How does community health feature in Global Financing Facility planning documents to support reproductive, maternal, newborn, child and adolescent health and nutrition (RMNAH-N)? insights from six francophone West African countries.

BACKGROUND: Community health is key for improving Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N). However, how community health supports integrated RMNCAH-N service delivery in francophone West Africa is under-researched. OBJECTIVE: We examined how six francophone West African countries (Burkina Faso, Côte d'Ivoire, Guinea, Mali, Niger, and Senegal) support community health through the Global Financing Facility for Women, Children and Adolescents (GFF). METHODS: We conducted a content analysis on Investment Cases and Project Appraisal Documents from selected countries, and set out the scope of the analysis and the key search terms. We applied an iterative hybrid inductive-deductive approach to identify themes for data coding and extraction. The extracted data were compared within and across countries and further grouped into meaningful categories. RESULTS: In country documents, there is a commitment to community health, with significant attention paid to various cadres of community health workers (CHWs) who undertake a range of preventive, promotive and curative roles across RMNCAH-N spectrum. While CHWs renumeration is mentioned, it varies considerably. Most community health indicators focus on CHWs' deliverables, with few related to governance and civil registration. Challenges in implementing community health include poor leadership and governance and resource shortages resulting in low CHWs performance and service utilization. While some countries invest significantly in training CHWs, structural reforms and broader community engagement are lacking. CONCLUSIONS: There is an opportunity to better prioritize and streamline community health interventions, including integrating them into health system planning and budgeting, to fully harness their potential to improve RMNCAH-N.

Main findings: Although community health is a key component of the Investment Cases and the Project Appraisal Documents of most of the six francophone West African countries studied, the level of investment varies considerably between countries, and mostly skewed to community health workers, with very little left over for broader community engagement and oversight processes.Added knowledge: The study describes community health actors, community health interventions and monitoring within a global health initiative, how they fit into the wider health system, the challenges and weaknesses they face and the measures taken to mitigate them, and how they are budgeted.Global health impact for policy and action: There is a need to adopt a holistic community health systems approach, rather than one focused mainly on CHWs, to fully harness community health's potential to improve reproductive, maternal, newborn, child, and adolescent health and nutrition.

Any better? A follow-up content analysis of adolescent sexual and reproductive health inclusion in Global Financing Facility country planning documents.

BACKGROUND: The Global Financing Facility (GFF) supports national reproductive, maternal, newborn, child, adolescent health, and nutrition needs. Previous analysis examined how adolescent sexual and reproductive health was represented in GFF national planning documents for 11 GFF partner countries. OBJECTIVES: This paper furthers that analysis for 16 GFF partner countries as part of a Special Series. METHODS: Content analysis was conducted on publicly available GFF planning documents for Afghanistan, Burkina Faso, Cambodia, CAR, Côte d'Ivoire, Guinea, Haiti, Indonesia, Madagascar, Malawi, Mali, Rwanda, Senegal, Sierra Leone, Tajikistan, Vietnam. Analysis considered adolescent health content (mindset), indicators (measure) and funding (money) relative to adolescent sexual and reproductive health needs, using a tracer indicator. RESULTS: Countries with higher rates of adolescent pregnancy had more content relating to adolescent reproductive health, with exceptions in fragile contexts. Investment cases had more adolescent content than project appraisal documents. Content gradually weakened from mindset to measures to money. Related conditions, such as fistula, abortion, and mental health, were insufficiently addressed. Documents from Burkina Faso and Malawi demonstrated it is possible to include adolescent programming even within a context of shifting or selective priorities. CONCLUSION: Tracing prioritisation and translation of commitments into plans provides a foundation for discussing global funding for adolescents. We highlight positive aspects of programming and areas for strengthening and suggest broadening the perspective of adolescent health beyond the reproductive health to encompass issues, such as mental health. This paper forms part of a growing body of accountability literature, supporting advocacy work for adolescent programming and funding.

Main findings: Adolescent health content is inconsistently included in the Global Financing Facility country documents, and despite strong or positive examples, the content is stronger in investment cases than project appraisal documents, and diminishes when comparing content, indicators and financing.Added knowledge: Although adolescent health content is generally strongest in countries with the highest proportion of births before age 18, there are exceptions in fragile contexts and gaps in addressing important issues related to adolescent health.Global health impact for policy and action: Adolescent health programming supported by the Global Financing Facility should build on examples of strong country plans, be more consistent in addressing adolescent health, and be accompanied by public transparency to facilitate accountability work such as this.

Form and functioning: contextualising the start of the global financing facility policy processes in Burkina Faso.

