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Bou-Karroum L, Iaia DG, El-Jardali F, Abou Samra C, Salameh S, Sleem Z, Masri R, Harb A, Hemadi N, Hilal N, Hneiny L, Nassour S, Shah MG, Langlois EV. Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003573. [PMID: 39264949 PMCID: PMC11392393 DOI: 10.1371/journal.pgph.0003573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 07/15/2024] [Indexed: 09/14/2024]
Abstract
Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.
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Affiliation(s)
- Lama Bou-Karroum
- Faculty of Health Sciences, Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
- Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
| | - Domenico G Iaia
- Partnership for Maternal Newborn and Child Health, World Health Organisation, Geneva, Switzerland
| | - Fadi El-Jardali
- Faculty of Health Sciences, Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
- Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Clara Abou Samra
- Faculty of Health Sciences, Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
- Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
| | - Sabine Salameh
- Faculty of Health Sciences, Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
- Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
| | - Zeina Sleem
- Faculty of Health Sciences, Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
- Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
| | - Reem Masri
- Faculty of Health Sciences, Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
- Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
| | - Aya Harb
- Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
| | - Nour Hemadi
- Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
| | - Nadeen Hilal
- Department of Internal Medicine, Ain Wazein Medical Village, Ain Wazein, Lebanon
| | - Layal Hneiny
- Saab Medical Library, American University of Beirut, Beirut, Lebanon
| | - Sahar Nassour
- Faculty of Health Sciences, Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
- Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
| | - Mehr Gul Shah
- Partnership for Maternal Newborn and Child Health, World Health Organisation, Geneva, Switzerland
| | - Etienne V Langlois
- Partnership for Maternal Newborn and Child Health, World Health Organisation, Geneva, Switzerland
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Aye TT, Nguyen HT, Petitfour L, Ridde V, Amberg F, Bonnet E, Seynou M, Kiendrébéogo JA, De Allegri M. How do free healthcare policies impact on utilization of maternal and child health services in fragile settings? Evidence from a controlled interrupted time-series analysis in Burkina Faso. Health Policy Plan 2024:czae077. [PMID: 39185585 DOI: 10.1093/heapol/czae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 07/29/2024] [Accepted: 08/14/2024] [Indexed: 08/27/2024] Open
Abstract
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.
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Affiliation(s)
- Thit Thit Aye
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Hoa Thi Nguyen
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Laurène Petitfour
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Valéry Ridde
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD) et Université Paris Cité, Inserm ERL 1244, 45 Rue Des Saints-Pères, 75006, Paris, France
| | - Felix Amberg
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Emmanuel Bonnet
- Institut de Recherche pour le Développement, F-93 322 Aubervilliers Cedex 2
- UMR 215 Prodig, 5, cours des Humanités, F-93 322 Aubervilliers Cedex
| | - Mariam Seynou
- Service Scientifique et Technique, Centre de Recherche en Santé de Nouna (CRSN) Nouna Secteur N°6 Rue Namory KEITA Burkina Faso
- Institut National de Santé Publique (INSP)
| | - Joël Arthur Kiendrébéogo
- Department of Public Health, University Joseph Ki-Zerbo, 04 BP 8398, Ouagadougou 04, Burkina Faso
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
- Department of Health Research, Recherche pour la Santé et le Développement (RESADE), 04 BP 8398, Ouagadougou 04, Burkina Faso
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
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Offosse MJ, Yameogo P, Ouedraogo AL, Traoré Z, Banke-Thomas A. Has the Gratuité policy reduced inequities in geographic access to antenatal care in Burkina Faso? Evidence from facility-based data from 2014 to 2022. Front Glob Womens Health 2024; 5:1345438. [PMID: 38585342 PMCID: PMC10996443 DOI: 10.3389/fgwh.2024.1345438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Background Evidence shows that user fee exemption policies improve the use of maternal, newborn, and child health (MNCH) services. However, addressing the cost of care is only one barrier to accessing MNCH services. Poor geographic accessibility relating to distance is another. Our objective in this study was to assess the effect of a user fee exemption policy in Burkina Faso (Gratuité) on antenatal care (ANC) use, considering distance to health facilities. Methods We conducted a cross-sectional study with sub-analysis by intervention period to compare utilization of ANC services (outcome of interest) in pregnant women who used the service in the context of the Gratuité user fee exemption policy and those who did not, in Manga district, Burkina Faso. Dependent variables included were socio-demographic characteristics, obstetric history, and distance to the lower-level health facility (known as Centre de Santé et Promotion Sociale) in which care was sort. Univariate, bivariate, and multivariate analyses were performed across the entire population, within those who used ANC before the policy and after its inception. Results For women who used services before the Gratuité policy was introduced, those living 5-9 km were almost twice (OR = 1.94; 95% CI: 1.17-3.21) more likely to have their first ANC visit (ANC1) in the first trimester compared to those living <5 km of the nearest health facility. After the policy was introduced, women living 5-9 km and >10 km from the nearest facility were almost twice (OR = 1.86; 95% CI: 1.14-3.05) and over twice (OR = 2.04; 95% CI: 1.20-3.48) more likely respectively to use ANC1 in the first trimester compared to those living within 5 km of the nearest health facility. Also, women living over 10 km from the nearest facility were 1.29 times (OR = 1.29; 95% CI: 1.00-1.66) more likely to have 4+ ANC than those living less than 5 km from the nearest health facility. Conclusions Insofar as the financial barrier to ANC has been lifted and the geographical barrier reduced for the populations that live farther away from services through the Gratuité policy, then the Burkinabé government must make efforts to sustain the policy and ensure that benefits of the policy reach the targeted and its gains maximized.
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Affiliation(s)
| | - Pierre Yameogo
- Technical Secretariat for Health Financing Reforms, Ministry of Health, Ouagadougou, Burkina Faso
| | - André Lin Ouedraogo
- Institute for Disease Modeling, Bill and Melinda Gates Foundation, Seattle, WA, United States
| | - Zanga Traoré
- Country Office, ThinkWell Institute, Ouagadougou, Burkina Faso
| | - Aduragbemi Banke-Thomas
- Country Office, ThinkWell Institute, Ouagadougou, Burkina Faso
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Ziegler S, Srivastava S, Parmar D, Basu S, Jain N, De Allegri M. A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India. BMC Health Serv Res 2024; 24:141. [PMID: 38279165 PMCID: PMC10821565 DOI: 10.1186/s12913-023-10473-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 12/12/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India's national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY). METHODS We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics. RESULTS At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled. CONCLUSION Findings are surprising in light of India's well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women's preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY.
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Affiliation(s)
- Susanne Ziegler
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, Friedrich-Ebert-Allee 32+36, 53113, Bonn, Germany.
| | - Swati Srivastava
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Divya Parmar
- Department of Population Health Sciences, School of Life Course and Population Sciences, King's College London, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Sharmishtha Basu
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B5/1 Safdarjung Enclave, 110029, New Delhi, India
| | - Nishant Jain
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B5/1 Safdarjung Enclave, 110029, New Delhi, India
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
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Marye DM, Debalkie Atnafu D, Belayneh M, Takele Alemu A. User Fee Exemption Policy Significantly Improved Adherence to Maternal Health Service Utilization in Bahir Dar City, Northwest Ethiopia: A Comparative Cross-Sectional Study. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:775-785. [PMID: 38106643 PMCID: PMC10722901 DOI: 10.2147/ceor.s431488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023] Open
Abstract
Background Increasing free and skilled delivery is a top priority in the global effort to reduce maternal and newborn mortality. Reducing user-fees through exemption policy has contributed to universal health coverage. However, there is scant evidence regarding the effect of exempted maternal services on adherence to utilization in Ethiopia. Thus, this study aimed to assess the effect of fee exemption policy on adherence to maternal health service utilization and its predictors. Methods A community-based comparative cross-sectional study was conducted in Bahir Dar City. A two-stage multistage sampling was employed; 497 women participated. Data were collected by face-to-face interview; entered and cleaned using Epi-Data 3.1. SPSS version 25 was used for further analysis. Bivariable and multivariable logistic regression models were computed to assess the association between explanatory and outcome variables. An adjusted odds ratio with a 95% confidence interval was used to interpret the degree of association. The effect of fee exemption policy on adherence to maternal health service utilization was measured by propensity score matching. Results The overall adherence to maternal service utilization was 54.2%. Factors associated with adherence to maternal health service utilization were pregnancy complications [AOR: 4.1, 95% CI (2.32, 7.28)], secondary and above education [AOR: 4.6, 95% CI (1.38, 15.08)], early ANC1 booking [AOR: 3.1, 95% CI (1.83, 5.16)], autonomous women [AOR: 2.1, 95% CI (1.02, 4.39)], user fee exemption [AOR: 2.3, 95% CI (1.20, 4.47)] and high parity [AOR: 0.39, 95% CI (0.2, 0.75)]. User fee exemption induced a 22.7% increment in adherence to maternal service utilization (ATET=0.227, t=2.13). Conclusion User fee exemption policy significantly improved adherence to maternal health service utilization. Promoting a fee exemption policy through third-party financing can enhance maternal health service utilization adherence in hard-to-reach settings of Ethiopia by targeting mothers with higher pregnancies, no complications, no autonomy, and less education.
