Estimation of maternal and child mortality one year after user-fee elimination: an impact evaluation and modelling study in Burkina Faso

Effects of the free healthcare policy on maternal and child health in Burkina Faso: a nationwide evaluation using interrupted time-series analysis

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.

Effect of cost-reduction interventions on facility-based deliveries in Burkina Faso: a controlled interrupted time-series study with multiple non-equivalent dependent variables

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.

Effects of the free healthcare policy on health services' usage by children under 5 years in Burkina Faso: a controlled interrupted time-series analysis

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.

Universal health coverage and the poor: to what extent are health financing policies making a difference? Evidence from a benefit incidence analysis in Zambia

Background

Zambia has invested in several healthcare financing reforms aimed at achieving universal access to health services. Several evaluations have investigated the effects of these reforms on the utilization of health services. However, only one study has assessed the distributional incidence of health spending across different socioeconomic groups, but without differentiating between public and overall health spending and between curative and maternal health services. Our study aims to fill this gap by undertaking a quasi-longitudinal benefit incidence analysis of public and overall health spending between 2006 and 2014.

Methods

We conducted 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 at three time points. We combined data from household surveys and National Health Accounts.

Results

Results showed that public (concentration index of − 0.003; SE 0.027 in 2006 and − 0.207; SE 0.011 in 2014) and overall (0.050; SE 0.033 in 2006 and − 0.169; SE 0.011 in 2014) health spending on curative services tended to benefit the poorer segments of the population while public (0.241; SE 0.018 in 2007 and 0.120; SE 0.007 in 2014) and overall health spending (0.051; SE 0.022 in 2007 and 0.116; SE 0.007 in 2014) on institutional delivery tended to benefit the least-poor. Higher inequalities were observed at higher care levels for both curative and institutional delivery services.

Conclusion

Our findings suggest that the implementation of UHC policies in Zambia led to a reduction in socioeconomic inequality in health spending, particularly at health centres and for curative care. Further action is needed to address existing barriers for the poor to benefit from health spending on curative services and at higher levels of care.

Does the implementation of UHC reforms foster greater equality in health spending? Evidence from a benefit incidence analysis in Burkina Faso

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.

Geographic barriers to achieving universal health coverage: evidence from rural Madagascar

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.

An Integrated Primary Care Initiative for Child Health in Northern Togo

OBJECTIVES

To determine if the Integrated Community-Based Health Systems-Strengthening (ICBHSS) initiative was effective in expanding health coverage, improving care quality, and reducing child mortality in Togo.

METHODS

Population-representative cross-sectional household surveys adapted from the Demographic Household Survey and Multiple Indicator Cluster Surveys were conducted at baseline (2015) and then annually (2016-2020) in 4 ICBHSS catchment sites in Kara, Togo. The primary outcome was under-5 mortality, with health service coverage and health-seeking behavior as secondary outcomes. Costing analyses were calculated by using "top-down" methodology with audited financial statements and programmatic data.

RESULTS

There were 10 022 household surveys completed from 2015 to 2020. At baseline (2015), under-5 mortality was 51.1 per 1000 live births (95% confidence interval [CI]: 35.5-66.8), and at the study end period (2020), under-5 mortality was 35.8 (95% CI: 23.4-48.2). From 2015 to 2020, home-based treatment by a community health worker increased from 24.1% (95% CI: 21.9%-26.4%) to 45.7% (95% CI: 43.3%-48.2%), and respondents reporting prenatal care in the first trimester likewise increased (37.5% to 50.1%). Among respondents who sought care for a child with fever, presenting for care within 1 day increased from 51.9% (95% CI: 47.1%-56.6%) in 2015 to 80.3% (95% CI: 74.6%-85.0%) in 2020. The estimated annual additional intervention cost was $8.84 per person.

CONCLUSIONS

Our findings suggest that the ICBHSS initiative, a bundle of evidence-based interventions implemented with a community-based strategy, improves care access and quality and was associated with reduction in child mortality.

Critical Interpretive Synthesis of Qualitative Data on the Health Care Ecosystem for Vulnerable Newborns in Low- to Middle-Income Countries

OBJECTIVE

To critically assess and synthesize qualitative findings regarding the health care ecosystem for vulnerable (low-birth-weight or sick) neonates in low- to middle-income countries (LMICs).

DATA SOURCES

Between May 4 and June 2, 2020, we searched four databases (Medline [PubMed], SCOPUS, PsycINFO, and Web of Science) for articles published from 2010 to 2020. Inclusion criteria were peer-reviewed reports of original studies focused on the health care ecosystem for vulnerable neonates in LMICs. We also searched the websites of several international development agencies and included findings from primary data collected between May and July 2019 at a tertiary hospital in Kenya. We excluded studies and reports if the focus was on healthy neonates or high-income countries and if they contained only quantitative data, were written in a language other than English, or were published before 2010.

STUDY SELECTION

One of the primary authors conducted an initial review of titles and abstracts (n = 102) and excluded studies that were not consistent with the purpose of the review (n = 60). The two primary authors used a qualitative appraisal checklist to assess the validity of the remaining studies (n = 42) and reached agreement on the final 13 articles.

DATA EXTRACTION

The two primary authors independently conducted open and axial coding of the data. We incorporated data from studies with different units of analysis, types of methodology, research topics, participant types, and analytical frameworks in an emergent conceptual development process according to the critical interpretive synthesis methodology.

