Itinéraires thérapeutiques et accès aux soins en santé mentale : une ethnographie au Burkina Faso.

INTRODUCTION: In Burkina Faso, there is a lack of studies on perceptions of existing mental healthcare systems. This limits understanding patients’ treatment pathways and barriers to care utilization. As in many countries in sub-Saharan Africa, this lack of information contributes to the difficulty of health systems to adapt the available care to patients’ realities and needs. PURPOSE OF RESEARCH: In this study, participant observations were made in different care settings in the city of Bobo-Dioulasso. Seven focus groups and 25 individual interviews were conducted to question knowledge, perception, and use of existing services. Different actors were interviewed: patients, caregivers, family members and key informants. The data were subjected to a descriptive thematic analysis. RESULTS: Three systems of care were identified: 1) psychiatric care was associated with a diagnostic function and the management of serious pathologies, or ones triggered by “natural” causes, 2) traditional care was seen as having a healing function for “supernatural” pathologies, but was associated with a risk of fraud, and 3) informal care provided by the family was identified as the mainstay of the therapeutic pathways. CONCLUSIONS: This study reveals that through the diversity of resources consulted, the family members represent the main provider of care. Also, financial constraints constitute the main obstacle to seeking care. These findings lead us to make recommendations regarding the development of public policies at the national level as well as regarding the organization of health services in the city of Bobo-Dioulasso.

Twelve months of implementation of health care performance-based financing in Burkina Faso: A qualitative multiple case study.

To improve health services' quantity and quality, African countries are increasingly engaging in performance-based financing (PBF) interventions. Studies to understand their implementation in francophone West Africa are rare. This study analysed PBF implementation in Burkina Faso 12 months post-launch in late 2014. The design was a multiple and contrasted case study involving 18 cases (health centres). Empirical data were collected from observations, informal (n = 224) and formal (n = 459) interviews, and documents. Outside the circle of persons trained in PBF, few in the community had knowledge of it. In some health centres, the fact that staff were receiving bonuses was intentionally not announced to populations and community leaders. Most local actors thought PBF was just another project, but the majority appreciated it. There were significant delays in setting up agencies for performance monitoring, auditing, and contracting, as well as in the payment. The first audits led rapidly to coping strategies among health workers and occasionally to some staging beforehand. No community-based audits had yet been done. Distribution of bonuses varied from one centre to another. This study shows the importance of understanding the implementation of public health interventions in Africa and of uncovering coping strategies.

An exploratory study assessing psychological distress of indigents in Burkina Faso: a step forward in understanding mental health needs in West Africa.

BACKGROUND: Poverty is known as an important determinant of health, but empirical data are still missing on the relationships between poverty, other adverse living conditions, and psychological distress, particularly in low-income countries. This study aimed to assess mental health needs and psychological distress among the poorest in rural settings in Burkina Faso where food security and access to water, electricity, schooling, and healthcare are limited. METHODS: We randomly selected 2000 individuals previously identified as indigents by a community-targeting process. Interviewers visited participants (n = 1652) in their homes and completed a questionnaire on mental health variables that included presence and intensity of anxious, depressive, psychotic, and aggressive symptoms, as well as level of psychological distress. Descriptive statistics, Spearman correlations, and logistic regressions were performed. RESULTS: In all, 40.2% of the sample reported 10 or more anxious/depressive symptoms in the past 30 days, and 25.5% reported having experienced at least one psychotic symptom over their lifetime, 65.6% of whom had had those symptoms for many years. The number of anxious and depressive symptoms was significantly associated with the level of psychological distress (r = 0.423, p < .001). Predictors of distress level included: poor health condition (F(1) = 23.743, p <. 001), being a woman (F(1) = 43.926, p < .001), not having any income (F(1) = 16.185, p < .001), having begged for food in the past 30 days (F(1) = 12.387, p < .001), being illiterate, and being older (F(1) = 21.487, p < .001). Approximately one third of respondents reporting anxious/depressive or psychotic symptoms (28.2 and 30.0%, respectively) had not talked about their symptoms to anyone in their social network. CONCLUSIONS: These results suggest alarmingly high levels of psychological distress and reported symptoms among the poorest in rural settings in Burkina Faso, which can be explained by their difficult living conditions. However, these results must be interpreted from a transcultural perspective to avoid decontextualized misinterpretations. Ethnographic works are needed to document the larger context within which these distress results can be analyzed.