BACKGROUND: Burkina Faso joined the Global Financing Facility for Women, Children and Adolescents (GFF) in 2017 to address persistent gaps in funding for reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). Few empirical papers deal with how global funding mechanisms, and specifically GFF, support resource mobilisation for health nationally. OBJECTIVE: This study describes the policy processes of developing the GFF planning documents (the Investment Case and Project Appraisal Document) in Burkina Faso. METHODS: We conducted an exploratory qualitative policy analysis. Data collection included document review (N = 74) and in-depth semi-structured interviews (N = 23). Data were analysed based on the components of the health policy triangle. RESULTS: There was strong national political support to RMNCAH-N interventions, and the process of drawing up the investment case (IC) and the project appraisal document was inclusive and multi-sectoral. Despite high-level policy commitments, subsequent implementation of the World Bank project, including the GFF contribution, was perceived by respondents as challenging, even after the project restructuring process occurred. These challenges were due to ongoing policy fragmentation for RMNCAH-N, navigation of differing procedures and perspectives between stakeholders in the setting up of the work, overcoming misunderstandings about the nature of the GFF, and weak institutional anchoring of the IC. Insecurity and political instability also contributed to observed delays and difficulties in implementing the commitments agreed upon. To tackle these issues, transformational and distributive leaderships should be promoted and made effective. CONCLUSIONS: Few studies have examined national policy processes linked to the GFF or other global health initiatives. This kind of research is needed to better understand the range of challenges in aligning donor and national priorities encountered across diverse health systems contexts. This study may stimulate others to ensure that the GFF and other global health initiatives respond to local needs and policy environments for better implementation.

Main findings: There was a high level of political commitment to the Global Financing Facility in Burkina Faso, but its implementation has been hindered by policy fragmentation, competing interests, weak institutional anchoring, and misunderstandings.Added knowledge: This study documents the initiation of a global health initiative, specifically the Global Financing Facility, including the development and implementation of its planning documents, namely the Investment Case and Project Appraisal Document.Global health impact for policy and action: An understanding of the factors that facilitated or impeded the policy processes of developing and implementing the Global Financing Facility can inform the design and implementation of future initiatives.

The role and contribution of civil society and community actors in COVID-19 prevention and control: the case of the COMVID COVID-19 movement in Burkina Faso.

Communities should play a crucial role in the fight against public health emergencies but ensuring their effective and sustained engagement remains a challenge in many countries. In this article, we describe the process of mobilising community actors to contribute to the fight against COVID-19 in Burkina Faso. During the early days of the pandemic, the national COVID-19 response plan called for the involvement of community actors, but no strategy had been defined for this purpose. The initiative to involve community actors in the fight against COVID-19 was taken, independently of the government, by 23 civil society organisations gathered through a platform called 'Health Democracy and Citizen Involvement (DES-ICI)'. In April 2020, this platform launched the movement 'Communities are committed to Eradicate COVID-19 (COMVID COVID-19)' which mobilised community-based associations organised into 54 citizen health watch units (CCVS) in Ouagadougou city. These CCVS worked as volunteers, performing door-to-door awareness campaigns. The psychosis created by the pandemic, the proximity of civil society organisations to the communities and the involvement of religious, customary and civil authorities facilitated the expansion of the movement. Given the innovative and promising nature of these initiatives, the movement gained recognition that earned them a seat on the national COVID-19 response plan. This gave them credibility in the eyes of the national and international donors, thus facilitating the mobilisation of resources for the continuity of their activities. However, the decrease in financial resources to offset the community mobilisers gradually reduced the enthusiasm for the movement. In a nutshell, the COMVID COVID-19 movement fostered dialogues and collaboration among civil society, community actors and the Ministry of Health, which plans to engage the CCVS beyond the COVID-19 response, for the implementation of other actions within the national community health policy.

The Landscape of Strategic Health Purchasing for Universal Health Coverage in Burkina Faso: Insights from Five Major Health Financing Schemes.

