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BACKGROUND: As countries reform health financing systems towards universal health coverage, increasing concerns emerge on the need to ensure inclusion of the most vulnerable segments of society, working to counteract existing inequities in service coverage. To this end, selected countries in sub-Saharan Africa have decided to couple performance-based financing (PBF) with demand-side equity measures. Still, evidence on the equity impacts of these more complex PBF models is largely lacking. We aimed at filling this gap in knowledge by assessing the equity impact of PBF combined with equity measures on utilization of maternal health services in Burkina Faso. METHODS: Our study took place in 24 districts in rural Burkina Faso. We implemented an experimental design (clusterrandomized trial) nested within a quasi-experimental one (pre- and post-test design with independent controls). Our analysis relied on self-reported data on pregnancy history from 9999 (baseline) and 11 010 (endline) women of reproductive age (15-49 years) on use of maternal healthcare and reproductive health services, and estimated effects using a difference-in-differences (DID) approach, purposely focused on identifying program effects among the poorest wealth quintile. RESULTS: PBF improved the utilization of few selected maternal health services compared to status quo service provision. These benefits, however, were not accrued by the poorest 20%, but rather by the other quintiles. PBF combined with equity measures did not produce better or more equitable results than standard PBF, with specific differences only on selected outcomes. CONCLUSION: Our findings challenge the notion that implementing equity measures alongside PBF is sufficient to produce an equitable distribution in program benefits and point at the need to identify more innovative and contextsensitive measures to ensure adequate access to care for the poorest. Our findings also highlight the importance of considering changing policy environments and the need to assess interferences across policies.
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Serviços de Saúde Materna , Adolescente , Adulto , Burkina Faso , Atenção à Saúde , Feminino , Instalações de Saúde , Humanos , Pessoa de Meia-Idade , Pobreza , Gravidez , Adulto JovemRESUMO
OBJECTIVE: To evaluate the impact of Performance-Based Financing (PBF) on effective coverage of child curative health services in primary healthcare facilities in Burkina Faso. METHODS: An impact evaluation of a PBF pilot programme, using an experiment nested within a quasi-experimental design, was carried out in 12 intervention and 12 comparison districts in six regions of Burkina Faso. Across the 24 districts, primary healthcare facilities (537 both at baseline and endline) and households (baseline = 7978 endline = 7898) were surveyed. Within these households, 12 350 and 15 021 under-five-year-olds caretakers were interviewed at baseline and endline respectively. Linking service quality to service utilisation, we used difference-in-differences to estimate the impact of PBF on effective coverage of curative child health services. RESULTS: Our study failed to detect any effect of PBF on effective coverage. Looking specifically into quality of care indicators, we detected a positive effect of PBF on structural elements of quality of care related to general service readiness, but not on the overall facility quality score, capturing both service readiness and the content of childcare. CONCLUSION: The current study makes a unique contribution to PBF literature, as this is the first study assessing PBF impact on effective coverage for curative child health services in low-income settings. The absence of any significant effects of PBF on effective coverage suggests that PBF programmes require a stronger design focus on quality of care elements especially when implemented in a context of free healthcare policy.
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Serviços de Saúde da Criança/economia , Reembolso de Incentivo , Burkina Faso , Serviços de Saúde da Criança/organização & administração , Pré-Escolar , Características da Família , Feminino , Instalações de Saúde , Humanos , Lactente , Recém-Nascido , Masculino , Projetos Piloto , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Non-communicable diseases are rapidly becoming one of the leading causes of morbidity and mortality in sub-Saharan Africa. Yet, little is known about patterns of healthcare seeking among people with chronic conditions in these settings. We aimed to explore determinants of healthcare seeking among people who reported at least one chronic condition in rural Burkina Faso. METHODS: Data were drawn from a cross-sectional population-based survey conducted across 24 districts on 52 562 individuals from March to June 2017. We used multinomial logistic regression to assess factors associated with seeking care at a formal provider (facility-based care) or at an informal provider (home and traditional treatment) compared to no care. RESULTS: 1124 individuals (2% of all respondents) reported at least one chronic condition. Among those, 22.8% reported formal care use, 10.6% informal care use, and 66.6% no care. The presence of other household members reporting a chronic condition (RRR = 0.57, 95%-CI [0.39, 0.82]) was negatively associated with seeking formal care. Wealthier households (RRR = 2.14, 95%-CI [1.26, 3.64]), perceived illness severity (RRR = 3.23, 95%-CI [2.22, 4.70]) and suffering from major chronic conditions (RRR = 1.54, 95%-CI [1.13, 2.11]) were positively associated with seeking formal care. CONCLUSION: Only a minority of individuals with chronic conditions sought formal care, with important differences due to socio-economic status. Policies and interventions aimed at increasing the availability and affordability of services for early detection and management in peripheral settings should be prioritised.