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Affiliation(s)
- Demlie Mekonnen Marye
- Department of Health System Management and Health Economics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Desta Debalkie Atnafu
- Department of Health System Management and Health Economics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Melesse Belayneh
- Department of Health System Management and Health Economics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Ayenew Takele Alemu
- Department of Public Health, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia
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Offosse MJ, Avoka C, Yameogo P, Manli AR, Goumbri A, Eboreime E, Boxshall M, Banke-Thomas A. Effectiveness of the Gratuité user fee exemption policy on utilization and outcomes of maternal, newborn and child health services in conflict-affected districts of Burkina Faso from 2013 to 2018: a pre-post analysis. Confl Health 2023; 17:33. [PMID: 37415179 DOI: 10.1186/s13031-023-00530-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Evidence on effectiveness of user fee exemption policies targeting maternal, newborn, and child health (MNCH) services is limited for conflict-affected settings. In Burkina Faso, a country that has had its fair share of conflicts, user fee exemption policies have been piloted since 2008 and implemented along with a national government-led user fee reduction policy ('SONU': Soins Obstétricaux et Néonataux d'Urgence). In 2016, the government transitioned the entire country to a user fee exemption policy known as Gratuité. Our study objective was to assess the effect of the policy on the utilization and outcomes of MNCH services in conflict-affected districts of Burkina Faso. METHODS We conducted a quasi-experimental study comparing four conflict-affected districts which had the user fee exemption pilot along with SONU before transitioning to Gratuité (comparator) with four other districts with similar characteristics, which had only SONU before transitioning (intervention). A difference-in-difference approach was initiated using data from 42 months before and 30 months after implementation. Specifically, we compared utilization rates for MNCH services, including antenatal care (ANC), facility delivery, postnatal care (PNC) and consultation for malaria. We reported the coefficient, including a 95% confidence interval (CI), p value, and the parallel trends test. RESULTS Gratuité led to significant increases in rates of 6th day PNC visits for women (Coeff 0.15; 95% CI 0.01-0.29), new consultations in children < 1 year (Coeff 1.80; 95% CI 1.13-2.47, p < 0.001), new consultations in children 1-4 years (Coeff 0.81; 95% CI 0.50-1.13, p = 0.001), and uncomplicated malaria cases treated in children < 5 years (Coeff 0.59; 95% CI 0.44-0.73, p < 0.001). Other service utilization indicators investigated, including ANC1 and ANC5+ rates, did not show any statistically significant positive upward trend. Also, the rates of facility delivery, 6th hour and 6th week postnatal visits were found to have increased more in intervention areas compared to control areas, but these were not statistically significant. CONCLUSIONS Our study shows that, even in conflict-affected areas, the Gratuité policy significantly influences MNCH service utilization. There is a strong case for continued funding of the user fee exemption policy to ensure that gains are not reversed, especially if the conflict ceases to abate.
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Affiliation(s)
- Marie-Jeanne Offosse
- ThinkWell, 11 B.P. 1255 CMS 11 Ouagadougou - Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Cephas Avoka
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Astrid Raissa Manli
- ThinkWell, 11 B.P. 1255 CMS 11 Ouagadougou - Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Aude Goumbri
- ThinkWell, 11 B.P. 1255 CMS 11 Ouagadougou - Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Ejemai Eboreime
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Matt Boxshall
- ThinkWell, 11 B.P. 1255 CMS 11 Ouagadougou - Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Aduragbemi Banke-Thomas
- ThinkWell, 11 B.P. 1255 CMS 11 Ouagadougou - Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso.
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
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Banke-Thomas A, Offosse MJ, Yameogo P, Manli AR, Goumbri A, Avoka C, Boxshall M, Eboreime E. Stakeholder perceptions and experiences from the implementation of the Gratuité user fee exemption policy in Burkina Faso: a qualitative study. Health Res Policy Syst 2023; 21:46. [PMID: 37280694 DOI: 10.1186/s12961-023-01008-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/18/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND In 2016, the Gratuité policy was initiated by the Government of Burkina Faso to remove user fees for maternal, newborn, and child Health (MNCH) services. Since its inception, there has not been any systematic capture of experiences of stakeholders as it relates to the policy. Our objective was to understand the perceptions and experiences of stakeholders regarding the implementation of the Gratuité policy. METHODS We used key informant interviews (KIIs) and focus group discussions (FGDs) to engage national and sub-national stakeholders in the Centre and Hauts-Bassin regions. Participants included policymakers, civil servants, researchers, non-governmental organizations in charge of monitoring the policy, skilled health personnel, health facility managers, and women who used MNCH services before and after the policy implementation. Topic guides aided sessions, which were audio recorded and transcribed verbatim. A thematic analysis was used for data synthesis. RESULTS There were five key themes emerging. First, majority of stakeholders have a positive perception of the Gratuité policy. Its implementation approach is deemed to have strengths including government leadership, multi-stakeholder involvement, robust internal capacity, and external monitoring. However, collateral shortage of financial and human resources, misuse of services, delays in reimbursement, political instability and health system shocks were highlighted as concerns that compromise the government's objective of achieving universal health coverage (UHC). However, many beneficiaries were satisfied at the point of use of MNHC services, though Gratuité did not always mean free to the service users. Broadly, there was consensus that the Gratuité policy has contributed to improvements in health-seeking behavior, access, and utilization of services, especially for children. However, the reported higher utilization is leading to some perceived increased workload and altered health worker attitude. CONCLUSIONS There is a general perception that the Gratuité policy is achieving what it set out to do, which is to increase access to care by removing financial barriers. While stakeholders recognized the intention and value of the Gratuité policy, and many beneficiaries were satisfied at the point of use, inefficiencies in its implementation undermines progress. As the country moves towards the goal of realizing UHC, reliable investment in the Gratuité policy is needed.
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Affiliation(s)
- Aduragbemi Banke-Thomas
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso.
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
- School of Human Sciences, University of Greenwich, London, United Kingdom.
| | - Marie-Jeanne Offosse
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | | | - Astrid Raissa Manli
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Aude Goumbri
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Cephas Avoka
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matt Boxshall
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Ejemai Eboreime
- Department of Psychiatry, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
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Ilboudo PG, Siri A. Effects of the free healthcare policy on maternal and child health in Burkina Faso: a nationwide evaluation using interrupted time-series analysis. HEALTH ECONOMICS REVIEW 2023; 13:27. [PMID: 37145306 PMCID: PMC10161454 DOI: 10.1186/s13561-023-00443-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Burkina Faso has recently instituted a free healthcare policy for women and children under five. This comprehensive study examined the effects of this policy on the use of services, health outcomes, and removal of costs. METHODS Interrupted time-series regressions were used to investigate the effects of the policy on the use of health services and health outcomes. In addition, an analysis of household expenditures was conducted to assess the effects of spending on delivery, care for children, and other exempted (antenatal, postnatal, etc.) services on household expenditures. RESULTS The findings show that the user fee removal policy significantly increased the use of healthcare facilities for child consultations and reduced mortality from severe malaria in children under the age of five years. It also has increased the use of health facilities for assisted deliveries, complicated deliveries, and second antenatal visits, and reduced cesarean deliveries and intrahospital infant mortality, although not significantly. While the policy has failed to remove all costs, it decreased household costs to some extent. In addition, the effects of the user fee removal policy seemed higher in districts with non-compromised security for most of the studied indicators. CONCLUSIONS Given the positive effects, the findings of this investigation support the pursuit of implementing the free healthcare policy for maternal and child care.
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Affiliation(s)
| | - Alain Siri
- Secrétariat Permanent du Plan National de Développement Economique et Social (SP/PNDES), Ouagadougou, Burkina Faso
- Institut des Sciences des Sociétés, Ouagadougou, Burkina Faso
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9
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Meda IB, Kouanda S, Ridde V. Effect of cost-reduction interventions on facility-based deliveries in Burkina Faso: a controlled interrupted time-series study with multiple non-equivalent dependent variables. J Epidemiol Community Health 2023; 77:133-139. [PMID: 36539278 PMCID: PMC9933164 DOI: 10.1136/jech-2022-218794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Evaluating health intervention effectiveness in low-income countries involves many methodological challenges to be addressed. The objective of this study was to estimate the sustained effects of two interventions to improve financial access to facility-based deliveries. METHODS In an innovative controlled interrupted time-series study with primary data, we used four non-equivalent dependent variables (antenatal care) as control outcomes to estimate the effects of a national subsidy for deliveries (January 2007-December 2013) and a local 'free delivery' intervention (June 2007-December 2010) on facility-based deliveries. The statistical analysis used spline linear regressions with random intercepts and slopes. RESULTS The analysis involved 20 877 observations for the national subsidy and 8842 for the 'free delivery' intervention. The two interventions did not have immediate effects. However, both were associated with positive trend changes varying from 0.21 to 0.52 deliveries per month during the first 12 months and from 0.78 to 2.39 deliveries per month during the first 6 months. The absolute effects, evaluated 84 and 42 months after introduction, ranged from 2.64 (95% CI 0.51 to 4.77) to 10.78 (95% CI 8.52 to 13.03) and from 9.57 (95% CI 5.97 to 13.18) to 14.47 (95% CI 10.47 to 18.47) deliveries per month for the national subsidy and the 'free delivery' intervention, respectively, depending on the type of antenatal care used as a control outcome. CONCLUSION The results suggest that both interventions were associated with sustained non-linear increases in facility-based deliveries. The use of multiple control groups strengthens the credibility of the results, making them useful for policy makers seeking solutions for universal health coverage.
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Affiliation(s)
- Ivlabèhiré Bertrand Meda
- Département Biomédical, Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso .,Institut Africain de Santé Publique (IASP), Ouagadougou, Burkina Faso
| | - Seni Kouanda
- Département Biomédical, Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso,Institut Africain de Santé Publique (IASP), Ouagadougou, Burkina Faso
| | - Valéry Ridde
- Centre Population et Développement (CEPED), Inserm, IRD, Université Paris Cité, F-75006 Paris, France
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10
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Ravit M, Lohmann J, Dumont A, Kabore C, Koulidiati JL, De Allegri M. How a supply-side intervention can help to increase caesarean section rates in Burkina Faso facilities-Evidence from an interrupted time-series analysis using routine health data. Trop Med Int Health 2023; 28:136-143. [PMID: 36480461 PMCID: PMC10107298 DOI: 10.1111/tmi.13840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES In Burkina Faso, only 2.1% of women give birth by caesarean section (CS). To improve the use of maternal health services during pregnancy and childbirth, many interventions were implemented during the 2010s including performance-based financing (PBF) and a free maternal health care policy (the gratuité). The objective of this study is to evaluate the impact of a supply-side intervention (PBF) combined with a demand-side intervention (gratuité) on institutional CS rates in Burkina Faso. METHODS We used routine health data from all the public health facilities in 21 districts (10 that implemented PBF and 11 that did not) from January 2013 to September 2017. We analysed CS rates as the proportion of CS performed out of all facility-based deliveries (FBD) that occurred in the district. We performed an interrupted time series (ITS) analysis to evaluate the impact of PBF alone and then in conjunction with the gratuité on institutional CS rates. RESULTS CS rates in Burkina Faso increased slightly between January 2013 and September 2017 in all districts. After the introduction of PBF, the increase of CS rates was higher in intervention than in non-intervention districts. However, after the introduction of the gratuité, CS rates decreased in all districts, independently of the PBF intervention. CONCLUSION In 2017, despite high FBD rates in Burkina Faso as well as the PBF intervention and the gratuité, less than 3% of women who gave birth in a health facility did so by CS. Our study shows that the positive PBF effects were not sustained in a context of user fee exemption.
