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.

Factors Influencing Community Engagement during Guinea Worm and Polio Eradication Endgames in Chad: Recommendations for "Last Mile" Programming.

Community engagement is a strategy commonly used in health and development programming. Many disease eradication programs engage with communities through different structures and mechanisms to detect, report, contain, and respond to the diseases they target. Qualitative operational research was conducted in a district of Chad co-endemic for both dracunculiasis (i.e., Guinea worm disease) and circulating vaccine-derived poliovirus to reveal factors influencing community engagement behavior in the context of eradication-related programming. Women and men from six communities and stakeholders from the local, district, and central levels were recruited to participate in focus group discussions and semi-structured in-depth interviews. A thematic analysis was performed to identify barriers and facilitators of community engagement. Barriers to community engagement included mistrust in exogenously established health program initiatives (i.e., initiatives designed by partners external to targeted program communities) resulting from negative past experiences with external entities and community groups and the lure of profit-motivating community engagement. Subgroup and intersectionality analyses revealed that gender and other identities influence whether and to what extent certain members of the community engage in a meaningful way. Facilitators of community engagement included leadership and the influence of authorities and leaders in community participation, perceived benefits of being engaged with community-based initiatives, and use of incentives to enhance community participation. Study findings may be used to inform the refinement of community engagement approaches in Chad and learning agendas for other "last mile" disease eradication programs.

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.