DATA SYNTHESIS

We synthesized our findings into one overarching theme, Pervasive Turbulence Is a Defining Characteristic of the Health Care Ecosystem in LMICs, and two subthemes: Pervasive Turbulence May Cause Tension Between the Setting and the Caregiver and Pervasive Turbulence May Result in a Loss of Synergy in the Caregiver-Parent Relationship.

CONCLUSION

Because pervasive turbulence characterizes the health care ecosystems in LMICs, interventions are needed to support the caregiver-parent interaction to mitigate the effects of tension in the setting.

Effectiveness of peer-supervision on pediatric fever illness treatment among registered private drug sellers in East-Central Uganda: An interrupted time series analysis

RATIONALE AIMS AND OBJECTIVES

Appropriate treatment of pediatric fever in rural areas remains a challenge and maybe partly due to inadequate supervision of licensed drug sellers. This study assessed the effectiveness of peer-supervision among drug sellers on the appropriate treatment of pneumonia symptoms, uncomplicated malaria, and non-bloody diarrhea among children less than 5 years of age in the intervention (Luuka) and comparison (Buyende) districts, in East-Central Uganda.

METHODS

Data on pneumonia symptoms, uncomplicated malaria, and non-bloody diarrhea among children less than 5 years of age was abstracted from drug shop sick child registers over a 12-month period; 6 months before and 6 months after the introduction of peer-supervision. Interrupted time series were applied to determine the effectiveness of the peer-supervision intervention on the appropriate treatment of pneumonia, uncomplicated malaria, and non-bloody diarrhea among children less than 5 years of age attending drug shops in East Central Uganda.

RESULTS

The proportion of children treated appropriately for pneumonia symptoms was 10.84% (P < .05, CI = [1.75, 19.9]) higher, for uncomplicated malaria was 1.46% (P = .79, CI = [-10.43, 13.36]) higher, and for non-bloody diarrhea was 4.00% (P < .05, CI = [-7.95, -0.13]) lower in the intervention district than the comparison district, respectively.Post-intervention trend results showed an increase of 1.21% (P = .008, CI = [0.36, 2.05]) in the proportion appropriately treated for pneumonia symptoms, no difference in appropriate treatment for uncomplicated malaria, and a reduction of 1% (P < .06, CI = [-1.95, 0.02]) in the proportion of children appropriately treated for non-bloody diarrhea, respectively.

CONCLUSIONS

Peer-supervision increased the proportion of children less than 5 years of age that received appropriate treatment for pneumonia symptoms but not for uncomplicated malaria and non-bloody diarrhea. Implementation of community-level interventions to improve pediatric fever management should consider including peer-supervision among drug sellers.

User fees removal and community-based management of undernutrition in Burkina Faso: what effects on children's nutritional status?

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.

User fee policies and women's empowerment: a systematic scoping review

BACKGROUND

Over the past decade, an increasing number of low- and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage. Despite the large number of studies (including meta-analyses and systematic reviews) that have shown this strategy's positive effects impact on health-related indicators, the repercussions on women's empowerment or gender equality has been overlooked in the literature. The aim of this study is to systematically review the evidence on the association between user fee policies in low- and middle-income countries and women's empowerment.

METHODS

A systematic scoping review was conducted. Two reviewers conducted the database search in six health-focused databases (Pubmed, CAB Abstracts, Embase, Medline, Global Health, EBM Reviews) using English key words. The database search was conducted on February 20, 2020, with no publication date limitation. Qualitative analysis of the included articles was conducted using a thematic analysis approach. The material was organized based on the Gender at Work analytical framework.

RESULTS

Out of the 206 initial records, nine articles were included in the review. The study settings include three low-income countries (Burkina Faso, Mali, Sierra Leone) and two lower-middle countries (Kenya, India). Four of them examine a direct association between user fee policies and women's empowerment, while the others address this issue indirectly -mostly by examining gender equality or women's decision-making in the context of free healthcare. The evidence suggests that user fee removal contributes to improving women's capability to make health decisions through different mechanisms, but that the impact is limited. In the context of free healthcare, women's healthcare decision-making power remains undermined because of social norms that are prevalent in the household, the community and the healthcare centers. In addition, women continue to endure limited access to and control over resources (mainly education, information and economic resources).

CONCLUSION

User fee removal policies alone are not enough to improve women's healthcare decision-making power. Comprehensive and multi-sectoral approaches are needed to bring sustainable change regarding women's empowerment. A focus on "gender equitable access to healthcare" is needed to reconcile women's empowerment and the efforts to achieve universal health coverage.

Peer supervision experiences of drug sellers in a rural district in East-Central Uganda: a qualitative study

BACKGROUND

Support supervision improves performance outcomes among health workers. However, the national professional guidelines for new licenses and renewal for Class C drug shops in Uganda prescribe self-supervision of licensed private drug sellers. Without support supervision, inappropriate treatment of malaria, pneumonia and diarrhoea among children under 5 years of age continues unabated. This study assessed experiences of drug sellers and peer supervisors at the end of a peer supervision intervention in Luuka District in East Central Uganda.

METHODS

Eight in-depth interviews (IDIs) were held with peer supervisors while five focus group discussions (FGDs) were conducted among registered drug sellers at the end of the peer supervision intervention. The study assessed experiences and challenges of peer supervisors and drug sellers regarding peer supervision. Transcripts were imported into Atlas.ti 7 qualitative data management software where they were analysed using thematic content analysis.

