitative component consisted of one-on-one interviews with community health workers, child caregivers and head nurses. Five dimensions (organizational accessibility, interpersonal relationship, technical competence, safety of care and satisfaction of child caregivers) adapted from the Donabedian quality of care model were used to assess the quality level of care. The Corlien et al. Health Systems Research Program Implementation Scale was used to establish quality scores for each of the five dimensions. The study sites were the health centers located in the administrative centers of the 4 communes of the health district of Boulsa. The data were collected during the first cycle of the 2017 SMC campaign. RESULTS: A total of 14 active pairs (28 CHWs) were observed and 40 in-depth interviews with community health workers, Head nurses in duty and community leaders were conducted. The results show that community health workers worked in pairs. They had all received SMC training and possessed equipment to do their job. The dimensions of organizational accessibility and satisfaction of the caregivers were rated as good. The dimensions of interpersonal relationship and technical competence were judged to be of an acceptable score. Safety of care was judged to be of a low-level score. The overall quality of care was considered acceptable. CONCLUSION: The results of this study have shown that despite the difficulties faced by community health workers, they manage to deliver acceptable quality of care. Their use would be an asset for SMC in particular and for the health system in general.

Impact Evaluation of Seasonal Malaria Chemoprevention under Routine Program Implementation: A Quasi-Experimental Study in Burkina Faso.

Seasonal malaria chemoprevention (SMC) for children < 5 is a strategy that is gaining popularity in West African countries. Although its efficacy to reduce malaria incidence has been demonstrated in trials, the effects of SMC implemented in routine program conditions, outside of experimental contexts, are unknown. In 2014 and 2015, a survey was conducted in 1,311 households located in Kaya District (Burkina Faso) where SMC had been recently introduced. All children < 72 months were tested for malaria and anemia. A pre-post study with control group was designed to measure SMC impact during high transmission season. A difference-in-differences approach was coupled in the analysis with propensity score weighting to control for observable and time-invariant nonobservable confounding factors. SMC reduced the parasitemia point and period prevalence by 3.3 and 24% points, respectively; this translated into protective effects of 51% and 62%. SMC also reduced the likelihood of having moderate to severe anemia by 32%, and history of recent fever by 46%. Self-reported coverage for children at the first cycle was 83%. The SMC program was successfully added to a package of interventions already in place. To our knowledge, with prevalence < 10% during the peak of the transmission season, this is the first time that malaria can be reported as hypo-endemic in a sub-Sahelian setting in Burkina Faso. SMC has great potential, and along with other interventions, it could contribute to approaching the threshold where elimination strategies will be envisioned in Burkina Faso.

Effect of interrupting free healthcare for children: Drawing lessons at the critical moment of national scale-up in Burkina Faso.

With solid evidence that free healthcare increases the utilization of health services, Burkina Faso recently exempted all children under five and pregnant women from direct payment at health facilities. However, there is little insight into the capacity to maintain the gains attributable to free healthcare under routine conditions of implementation at the national scale. In particular, the repercussions of its interruption are unknown. The objective is to assess the effects of a sequence of natural interventions including the introduction, interruption and reintroduction of free healthcare on health-seeking practices and utilization of healthcare facilities by children under five. This is an embedded mixed methods study conducted in Kaya district, Burkina Faso. The quantitative component is based on a reversal longitudinal design. Pooled interrupted time-series analysis was performed to assess changes in the monthly number of visits from January 2005 to March 2015. Qualitative data were collected through in-depth interviews with health personnel and mothers to better understand the quantitative results. The results show that visits to health centres dropped immediately and significantly when free healthcare was interrupted (-146, CI95% [-255; -37]). They increased again when free healthcare was reintroduced (+89, CI95% [-11; 187]). Both urban and rural centres were affected. Self-medication and visits to traditional healers were reported more frequently during the withdrawal of free healthcare, and tensions between the population and health personnel increased. Implementation problems other than insufficient funding limited the coverage or intensity of free healthcare. While removing user fees could potentially improve mothers and children's health in Burkina Faso, this study shows that demand for healthcare remains highly sensitive to price changes. Gains in utilization attributable to free healthcare may vanish rapidly if user fees are reintroduced. It is essential to support an effective and sustainable implementation of this ambitious initiative.

Effect of a policy to reduce user fees on the rate of skilled birth attendance across socioeconomic strata in Burkina Faso.