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Affiliation(s)
- Marion Ravit
- Emergency Obstetric and Quality of Care Unit, Liverpool School of Tropical Medicine, Liverpool, UK.,Université Paris Cité, IRD, Inserm, Ceped, F-75006 Paris, France
| | - Julia Lohmann
- London School of Hygiene & Tropical Medicine, UK.,Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Germany
| | - Alexandre Dumont
- Université Paris Cité, IRD, Inserm, Ceped, F-75006 Paris, France
| | - Charles Kabore
- Institut de Recherche en Sciences de La Santé, Ouagadougou, Burkina Faso
| | - Jean-Louis Koulidiati
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Germany.,Institut supérieur des sciences de la santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Germany
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11
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Ramadan M, Gutierrez JC, Feil C, Bolongaita S, Bernal O, Villar Uribe M. Capacity and quality of maternal and child health services delivery at the subnational primary healthcare level in relation to intermediate health outputs: a cross-sectional study of 12 low-income and middle-income countries. BMJ Open 2023; 13:e065223. [PMID: 36720573 PMCID: PMC9890757 DOI: 10.1136/bmjopen-2022-065223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To examine the capacity and quality of maternal and child health (MCH) services at the subnational primary healthcare (PHC) level in 12 low-income and middle-income countries (LMICs) and its association with intermediate health outputs such as coverage and access to care. DESIGN Observational cross-sectional study using matched subnational data from service provision assessment surveys and demographic health surveys from 2007 to 2019. SETTINGS 138 subnational areas with available survey data in 12 LMICs (Afghanistan, Bangladesh, Democratic Republic of Congo, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania and Uganda). OUTCOMES Eight intermediate MCH outcomes/outputs were explored: (1) met need for family planning by modern methods; (2) attendance of four or more antenatal care visits; (3) perceived financial barriers to care; (4) perceived geographical barriers to care; (5) diphtheria-pertussis-tetanus (DPT) third dose coverage; (6) DPT dropout-rate; (7) care-seeking for pneumonia; and (8) oral rehydration solutions coverage. RESULTS Overall, moderate-to-poor PHC performance was observed across the 12 countries, with substantial heterogeneity between the different subnational areas in the same country as well as within the same subnational area across both capacity and quality subdomains. The analysis of the relationship between PHC service delivery and child health outcomes revealed that recent supervision (b=0.34, p<0.01) and supervisors' feedback (b=0.28, p<0.05) were each associated with increased care-seeking for pneumonia. We also observed the associations of several measures of capacity and quality with DPT immunisation. The analysis of maternal health outcomes yielded only a few statistically significant results at p<0.05 level, however, none remained significant after adjusting for other covariates. CONCLUSION The results of this analysis illustrate the heterogeneity in the capacity and quality of PHC service delivery within LMICs. Countries seeking to strengthen their PHC systems could improve PHC monitoring at the subnational level to better understand subnational bottlenecks in service delivery.
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Affiliation(s)
- Marwa Ramadan
- Health, Nutrition and Population, The World Bank Group, Washington, DC, USA
| | | | - Cameron Feil
- Health, Nutrition and Population, The World Bank Group, Washington, DC, USA
| | - Sarah Bolongaita
- Health, Nutrition and Population, The World Bank Group, Washington, DC, USA
| | - Oscar Bernal
- Health, Nutrition and Population, The World Bank Group, Washington, DC, USA
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12
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Turcotte-Tremblay AM, Leerapan B, Akweongo P, Amponsah F, Aryal A, Asai D, Awoonor-Williams JK, Ayele W, Bauhoff S, Doubova SV, Gadeka DD, Dulal M, Gage A, Gordon-Strachan G, Haile-Mariam D, Joseph JP, Kaewkamjornchai P, Kapoor NR, Gelaw SK, Kim MK, Kruk ME, Kubota S, Margozzini P, Mehata S, Mthethwa L, Nega A, Oh J, Park SK, Passi-Solar A, Perez Cuevas RE, Reddy T, Rittiphairoj T, Sapag JC, Thermidor R, Tlou B, Arsenault C. Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium. Health Res Policy Syst 2023; 21:14. [PMID: 36721180 PMCID: PMC9888332 DOI: 10.1186/s12961-022-00956-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 12/28/2022] [Indexed: 02/02/2023] Open
Abstract
COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.
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Affiliation(s)
- Anne-Marie Turcotte-Tremblay
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor East, room L3-015A5, Landmark Center, Boston, MA, 02215, USA.
- Université Laval, Québec, Canada.
| | - Borwornsom Leerapan
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Freddie Amponsah
- Policy, Planning, Monitoring and Evaluation, Ghana Health Services, Accra, Ghana
| | - Amit Aryal
- Swiss TPH, University of Basel, Basel, Switzerland
| | - Daisuke Asai
- World Health Organization, Vientiane, Lao People's Democratic Republic
| | | | - Wondimu Ayele
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sebastian Bauhoff
- Department of Global Health and Population, Harvard University, Boston, USA
| | - Svetlana V Doubova
- Epidemiology and Health Services Research Unit CMN Siglo XXI, Mexican Institute of Social Security, Mexico City, Mexico
| | | | - Mahesh Dulal
- Office of the Member of Federal Parliament Gagan Kumar Thapa, Kathmandu, Nepal
| | - Anna Gage
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor East, room L3-015A5, Landmark Center, Boston, MA, 02215, USA
| | | | | | - Jean Paul Joseph
- Hôpital Universitaire de Mirebalais, Zanmi Lasante, Arrondissement de Mirebalais, Haïti
| | | | - Neena R Kapoor
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor East, room L3-015A5, Landmark Center, Boston, MA, 02215, USA
| | | | - Min Kyung Kim
- Tufts Clinical and Translational Science Institute, Boston, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard University, Boston, USA
| | - Shogo Kubota
- World Health Organization, Vientiane, Lao People's Democratic Republic
| | - Paula Margozzini
- Public Health Department, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Suresh Mehata
- Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Londiwe Mthethwa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Adiam Nega
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Juhwan Oh
- Tufts Clinical and Translational Science Institute, Boston, USA
- Seoul National University College of Medicine, Seoul, South Korea
| | - Soo Kyung Park
- Korea National Health Insurance Services, Health Insurance Research Institute, Wonju, Gangwon-Do, South Korea
| | - Alvaro Passi-Solar
- Public Health Department, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council, Durban, South Africa
| | | | - Jaime C Sapag
- Public Health Department, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Roody Thermidor
- Studies and Planning Unit, Ministry of Public Health and Population, Port-Au-Prince, Haiti
| | - Boikhutso Tlou
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Catherine Arsenault
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor East, room L3-015A5, Landmark Center, Boston, MA, 02215, USA
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Aye TT, Nguyen HT, Brenner S, Robyn PJ, Tapsoba LDG, Lohmann J, Allegri MD. 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. Int J Health Policy Manag 2022; 12:6767. [PMID: 37579448 PMCID: PMC10125104 DOI: 10.34172/ijhpm.2022.6767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/22/2022] [Indexed: 08/16/2023] Open
Abstract
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.
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Affiliation(s)
- Thit Thit Aye
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Hoa Thi Nguyen
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
| | - Paul Jacob Robyn
- Health, Nutrition and Population Global Practice, World Bank, Washington, DC, USA
| | | | - Julia Lohmann
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
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14
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Debe S, Ilboudo PG, Kabore L, Zoungrana N, Gansane A, Ridde V, De Brouwere V, Samandoulougou FK. Effects of the free healthcare policy on health services' usage by children under 5 years in Burkina Faso: a controlled interrupted time-series analysis. BMJ Open 2022; 12:e058077. [PMID: 36410840 PMCID: PMC9680150 DOI: 10.1136/bmjopen-2021-058077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 09/21/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES This study aimed to analyse, at national level, the effects of the free healthcare policy for children on the use of health services by children under five in Burkina Faso. We hypothesised that this policy has led to an immediate and sustained increase in the use of health services for these children in the country. SETTING We conducted a controlled interrupted time series. Monthly data at district level, spanning from January 2013 to December 2018 and corresponding to 72 monthly data points (39 before and 33 after), were extracted from the Burkina Faso National Health Information System. The analysed dataset included data from all the 70 health districts of the country. PARTICIPANTS The study consisted of aggregated data from children under five as the target for the policy with children aged between 5 and 14 years old as control group. INTERVENTION The intervention was the introduction of the free healthcare policy for women and children under 5 years from April 2016. OUTCOME The primary outcome was the monthly mean rate of health services visits by children. RESULTS Among the children under five, the rate of visits increased of 57% (incidence rate ratio (IRR)=1.57; 95% CI 1.2 to 2.0) in the month immediately following the launching of the free healthcare policy. An increase in the rate of health facility visits of 1% (IRR=1.01; 95% CI 1.0 to 1.1) per month was also noted during postintervention. Compared with the control group, we observed an increase in the rate of visits of 2.5% (IRR=1.025; 95% CI 1.023 to 1.026) per month. CONCLUSION Findings suggest that the free healthcare policy increased the use of health facilities for care in Burkina Faso immediately after the implementation of the policy with a small increase in the rate overtime. Strategies to maintain the policy effect over time are necessary.