RESULTS

Initially, peer supervisors were disliked and regarded by drug sellers as another extension of drug inspectors. However, with time a good relationship was established between drug sellers and peer supervisors leading to regular, predictable and supportive peer supervision. This increased confidence of drug sellers in using respiratory timers and rapid diagnostic tests in diagnosing pneumonia symptoms and uncomplicated malaria, respectively, among children under 5 years. There was also an improvement in completing the sick child register which was used for self-assessment by drug sellers. The drug shop association was mentioned as a place where peer supervision should be anchored since it was a one-stop centre for sharing experiences and continuous professional development. Drug sellers proposed including community health workers in monthly drug shop association meetings so that they may also gain from the associated benefits. Untimely completion of the sick child registers by drug sellers and inadequate financial resources were the main peer supervision challenges mentioned.

CONCLUSION

Drug sellers benefitted from peer supervision by developing a good relationship with peer supervisors. This relationship guaranteed reliable and predictable supervision ultimately leading to improved treatment practices. There is need to explore the minimum resources needed for peer supervision of drug sellers to further inform practice and policy.

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

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.

Economic Evaluation of User-Fee Exemption Policies for Maternal Healthcare in Burkina Faso: Evidence From a Cost-Effectiveness Analysis

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.

Are there decision support tools that might strengthen the health system for perinatal care in South African district hospitals? A review of the literature

Background

South Africa has a high burden of perinatal deaths in spite of the availability of evidence-based interventions. The majority of preventable perinatal deaths occur in district hospitals and are mainly related to the functioning of the health system. Particularly, leadership in district hospitals needs to be strengthened in order to decrease the burden of perinatal mortality. Decision-making is a key function of leaders, however leaders in district hospitals are not supported to make evidence-based decisions. The aim of this research was to identify health system decision support tools that can be applied at district hospital level to strengthen decision-making in the health system for perinatal care in South Africa.

Methods

A structured approach, the systematic quantitative literature review method, was conducted to find published articles that reported on decision support tools to strengthen decision-making in a health system for perinatal, maternal, neonatal and child health. Articles published in English between 2003 and 2017 were sought through the following search engines: Google Scholar, EBSCOhost and Science Direct. Furthermore, the electronic databases searched were: Academic Search Complete, Health Source – Consumer Edition, Health Source – Nursing/Academic Edition and MEDLINE.

Results

The search yielded 6366 articles of which 43 met the inclusion criteria for review. Four decision support tools identified in the articles that met the inclusion criteria were the Lives Saved Tool, Maternal and Neonatal Directed Assessment of Technology model, OneHealth Tool, and Discrete Event Simulation. The analysis reflected that none of the identified decision support tools could be adopted at district hospital level to strengthen decision-making in the health system for perinatal care in South Africa.

Conclusion

There is a need to either adapt an existing decision support tool or to develop a tool that will support decision-making at district hospital level towards strengthening the health system for perinatal care in South Africa.

Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol

BACKGROUND

Over the past decade, prevalence of maternal and child morbidity and mortality in Togo, particularly in the northern regions, has remained high despite global progress. The causes of under-five child mortality in Togo are diseases with effective and low-cost prevention and/or treatment strategies, including malaria, acute lower respiratory infections, and diarrheal diseases. While Togo has a national strategy for implementing the integrated management of childhood illness (IMCI) guidelines, including a policy on integrated community case management (iCCM), challenges in implementation and low public sector health service utilization persist. There are critical gaps to access and quality of community health systems throughout the country. An integrated facility- and community-based initiative, the Integrated Community-Based Health Systems Strengthening (ICBHSS) initiative, seeks to address these gaps while strengthening the public sector health system in northern Togo. This study aims to evaluate the effect and implementation strategy of the ICBHSS initiative over 48 months in the catchment areas of 21 public sector health facilities.

METHODS

The ICBHSS model comprises a bundle of evidence-based interventions targeting children under five, women of reproductive age, and people living with HIV through (1) community engagement and feedback; (2) elimination of point-of-care costs; (3) proactive community-based IMCI using community health workers (CHWs) with additional services including family planning, HIV testing, and referrals; (4) clinical mentoring and enhanced supervision; and (5) improved supply chain management and facility structures. Using a pragmatic type II hybrid effectiveness-implementation study, we will evaluate the ICBHSS initiative with two primary aims: (1) determine effectiveness through changes in under-five mortality rates and (2) assess the implementation strategy through measures of reach, adoption, implementation, and maintenance. We will conduct a mixed-methods assessment using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. This assessment consists of four components: (1) a stepped-wedge cluster randomized control trial using a community-based household survey, (2) annual health facility assessments, (3) key informant interviews, and (4) costing and return-on-investment assessments for each randomized cluster.

DISCUSSION

Our research is expected to contribute to continuous quality improvement initiatives, optimize implementation factors, provide knowledge regarding health service delivery, and accelerate health systems improvements in Togo and more broadly.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03694366 , registered 3 October 2018.

Incidence of catastrophic expenditures linked to obstetric and neonatal care at 92 facilities in Lubumbashi, Democratic Republic of the Congo, 2015

Background

In the Democratic Republic of the Congo (DRC), more than 93% of users must pay out of pocket for care. Despite the risk of catastrophic expenditures (CE), 94% of births in Lubumbashi are attended by skilled personnel. We aimed to identify risk factors for CE associated with obstetric and neonatal care in this setting, to document coping mechanisms employed by households to pay the price of care, and to identify consequences of CE on households.