Strategic health purchasing is a key strategy in Burkina Faso to spur progress toward universal health coverage (UHC). However, a comprehensive analysis of existing health financing arrangements and their purchasing functions has not been undertaken to date. This article provides an in-depth analysis of five key health financing schemes in Burkina Faso: Gratuité (a national free health care program for women and children under age 5), crédits délégués (delegated credits), crédits transférés (transfers to municipalities), community-based health insurance, and occupation-based health insurance. This study involved a document review and complementary key informant interviews using the Strategic Health Purchasing Progress Tracking Framework developed by the Strategic Purchasing Africa Resource Center (SPARC). Data were collected using the framework's accompanying Microsoft Excel-based tool. We analyzed the data manually to examine and identify the strengths and weaknesses of governance arrangements and purchasing functions and capacities. The study provides insight into areas that are working well from a strategic purchasing perspective and, more importantly, areas that need more attention. Areas for improvement include low financial and managerial autonomy for some schemes, weak accountability measures, lack of explicit quality standards for contracting and for service delivery, budget overruns and late provider payment, provider payment that is not linked to provider performance, fragmented health information systems, and information generated is not linked to purchasing decisions. Improvements in purchasing functions are required to address shortcomings while consolidating achievements. This study will inform next steps for Burkina Faso to improve purchasing and advance progress toward UHC.

Evaluation of Effectiveness of a Community-Based Intervention for Control of Dengue Virus Vector, Ouagadougou, Burkina Faso.

We evaluated the effectiveness of a community-based intervention for dengue vector control in Ouagadougou, the capital city of Burkina Faso. Households in the intervention (n = 287) and control (n = 289) neighborhoods were randomly sampled and the outcomes collected before the intervention (October 2015) and after the intervention (October 2016). The intervention reduced residents' exposure to dengue vector bites (vector saliva biomarker difference -0.08 [95% CI -0.11 to -0.04]). The pupae index declined in the intervention neighborhood (from 162.14 to 99.03) and increased in the control neighborhood (from 218.72 to 255.67). Residents in the intervention neighborhood were less likely to associate dengue with malaria (risk ratio 0.70 [95% CI 0.58-0.84]) and had increased knowledge about dengue symptoms (risk ratio 1.44 [95% CI 1.22-1.69]). Our study showed that well-planned, evidence/community-based interventions that control exposure to dengue vectors are feasible and effective in urban settings in Africa that have limited resources.

Community-based dengue control intervention in Ouagadougou: intervention theory and implementation fidelity.

BACKGROUND: While malaria control is the primary health focus in Burkina Faso, the recent dengue epidemic calls for new interventions. This paper examines the implementation fidelity of an innovative intervention to control dengue in the capital Ouagadougou. METHODS: First we describe the content of the intervention and its theory. We then assess the fidelity of the implementation. This step is essential as preparation for subsequent evaluation of the intervention's effectiveness. Observations (n = 62), analysis of documents related to the intervention (n = 8), and semi-structured interviews with stakeholders (n = 18) were conducted. The collected data were organized and analyzed using QDA Miner. The theory of the intervention, grounded in reported good practices of community-based interventions, was developed and discussed with key stakeholders. RESULTS: The theory of the intervention included four components: mobilization and organization, operational planning, community action, and monitoring/evaluation. The interactions among these components were intended to improve people's knowledge about dengue and enhance the community's capacity for vector control, which in turn would reduce the burden of the disease. The majority of the planned activities were conducted according to the intervention's original theory. Adaptations pertained to implementation and monitoring of activities. CONCLUSIONS: Despite certain difficulties, some of which were foreseeable and others not, this experience showed the feasibility of developing community-based interventions for vector-borne diseases in Africa.

Assessing communities of practice in health policy: a conceptual framework as a first step towards empirical research.

Communities of Practice (CoPs) are groups of people that interact regularly to deepen their knowledge on a specific topic. Thanks to information and communication technologies, CoPs can involve experts distributed across countries and adopt a 'transnational' membership. This has allowed the strategy to be applied to domains of knowledge such as health policy with a global perspective. CoPs represent a potentially valuable tool for producing and sharing explicit knowledge, as well as tacit knowledge and implementation practices. They may also be effective in creating links among the different 'knowledge holders' contributing to health policy (e.g., researchers, policymakers, technical assistants, practitioners, etc.). CoPs in global health are growing in number and activities. As a result, there is an increasing need to document their progress and evaluate their effectiveness. This paper represents a first step towards such empirical research as it aims to provide a conceptual framework for the analysis and assessment of transnational CoPs in health policy.The framework is developed based on the findings of a literature review as well as on our experience, and reflects the specific features and challenges of transnational CoPs in health policy. It organizes the key elements of CoPs into a logical flow that links available resources and the capacity to mobilize them, with knowledge management activities and the expansion of knowledge, with changes in policy and practice and, ultimately, with an improvement in health outcomes. Additionally, the paper addresses the challenges in the operationalization and empirical application of the framework.

Transversal analysis of public policies on user fees exemptions in six West African countries.

