Do Targeted User Fee Exemptions Reach the Ultra-Poor and Increase their Healthcare Utilisation? A Panel Study from Burkina Faso

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

BACKGROUND

Burkina Faso has been implementing financing reforms towards universal health coverage (UHC) since 2006. Recently, the country introduced a performance-based financing (PBF) program as well as user fee removal (gratuité) policy for health services aimed at pregnant and lactating women and children under 5. We aim to assess the effect of gratuité and PBF policies on facility-based out-of-pocket expenditures (OOPEs) for outpatient services.

METHODS

Our study is a controlled pre- and post-test design using healthcare facility data from the PBF program's impact evaluation collected in 2014 and 2017. We compared OOPE related to primary healthcare use incurred by children under 5 and individuals above 5 to assess the effect of the gratuité policy on OOPE. We further compared OOPE incurred by individuals residing in PBF districts and non-PBF districts to estimate the effect of the PBF on OOPE. Effects were estimated using difference-in-differences models, distinguishing the estimation of the probability of incurring OOPE from the estimation of the magnitude of OOPE using a generalized linear model (GLM).

RESULTS

The proportion of children under 5 incurring OOPE declined significantly from 90% in 2014 to 3% in 2017. Concurrently, mean OOPE also decreased. Differences in both the probability of incurring OOPE and mean OOPE between PBF and non-PBF facilities were small. Our difference in differences estimates indicated that gratuité produced an 84% (CI -86%, -81%) reduction in the probability of incurring OOPE and reduced total OOPE by 54% (CI 63%, 42%). We detected no significant effects of PBF, either in reducing the probability of incurring OOPE or in its magnitude.

CONCLUSION

User fee removal is an effective demand-side intervention for enhancing financial accessibility. As a supply-side intervention, PBF appears to have limited effects on reducing financial burden.

Effects of a free health insurance programme for the poor on health service utilisation and financial protection in Senegal

INTRODUCTION

Implemented in 2013 in Senegal, the Programme National de Bourses de Sécurité Familiale (PNBSF) is a national cash transfer programme for poor households. Besides reducing household poverty and encouraging children's school attendance, an objective of the PNBSF is to expand health coverage by guaranteeing free enrolment in community-based health insurance (CBHI) schemes. In this paper, we provide the first assessment of the PNBSF free health insurance programme on health service utilisation and health-related financial protection.

METHODS

We collected household-level and individual-level cross-sectional data on health insurance in 2019-2020 within the Niakhar Population Observatory in rural Senegal. We conducted a series of descriptive analyses to fully describe the application of the PNBSF programme in terms of health coverage. We then used multivariate logistic and Poisson regression models within an inverse probability weighting framework to estimate the effect of being registered in a CBHI through the PNBSF-as compared with having no health insurance or having voluntarily enrolled in a CBHI scheme-on a series of outcomes.

RESULTS

With the exception of health facility deliveries, which were favoured by free health insurance, the PNBSF did not reduce the unmet need for healthcare or the health-related financial risk. It did not increase individuals' health service utilisation in case of health problems, did not increase the number of antenatal care visits and did not protect households against the risk of forgoing medical care and of catastrophic health expenditure.

CONCLUSION

We found limited effects of the PNBSF free health insurance on health service utilisation and health-related financial protection, although these failures were not necessarily due to the provision of free health insurance per se. Our results point to both implementation failures and limited programme outcomes. Greater commitment from the state is needed, particularly through strategies to reduce barriers to accessing covered healthcare.

Knowledge of COVID-19 and the impact on indigents' access to healthcare in Burkina Faso

BACKGROUND

COVID-19 constitutes a global health emergency of unprecedented proportions. Preventive measures, however, have run up against certain difficulties in low and middle-income countries. This is the case in socially and geographically marginalized communities, which are excluded from information about preventive measures. This study contains a dual objective, i) to assess knowledge of COVID-19 and the preventive measures associated with it concerning indigents in the villages of Diebougou's district in Burkina Faso. The aim is to understand if determinants of this understanding exist, and ii) to describe how their pathways to healthcare changed from 2019 to 2020 during the COVID-19 pandemic.