OBJECTIF: Les maladies non transmissibles deviennent rapidement l'une des principales causes de morbidité et de mortalité en Afrique subsaharienne. Pourtant, on en sait peu sur les profils de recherche de soins de santé chez les personnes atteintes de maladies chroniques dans ces milieux. Nous visions à explorer les déterminants de la recherche de soins de santé chez les personnes qui ont déclaré au moins une maladie chronique dans les régions rurales du Burkina Faso. MÉTHODES: Les données ont été tirées d'une enquête transversale de population menée dans 24 districts auprès de 52.562 personnes de mars à juin 2017. Nous avons utilisé une régression logistique multinomiale pour évaluer les facteurs associés à la recherche de soins chez un prestataire formels (soins en établissement) ou chez un prestataire informel (traitement à domicile et traditionnel) par rapport à l'absence de soins. RÉSULTATS: 1.124 personnes (2% de tous les répondants) ont déclaré au moins une maladie chronique. Parmi ceux-ci, 22,8% ont déclaré avoir recours à des soins formels, 10,6% à des soins informels et 66,6% à aucun soin. La présence d'autres membres du ménage déclarant une maladie chronique (RRR = 0,57, IC95%: 0,39, 0,82) était associée négativement à la recherche de soins formels. Les ménages plus riches (RRR = 2,14; IC95%: 1,26-3,64), la sévérité perçue de la maladie (RRR = 3,23 ; IC95%: 2,22-4,70) et souffrir de maladies chroniques majeures (RRR = 1,54 ; IC95%: 1,13-2,11) étaient positivement associés à la recherche de soins formels. CONCLUSION: Seule une minorité de personnes atteintes de maladies chroniques ont recherché des soins formels, avec des différences importantes en raison du statut socioéconomique. Les politiques et interventions visant à accroître la disponibilité et l'accessibilité des services de détection précoce et de prise en charge dans les régions périphériques doivent être prioritaires.
Assuntos
Doença Crônica/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Burkina Faso/epidemiologia , Criança , Pré-Escolar , Doença Crônica/economia , Doença Crônica/psicologia , Estudos Transversais , Características da Família , Feminino , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , População Rural/estatística & dados numéricos , Classe Social , Inquéritos e Questionários , Adulto JovemRESUMO
This analysis describes specific gaps in the quality of health care in Central Africa and assesses the association between quality of clinical care and mortality at age 2-59 months. Regionally representative facility and household surveys for the Democratic Republic of the Congo, Cameroon and Central African Republic were collected between 2012 and 2016. These data are novel in linking facilities with households in their catchment area. Compliance with diagnostic and danger sign protocols during sick-child visits was observed by trained assessors. We computed facility- and district-level compliance indicators for patients aged 2-59 months and used multivariate multi-level logistic regression models to estimate the association between clinical assessment quality and mortality at age 2-59 months in the catchment areas of the observed facilities. A total of 13 618 live births were analysed and 1818 sick-child visits were directly observed and used to rate 643 facilities. Eight percent of observed visits complied with 80% of basic diagnostic protocols, and 13% of visits fully adhered to select general danger sign protocols. A 10% greater compliance with diagnostic protocols was associated with a 14.1% (adjusted odds ratio (aOR) 95% CI: 0.025-0.244) reduction in the odds of mortality at age 2-59 months; a 10% greater compliance with select general danger sign protocols was associated with a 15.3% (aOR 95% CI: 0.058-0.237) reduction in the same odds. The results of this article suggest that compliance with recommended clinical protocols remains poor in many settings and improvements in mortality at age 2-59 months could be possible if compliance were improved.