BACKGROUND: While more and more West African countries are implementing public user fees exemption policies, there is still little knowledge available on this topic. The long time required for scientific production, combined with the needs of decision-makers, led to the creation in 2010 of a project to support implementers in aggregating knowledge on their experiences. This article presents a transversal analysis of user fees exemption policies implemented in Benin, Burkina Faso, Mali, Niger, Togo and Senegal. METHODS: This was a multiple case study with several embedded levels of analysis. The cases were public user fees exemption policies selected by the participants because of their instructive value. The data used in the countries were taken from documentary analysis, interviews and questionnaires. The transversal analysis was based on a framework for studying five implementation components and five actors' attitudes usually encountered in these policies. RESULTS: The analysis of the implementation components revealed: a majority of State financing; maintenance of centrally organized financing; a multiplicity of reimbursement methods; reimbursement delays and/or stock shortages; almost no implementation guides; a lack of support measures; communication plans that were rarely carried out, funded or renewed; health workers who were given general information but not details; poorly informed populations; almost no evaluation systems; ineffective and poorly funded coordination systems; low levels of community involvement; and incomplete referral-evacuation systems. With regard to actors' attitudes, the analysis revealed: objectives that were appreciated by everyone; dissatisfaction with the implementation; specific tensions between healthcare providers and patients; overall satisfaction among patients, but still some problems; the perception that while the financial barrier has been removed, other barriers persist; occasionally a reorganization of practices, service rationing due to lack of reimbursement, and some overcharging or shifting of resources. CONCLUSIONS: This transversal analysis confirms the need to assign a great deal of importance to the implementation of user fees exemption policies once these decisions have been taken. It also highlights some practices that suggest avenues of future research.

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.

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.

[How the financial resources of health centre management committees in Burkina Faso can be used to improve equity of access to health care]. / Les ressources financières des comités de gestion du Burkina Faso peuvent améliorer l'équité d'accès au système de santé

With the advent of cost-recovery system in the 1990s in Burkina Faso, patients contribute to the financing of health centres (CSPS), which are managed by management committees (COGES). Asking patients to pay, however, erects a financial barrier to treatment for the poorest. The aim of this paper is to study how the financial resources from cost recovery can be used to improve equity of access to health care. The study took place in the health district of Ouargaye and documents the financial position of 17 COGES over a period of 12 months, with their accounting data. The results show that COGES spent an average of 7 million francs CFA, 65% for the purchase of medicines, 15% for operating costs, 7% for staff salaries and bonuses to COGES and 3.4% for discounts for health workers. Average revenue per COGES was 7.3 million FCFA. The sale of generic drugs accounted for 82% of revenue and fees for medical care to 10%. The average profit was 300,000 FCFA. The cost recovery rate averaged 104% and the profit margin on the sale of drugs 31%. Discounts to health workers represented 30% of the revenues from medical fees. The average cash position of a COGES was 3.1 million FCFA. The financial standing of the COGES is thus good. They could improve access to care and provide the standards discount to employees (20%) by removing fees for services, reducing the margins on the sale of drugs, or by using a portion of profits to exempt the poorest from payment.

Low coverage but few inclusion errors in Burkina Faso: a community-based targeting approach to exempt the indigent from user fees.

BACKGROUND: User fees were generalized in Burkina Faso in the 1990s. At the time of their implementation, it was envisioned that measures would be instituted to exempt the poor from paying these fees. However, in practice, the identification of indigents is ineffective, and so they do not have access to care. Thus, a community-based process for selecting indigents for user fees exemption was tested in a district. In each of the 124 villages in the catchment areas of ten health centres, village committees proposed lists of indigents that were then validated by the health centres' management committees. The objective of this study is to evaluate the effectiveness of this community-based selection. METHODS: An indigent-selection process is judged effective if it minimizes inclusion biases and exclusion biases. The study compares the levels of poverty and of vulnerability of indigents selected by the management committees (n = 184) with: 1) indigents selected in the villages but not retained by these committees (n = 48); ii) indigents selected by the health centre nurses (n = 82); and iii) a sample of the rural population (n = 5,900). RESULTS: The households in which the three groups of indigents lived appeared to be more vulnerable and poorer than the reference rural households. Indigents selected by the management committees and the nurses were very comparable in terms of levels of vulnerability, but the former were more vulnerable socially. The majority of indigents proposed by the village committees who lived in extremely poor households were retained by the management committees. Only 0.36% of the population living below the poverty threshold and less than 1% of the extremely poor population were selected. CONCLUSIONS: The community-based process minimized inclusion biases, as the people selected were poorer and more vulnerable than the rest of the population. However, there were significant exclusion biases; the selection was very restrictive because the exemption had to be endogenously funded.