Methods

We used mixed methods and conducted both a cross-sectional study and a phenomenological study of women who delivered at 92 health care facilities in all 11 health zones of Lubumbashi. In April and May 2015 we followed 1,627 women and collected data on their health care and household expenses to determine whether they experienced CE, defined as payments that reached or exceeded 40% of a household’s capacity to pay. Two months after discharge, we conducted semi-structured interviews with 58 women at their homes to assess the consequences of CE.

Results

In all, 261 of 1,627 (16.0%) women experienced CE. Whether a woman or her infant experienced complications was an important contributor to her risk of CE; poverty, younger age, being unmarried, and delivering in a parastatal facility or with more highly trained personnel also increased risk. Among a subset of women with CE interviewed 2 months after discharge, those who were in debt or who had lost their trading income or goods were unable to pay their rent, their children’s school fees, or were obliged to reduce food consumption in the household; some had become victims of mistreatment such as verbal abuse, disputes with in-laws, denial of paternity, abandonment by partners, financial deprivation, even divorce.

Conclusions

We found a higher proportion of CE than previously reported in the DRC or in other urban settings in Africa. We suggest that the government and funders in DRC support initiatives to put in place mutual-aid health risk pools and health insurance and introduce and institutionalize free maternal and infant care. We further suggest that the government ensure decent and regular payment of providers and improve the financing and functioning of health care facilities to improve the quality of care and alleviate the burden on users.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7260-9) contains supplementary material, which is available to authorized users.

An Evaluation of Healthcare Use and Child Morbidity 4 Years After User Fee Removal in Rural Burkina Faso

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.

The impact of reducing and eliminating user fees on facility-based delivery: a controlled interrupted time series in Burkina Faso

User fee reduction and removal policies have been the object of extensive research, but little rigorous evidence exists on their sustained effects in relation to use of delivery care services, and no evidence exists on the effects of partial reduction compared with full removal of user fees. We aimed to fill these knowledge gaps by assessing sustained effects of both partial reduction and complete removal of user fees on utilization of facility-based delivery. Our study took place in four districts in the Sahel region of Burkina Faso, where the national user fee reduction policy (SONU) launched in 2007 (lowering fees at point of use by 80%) co-existed with a user fee removal pilot launched in 2008. We used Health Management Information System data to construct a controlled interrupted time-series analysis and examine both immediate and sustained effects of SONU and the pilot from January 2004 to December 2014. We found that both SONU and the pilot led to a sustained increase in the use of facility-based delivery. SONU produced an accumulative increase of 31.4% (P < 0.01) over 8 years in the four study districts. The pilot further enhanced utilization and produced an additional increase of 23.2% (P < 0.001) over 6 years. These increasing trends did not continue to reach full coverage, i.e. ensuring that all women had a facility-based delivery. Instead, they stabilized 3 years and 4 years after the onset of SONU and the pilot, respectively. Our study provides further evidence that user fee reduction and removal policies are effective in increasing service use in the long term. However, they alone are not sufficient to achieve full coverage. This calls for the need to implement additional measures, targeting for instance geographical barriers and knowledge gaps, to achieve the target of all women delivering in the presence of a skilled attendant.

How to assure access of essential RMNCH medicines by looking at policy and systems factors: an analysis of countdown to 2015 countries

BACKGROUND

In 2000, the Millennium Development Goals set targets for social achievements by 2015 including goals related to maternal and child health, with mixed success. Several initiatives supported these goals including assuring availability of appropriate medicines and commodities to meet health service targets. To reach the new Sustainable Development Goals by 2030, information is needed to address policy and systems factors to improve access to lifesaving commodities.

METHODS

We compiled indicator data on 15 commodities related to reproductive, maternal, newborn, and child health (RMNCH) and analyzed them across 75 Countdown to 2015 countries from eight regions to identify problems with specific commodities and determinants of access. The determinants related to policy, regulatory environment, financing, pharmaceutical procurement and supply chain, and information systems. We mapped commodity information from four datasets from the World Health Organization and the United Nation's Commission on Life Saving Commodities creating a stoplight dashboard to illustrate countries' environment to assure access. We also developed a dashboard for policy and systems indicators for select countries.

RESULTS

The commodities we identified as having the fewest barriers to access had been in use longer, including oral rehydration solution and oxytocin injection. Looking across the different systems and policy determinants of access, only Zimbabwe had all 15 commodities on both its essential medicines list and in its standard treatment guidelines, and only Cameroon and Zambia had at least one product registered for each commodity. Senegal alone procured all tracer commodities centrally in the previous year, and 70% of responding countries had costed plans for maternal, newborn, and child health. No country reported recent stock-outs of all the 15 commodities at the central level-countries always had some of the 15 commodities available; however, products with frequent stock-outs included misoprostol, calcium gluconate, penicillin injections, ceftriaxone, and amoxicillin dispersible tablets.

CONCLUSIONS

This analysis highlights country deficiencies in policies and systems, such as incoherent policy guidelines, problems in product registration, lack of logistics data, and central-level stock-outs that may affect access to essential RMNCH commodities. To tackle these deficiencies, countries need to integrate commodity-related indicators into other health monitoring activities to improve service quality.

Baseline population health conditions ahead of a health system strengthening program in rural Madagascar

Background: A model health district was initiated through a program of health system strengthening (HSS) in Ifanadiana District of southeastern Madagascar in 2014. We report population health indicators prior to initiation of the program.