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Affiliation(s)
- Siaka Debe
- Recherche Clinique, Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso
| | - Patrick G Ilboudo
- Nutrition and Food System, African Population and Health Research Center, Nairobi, Kenya
| | - Lassane Kabore
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Noelie Zoungrana
- Service d'information et d'épidémiologie, Hôpital de Tengandogo, Ouagadougou, Burkina Faso
| | - Adama Gansane
- Recherche Clinique, Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso
| | - Valéry Ridde
- IRD, Inserm, Ceped, Université Sorbonne Paris Cité, Paris, France
| | | | - Fati Kirakoya Samandoulougou
- Centre de Recherche en Epidemiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université libre de Bruxelles, Bruxelles, Belgique
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15
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Browne L, Cooper S, Tiendrebeogo C, Bicaba F, Bila A, Bicaba A, Druetz T. Using experience to create evidence: a mixed methods process evaluation of the new free family planning policy in Burkina Faso. Reprod Health 2022; 19:67. [PMID: 35303898 PMCID: PMC8932047 DOI: 10.1186/s12978-022-01375-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2019, Burkina Faso was one of the first countries in Sub-Saharan Africa to introduce a free family planning (FP) policy. This process evaluation aims to identify obstacles and facilitators to its implementation, examine its coverage in the targeted population after six months, and investigate its influence on the perceived quality of FP services. METHODS This process evaluation was conducted from November 2019 through March 2020 in the two regions of Burkina Faso where the new policy was introduced as a pilot. Mixed methods were used with a convergent design. Semi-directed interviews were conducted with the Ministry of Health (n = 3), healthcare workers (n = 10), and women aged 15-49 years (n = 10). Surveys were also administered to the female members of 696 households randomly selected from four health districts (n = 901). RESULTS Implementation obstacles include insufficient communication, shortages of consumables and contraceptives, and delays in reimbursement from the government. The main facilitators were previous experience with free healthcare policies, good acceptability in the population, and support from local associations. Six months after its introduction, only 50% of the surveyed participants knew about the free FP policy. Higher education level, being sexually active or in a relationship, having recently seen a healthcare professional, and possession of a radio significantly increased the odds of knowing. Of the participants, 39% continued paying for FP services despite the new policy, mainly because of stock shortages forcing them to buy their contraceptive products elsewhere. Increased waiting time and shorter consultations were also reported. CONCLUSION Six months after its introduction, the free FP policy still has gaps in its implementation, as women continue to spend money for FP services and have little knowledge of the policy, particularly in the Cascades region. While its use is reportedly increasing, addressing implementation issues could further improve women's access to contraception.
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Affiliation(s)
- Lalique Browne
- School of Public Health, University of Montreal, C.P 6128, Succursale Centre-Ville, Montreal, QC, H3C 3J7, Canada
| | - Sarah Cooper
- School of Public Health, University of Montreal, C.P 6128, Succursale Centre-Ville, Montreal, QC, H3C 3J7, Canada
| | - Cheick Tiendrebeogo
- School of Public Health, University of Montreal, C.P 6128, Succursale Centre-Ville, Montreal, QC, H3C 3J7, Canada
| | - Frank Bicaba
- Société d'Études et de Recherche en Santé Publique (SERSAP), Ouagadougou, Burkina Faso.,Sciences de la vie et de la Santé, Université Aix-Marseille, Marseille, France
| | - Alice Bila
- Société d'Études et de Recherche en Santé Publique (SERSAP), Ouagadougou, Burkina Faso
| | - Abel Bicaba
- Société d'Études et de Recherche en Santé Publique (SERSAP), Ouagadougou, Burkina Faso
| | - Thomas Druetz
- School of Public Health, University of Montreal, C.P 6128, Succursale Centre-Ville, Montreal, QC, H3C 3J7, Canada. .,Centre de Recherche en Santé Publique (CReSP), Montreal, QC, Canada. .,Center for Applied Malaria Research and Evaluation, Department of Tropical Medicine, Tulane University, New Orleans, LA, USA.
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16
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Ochieng BM, Kaseje M, Kaseje DCO, Oria K, Magadi M. Perspectives of stakeholders of the free maternity services for mothers in western Kenya: lessons for universal health coverage. BMC Health Serv Res 2022; 22:226. [PMID: 35183169 PMCID: PMC8857830 DOI: 10.1186/s12913-022-07632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 02/11/2022] [Indexed: 11/14/2022] Open
Abstract
Background The strategic aim of universal health coverage (UHC) is to ensure that everyone can use health services they need without risk of financial hardship. Linda Mama (Taking care of the mother) initiative focuses on the most vulnerable women, newborns and infants in offering free health services. Financial risk protection is one element in the package of measures that provides overall social protection, as well as protection against severe financial difficulties in the event of pregnancy, childbirth, neonatal and perinatal health care for mothers and their children. Purpose The aim of this study was to find out the extent of awareness, and involvement among managers, service providers and consumers of Linda mama supported services and benefits of the initiative from the perspectives of consumers, providers and managers. Methods We carried out cross sectional study in four sub counties in western Kenya: Rachuonyo East, Nyando, Nyakach, and Alego Usonga. We used qualitative techniques to collect data from purposively selected Linda Mama project implementors, managers, service providers and service consumers. We used key informant interview guides to collect data from a total of thirty six managers, nine from each Sub -County and focus group discussion tools to collect data from sixteen groups of service consumers attending either antenatal or post-natal clinics, four from each sub county, selecting two groups from antenatal and two from postnatal clinics in each sub county. Data analysis was based on thematic content analysis. Findings Managers and service providers were well aware of the initiative and were involved in it. Participation in Linda Mama, either in providing or using, seemed to be more prominent among managers and service providers. Routine household visits by community health volunteers to sensitize mothers and community engagement was core to the initiative. The managers and providers of services displayed profound awareness of how requiring identification cards and telephone numbers had the potential to undermine equity by excluding those in greater need of care such as under-age pregnant adolescents. Maternity and mother child health services improved as a result of the funds received by health facilities. Linda Mama reimbursements helped to purchase drug and reduced workload in the facility by hiring extra hands. Conclusion The initiative seems to have influenced attitudes on health facility delivery through: Partnership among key stakeholders and highlighting the need for enhanced partnership with the communities. It enhanced the capacity of health facilities to deliver high quality comprehensive, essential care package and easing economic burden.
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Rudasingwa M, Yeboah E, Ridde V, Bonnet E, De Allegri M, Muula AS. How equitable is health spending on curative services and institutional delivery in Malawi? Evidence from a quasi-longitudinal benefit incidence analysis. Int J Equity Health 2022; 21:25. [PMID: 35180861 PMCID: PMC8856874 DOI: 10.1186/s12939-022-01624-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/24/2022] [Indexed: 11/18/2022] Open
Abstract
Background Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016. Methods We relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group. Results Socioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively. Conclusions Through its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-022-01624-5.
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Affiliation(s)
- Martin Rudasingwa
- Heidelberg Institute of Global Health, University Hospital & Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Edmund Yeboah
- Heidelberg Institute of Global Health, University Hospital & Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Valéry Ridde
- CEPED, Institute for Research on Sustainable Development, IRD-Université de Paris, ERL INSERM SAGESUD, Paris, France
| | - Emmanuel Bonnet
- IRD, UMR 215 Prodig, CNRS, Université Paris 1 Panthéon-Sorbonne, AgroParisTech, 5, Cours des Humanités, F-93 322, Aubervilliers, Cedex, France
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital & Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Adamson Sinjani Muula
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi. .,Kamuzu University of Health Sciences, Blantyre, Malawi.
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Binyaruka P, Mori AT. Economic consequences of caesarean section delivery: evidence from a household survey in Tanzania. BMC Health Serv Res 2021; 21:1367. [PMID: 34965864 PMCID: PMC8715568 DOI: 10.1186/s12913-021-07386-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/07/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Caesarean section (C-section) delivery is an important indicator of access to life-saving essential obstetric care. Yet, there is limited understanding of the costs of utilising C-section delivery care in sub-Saharan Africa. Thus, we estimated the direct and indirect patient cost of accessing C-section in Tanzania. METHODS Cross-sectional survey data of 2012 was used, which covered 3000 households from 11 districts in three regions. We interviewed women who had given births in the last 12 months before the survey to capture their experience of care. We used a regression model to estimate the effect of C-section on costs, while the degree of inequality on C-section coverage was assessed with a concentration index. RESULTS C-section increased the likelihood of paying for health care by 16% compared to normal delivery. The additional cost of C-section compared to normal delivery was 20 USD, but reduced to about 11 USD when restricted to public facilities. Women with C-section delivery spent an extra 2 days at the health facility compared to normal delivery, but this was reduced slightly to 1.9 days in public facilities. The distribution of C-section coverage was significantly in favour of wealthier than poorest women (CI = 0.2052, p < 0.01), and this pro-rich pattern was consistent in rural districts but with unclear pattern in urban districts. CONCLUSIONS C-section is a life-saving intervention but is associated with significant economic burden especially among the poor families. More health resources are needed for provision of free maternal care, reduce inequality in access and improve birth outcomes in Tanzania.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania.
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De Allegri M, Rudasingwa M, Yeboah E, Bonnet E, Somé PA, Ridde V. Does the implementation of UHC reforms foster greater equality in health spending? Evidence from a benefit incidence analysis in Burkina Faso. BMJ Glob Health 2021; 6:bmjgh-2021-005810. [PMID: 34880059 PMCID: PMC8655516 DOI: 10.1136/bmjgh-2021-005810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/28/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction Burkina Faso is one among many countries in sub-Saharan Africa having invested in Universal Health Coverage (UHC) policies, with a number of studies have evaluated their impacts and equity impacts. Still, no evidence exists on how the distributional incidence of health spending has changed in relation to their implementation. Our study assesses changes in the distributional incidence of public and overall health spending in Burkina Faso in relation to the implementation of UHC policies. Methods We combined National Health Accounts data and household survey data to conduct a series of Benefit Incidence Analyses. We captured the distribution of public and overall health spending at three time points. We conducted separate analyses for maternal and curative services and estimated the distribution of health spending separately for different care levels. Results Inequalities in the distribution of both public and overall spending decreased significantly over time, following the implementation of UHC policies. Pooling data on curative services across all care levels, the concentration index (CI) for public spending decreased from 0.119 (SE 0.013) in 2009 to −0.024 (SE 0.014) in 2017, while the CI for overall spending decreased from 0.222 (SE 0.032) in 2009 to 0.105 (SE 0.025) in 2017. Pooling data on institutional deliveries across all care levels, the CI for public spending decreased from 0.199 (SE 0.029) in 2003 to 0.013 (SE 0.002) in 2017, while the CI for overall spending decreased from 0.242 (SE 0.032) in 2003 to 0.062 (SE 0.016) in 2017. Persistent inequalities were greater at higher care levels for both curative and institutional delivery services. Conclusion Our findings suggest that the implementation of UHC in Burkina Faso has favoured a more equitable distribution of health spending. Nonetheless, additional action is urgently needed to overcome remaining barriers to access, especially among the very poor, further enhancing equality.
