To What Extent Do Free Healthcare Policies and Performance-Based Financing Reduce Out-of-Pocket Expenditures for Outpatient services? Evidence From a Quasi-experimental Study in Burkina Faso.

BACKGROUND: Burkina Faso has been implementing financing reforms towards universal health coverage (UHC) since 2006. Recently, the country introduced a performance-based financing (PBF) program as well as user fee removal (gratuité) policy for health services aimed at pregnant and lactating women and children under 5. We aim to assess the effect of gratuité and PBF policies on facility-based out-of-pocket expenditures (OOPEs) for outpatient services. METHODS: Our study is a controlled pre- and post-test design using healthcare facility data from the PBF program's impact evaluation collected in 2014 and 2017. We compared OOPE related to primary healthcare use incurred by children under 5 and individuals above 5 to assess the effect of the gratuité policy on OOPE. We further compared OOPE incurred by individuals residing in PBF districts and non-PBF districts to estimate the effect of the PBF on OOPE. Effects were estimated using difference-in-differences models, distinguishing the estimation of the probability of incurring OOPE from the estimation of the magnitude of OOPE using a generalized linear model (GLM). RESULTS: The proportion of children under 5 incurring OOPE declined significantly from 90% in 2014 to 3% in 2017. Concurrently, mean OOPE also decreased. Differences in both the probability of incurring OOPE and mean OOPE between PBF and non-PBF facilities were small. Our difference in differences estimates indicated that gratuité produced an 84% (CI -86%, -81%) reduction in the probability of incurring OOPE and reduced total OOPE by 54% (CI 63%, 42%). We detected no significant effects of PBF, either in reducing the probability of incurring OOPE or in its magnitude. CONCLUSION: User fee removal is an effective demand-side intervention for enhancing financial accessibility. As a supply-side intervention, PBF appears to have limited effects on reducing financial burden.

[Contraceptive use by married women or concubines living in rural areas in Burkina Faso: a qualitative study of free voucher use]. / Utilisation des contraceptifs par les femmes rurales mariées ou en concubinage au Burkina Faso: une analyse qualitative de l'utilisation d'un bon gratuit.

INTRODUCTION: low levels of contraceptive use in Western Africa are responsible for high fertility rates, which limits economic development. The cost of modern contraceptives is a significant constraint, then the government of Burkina Faso has implemented free family planning. Given this new policy, we provided rural women with a healthcare voucher giving free access to modern contraceptives. We conducted an analysis of the determinants of good free voucher use in order to implement adequate government policy. METHODS: six months after the distribution of vouchers to women living in 30 villages in the Houet Province, we conducted a focus-group study based on individual in-depth health care provider interviews in partner healthcare centers. RESULTS: the benefits of family planning, free contraceptive use, husband's approval and moral obligation were factors facilitating voucher use. The desire to become pregnant, husband's opposition, women's reluctance, women's lack of knowledge of contraceptives and factors associated with the intervention were the leading reasons for not using the vouchers. CONCLUSION: the promotion of modern contraceptive use among married women or concubines requires a holistic approach combining free access to modern contraceptives, effective policies involving men in family planning and the reduction of fertility preferences among the couples.

Determinants of individual healthcare expenditure: A cross-sectional analysis in rural Burkina Faso.

INTRODUCTION: Overwhelming evidence suggests that out-of-pocket expenditures (OOPEs) hamper access to care and impose a heavy economic burden across sub-Saharan Africa (SSA). Still, current user fee reduction and removal policies often target specific groups and services, leaving large sections of the population exposed to OOPE. METHODS: To estimate the magnitude and the determinants of OOPE for curative services in Burkina Faso, we used data from a household survey conducted in 24 districts between October 2013 and March 2014 (n = 7844). Given a context of medical pluralism, we purposely focused on total OOPE irrespective of type of care sought. We used a two-part regression model to estimate determinants of OOPE. RESULTS: Nearly 60% of those who reported an illness episode incurred a positive expenditure, with an average amount of 9362.52 FRS CFA per episode (1 USD = 577.94 FRS CFA). The first model revealed that the probability of incurring a positive OOPE was positively associated with perceived illness severity (P < .001), hospitalization (P < .001), and negatively associated with age (P = .026), distance (P = .060), and poorest wealth quintile (P = .054). The second model revealed that the magnitude of OOPE was positively associated with age (P = .087), education (P = .025), being household head (P = .015), having a chronic comorbidity (P = .025), perceived illness severity (P = .029), and hospitalization (P < .001) and negatively associated with symptoms unlikely to lead to adverse outcomes if not attended to in time (P = .056). CONCLUSION: Our findings indicate that OOPEs remain a problem in Burkina Faso and that broader spectrum policy reforms are urgently needed to ensure adequate financial protection.

Satisfaction des parents accompagnateurs des enfants de moins de 5 ans pris en charge au centre médical de Kokologho au Burkina Faso

La satisfaction des usagers des centres médicaux (CM) au Burkina Faso n'est pas connue. Notre objectif était d´étudier le niveau de satisfaction et les facteurs associés des parents accompagnateurs des enfants de moins de 5 ans pris en charge au CM de Kokologho en 2018. Il s'est agi d'une étude transversale. Réalisée dans l'aire de santé du CM de Kokologho, les cibles étaient les parents accompagnateurs d'enfants de moins de 5 ans pour l´enquête ménage et pour les entretiens qualitatifs les représentants de la communauté, les agents de santé et les leaders administratifs et coutumiers. Les outils de collecte des données ont été construits à partir des référentiels (SAPHORA-job 2014, conseil Québécois d'Agrément 2005). Des scores de satisfaction, Odds Ratio ajustées et IC95 % ont été calculés. Des analyses thématiques ont été effectuées. Le niveau de satisfaction globale des parents accompagnateurs des enfants pris en charge au CM de Kokologho en 2018 était satisfaisant (70,6 %). Les dimensions étudiées étaient l'accueil (47,2 %), le respect (65,3 %), l'empathie (60,5 %), la confidentialité (73,8 %), la fiabilité (71,9 %), la rapidité (51,4 %), le confort (89,0 %), l'accessibilité géographique (97,5 %) et l'accessibilité financière (28,5 %). Le niveau d'instruction non scolarisé, le sexe féminin et la situation matrimoniale mariée étaient significativement associés à la satisfaction globale des parents. Les usagers sont satisfaits des services du CM de Kokologho. Cependant, des efforts doivent être faits pour améliorer l'accueil, la rapidité de l'offre de service et l'accessibilité financière