Methods: A representative household survey based on the Demographic Health Survey was conducted using a two-stage cluster sampling design in two strata – the initial program catchment area and the future catchment area. Chi-squared and t-tests were used to compare data by stratum, using appropriate sampling weights. Madagascar data for comparison were taken from a 2013 national study.

Results: 1522 households were surveyed, representing 8310 individuals including 1635 women ages 15–49, 1685 men ages 15–59 and 1251 children under age 5. Maternal mortality rates in the district are 1044/100,000. 81% of women’s last childbirth deliveries were in the home; only 20% of deliveries were attended by a doctor or nurse/midwife (not different by stratum). 9.3% of women had their first birth by age 15, and 29.5% by age 18. Under-5 mortality rate is high: 145/1000 live births vs. 62/1000 nationally. 34.6% of children received all recommended vaccines by age 12 months (compared to 51.5% in Madagascar overall). In the 2 weeks prior to interview, approximately 28% of children under age 5 had acute respiratory infections of whom 34.7% were taken for care, and 14% of children had diarrhea of whom 56.6% were taken for care. Under-5 mortality, illness, care-seeking and vaccination rates were not significantly different between strata.

Conclusions: Indicators of population health and health care-seeking reveal low use of the formal health system, which could benefit from HSS. Data from this survey and from a longitudinal follow-up study will be used to target needed interventions, to assess change in the district and the impact of HSS on individual households and the population of the district.

[Is the fight against maternal mortality in Burkina Faso adapted to reduce the three delays?]

OBJECTIVE

Maternal mortality remains high in Burkina Faso despite numerous interventions designed to reduce this mortality. It therefore appeared important to analyse attempts to lower maternal mortality in Burkina Faso over the last fifteen years in order to identify the strengths and weaknesses and to improve the national programme.

METHODS

Analysis according to the ?three delays? model using the strengths, weaknesses, opportunities and threats method was conducted. Data sources were scientific publications as well as national gray literature.

RESULTS

Many studies have identified factors predisposing to the first delay, but very few effective interventions covering all of the country have been conducted to reduce this delay. The development of infrastructures, a rapid transfer system and integration of the cost of transfer into the cost of delivery subsidy were interventions designed to reduce the second delay. The promotion of blood transfusion, emergency obstetric and neonatal care, an increased number of trained health professionals, delegation of tasks, subsidy and then free delivery costs were interventions designed to reduce the third delay. The analysis globally demonstrated that interventions on the first delay were insufficient and rarely implemented and weaknesses were observed in relation to the intervention designed to act on the last two delays.

CONCLUSION

Due to their inadequacy and poor quality, the interventions failed to significantly reduce the three delays. Priority needs to be given to new interventions, especially community-based interventions, and reinforcement of the quality of care by health training.

Distribution of health facilities in Nigeria: Implications and options for Universal Health Coverage

BACKGROUND

Nigeria is considering adopting Universal Health Coverage (UHC) as an official policy target to ensure access to quality health care services for her population without financial hardship. To facilitate discussion on the topic, the President of Nigeria convened a UHC summit in March 2014 to discuss Nigeria's options and strategies to achieve UHC. A strategy for achieving UHC requires analysis of the available infrastructure to deliver the services. We review the geographic and sectoral distribution of health facilities in Nigeria and discuss implications on the UHC strategy selected.

METHODS

Secondary analysis of data from the Federal Ministry of Health's facility register was performed to assess the geographic and sectoral distribution of health facilities in Nigeria. Additionally, an extensive literature review was conducted to understand UHC strategies used by various countries and the associated health facility requirements.

RESULTS

Primary health facilities make up 88% of health facilities in Nigeria while secondary and tertiary health facilities make up 12% and 0.25%, respectively. There are more government-owned health facilities than privately owned health facilities (67% vs 33%). Secondary health facilities are predominantly privately owned. The ratio of public to private health facilities is much higher in the northern part of the country than in the southern part.

CONCLUSIONS

The distribution of health facilities across Nigeria is nonuniform. As such, a UHC strategy must be responsive to the variation in health facility distribution across the country. Additional investments are needed in some parts of the country to improve access to tertiary health facilities and leverage private sector capacity.

Modelling the effect of a mass radio campaign on child mortality using facility utilisation data and the Lives Saved Tool (LiST): findings from a cluster randomised trial in Burkina Faso

BACKGROUND

A cluster randomised trial (CRT) in Burkina Faso was the first to demonstrate that a radio campaign increased health-seeking behaviours, specifically antenatal care attendance, health facility deliveries and primary care consultations for children under 5 years.

METHODS

Under-five consultation data by diagnosis was obtained from primary health facilities in trial clusters, from January 2011 to December 2014. Interrupted time-series analyses were conducted to assess the intervention effect by time period on under-five consultations for separate diagnosis categories that were targeted by the media campaign. The Lives Saved Tool was used to estimate the number of under-five lives saved and the per cent reduction in child mortality that might have resulted from increased health service utilisation. Scenarios were generated to estimate the effect of the intervention in the CRT study areas, as well as a national scale-up in Burkina Faso and future scale-up scenarios for national media campaigns in five African countries from 2018 to 2020.