Free versus subsidised healthcare: options for fee exemptions, access to care for vulnerable groups and effects on the health system in Burkina Faso.

BACKGROUND: The many forms of healthcare fee exemptions implemented in Burkina Faso since the 2000s have varied between total exemption (free) and cost subsidisation. This article examines both options, their contextual variations and the ways in which they affect access to healthcare for vulnerable people as well as the operation of the health system. This research is part of an interdisciplinary regional program on the elimination of user fees for health services in West Africa (Burkina Faso, Mali and Niger). METHOD: A conceptual framework and a chronological review of policy interventions are used as references to summarise the results of the three qualitative studies presented. Historical reference points are used to describe the emergence of healthcare fee exemption policies in Burkina Faso and the events that influenced their adoption. The joint analysis of opinions on options for fee exemption focuses on the different types of repercussions on access to healthcare and the operation of the health system. RESULTS: In conjunction with the twists and turns of the gradual development of a national health policy and in response to international recommendations, healthcare fee exemptions have evolved since colonisation. The limitations of the changes introduced with cost recovery and the barriers to healthcare access for the poorest people led to the adoption of the current sectorial fee exemptions. The results provide information on the reasons for the changes that have occurred over time. The nuanced perspectives of different categories of people surveyed about fee exemption options show that, beyond the perceived effects on healthcare access and the health system, the issue is one of more equitable governance. CONCLUSIONS: In principle, the fee exemption measures are intended to provide improved healthcare access for vulnerable groups. In practice, the negative effects on the operation of the health system advocate for reforms to harmonise the changes to multifaceted fee exemptions and the actual needs to promote effectiveness and sustainability.

The obstetric care subsidy policy in Burkina Faso: what are the effects after five years of implementation? Findings of a complex evaluation.

BACKGROUND: Burkina Faso, like many low and middle income countries, has been taking a range of actions to address its poor maternal and neonatal health indicators. In 2006 the government introduced an innovative national subsidy scheme for deliveries and emergency obstetric care in public facilities. This article reports on a complex evaluation of this policy, carried out 5 years after its introduction, which examined its effects on utilisation, quality of care, equity and the health system as a whole, as well as its cost and sustainability. METHODS: The evaluation was carried out in six purposively selected districts, as well as at national level, using a case study approach. Data sources included: national and district routine and survey data, household interviews with women who had recently given birth, data extraction from hospital and medical records, and key informant and health worker interviews. RESULTS: The underlying secular trend of a 1% annual increase in the facility-based delivery rate (1988-2010) was augmented by an additional 4% annual increase from 2007 onwards (after the policy was introduced), especially in rural areas and amongst women from poor households. The absence of baseline quality of care data made it difficult to assess the impact of the policy on quality of care, but hospitals with the best level of implementation of the subsidy offered higher quality of care (as measured by health care near-misses), so there is no evidence of a negative impact on quality (as is often feared). Similarly, there is little evidence of unintended negative effects on untargeted services. Household payments for facility-based deliveries have reduced significantly, compared with payments before the policy, and the policy as a whole is affordable, costing about 2% of total public health expenditure. Concerns include that the amounts paid by households are higher than the rates set by the policy, and also that 7% of households still say that they cannot afford to pay. Wealthier women have higher utilisation of services, as before, and the policy of fully exempting indigents is not being put into practice. CONCLUSIONS: These findings highlight the importance of maintaining the subsidy policy, given the evidence of positive outcomes, but they also point out areas where attention is needed to ensure the poor and most vulnerable population benefit fully from the policy.

Local sustainability and scaling up for user fee exemptions: medical NGOs vis-à-vis health systems.

Free healthcare obviously works when a partner from abroad supplies a health centre or a health district with medicines and funding on a regular basis, provides medical, administrative and managerial training, and gives incentive bonuses and daily subsistence allowances to staff. The experiments by three international NGO in Burkina Faso, Mali and Niger have all been success stories. But withdrawing NGO support means that health centres that have enjoyed a time of plenty under NGO management will return to the fold of health centres run by the state in its present condition and the health system in its present condition, with the everyday consequences of late reimbursements and stock shortages. The local support given by international NGOs has more often than not an effect of triggering an addiction to aid instead of inducing local sustainability without infusion. In the same way, scaling up to the entire country a local pilot experiment conducted under an NGO involves its insertion into a national bureaucratic machine with its multiple levels, all of which are potential bottlenecks. Only experiments carried out under the "ordinary" management of the state are capable of laying bare the problems associated with this process. Without reformers 'on the inside' (within the health system itself and among health workers), no real reform of the health system induced by reformers 'from the outside' can succeed.