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Affiliation(s)
- Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Martin Rudasingwa
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Edmund Yeboah
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Emmanuel Bonnet
- IRD, UMR 215 Prodig, CNRS, Université Paris 1 Panthéon-Sorbonne, AgroParisTech, 5, cours des Humanités, F-93 322, Aubervilliers Cedex, France
| | | | - Valéry Ridde
- Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal.,Université de Paris, IRD, INSERM, Ceped, F-75006, Paris, France
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20
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Garchitorena A, Ihantamalala FA, Révillion C, Cordier LF, Randriamihaja M, Razafinjato B, Rafenoarivamalala FH, Finnegan KE, Andrianirinarison JC, Rakotonirina J, Herbreteau V, Bonds MH. Geographic barriers to achieving universal health coverage: evidence from rural Madagascar. Health Policy Plan 2021; 36:1659-1670. [PMID: 34331066 PMCID: PMC8597972 DOI: 10.1093/heapol/czab087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/29/2021] [Accepted: 07/16/2021] [Indexed: 11/12/2022] Open
Abstract
Poor geographic access can persist even when affordable and well-functioning health systems are in place, limiting efforts for universal health coverage (UHC). It is unclear how to balance support for health facilities and community health workers in UHC national strategies. The goal of this study was to evaluate how a health system strengthening (HSS) intervention aimed towards UHC affected the geographic access to primary care in a rural district of Madagascar. For this, we collected the fokontany of residence (lowest administrative unit) from nearly 300 000 outpatient consultations occurring in facilities of Ifanadiana district in 2014-2017 and in the subset of community sites supported by the HSS intervention. Distance from patients to facilities was accurately estimated following a full mapping of the district's footpaths and residential areas. We modelled per capita utilization for each fokontany through interrupted time-series analyses with control groups, accounting for non-linear relationships with distance and travel time among other factors, and we predicted facility utilization across the district under a scenario with and without HSS. Finally, we compared geographic trends in primary care when combining utilization at health facilities and community sites. We find that facility-based interventions similar to those in UHC strategies achieved high utilization rates of 1-3 consultations per person year only among populations living in close proximity to facilities. We predict that scaling only facility-based HSS programmes would result in large gaps in access, with over 75% of the population unable to reach one consultation per person year. Community health delivery, available only for children under 5 years, provided major improvements in service utilization regardless of their distance from facilities, contributing to 90% of primary care consultations in remote populations. Our results reveal the geographic limits of current UHC strategies and highlight the need to invest on professionalized community health programmes with larger scopes of service.
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Affiliation(s)
- Andres Garchitorena
- MIVEGEC, University Montpellier, CNRS, IRD, 911 Avenue Agropolis, 34394 Montpellier, Montpellier, France
- NGO PIVOT, BP23 Ranomafana, 312 Ifanadiana, Madagascar
| | | | - Christophe Révillion
- Université de La Réunion, UMR 228 Espace-Dev (IRD, UA, UG, UM, UR), 40 Av De Soweto, 97410 Saint-Pierre, Réunion, France
| | | | - Mauricianot Randriamihaja
- NGO PIVOT, BP23 Ranomafana, 312 Ifanadiana, Madagascar
- School of Management and Technological innovation, University of Fianarantsoa, BP 1135 Andrainjato, 301 Fianarantsoa, Madagascar
| | | | | | - Karen E Finnegan
- NGO PIVOT, BP23 Ranomafana, 312 Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Jean Claude Andrianirinarison
- Ministry of Public Health, Ambohidahy, 101 Antananarivo, Madagascar
- National Institut of Public Health, Befelatanana, 101 Antananarivo, Madagascar
| | - Julio Rakotonirina
- Ministry of Public Health, Ambohidahy, 101 Antananarivo, Madagascar
- Faculty of Medicine, BP. 375, 101 Antananarivo, Madagascar
| | - Vincent Herbreteau
- Institut de Recherche pour le Développement, UMR 228 Espace-Dev (IRD, UA, UG, UM, UR), B.P. 86, Phnom Penh, Cambodia
| | - Matthew H Bonds
- NGO PIVOT, BP23 Ranomafana, 312 Ifanadiana, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, Massachusetts 02115, USA
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21
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Kuunibe N, Lohmann J, Hillebrecht M, Nguyen HT, Tougri G, De Allegri M. What happens when performance-based financing meets free healthcare? Evidence from an interrupted time-series analysis. Health Policy Plan 2021; 35:906-917. [PMID: 32601671 DOI: 10.1093/heapol/czaa062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2020] [Indexed: 11/12/2022] Open
Abstract
In spite of the wide attention performance-based financing (PBF) has received over the past decade, no evidence is available on its impacts on quantity and mix of service provision nor on its interaction with parallel health financing interventions. Our study aimed to examine the PBF impact on quantity and mix of service provision in Burkina Faso, while accounting for the parallel introduction of a free healthcare policy. We used Health Management Information System data from 838 primary-level health facilities across 24 districts and relied on an interrupted time-series analysis with independent controls. We placed two interruptions, one to account for PBF and one to account for the free healthcare policy. In the period before the free healthcare policy, PBF produced significant but modest increases across a wide range of maternal and child services, but a significant decrease in child immunization coverage. In the period after the introduction of the free healthcare policy, PBF did not affect service provision in intervention compared with control facilities, possibly indicating a saturation effect. Our findings indicate that PBF can produce modest increases in service provision, without altering the overall service mix. Our findings, however, also indicate that the introduction of other health financing reforms can quickly crowd out the effects produced by PBF. Further qualitative research is required to understand what factors allow healthcare providers to increase the provision of some, but not all services and how they react to the joint implementation of PBF and free health care.
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Affiliation(s)
- Naasegnibe Kuunibe
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany.,Department of Economics and Entrepreneurship Development, Faculty of Integrated development Studies, University for Development Studies, Wa Campus, Box 520, Wa, Upper West Region, Ghana
| | - Julia Lohmann
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany.,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Michael Hillebrecht
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Sectoral Department, Dag-Hammarskjöld-Weg 1-5, 65760 Eschborn, Germany
| | - Hoa Thi Nguyen
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany
| | | | - Manuela De Allegri
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany
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Garchitorena A, Miller AC, Cordier LF, Randriamanambintsoa M, Razanadrakato HTR, Randriamihaja M, Razafinjato B, Finnegan KE, Haruna J, Rakotonirina L, Rakotozafy G, Raharimamonjy L, Atwood S, Murray MB, Rich M, Loyd T, Solofomalala GD, Bonds MH. District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018. BMJ Glob Health 2021; 5:bmjgh-2020-003647. [PMID: 33272943 PMCID: PMC7716667 DOI: 10.1136/bmjgh-2020-003647] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction Despite renewed commitment to universal health coverage and health system strengthening (HSS) to improve access to primary care, there is insufficient evidence to guide their design and implementation. To address this, we conducted an impact evaluation of an ongoing HSS initiative in rural Madagascar, combining data from a longitudinal cohort and primary health centres. Methods We carried out a district representative household survey at the start of the HSS intervention in 2014 in over 1500 households in Ifanadiana district, and conducted follow-up surveys at 2 and 4 years. At each time point, we estimated maternal, newborn and child health coverage; economic and geographical inequalities in coverage; and child mortality rates; both in the HSS intervention and control catchments. We used logistic regression models to evaluate changes associated with exposure to the HSS intervention. We also estimated changes in health centre per capita utilisation during 2013 to 2018. Results Child mortality rates decreased faster in the HSS than in the control catchment. We observed significant improvements in care seeking for children under 5 years of age (OR 1.23; 95% CI 1.05 to 1.44) and individuals of all ages (OR 1.37, 95% CI 1.19 to 1.58), but no significant differences in maternal care coverage. Economic inequalities in most coverage indicators were reduced, while geographical inequalities worsened in nearly half of the indicators. Conclusion The results demonstrate improvements in care seeking and economic inequalities linked to the early stages of a HSS intervention in rural Madagascar. Additional improvements in this context of persistent geographical inequalities will require a stronger focus on community health.
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Affiliation(s)
- Andres Garchitorena
- MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France .,PIVOT, Ifanadiana, Madagascar
| | - Ann C Miller
- PIVOT, Ifanadiana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Marius Randriamanambintsoa
- Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique, Antananarivo, Madagascar
| | - Hery-Tiana R Razanadrakato
- Direction de la Démographie et des Statistiques Sociales, Institut National de la Statistique, Antananarivo, Madagascar
| | | | | | - Karen E Finnegan
- PIVOT, Ifanadiana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Megan B Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Matthew H Bonds
- PIVOT, Ifanadiana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Orangi S, Kairu A, Malla L, Ondera J, Mbuthia B, Ravishankar N, Barasa E. Impact of free maternity policies in Kenya: an interrupted time-series analysis. BMJ Glob Health 2021; 6:e003649. [PMID: 34108145 PMCID: PMC8191610 DOI: 10.1136/bmjgh-2020-003649] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 05/19/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND User fees have been reported to limit access to services and increase inequities. As a result, Kenya introduced a free maternity policy in all public facilities in 2013. Subsequently in 2017, the policy was revised to the Linda Mama programme to expand access to private sector, expand the benefit package and change its management. METHODS An interrupted time-series analysis on facility deliveries, antenatal care (ANC) and postnatal care (PNC) visits data between 2012 and 2019 was used to determine the effect of the two free maternity policies. These data were from 5419 public and 305 private and faith-based facilities across all counties, with data sourced from the health information system. A segmented negative binomial regression with seasonality accounted for, was used to determine the level (immediate) effect and trend (month-on-month) effect of the policies. RESULTS The 2013 free-maternity policy led to a 19.6% and 28.9% level increase in normal deliveries and caesarean sections, respectively, in public facilities. There was also a 1.4% trend decrease in caesarean sections in public facilities. A level decrease followed by a trend increase in PNC visits was reported in public facilities. For private and faith-based facilities, there was a level decrease in caesarean sections and ANC visits followed by a trend increase in caeserean sections following the 2013 policy.Furthermore, the 2017 Linda Mama programme showed a level decrease then a trend increase in PNC visits and a 1.1% trend decrease in caesarean sections in public facilities. In private and faith-based facilities, there was a reported level decrease in normal deliveries and caesarean sections and a trend increase in caesarean sections. CONCLUSION The free maternity policies show mixed effects in increasing access to maternal health services. Emphasis on other accessibility barriers and service delivery challenges alongside user fee removal policies should be addressed to realise maximum benefits in maternal health utilisation.