BACKGROUND: In Sub-Saharan Africa, maternal and neonatal morbidity and mortality rates are associated with underutilization of skilled birth attendance (SBA). In 2007, Burkina Faso introduced a subsidy scheme for SBA fees. The objective of this study was to evaluate the effect of Burkina Faso's subsidy policy on SBA rate across socioeconomic status (SES) strata. METHODS: We used a quasi-experimental design. The data sources were two representative surveys (n = 1408 and n = 1403) of women from Houndé and Ziniaré health districts of Burkina Faso, and a survey of health centres assessing structural quality of care. Multilevel Poisson regression models were used with robust variance estimators. We estimated adjusted rate ratios (RR) and rate differences (RD) as a function of time and SES. RESULTS: For lowest-SES women, immediately upon the introduction of the subsidy policy, the rate of SBA was 45% higher (RR = 1.45, 95% confidence interval (CI): 1.19-1.77) than expected in the absence of subsidy introduction. The results indicated a sustained effect after introduction of the subsidy policy, based on RR estimate (95% CI) of 1.48 (1.21-1.81) at 2 years. For middle-SES women, the RR estimates were 1.28 (1.09-1.49) immediately after introduction of the subsidy policy and 1.30 (1.11-1.51) at 2 years, respectively. For highest-SES women, the RR estimates were 1.19 (1.02-1.38) immediately after subsidy introduction and 1.21 (1.06-1.38) at 2 years, respectively. The RD (95% CI) was 14% (3-24%) for lowest-SES women immediately after introduction of the policy, and the effect was sustained at 14% (4-25%) at 2 years. CONCLUSION: Our study suggests that the introduction of a user-fee subsidy in Burkina Faso resulted in increased rates of SBA across all SES strata. The increase was sustained over time and strongest among the poorest women. These findings have important implications for evidence-informed policy making in Burkina Faso and other countries in Sub-Saharan Africa.

An exploratory analysis of the regionalization policy for the recruitment of health workers in Burkina Faso.

BACKGROUND: Health personnel retention in remote areas is a key health systems issue wordwide. To deal with this issue, since 2002 the government of Burkina Faso has implemented a staff retention policy, the regionalized health personnel recruitment policy, aimed at front-line workers such as nurses, midwives, and birth attendants. This study aimed to describe the policy's development, formulation, and implementation process for the regionalization of health worker recruitment in Burkina Faso. METHODS: We conducted a qualitative study. The unit of analysis is a single case study with several levels of analysis. This study was conducted in three remote areas in Burkina Faso for the implementation portion, and at the central level for the development portion. Indepth interviews were conducted with Ministry of Health officials in charge of human resources, regional directors, regional human resource managers, district chief medical officers, and health workers at primary health centres. In total, 46 in depth interviews were conducted (February 3 - March 16, 2011). DEVELOPMENT: The idea for this policy emerged after finding a highly uneven distribution of health personnel across urban and rural areas, the availability of a large number of health officers in the labour market, and the opportunity given to the Ministry of Health by the government to recruit personnel through a specific budget allocation. FORMULATION: The formulation consisted of a call for job applications from the Ministry of Health, which indicates the number of available posts by region.The respondents interviewed unanimously acknowledged the lack of documents governing the status of this new personnel category. IMPLEMENTATION: During the initial years of implementation (2002-2003), this policy was limited to recruiting health workers for the regions with no possibility of transfer. The possibility of job-for-job exchange was then approved for a certain time, then cancelled. Starting in 2005, a departure condition was added. Now, regionalized health workers can leave the regions after undergoing a competitive selection process. CONCLUSION: The policy was characterized by the absence of written directives and by targeting only one category of personnel. Moreover, there was no associated incentive-financial or otherwise-which poses the question of long-term viability.

Challenges of scaling up and of knowledge transfer in an action research project in Burkina Faso to exempt the worst-off from health care user fees.

BACKGROUND: Systems to exempt the indigent from user fees have been put in place to prevent the worst-off from being excluded from health care services for lack of funds. Yet the implementation of these mechanisms is as rare as the operational research on this topic. This article analyzes an action research project aimed at finding an appropriate solution to make health care accessible to the indigent in a rural district of Burkina Faso. RESEARCH: This action research project was initiated in 2007 to study the feasibility and effectiveness of a community-based, participative and financially sustainable process for exempting the indigent from user fees. A interdisciplinary team of researchers from Burkina Faso and Canada was mobilized to document this action research project. RESULTS AND KNOWLEDGE SHARING: The action process was very well received. Indigent selection was effective and strengthened local solidarity, but coverage was reduced by the lack of local financial resources. Furthermore, the indigent have many other needs that cannot be addressed by exemption from user fees. Several knowledge transfer strategies were implemented to share research findings with residents and with local and national decision-makers. PARTNERSHIP ACHIEVEMENTS AND DIFFICULTIES: Using a mixed and interdisciplinary research approach was critical to grasping the complexity of this community-based process. The adoption of the process and the partnership with local decision-makers were very effective. Therefore, at the instigation of an NGO, four other districts in Burkina Faso and Niger reproduced this experiment. However, national decision-makers showed no interest in this action and still seem unconcerned about finding solutions that promote access to health care for the indigent. LESSONS LEARNED: The lessons learned with regard to knowledge transfer and partnerships between researchers and associated decision-makers are: i) involve potential users of the research results from the research planning stage; ii) establish an ongoing partnership between researchers and users; iii) ensure that users can participate in certain research activities; iv) use a variety of strategies to disseminate results; and v) involve users in dissemination activities.