RESULTS

Consultations for malaria symptoms increased by 56% in the first year (95% CI 30% to 88%; p<0.001) of the campaign, 37% in the second year (95% CI 12% to 69%; p=0.003) and 35% in the third year (95% CI 9% to 67%; p=0.006) relative to the increase in the control arm. Consultations for lower respiratory infections increased by 39% in the first year of the campaign (95% CI 22% to 58%; p<0.001), 25% in the second (95% CI 5% to 49%; p=0.010) and 11% in the third year (95% CI -20% to 54%; p=0.525). Diarrhoea consultations increased by 73% in the first year (95% CI 42% to 110%; p<0.001), 60% in the second (95% CI 12% to 129%; p=0.010) and 107% in the third year (95% CI 43% to 200%; p<0.001). Consultations for other diagnoses that were not targeted by the radio campaign did not differ between intervention and control arms. The estimated reduction in under-five mortality attributable to the radio intervention was 9.7% in the first year (uncertainty range: 5.1%-15.1%), 5.7% in the second year and 5.5% in the third year. The estimated number of under-five lives saved in the intervention zones during the trial was 2967 (range: 1110-5741). If scaled up nationally, the estimated reduction in under-five mortality would have been similar (9.2% in year 1, 5.6% in year 2 and 5.5% in year 3), equating to 14 888 under-five lives saved (range: 4832-30 432). The estimated number of lives that could be saved by implementing national media campaigns in other low-income settings ranged from 7205 in Burundi to 21 443 in Mozambique.

CONCLUSION

Evidence from a CRT shows that a child health radio campaign increased under-five consultations at primary health centres for malaria, pneumonia and diarrhoea (the leading causes of postneonatal child mortality in Burkina Faso) and resulted in an estimated 7.1% average reduction in under-five mortality per year. These findings suggest important reductions in under-five mortality can be achieved by mass media alone, particularly when conducted at national scale.

In Madagascar, Use Of Health Care Services Increased When Fees Were Removed: Lessons For Universal Health Coverage

Despite overwhelming burdens of disease, health care access in most developing countries is extremely low. As governments work toward achieving universal health coverage, evidence on appropriate interventions to expand access in rural populations is critical for informing policies. Using a combination of population and health system data, we evaluated the impact of two pilot fee exemption interventions in a rural area of Madagascar. We found that fewer than one-third of people in need of health care accessed treatment when point-of-service fees were in place. However, when fee exemptions were introduced for targeted medicines and services, the use of health care increased by 65 percent for all patients, 52 percent for children under age five, and over 25 percent for maternity consultations. These effects were sustained at an average direct cost of US$0.60 per patient. The pilot interventions can become a key element of universal health care in Madagascar with the support of external donors.

Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar

INTRODUCTION

The Sustainable Development Goals framed an unprecedented commitment to achieve global convergence in child and maternal mortality rates through 2030. To meet those targets, essential health services must be scaled via integration with strengthened health systems. This is especially urgent in Madagascar, the country with the lowest level of financing for health in the world. Here, we present an interim evaluation of the first 2 years of a district-level health system strengthening (HSS) initiative in rural Madagascar, using estimates of intervention coverage and mortality rates from a district-wide longitudinal cohort.

METHODS

We carried out a district representative household survey at baseline of the HSS intervention in over 1500 households in Ifanadiana district. The first follow-up was after the first 2 years of the initiative. For each survey, we estimated maternal, newborn and child health (MNCH) coverage, healthcare inequalities and child mortality rates both in the initial intervention catchment area and in the rest of the district. We evaluated changes between the two areas through difference-in-differences analyses. We estimated annual changes in health centre per capita utilisation from 2013 to 2016.

RESULTS

The intervention was associated with 19.1% and 36.4% decreases in under-five and neonatal mortality, respectively, although these were not statistically significant. The composite coverage index (a summary measure of MNCH coverage) increased by 30.1%, with a notable 63% increase in deliveries in health facilities. Improvements in coverage were substantially larger in the HSS catchment area and led to an overall reduction in healthcare inequalities. Health centre utilisation rates in the catchment tripled for most types of care during the study period.

CONCLUSION

At the earliest stages of an HSS intervention, the rapid improvements observed for Ifanadiana add to preliminary evidence supporting the untapped and poorly understood potential of integrated HSS interventions on population health.

Effect of interrupting free healthcare for children: Drawing lessons at the critical moment of national scale-up in Burkina Faso

With solid evidence that free healthcare increases the utilization of health services, Burkina Faso recently exempted all children under five and pregnant women from direct payment at health facilities. However, there is little insight into the capacity to maintain the gains attributable to free healthcare under routine conditions of implementation at the national scale. In particular, the repercussions of its interruption are unknown. The objective is to assess the effects of a sequence of natural interventions including the introduction, interruption and reintroduction of free healthcare on health-seeking practices and utilization of healthcare facilities by children under five. This is an embedded mixed methods study conducted in Kaya district, Burkina Faso. The quantitative component is based on a reversal longitudinal design. Pooled interrupted time-series analysis was performed to assess changes in the monthly number of visits from January 2005 to March 2015. Qualitative data were collected through in-depth interviews with health personnel and mothers to better understand the quantitative results. The results show that visits to health centres dropped immediately and significantly when free healthcare was interrupted (-146, CI_95% [-255; -37]). They increased again when free healthcare was reintroduced (+89, CI_95% [-11; 187]). Both urban and rural centres were affected. Self-medication and visits to traditional healers were reported more frequently during the withdrawal of free healthcare, and tensions between the population and health personnel increased. Implementation problems other than insufficient funding limited the coverage or intensity of free healthcare. While removing user fees could potentially improve mothers and children's health in Burkina Faso, this study shows that demand for healthcare remains highly sensitive to price changes. Gains in utilization attributable to free healthcare may vanish rapidly if user fees are reintroduced. It is essential to support an effective and sustainable implementation of this ambitious initiative.