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Mortalidade da Criança , Fidelidade a Diretrizes , Instalações de Saúde , Camarões , República Centro-Africana , Criança , Pré-Escolar , Estudos Transversais , República Democrática do Congo , Fidelidade a Diretrizes/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Instalações de Saúde/normas , Instalações de Saúde/estatística & dados numéricos , Humanos , Lactente , Exame Físico/normas , Exame Físico/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
Due to an error introduced during copyediting of this article [1], there are two corrections about the Figs. 1. The caption of Fig. 1 should be changed to "Study design". 2. The Fig. 2 is missing.
RESUMO
BACKGROUND: The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. METHODS: This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. DISCUSSION: We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention's impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. TRIAL REGISTRATION: Registered with RIDIE (RIDIE-STUDY-ID- 54412a964bce8 ) on 10/17/2014.
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Capitação/organização & administração , Burkina Faso , Capitação/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde , Humanos , Avaliação das Necessidades , Projetos de PesquisaRESUMO
BACKGROUND: Poor and marginalized segments of society often display the worst health status due to limited access to health enhancing interventions. It follows that in order to enhance the health status of entire populations, inequities in access to health care services need to be addressed as an inherent element of any effort targeting Universal Health Coverage. In line with this observation and the need to generate evidence on the equity status quo in sub-Saharan Africa, we assessed the magnitude of the inequities and their determinants in coverage of maternal health services in Burkina Faso. METHODS: We assessed coverage for three basic maternal care services (at least four antenatal care visits, facility-based delivery, and at least one postnatal care visit) using data from a cross-sectional household survey including a total of 6655 mostly rural, poor women who had completed a pregnancy in the 24 months prior to the survey date. We assessed equity along the dimensions of household wealth, distance to the health facility, and literacy using both simple comparative measures and concentration indices. We also ran hierarchical random effects regression to confirm the presence or absence of inequities due to household wealth, distance, and literacy, while controlling for potential confounders. RESULTS: Coverage of facility based delivery was high (89%), but suboptimal for at least four antenatal care visits (44%) and one postnatal care visit (53%). We detected inequities along the dimensions of household wealth, literacy and distance. Service coverage was higher among the least poor, those who were literate, and those living closer to a health facility. We detected a significant positive association between household wealth and all outcome variables, and a positive association between literacy and facility-based delivery. We detected a negative association between living farther away from the catchment facility and all outcome variables. CONCLUSION: Existing inequities in maternal health services in Burkina Faso are likely going to jeopardize the achievement of Universal Health Coverage. It is important that policy makers continue to strengthen and monitor the implementation of strategies that promote proportionate universalism and forge multi-sectoral approach in dealing with social determinants of inequities in maternal health services coverage.
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Acessibilidade aos Serviços de Saúde/organização & administração , Disparidades em Assistência à Saúde/organização & administração , Serviços de Saúde Materna/organização & administração , Bem-Estar Materno/estatística & dados numéricos , População Rural/estatística & dados numéricos , Adolescente , Adulto , Burkina Faso , Serviços de Saúde Comunitária/organização & administração , Estudos Transversais , Feminino , Humanos , Gravidez , Cuidado Pré-Natal/organização & administração , Fatores Socioeconômicos , Inquéritos e Questionários , Adulto JovemRESUMO
Given the current low contraceptive use and corresponding high levels of unwanted pregnancies leading to induced abortions and poor maternal health outcomes among rural populations, a detailed understanding of the factors that limit contraceptive use is essential. Our study investigated household and health facility factors that influence contraceptive use decisions among rural women in rural Burkina Faso. We collected data on fertile non-pregnant women in 24 rural districts in 2014. Of 8,657 women, 1,098 used a modern contraceptive. Women having a living son, a child younger than one year, and household wealth were more likely to use modern contraceptives. Women in polygamous marriages and women living at least 5 kilometers from a health facility were less likely to use contraception. We conclude that modern contraceptive use remains weak, hence, programs aiming to encourage contraceptive use must address barriers at both the health facility and the household level.