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Affiliation(s)
- Stacey Orangi
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Angela Kairu
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | | | | | | | - Edwine Barasa
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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[Improving provision of mother-and-child care in Chad at the community level: A quasi-experimental study]. Rev Epidemiol Sante Publique 2021; 69:193-203. [PMID: 34030893 DOI: 10.1016/j.respe.2021.04.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/23/2020] [Accepted: 04/08/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Chad is among the countries with the highest maternal and infant mortality rates in the world. An initiative aimed at improving mother-and-child health services was implemented from 2016 to 2019 in three rural health districts in southern Chad, with strong community input, while concomitantly increasing the supply and demand for care. The objective of this study is to evaluate the effects of this program on health service use. METHODS Interrupted time-series analyses with a control group was used to measure the effects of the intervention by applying a quasi-experimental approach. Monthly attendance data were collected from the registries of the 18 health centres that participated in the program and 18 centres that did not participate (control group), before (18 months) and after (24 months) the start of implementation. RESULTS On average, there were 10.98 (95% CI: 6.57-15.39, P<0.001) additional paediatric visits and 0.68 additional deliveries (95% CI: 0.42-0.95, P<0.001) each month in the participation group compared to the control group. Community involvement decisively contributed to the change. CONCLUSION During the 24 months of implementation, the initiative significantly increased the use of essential mother-and-child health services in Chad. This study highlights the benefits of a strong partnership with communities trained and involved in health system activities, with the objective of achieving universal health coverage.
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User fees removal and community-based management of undernutrition in Burkina Faso: what effects on children's nutritional status? Public Health Nutr 2021; 24:3768-3779. [PMID: 33593454 DOI: 10.1017/s1368980021000732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To examine the effect of an intervention combining user fees removal with community-based management of undernutrition on the nutrition status in children under 5 years of age in Burkina Faso. DESIGN The study was a non-equivalent control group post-test-only design based on household survey data collected 4 years after the intervention onset in the intervention and comparison districts. Additionally, we used propensity score weighting to achieve balance on covariates between the two districts, followed by logistic multilevel modelling. SETTING Two health districts in the Sahel region. PARTICIPANTS Totally, 1116 children under 5 years of age residing in 41 intervention communities and 1305 from 51 control communities. RESULTS When comparing children living in the intervention district to children living in a non-intervention district, we determined no differences in terms of stunting (OR = 1·13; 95 % CI 0·83, 1·54) and wasting (OR = 1·21; 95 % CI 0·90, 1·64), nor in severely wasted (OR = 1·27; 95 % CI 0·79, 2·04) and severely stunted (OR = 0·99; 95 % CI 0·76, 1·26). However, we determined that 3 % of the variance of wasting (95 % CI 1·25, 10·42) and 9·4 % of the variance of stunting (95 % CI 6·45, 13·38) were due to systematic differences between communities of residence. The presence of the intervention in the communities explained 2 % of the community-level variance of stunting and 3 % of the community-level variance of wasting. CONCLUSIONS With the scaling-up of the national free health policy in Africa, we stress the need for rigorous evaluations and the means to measure expected changes in order to better inform health interventions.
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Vossius C, Mduma E, Moshiro R, Mdoe P, Kvaløy JT, Kidanto H, Lyanga S, Ersdal H. The impact of introducing ambulance and delivery fees in a rural hospital in Tanzania. BMC Health Serv Res 2021; 21:99. [PMID: 33509195 PMCID: PMC7844989 DOI: 10.1186/s12913-021-06107-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background Access to health care facilities is a key requirement to enhance safety for mothers and newborns during labour and delivery. Haydom Lutheran Hospital (HLH) is a regional hospital in rural Tanzania with a catchment area of about two million inhabitants. Up to June 2013 ambulance transport and delivery at HLH were free of charge, while a user fee for both services was introduced from January 2014. We aimed to explore the impact of introducing user fees on the population of women giving birth at HLH in order to document potentially unwanted consequences in the period after introduction of fees. Methods Retrospective analysis of data from a prospective observational study. Data was compared between the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. Logistic regression modelling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes. Results A total of 28,601 births were observed. The monthly number of births was reduced by 17.3% during the post-introduction period. Spontaneous vaginal deliveries were registered less frequently with a decrease of about 17/1000 births in non-cephalic presentations. Labour complications and caesarean sections increased with about 80/1000 births. There was a reduction in newborns with birth weight less than 2500 g. The observed changes were stable over time. For most variables, a significant change could be detected after a few weeks. Conclusion After the introduction of ambulance and delivery fees, an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight were observed. This might indicate that women delay the decision to seek skilled birth attendance or do not seek help at all, possibly due to financial reasons. Lower rates of births in a safe health care facility like HLH is of great concern, as access to skilled birth attendance is a key requirement in order to further reduce perinatal mortality. Therefore, free delivery care should be a high priority.
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Affiliation(s)
- Corinna Vossius
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, PB 8100, 4068, Stavanger, Norway.
| | - Estomih Mduma
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Tanzania.,Department of Research, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Robert Moshiro
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Tanzania.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Paschal Mdoe
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Tanzania.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Jan Terje Kvaløy
- Department of Research, Stavanger University Hospital, Stavanger, Norway.,Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
| | - Hussein Kidanto
- Department of Research, Stavanger University Hospital, Stavanger, Norway.,Medical College, Aga Khan University, Dar es Salaam, Tanzania
| | - Sara Lyanga
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Hege Ersdal
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, PB 8100, 4068, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Sas Trakinsky B, Irwin BR, Guéné HJL, Grépin KA. An empirical evaluation of the performance of financial protection indicators for UHC monitoring: Evidence from Burkina Faso. HEALTH POLICY OPEN 2020; 1:100001. [PMID: 37383309 PMCID: PMC10297743 DOI: 10.1016/j.hpopen.2019.100001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 11/08/2019] [Accepted: 11/25/2019] [Indexed: 11/24/2022] Open
Abstract
Achieving Universal Health Coverage (UHC) has been recognized as one of the Sustainable Development Goals (SDGs) and includes both ensuring access to health services and providing financial protection (FP) against using these services. Currently, progress towards achieving the FP component of UHC is assessed using the catastrophic health expenditure budget share indicator, which estimates the proportion of the population with health expenditures exceeding 10% of total income or consumption. Other indicators exist, however, and are widely used in the literature, yet few studies have compared the usefulness of these indicators for UHC monitoring. Using panel data from Burkina Faso, this paper seeks to evaluate the performance of common FP indicators based on three properties: (1) their ability to identify those most at risk of financial hardship (i.e. the poor), (2) their ability to detect households with health shocks, and (3) their sensitivity to seasonal variation. Our results indicate that, while some indicators perform better in certain conditions than others, none are without limitation. Indeed, despite being the best able to differentiate households who have experienced a health shock, the official SDG indicator performs the worst at identifying the poorest group of the population and is the most sensitive to seasonal variation. As such, more research is needed in order to improve the measurement of FP such that progress towards achieving UHC can be accurately monitored.
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Affiliation(s)
| | | | - Hervé J.-L. Guéné
- Institut National de la Statistique et de la Démographie, Burkina Faso
| | - Karen A. Grépin
- Wilfrid Laurier University, Canada
- The University of Hong Kong, Hong Kong SAR, China
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28
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Mathonnat J, Audibert M, Belem S. Analyzing the Financial Sustainability of User Fee Removal Policies: A Rapid First Assessment Methodology with a Practical Application for Burkina Faso. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:767-780. [PMID: 31432456 PMCID: PMC7716817 DOI: 10.1007/s40258-019-00506-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The purpose of this paper is to briefly present a methodological framework that does not require cumbersome investigations for a first assessment of the financial sustainability of policies aiming to remove or reduce healthcare user fees (the so-called free healthcare policy [FHCP]). This paper is organized in two main sections. The first analyzes the various possibilities available to finance an FHCP. Using several scenarios, it includes a special focus devoted to the calculus of what to consider when assessing the sustainability of expanding fiscal space for financing the FHCP. The second section relies on the current FHCP being implemented in Burkina Faso to illustrate a selection of specific issues raised in the methodological framework. The results suggest that sustainable FHCP financing is not outside the range of the government but does represent a significant challenge, as it will require, both currently and in the future, complex and delicate budget trade-offs at the highest governmental levels, regardless of other policy options to be considered.
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Affiliation(s)
- Jacky Mathonnat
- University Clermont Auvergne and FERDI (Fondation pour les Etudes et Recherches sur le Développement International), 63 Bd François Mitterrand, 63000, Clermont-Ferrand, France.
| | - Martine Audibert
- University Clermont Auvergne, CERDI (Centre d'Etudes et de Recherches sur le Développement International), 26, Avenue Léon Blum, 63000, Clermont-Ferrand, France
| | - Salam Belem
- Sahel Demographic Dividend (SWEDD), Health Development Support Program, Ministry of Health, Ouagadougou, Burkina Faso
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29
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Beaugé Y, De Allegri M, Ouédraogo S, Bonnet E, Kuunibe N, Ridde V. Do Targeted User Fee Exemptions Reach the Ultra-Poor and Increase their Healthcare Utilisation? A Panel Study from Burkina Faso. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186543. [PMID: 32911868 PMCID: PMC7559284 DOI: 10.3390/ijerph17186543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/25/2020] [Accepted: 09/02/2020] [Indexed: 12/22/2022]
Abstract
Background: A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of user fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of user fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of user fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diébougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (β = −0.07; 95% CI = −0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.
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Affiliation(s)
- Yvonne Beaugé
- Heidelberg Institute for Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany; (M.D.A.); (N.K.)
- Correspondence: ; Tel.: +49-6221-56-35057; Fax: +49-6221-56-5948
| | - Manuela De Allegri
- Heidelberg Institute for Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany; (M.D.A.); (N.K.)
| | - Samiratou Ouédraogo
- The Canadian Institutes of Health Research (CIHR), Ottawa, ON K1A 0W9, Canada;
- National Public Health Institute of Quebec (INSPQ), Quebec City, QC G1V 5B3, Canada
- Department of Epidemiology, Biostatistics and Occupational Health (EBOH), Faculty of Medicine, McGill University, Montreal, QC H3A 1A2, Canada
| | - Emmanuel Bonnet
- French Institute for Research on Sustainable Development (IRD), Unité Mixte Internationale (UMI) Résiliences, 93143 Bondy, France;
| | - Naasegnibe Kuunibe
- Heidelberg Institute for Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany; (M.D.A.); (N.K.)