METHODS

The study was conducted in the Diebougou healthcare district, in the south-west region of Burkina Faso. We relied on a cross-sectional design and used data from the fourth round of a panel survey conducted among a sample of ultra-poor people that had been monitored since 2015. Data were collected in August 2020 and included a total of 259 ultra-poor people. A multivariate logistic regression to determine the factors associated with the respondents' knowledge of COVID-19 was used.

RESULTS

Half of indigents in the district said they had heard about COVID-19. Only 29% knew what the symptoms of the disease were. The majority claimed that they protected themselves from the virus by using preventive measures. This level of knowledge of the disease can be observed with no differences between the villages. Half of the indigents who expressed themselves agreed with government measures except for the closure of markets. An increase of over 11% can be seen in indigents without the opportunity for getting healthcare compared with before the pandemic.

CONCLUSIONS

This research indicates that COVID-19 is partially known and that prevention measures are not universally understood. The study contributes to reducing the fragmentation of knowledge, in particular on vulnerable and marginalized populations. Results should be useful for future interventions for the control of epidemics that aim to leave no one behind.

Effect of the free healthcare policy on socioeconomic inequalities in care seeking for fever in children under five years in Burkina Faso: a population-based surveys analysis

Background

In 2016, Burkina Faso implemented a free healthcare policy as an initiative to remove user fees for women and under-5 children to improve access to healthcare. Socioeconomic inequalities create disparities in the use of health services which can be reduced by removing user fees. This study aimed to assess the effect of the free healthcare policy (FHCP) on the reduction of socioeconomic inequalities in the use of health services in Burkina Faso.

Methods

Data were obtained from three nationally representative population based surveys of 2958, 2617, and 1220 under-5 children with febrile illness in 2010, 2014, and 2017–18 respectively. Concentration curves were constructed for the periods before and after policy implementation to assess socioeconomic inequalities in healthcare seeking. In addition, Erreyger’s corrected concentration indices were computed to determine the magnitude of these inequalities.

Results

Prior to the implementation of the FHCP, inequalities in healthcare seeking for febrile illnesses in under-5 children favoured wealthier households [Erreyger’s concentration index = 0.196 (SE = 0.039, p = 0.039) and 0.178 (SE = 0.039, p < 0.001) in 2010 and 2014, respectively]. These inequalities decreased after policy implementation in 2017–18 [Concentration Index (CI) = 0.091, SE = 0.041; p = 0.026]. Furthermore, existing pro-rich disparities in healthcare seeking between regions before the implementation of the FHCP diminished after its implementation, with five regions having a high CI in 2010 (0.093–0.208), four regions in 2014, and no region in 2017 with such high CI. In 2017–18, pro-rich inequalities were observed in ten regions (CI:0.007–0.091),whereas in three regions (Plateau Central, Centre, and Cascades), the CI was negative indicating that healthcare seeking was in favour of poorest households.

Conclusion

This study demonstrated that socioeconomic inequalities for under-5 children with febrile illness seeking healthcare in Burkina Faso reduced considerably following the implementation of the free healthcare policy. To reinforce the reduction of these disparities, policymakers should maintain the policy and focus on tackling geographical, cultural, and social barriers, especially in regions where healthcare seeking still favours rich households.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01732-2.

Why did performance-based financing in Burkina Faso fail to achieve the intended equity effects? A process tracing study

In recent years, performance-based financing (PBF) has attracted attention as a means of reforming provider payment mechanisms in low- and middle-income countries. Particularly in combination with demand-side interventions, PBF has been assumed to benefit also the most vulnerable and disadvantaged groups. However, impact evaluations have often found this not to be the case. In Burkina Faso, PBF was coupled with specific equity measures to enhance healthcare utilization among the ultra-poor, but failed to produce the expected effects. Our study used the process tracing methodology to unravel the reasons for the lack of impact produced by the equity measures. We relied on published evidence, secondary data analysis, and findings from a qualitative study to support or invalidate the hypothesized causal mechanism, that is the reconstructed theory of change of the equity measures. Our findings show how various contextual, design, and implementation challenges hindered the causal mechanism from unfolding as planned. These included issues with the identification and exemption of the ultra-poor on the demand side, and with financial issues and considerations on the supply side. In broader terms, our findings underline the difficulty in improving access to care for the ultra-poor, given the multifaceted and complex nature of barriers to care the most vulnerable face. From a methodological point of view, our study demonstrates the value and applicability of process tracing in complementing other forms of evaluation for complex interventions in global health.