Local initiatives to access emergency obstetric and neonatal care in Burkina Faso

OBJECTIVE

To describe the various local initiatives to access emergency obstetric and neonatal care in Burkina Faso.

METHODS

An existing framework was used to review the three processes for local initiatives: emergence, formulation, and implementation. Multiple case studies were conducted, followed by literature review and semi-structured interviews with key informants.

RESULTS

Sixteen districts had implemented local initiatives, including cost sharing, free care for women and children, and free care for delivery and cesareans. Most districts (n=10) had implemented the cost-sharing intervention. These initiatives were initiated by local actors as well as nongovernmental organizations. The profile of those involved led to different ways of handling the emergence and formulation processes. At implementation, these initiatives faced many issues including late payment of contributions, low involvement of local governments, and equity in participation.

CONCLUSION

There are some issues in the implementation and sustainability of the local initiatives. Although many initiatives exist, these are unable to fully address the financial barriers to care. However, these initiatives highlight context-based financial barriers that must be taken into account to accelerate universal access to health care.

Using routine health data and intermittent community surveys to assess the impact of maternal and neonatal health interventions in low-income countries: A systematic review

BACKGROUND

There is a need to provide increased evidence on effective interventions to reduce maternal and neonatal mortality in low- and middle-income countries (LMICs).

OBJECTIVES

To summarize the breadth of knowledge on using routine data (Routine Health Information Systems [RHIS] and Intermittent Community Surveys [ICS]) for well-designed maternal and neonatal health evaluations in LMICs.

SEARCH STRATEGY

We searched reports and articles published in Embase, Medline, and Google scholar. Selection criteria Studies were considered for inclusion if they were carried out in LMICs, using RHIS or ICS data with experimental or quasi-experimental design.

DATA COLLECTION AND ANALYSIS

A form was used to collect information on indicators used for interventions' impact assessment. Descriptive statistics and multiple correspondence analyses were then performed.

MAIN RESULTS

Of the 1201 publications identified, 46 studies met the inclusion criteria. Most of these were using RHIS data (n=40), mainly extracted from health facility registers (n=34), and non-controlled before and after design (n=30). The indicators, which were mostly reported, were related to the use of healthcare services (n=36) and maternal/neonatal health outcomes (n=31). Few studies used ICS data (n=6) or indicators of severity (n=2).

CONCLUSION

RHIS and ICS data should be increasingly used for impact studies on maternal and neonatal health in LMICs.

A retrospective cohort study to quantify the contribution of health systems to child survival in Kenya: 1996-2014

Globally, the majority of childhood deaths in the post-neonatal period are caused by infections that can be effectively treated or prevented with inexpensive interventions delivered through even very basic health facilities. To understand the role of inadequate health systems on childhood mortality in Kenya, we assemble a large, retrospective cohort of children (born 1996–2013) and describe the health systems context of each child using health facility survey data representative of the province at the time of a child’s birth. We examine the relationship between survival beyond 59 months of age and geographic distribution of health facilities, quality of services, and cost of services. We find significant geographic heterogeneity in survival that can be partially explained by differences in distribution of health facilities and user fees. Higher per capita density of health facilities resulted in a 25% reduction in the risk of death (HRR = 0.73, 95% CI:0.58 to 0.91) and accounted for 30% of the between-province heterogeneity in survival. User fees for sick-child visits increased risk by 30% (HRR = 1.30, 95% CI:1.11 to 1.53). These results implicate health systems constraints in child mortality, quantify the contribution of specific domains of health services, and suggest priority areas for improvement to accelerate reductions in child mortality.

Immediate and sustained effects of user fee exemption on healthcare utilization among children under five in Burkina Faso: A controlled interrupted time-series analysis

BACKGROUND

Little is known about the long-term effects of user fee exemption policies on health care use in developing countries. We examined the association between user fee exemption and health care use among children under five in Burkina Faso. We also examined how factors related to characteristics of health facilities and their environment moderate this association.

METHOD

We used a multilevel controlled interrupted time-series design to examine the strength of effect and long term effects of user fee exemption policy on the rate of health service utilization in children under five between January 2004 and December 2014.

RESULTS

The initiation of the intervention more than doubled the utilization rate with an immediate 132.596% increase in intervention facilities (IRR: 2.326; 95% CI: 1.980 to 2.672). The effect of the intervention was 32.766% higher in facilities with higher workforce density (IRR: 1.328; 95% CI (1.209-1.446)) and during the rainy season (IRR:1.2001; 95% CI: 1.0953-1.3149), but not significant in facilities with higher dispersed populations (IRR: 1.075; 95% CI: (0.942-1.207)). Although the intervention effect was substantially significant immediately following its inception, the pace of growth, while positive over a first phase, decelerated to stabilize itself three years and 7 months later before starting to decrease slowly towards the end of the study period.

CONCLUSION

This study provides additional evidence to support user fee exemption policies complemented by improvements in health care quality. Future work should include an assessment of the impact of user fee exemption on infant morbidity and mortality and better discuss factors that could explain the slowdown in this upward trend of utilization rates three and a half years after the intervention onset.