- Department of Economics and Entrepreneurship Development Studies, Faculty of Integrated Development Studies, University for Development Studies, P. O. Box 520, Wa, Upper West Region, Ghana
| | - Valéry Ridde
- French Institute for Research on sustainable Development (IRD), Centre Population et Développement (CEPED), Universités de Paris, ERL INSERM SAGESUD, 75006 Paris, France;
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30
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Hung YW, Hoxha K, Irwin BR, Law MR, Grépin KA. Using routine health information data for research in low- and middle-income countries: a systematic review. BMC Health Serv Res 2020; 20:790. [PMID: 32843033 PMCID: PMC7446185 DOI: 10.1186/s12913-020-05660-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 08/16/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications. METHODS Using terms 'routine health information system', 'health information system', or 'health management information system' and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form. RESULTS We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored. CONCLUSIONS Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.
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Affiliation(s)
- Yuen W Hung
- University of Waterloo, School of Public Health and Health Systems, Waterloo, Canada
| | - Klesta Hoxha
- University of Waterloo, School of Public Health and Health Systems, Waterloo, Canada
| | - Bridget R Irwin
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, Canada
| | - Karen A Grépin
- School of Public Health, Hong Kong University, Pok Fu Lam, Hong Kong.
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31
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Sia D, Dondbzanga BDG, Carabali M, Bonnet E, Enok Bonong PR, Ridde V. Effect of a free healthcare policy on health services utilisation for non-malarial febrile illness by children under five years in Burkina Faso: an interrupted time series analysis. Trop Med Int Health 2020; 25:1226-1234. [PMID: 32686252 DOI: 10.1111/tmi.13468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effect of a free healthcare policy for children under five years old implemented in Burkina Faso since April 2016, on the use of health care of non-malarial febrile illnesses (NMFI). METHODS To assess the immediate and long-term effect of the free healthcare policy in place, we conducted an interrupted time series analysis of routinely collected data on febrile illnesses from three urban primary health centres of Ouagadougou between 1 January 2015 and 31 December 2016. RESULTS Of the 39 046 febrile cases reported in the study period, 17 017 NMFI were included in the study. Compared to the period before the intervention, we observed an immediate, non-statistically significant increase of 7% in the number of NMFI (IRR = 1.07; 95% CI = 0.75, 1.51). Compared to the trend that would have been expected in absence of the intervention, the results showed a small but sustained increase of 6% in the trend of monthly number of NMFI during the intervention period (IRR = 1.06; 95%CI = 1.01, 1.12). CONCLUSION Our study highlighted an increase in the uptake of healthcare services, specifically for NMFI by children under five years of age, after the implementation of a free care policy. This analysis contributes to informing decision makers on the need to strengthen the capacities of healthcare centres and to anticipate the challenges of the sustainability of this policy.
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Affiliation(s)
- D Sia
- University of Québec in Outaouais, Saint-Jérôme, QC, Canada
| | | | - M Carabali
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - E Bonnet
- IRD (French Institute for Research on Sustainable Development), UMI Résiliences, Bondy, France
| | - P R Enok Bonong
- Department of Médecine Préventive, University of Montréal, Montreal, Canada
| | - V Ridde
- IRD (French Institute for Research on Sustainable Development), UMI Résiliences, Bondy, France
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32
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Ihantamalala FA, Herbreteau V, Révillion C, Randriamihaja M, Commins J, Andréambeloson T, Rafenoarimalala FH, Randrianambinina A, Cordier LF, Bonds MH, Garchitorena A. Improving geographical accessibility modeling for operational use by local health actors. Int J Health Geogr 2020; 19:27. [PMID: 32631348 PMCID: PMC7339519 DOI: 10.1186/s12942-020-00220-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/29/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Geographical accessibility to health facilities remains one of the main barriers to access care in rural areas of the developing world. Although methods and tools exist to model geographic accessibility, the lack of basic geographic information prevents their widespread use at the local level for targeted program implementation. The aim of this study was to develop very precise, context-specific estimates of geographic accessibility to care in a rural district of Madagascar to help with the design and implementation of interventions that improve access for remote populations. METHODS We used a participatory approach to map all the paths, residential areas, buildings and rice fields on OpenStreetMap (OSM). We estimated shortest routes from every household in the District to the nearest primary health care center (PHC) and community health site (CHS) with the Open Source Routing Machine (OSMR) tool. Then, we used remote sensing methods to obtain a high resolution land cover map, a digital elevation model and rainfall data to model travel speed. Travel speed models were calibrated with field data obtained by GPS tracking in a sample of 168 walking routes. Model results were used to predict travel time to seek care at PHCs and CHSs for all the shortest routes estimated earlier. Finally, we integrated geographical accessibility results into an e-health platform developed with R Shiny. RESULTS We mapped over 100,000 buildings, 23,000 km of footpaths, and 4925 residential areas throughout Ifanadiana district; these data are freely available on OSM. We found that over three quarters of the population lived more than one hour away from a PHC, and 10-15% lived more than 1 h away from a CHS. Moreover, we identified areas in the North and East of the district where the nearest PHC was further than 5 h away, and vulnerable populations across the district with poor geographical access (> 1 h) to both PHCs and CHSs. CONCLUSION Our study demonstrates how to improve geographical accessibility modeling so that results can be context-specific and operationally actionable by local health actors. The importance of such approaches is paramount for achieving universal health coverage (UHC) in rural areas throughout the world.
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Affiliation(s)
- Felana Angella Ihantamalala
- NGO PIVOT, Ranomafana, Madagascar. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.
| | - Vincent Herbreteau
- Institut de Recherche pour le Développement, UMR 228 Espace-Dev (IRD, UA, UG, UM, UR), Phnom Penh, Cambodia
| | - Christophe Révillion
- Université de La Réunion, UMR 228 Espace-Dev (IRD, UA, UG, UM, UR), Saint-Pierre, La Réunion, France
| | - Mauricianot Randriamihaja
- NGO PIVOT, Ranomafana, Madagascar.,School of Management and Technological Innovation, University of Fianarantsoa, Fianarantsoa, Madagascar
| | - Jérémy Commins
- Institut de Recherche pour le Développement, UMR 228 Espace-Dev (IRD, UA, UG, UM, UR), Phnom Penh, Cambodia
| | - Tanjona Andréambeloson
- NGO PIVOT, Ranomafana, Madagascar.,School of Management and Technological Innovation, University of Fianarantsoa, Fianarantsoa, Madagascar
| | | | | | | | - Matthew H Bonds
- NGO PIVOT, Ranomafana, Madagascar.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Andres Garchitorena
- NGO PIVOT, Ranomafana, Madagascar.,MIVEGEC, Univ. Montpellier, CNRS, IRD, Montpellier, France
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Nguyen HT, Torbica A, Brenner S, Kiendrébéogo JA, Tapsoba L, Ridde V, De Allegri M. Economic Evaluation of User-Fee Exemption Policies for Maternal Healthcare in Burkina Faso: Evidence From a Cost-Effectiveness Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:300-308. [PMID: 32197725 DOI: 10.1016/j.jval.2019.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The reduction and removal of user fees for essential care services have recently become a key instrument to advance universal health coverage in sub-Saharan Africa, but no evidence exists on its cost-effectiveness. We aimed to address this gap by estimating the cost-effectiveness of 2 user-fee exemption interventions in Burkina Faso between 2007 and 2015: the national 80% user-fee reduction policy for delivery care services and the user-fee removal pilot (ie, the complete [100%] user-fee removal for delivery care) in the Sahel region. METHODS We built a single decision tree to evaluate the cost-effectiveness of the 2 study interventions and the baseline. The decision tree was populated with an own impact evaluation and the best available epidemiological evidence. RESULTS Relative to the baseline, both the national 80% user-fee reduction policy and the user-fee removal pilot are highly cost-effective, with incremental cost-effectiveness ratios of $210.22 and $252.51 per disability-adjusted life-year averted, respectively. Relative to the national 80% user-fee reduction policy, the user-fee removal pilot entails an incremental cost-effectiveness ratio of $309.74 per disability-adjusted life-year averted. CONCLUSIONS Our study suggests that it is worthwhile for Burkina Faso to move from an 80% reduction to the complete removal of user fees for delivery care. Local analyses should be done to identify whether it is worthwhile to implement user-fee exemptions in other sub-Saharan African countries.
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Affiliation(s)
- Hoa Thi Nguyen
- Heidelberg Institute of Global Health, University Hospital, University of Heidelberg, Heidelberg, Germany.
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy
| | - Stephan Brenner
- Heidelberg Institute of Global Health, University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Joël Arthur Kiendrébéogo
- Heidelberg Institute of Global Health, University Hospital, University of Heidelberg, Heidelberg, Germany; University Joseph Ki-Zerbo, Ouagadougou, Burkina Faso; Institute of Tropical Medicine, Antwerp, Belgium
| | - Ludovic Tapsoba
- National Institute of Public Health, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Valéry Ridde
- Institute for Research on Sustainable Development, CEPED, Université de Paris, French National Institute of Health and Medical Research, Paris, France
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital, University of Heidelberg, Heidelberg, Germany
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Zombré D, De Allegri M, Platt RW, Ridde V, Zinszer K. An Evaluation of Healthcare Use and Child Morbidity 4 Years After User Fee Removal in Rural Burkina Faso. Matern Child Health J 2019; 23:777-786. [PMID: 30580393 PMCID: PMC6510853 DOI: 10.1007/s10995-018-02694-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objectives Increasing financial access to healthcare is proposed to being essential for improving child health outcomes, but the available evidence on the relationship between increased access and health remains scarce. Four years after its launch, we evaluated the contextual effect of user fee removal intervention on the probability of an illness occurring and the likelihood of using health services among children under 5. We also explored the potential effect on the inequality in healthcare access. Methods We used a comparative cross-sectional design based upon household survey data collected years after the intervention onset in one intervention and one comparison district. Propensity scores weighting was used to achieve balance on covariates between the two districts, which was followed by logistic multilevel modelling to estimate average marginal effects (AME). Results We estimated that there was not a significant difference in the reduced probability of an illness occurring in the intervention district compared to the non-intervention district [AME 4.4; 95% CI 1.0-9.8)]. However, the probability of using health services was 17.2% (95% CI 15.0-26.6) higher among children living in the intervention district relative to the comparison district, which rose to 20.7% (95% CI 9.9-31.5) for severe illness episodes. We detected no significant differences in the probability of health services use according to socio-economic status [χ2 (5) = 12.90, p = 0.61]. Conclusions for Practice In our study, we found that user fee removal led to a significant increase in the use of health services in the longer term, but it is not adequate by itself to reduce the risk of illness occurrence and socioeconomic inequities in the use of health services.
