RESUMEN
Burkina Faso has implemented a nationwide free healthcare policy (gratuité) for pregnant and lactating women and children under five since April 2016. Studies have shown that free healthcare policies can increase healthcare service use. However, the emerging COVID-19 pandemic, escalating insecurity, and the political situation in recent years might have affected the implementation of such policies. No studies have looked at whether the gratuité maintained high service use under such changing circumstances. Our study aimed to assess the effects of gratuité on the utilization of facility-based delivery and curative care of children under five in light of this changing context. We employed a controlled interrupted time series analysis using data from the Health Management Information System and annual statistical reports of 2,560 primary health facilities from January 2013 to December 2021. We focused on facility-based deliveries and curative care for children under five, with antenatal care and curative care for children over five as non-equivalent controls. We employed segmented regression with the generalized least square model, accounting for autocorrelation and monthly seasonality. The monthly utilization rate among children under five compared to those above five (controls) immediately increased by 111.19 visits per 1,000 children (95% CI: 91.12; 131.26) due to the gratuité. This immediate effect declined afterwards with a monthly change of 0.93 per 1,000 children (95% CI: -1.57, -0.29). We found no significant effects, both immediate and long-term, on the use of maternal care services attributable to the gratuité. Our findings suggest that free healthcare policies can be instrumental in improving healthcare, yet more comprehensive strategies are needed to maintain healthcare utilization. Our findings reflect the overall situation in the country, while localised research is needed to understand the effect of insecurity and the pandemic at the local level, and the effects of gratuité across geographies and socio-economic statuses.
RESUMEN
BACKGROUND: Armed conflict is on the rise in sub-Saharan Africa and affects public infrastructures, including health systems, although evidence on population health is sparse. We aimed to establish how these disruptions ultimately affect health service coverage. METHODS: We geospatially matched Demographic and Health Survey data with the Uppsala Conflict Data Program Georeferenced Events Dataset, covering 35 countries for the period from 1990 to 2020. We relied on linear probability models with fixed effects to capture the effect of nearby armed conflict (within 50 km of the survey cluster) on four service coverage indicators along the continuum of maternal and child health care. We also investigated effect heterogeneity by varying conflict intensity and duration, and sociodemographic status. FINDINGS: The estimated coefficients represent the decrease in the probability (in percentage points) of the child or their mother being covered by the respective health service following deadly conflicts within 50 km. Any nearby armed conflict was associated with reduced coverage for all examined health services, with the exception of early antenatal care: early antenatal care (-0·5 percentage points, 95% CI -1·1 to 0·1), facility-based delivery (-2·0, -2·5 to -1·4), timely childhood vaccination (-2·5, -3·1 to -1·9), and treatment of common childhood illnesses (-2·5, -3·5 to -1·4). For all four health services, the negative effects increased for high-intensity conflicts and were significant throughout. When examining conflict duration, we did not find negative effects on the treatment of common childhood illnesses in prolonged conflicts. The analysis on effect heterogeneity revealed that, except for timely childhood vaccination, the negative effects of armed conflict on health service coverage were more pronounced in urban settings. INTERPRETATION: Our findings suggest that health service coverage is significantly affected by contemporaneous conflict, but health systems can adapt to provide routine services, such as child curative services, in situations of prolonged conflict. Our analysis underlines the importance of studying health service coverage during conflict both at the finest possible scales and across different indicators, pointing at the need for differential policy interventions. FUNDING: None. TRANSLATIONS: For the French and Portuguese translations of the abstract see Supplementary Materials section.