Factors influencing primary care access, utilisation and quality of management for patients living with hypertension in West Africa: a scoping review protocol.

INTRODUCTION: Hypertension, one of the most prevalent non-communicable diseases in West Africa, can be well managed with good primary care. This scoping review will explore what is documented in the literature about factors that influence primary care access, utilisation and quality of management for patients living with hypertension in West Africa. METHODS AND ANALYSIS: The scoping review will employ the approach described by Arksey and O'Malley (2005) . The approach has five stages: (1) formulating the research questions, (2) identifying relevant studies, (3) selecting eligible studies, (4) charting the data and (5) collating, summarising and reporting the results. This review will employ the Preferred Reporting Items for Systematic review and Meta-Analysis extension for scoping reviews to report the results. PubMed, Embase, Scopus, Cairn Info and Google Scholar will be searched for publications from 1 January 2000 to 31 December 2023. Studies reported in English, French or Portuguese will be considered for inclusion. Research articles, systematic reviews, observational studies and reports that include information on the relevant factors that influence primary care management of hypertension in West Africa will be eligible for inclusion. Study participants should be adults (aged 18 years or older). Clinical case series/case reports, short communications, books, grey literature and conference proceedings will be excluded. Papers on gestational hypertension and pre-eclampsia will be excluded. ETHICS AND DISSEMINATION: This review does not require ethics approval. Our dissemination strategy includes peer-reviewed publications, policy briefs, presentations at conferences, dissemination to stakeholders and intervention co-production forums.

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.

Protocol for the process evaluation of interventions combining performance-based financing with health equity in Burkina Faso.

BACKGROUND: The low quality of healthcare and the presence of user fees in Burkina Faso contribute to low utilization of healthcare and elevated levels of mortality. To improve access to high-quality healthcare and equity, national authorities are testing different intervention arms that combine performance-based financing with community-based health insurance and pro-poor targeting. There is a need to evaluate the implementation of these unique approaches. We developed a research protocol to analyze the conditions that led to the emergence of these intervention arms, the fidelity between the activities initially planned and those conducted, the implementation and adaptation processes, the sustainability of the interventions, the possibilities for scaling them up, and their ethical implications. METHODS/DESIGN: The study adopts a longitudinal multiple case study design with several embedded levels of analyses. To represent the diversity of contexts where the intervention arms are carried out, we will select three districts. Within districts, we will select both primary healthcare centers (n =18) representing different intervention arms and the district or regional hospital (n =3). We will select contrasted cases in relation to their initial performance (good, fair, poor). Over a period of 18 months, we will use quantitative and qualitative data collection and analytical tools to study these cases including in-depth interviews, participatory observation, research diaries, and questionnaires. We will give more weight to qualitative methods compared to quantitative methods. DISCUSSION: Performance-based financing is expanding rapidly across low- and middle-income countries. The results of this study will enable researchers and decision makers to gain a better understanding of the factors that can influence the implementation and the sustainability of complex interventions aiming to increase healthcare quality as well as equity.

Targeting the worst-off for free health care: a process evaluation in Burkina Faso.

Effective mechanisms to exempt the indigent from user fees at health care facilities are rare in Africa. A State-led intervention (2004-2005) and two action research projects (2007-2010) were implemented in a health district in Burkina Faso to exempt the indigent from user fees. This article presents the results of the process evaluation of these three interventions. Individual and group interviews were organized with the key stakeholders (health staff, community members) to document the strengths and weaknesses of key components of the interventions (relevance and uptake of the intervention, worst-off selection and information, financial arrangements). Data was subjected to content analysis and thematic analysis. The results show that all three intervention processes can be improved. Community-based targeting was better accepted by the stakeholders than was the State-led intervention. The strengths of the community-based approach were in clearly defining the selection criteria, informing the waiver beneficiaries, using a participative process and using endogenous funding. A weakness was that using endogenous funding led to restrictive selection by the community. The community-based approach appears to be the most effective, but it needs to be improved and retested to generate more knowledge before scaling up.