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Affiliation(s)
- David Zombré
- Department of Social and Preventive Medicine, University of Montreal, Montréal, Canada.
- University of Montreal Public Health Research Institute - IRSPUM, Pavillon 7101 Avenue du Parc C.P 6128 Succursale C, local, 3224, Montréal, QC, H3C 3J7, Canada.
| | - Manuela De Allegri
- Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Robert W Platt
- Departments of Pediatrics and of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
| | - Valéry Ridde
- Department of Social and Preventive Medicine, University of Montreal, Montréal, Canada
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
| | - Kate Zinszer
- Department of Social and Preventive Medicine, University of Montreal, Montréal, Canada
- University of Montreal Public Health Research Institute - IRSPUM, Pavillon 7101 Avenue du Parc C.P 6128 Succursale C, local, 3224, Montréal, QC, H3C 3J7, Canada
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35
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Kaboré C, Ridde V, Chaillet N, Yaya Bocoum F, Betrán AP, Dumont A. DECIDE: a cluster-randomized controlled trial to reduce unnecessary caesarean deliveries in Burkina Faso. BMC Med 2019; 17:87. [PMID: 31046752 PMCID: PMC6498483 DOI: 10.1186/s12916-019-1320-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/10/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In Burkina Faso, facility-based caesarean delivery rates have markedly increased since the national subsidy policy for deliveries and emergency obstetric care was implemented in 2006. Effective and safe strategies are needed to prevent unnecessary caesarean deliveries. METHODS We conducted a cluster-randomized controlled trial of a multifaceted intervention at 22 referral hospitals in Burkina Faso. The evidence-based intervention was designed to promote the use of clinical algorithms for caesarean decision-making using in-site training, audits and feedback of caesarean indications and SMS reminders. The primary outcome was the change in the percentage of unnecessary caesarean deliveries. Unnecessary caesareans were defined on the basis of the literature review and expert consensus. Data were collected daily using a standardized questionnaire, in the same way at both the intervention and control hospitals. Caesareans were classified as necessary or unnecessary in the same way, in both arms of the trial using a standardized computer algorithm. RESULTS A total of 2138 and 2036 women who delivered by caesarean section were analysed in the pre and post-intervention periods, respectively. A significant reduction in the percentage of unnecessary caesarean deliveries was evident from the pre- to post-intervention period in the intervention group compared with the control group (18.96 to 6.56% and 18.27 to 23.30% in the intervention and control groups, respectively; odds ratio [OR] for incremental change over time, adjusted for hospital and patient characteristics, 0.22; 95% confidence interval [CI], 0.14 to 0.34; P < 0.001; adjusted risk difference, - 17.02%; 95% CI, - 19.20 to - 13.20%). The intervention did not significantly affect the rate of maternal death (0.75 to 0.19% and 0.92 to 0.40% in the intervention and control groups, respectively; adjusted OR 0.32; 95% CI 0.04 to 2.23; P = 0.253) or intrapartum-related neonatal death (4.95 to 6.32% and 5.80 to 4.29% in the intervention and control groups, respectively, adjusted OR 1.73; 95% CI 0.82 to 3.66; P = 0.149). The overall perinatal mortality data were not available. CONCLUSION Promotion and training on clinical algorithms for decision-making, audit and feedback and SMS reminders reduced unnecessary caesarean deliveries, compared with usual care in a low-resource setting. TRIAL REGISTRATION The DECIDE trial is registered on the Current Controlled Trials website: ISRCTN48510263 .
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Affiliation(s)
- Charles Kaboré
- IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France. .,Research Institute of Health Sciences, Ouagadougou, Burkina Faso.
| | - Valéry Ridde
- IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France.,University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada
| | - Nils Chaillet
- Hospital Center of Laval University (CHUL), Quebec, Canada
| | | | - Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland
| | - Alexandre Dumont
- IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
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Steele SJ, Sugianto H, Baglione Q, Sedlimaier S, Niyibizi AA, Duncan K, Hill J, Brix J, Philips M, Cutsem GV, Shroufi A. Removal of user fees and system strengthening improves access to maternity care, reducing neonatal mortality in a district hospital in Lesotho. Trop Med Int Health 2018; 24:2-10. [PMID: 30365204 PMCID: PMC7379625 DOI: 10.1111/tmi.13175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objective Lesotho has one of the highest maternal mortality rates in the world. While at primary health care (PHC) level maternity care is free, at hospital level co‐payments are required from patients. We describe service utilisation and delivery outcomes before and after removal of user fees and quality of delivery care, and associated costs, at St Joseph's Hospital (SJH) in Roma, Lesotho. Methods We compared utilisation of delivery services, stillbirths and maternal and neonatal mortality for the periods before (1 July 2012 to 31 December 2013) and after (1 January 2014 to 30 June 2015) user fee removal through a retrospective chart review and estimated additional costs attributed to user fee removal from provider (hospital) and patient perspectives. Results Of 4715 deliveries 3855 were at SJH and 860 at PHC centres. Of women delivering at SJH 684 (18.5%) were ≤19 years and 894 (23.6%) were HIV positive. After user fee removal hospital deliveries increased by 49% — from 1547 to 2308 — and neonatal mortality decreased from 4.8 to 1.3 per 1000 live births (P = 0.033). Extrapolating costs to the entire country, 1 USD per capita per year would allow user fee removal at hospital level, the provision of free transport to/from and accommodation at hospital. Conclusion Removing user fees for hospital delivery care in Lesotho is feasible and affordable, and has the potential to improve maternal and neonatal outcomes by removing financial barriers to skilled birth attendants and increasing coverage of institutional deliveries.
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Affiliation(s)
- Sarah Jane Steele
- Médecins Sans Frontières South Africa and Lesotho, Cape Town, South Africa
| | - Hartini Sugianto
- Médecins Sans Frontières South Africa and Lesotho, Cape Town, South Africa
| | - Quentin Baglione
- Agence Européenne pour le Développement et la Santé, Brussels, Belgium
| | | | | | - Kristal Duncan
- Médecins Sans Frontières South Africa and Lesotho, Cape Town, South Africa
| | - Julia Hill
- Médecins Sans Frontières South Africa and Lesotho, Cape Town, South Africa
| | - Jesper Brix
- Médecins Sans Frontières South Africa and Lesotho, Roma, Lesotho
| | - Mit Philips
- Médecins Sans Frontières Operational Centre Brussels, Brussels, Belgium
| | - Gilles Van Cutsem
- Médecins Sans Frontières South Africa and Lesotho, Cape Town, South Africa.,University of Cape Town, Cape Town, South Africa
| | - Amir Shroufi
- Médecins Sans Frontières South Africa and Lesotho, Cape Town, South Africa
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Meda IB, Dumont A, Kouanda S, Ridde V. Impact of fee subsidy policy on perinatal health in a low-resource setting: A quasi-experimental study. PLoS One 2018; 13:e0206978. [PMID: 30408129 PMCID: PMC6224097 DOI: 10.1371/journal.pone.0206978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 10/23/2018] [Indexed: 11/25/2022] Open
Abstract
Background A national subsidy policy was introduced in 2007 in Burkina Faso to improve financial accessibility to facility-based delivery. In this article, we estimated the effects of reducing user fees on institutional delivery and neonatal mortality, immediately and three years after the introduction of the policy. Methods The study was based on a quasi-experimental design. We used data obtained from the 2010 Demographic and Health Survey, including survival information for 32,102 live-born infants born to 12,474 women. We used a multilevel Poisson regression model with robust variances to control for secular trends in outcomes between the period before the introduction of the policy (1 January, 2007) and the period after. In sensitivity analyses, we used two different models according to the different definitions of the period “before” and the period “after”. Results Immediately following its introduction, the subsidy policy was associated with increases in institutional deliveries by 4% (RR = 1.04, 95% CI: 0.98–1.10) in urban areas and by 12% (RR = 1.12, 95% CI: 1.04–1.20) in rural areas. The results showed similar patterns in sensitivity analyses. This effect was particularly marked among rural clusters with low institutional delivery rates at baseline (RR = 1.44, 95% CI: 1.33–1.55). It was persistent for 42 months after the introduction of the policy but these increases were not statistically significant. At 42 months, the delivery rates had increased by 26% in rural areas (RR = 1.26; 95% CI: 0.86–1.86) and 13% (RR = 1.13; 95% CI: 0.88–1.46) in urban areas. There was no evidence of a significant decrease in neonatal mortality rates. Conclusion The delivery subsidy implemented in Burkina Faso is associated with short-term increases in health facility deliveries. This policy has been particularly beneficial for rural households.
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Affiliation(s)
- Ivlabèhiré Bertrand Meda
- Département Biomédical et Santé Publique, Institut de Recherche en Sciences de la Santé (IRSS/CNRST), Ouagadougou, Burkina Faso
- École de Santé Publique de l’Université de Montréal (ESPUM), Montréal, Canada
- Institut de Recherche en Santé Publique de l’Université de Montréal (IRSPUM), Montréal, Canada
- Institut Africain de Santé Publique (IASP), Ouagadougou, Burkina Faso
- * E-mail:
| | - Alexandre Dumont
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
| | - Seni Kouanda
- Département Biomédical et Santé Publique, Institut de Recherche en Sciences de la Santé (IRSS/CNRST), Ouagadougou, Burkina Faso
- Institut Africain de Santé Publique (IASP), Ouagadougou, Burkina Faso
| | - Valéry Ridde
- Institut de Recherche en Santé Publique de l’Université de Montréal (IRSPUM), Montréal, Canada
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
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