From institutionalization of user fees to their abolition in West Africa: a story of pilot projects and public policies

This article analyzes the historical background of the institutionalization of user fees and their subsequent abolition in West Africa. Based on a narrative review, we present the context that frames the different articles in this supplement. We first show that a general consensus has emerged internationally against user fees, which were imposed widely in Africa in the 1980s and 1990s; at that time, the institutionalization of user fees was supported by evidence from pilot projects funded by international aid agencies. Since then there have been other pilot projects studying the abolition of user fees in the 2000s, but these have not yet had any real influence on public policies, which are often still chaotic. This perplexing situation might be explained more by ideologies and political will than by insufficient financial capacity of states.

Maternal healthcare in context: A qualitative study of women's tactics to improve their experience of public healthcare in rural Burkina Faso

Improving the use of public maternal health facilities to prevent maternal death is a priority in developing countries. Accumulating evidence suggests that a key factor in choosing a facility-based delivery is the collaboration and the communication between healthcare providers and women. This article attempts to provide a fine-grained understanding of health system deficiencies, healthcare provider practices and women's experiences with maternal public healthcare. This article presents findings from ethnographic research conducted in the Central-East Region of Burkina Faso over a period of eight months (January-August 2013). It is based on monthly interviews with 14 women from village (10) and town (4) and on structured observations of clinical encounters in three primary healthcare facilities (two rural and one urban) (23 days). In addition, 13 health workers were interviewed and 11 focus groups with women from village (6) and town (5) were conducted (48 participants). Guided by an analytic focus on strategies and tactics and drawing on recent discussions on the notion of 'biomedical security', the article explores what tactics women employ in their efforts to maximize their chances of having a positive experience with public maternal healthcare. The synthesis of the cases shows that, in a context of poverty and social insecurity, women employ five tactics: establishing good relations with health workers, being mindful of their 'health booklet', attending prenatal care consultations, minimizing the waiting time at the maternity unit and using traditional medicines. In this way, women strive to achieve biomedical security for themselves and their child and to preserve their social reputation. The study reveals difficulty in the collaboration and communication between health workers and women and suggests that greater attention should be paid to social relations between healthcare providers and users.

Effect of a policy to reduce user fees on the rate of skilled birth attendance across socioeconomic strata in Burkina Faso

BACKGROUND

In Sub-Saharan Africa, maternal and neonatal morbidity and mortality rates are associated with underutilization of skilled birth attendance (SBA). In 2007, Burkina Faso introduced a subsidy scheme for SBA fees. The objective of this study was to evaluate the effect of Burkina Faso's subsidy policy on SBA rate across socioeconomic status (SES) strata.

METHODS

We used a quasi-experimental design. The data sources were two representative surveys (n = 1408 and n = 1403) of women from Houndé and Ziniaré health districts of Burkina Faso, and a survey of health centres assessing structural quality of care. Multilevel Poisson regression models were used with robust variance estimators. We estimated adjusted rate ratios (RR) and rate differences (RD) as a function of time and SES.

RESULTS

For lowest-SES women, immediately upon the introduction of the subsidy policy, the rate of SBA was 45% higher (RR = 1.45, 95% confidence interval (CI): 1.19-1.77) than expected in the absence of subsidy introduction. The results indicated a sustained effect after introduction of the subsidy policy, based on RR estimate (95% CI) of 1.48 (1.21-1.81) at 2 years. For middle-SES women, the RR estimates were 1.28 (1.09-1.49) immediately after introduction of the subsidy policy and 1.30 (1.11-1.51) at 2 years, respectively. For highest-SES women, the RR estimates were 1.19 (1.02-1.38) immediately after subsidy introduction and 1.21 (1.06-1.38) at 2 years, respectively. The RD (95% CI) was 14% (3-24%) for lowest-SES women immediately after introduction of the policy, and the effect was sustained at 14% (4-25%) at 2 years.

CONCLUSION

Our study suggests that the introduction of a user-fee subsidy in Burkina Faso resulted in increased rates of SBA across all SES strata. The increase was sustained over time and strongest among the poorest women. These findings have important implications for evidence-informed policy making in Burkina Faso and other countries in Sub-Saharan Africa.

Protocol for the process evaluation of interventions combining performance-based financing with health equity in Burkina Faso

BACKGROUND

The low quality of healthcare and the presence of user fees in Burkina Faso contribute to low utilization of healthcare and elevated levels of mortality. To improve access to high-quality healthcare and equity, national authorities are testing different intervention arms that combine performance-based financing with community-based health insurance and pro-poor targeting. There is a need to evaluate the implementation of these unique approaches. We developed a research protocol to analyze the conditions that led to the emergence of these intervention arms, the fidelity between the activities initially planned and those conducted, the implementation and adaptation processes, the sustainability of the interventions, the possibilities for scaling them up, and their ethical implications.

METHODS/DESIGN

The study adopts a longitudinal multiple case study design with several embedded levels of analyses. To represent the diversity of contexts where the intervention arms are carried out, we will select three districts. Within districts, we will select both primary healthcare centers (n =18) representing different intervention arms and the district or regional hospital (n =3). We will select contrasted cases in relation to their initial performance (good, fair, poor). Over a period of 18 months, we will use quantitative and qualitative data collection and analytical tools to study these cases including in-depth interviews, participatory observation, research diaries, and questionnaires. We will give more weight to qualitative methods compared to quantitative methods.

DISCUSSION

Performance-based financing is expanding rapidly across low- and middle-income countries. The results of this study will enable researchers and decision makers to gain a better understanding of the factors that can influence the implementation and the sustainability of complex interventions aiming to increase healthcare quality as well as equity.