Financial burden associated with attendance at a public hospital emergency department in Johannesburg

•

Poverty and inequality are two of the most significant issues affecting people living in Africa

•

Catastrophic health care expenditure (CHCE), which is out-of-pocket expenditure on medical care that leads to a severe financial burden for the individual or household, affects 44 million individuals from 150 million households globally

•

Various expenses including transport costs, general practitioner fees acquired prior to the EC visit, loans and loss of usual daily income contribute to the financial burden associated with a visit to the EC

Introduction: More than half of South Africans live below the poverty line. Indirect medical costs can contribute significantly to the financial burden of patients seeking medical care. The aim of this study was to determine the expenses incurred by patients and/or their escorts during a visit to the emergency centre (EC).

Methods: Patients and/or their escorts presenting to an EC in Johannesburg were asked to complete the study questionnaire relating to expenses incurred during a visit to the EC.

Results: Of the total 396 participants that completed the questionnaire, 108 (27.2%) did not have any source of income, 146 (36.9%) were the sole breadwinner in their household and 36 (9.1%) belonged to zero-income households. Among those earning ≤R2000 per month, the mean expenses relating to the EC visit was R240 (SD R372), equating to an average of 33.2% of mean monthly income. Transport costs were the most common expense (n=302, 76.3%), while general practitioner (GP) fees incurred prior to the EC visit accounted for the bulk of the expenses (median R450, IQR 350-820). Participants that earned >R2000 per month were significantly more likely to incur GP fees (p =0.012), while those earning ≤R2000 per month were significantly more likely to take a loan to cover EC related expenses (p =0.014).

Conclusion: A visit to the EC can have a substantial financial impact on patients and their accompanying escorts in South Africa. Strategies should be aimed at identifying and assisting those that are in need of financial assistance to cover indirect healthcare costs.

Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia

In Cambodia, diabetes caused nearly 3% of the country’s mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ($27 per DALY averted) and increases in financial risk protection ($2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated $28 and $58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.

How could patient navigation help promote health equity in sub-Saharan Africa? A qualitative study among public health experts

The indigents have long been excluded from health policies in sub-Saharan Africa. Despite recent efforts by some countries to allow them free access to health services, they face a multitude of non-financial barriers that prevent them from accessing care. Interventions to address the multiple patient-level barriers to care, such as patient navigation interventions, could help reverse this trend. However, our scoping review showed that no navigation interventions in low-income countries targeted the indigents. The objective of this qualitative study is, therefore, to go beyond the lack of evidence and discuss relevant approaches to act in favor of health care equity. We interviewed 22 public health experts with the objective of finding out which actions related to patient navigation programs (identified in the scoping review for other target groups) could be relevant and/or adapted for the indigents. For each ability to access care described by Levesque and colleagues, we were thus able to list the potential opportunities and challenges of implementing each type of action for the indigents in sub-Saharan Africa. Overall, the experts all felt that patient navigation programs were very relevant to implement for the indigents. They emphasized the need for personalized follow-up and for holistic actions to consider the whole context of the situation of indigence. The recommendations made by the experts are valuable in guiding political decision-making, while leaving room for adaptation of the proposed guidelines according to different contexts.

Factors related to excessive out-of-pocket expenditures among the ultra-poor after discontinuity of PBF: a cross-sectional study in Burkina Faso

BACKGROUND

Measuring progress towards financial risk protection for the poorest is essential within the framework of Universal Health Coverage. The study assessed the level of out-of-pocket expenditure and factors associated with excessive out-of-pocket expenditure among the ultra-poor who had been targeted and exempted within the context of the performance-based financing intervention in Burkina Faso. Ultra-poor were selected based on a community-based approach and provided with an exemption card allowing them to access healthcare services free of charge.

METHODS

We performed a descriptive analysis of the level of out-of-pocket expenditure on formal healthcare services using data from a cross-sectional study conducted in Diébougou district. Multivariate logistic regression was performed to investigate the factors related to excessive out-of-pocket expenditure among the ultra-poor. The analysis was restricted to individuals who reported formal health service utilisation for an illness-episode within the last six months. Excessive spending was defined as having expenditure greater than or equal to two times the median out-of-pocket expenditure.

RESULTS

Exemption card ownership was reported by 83.64% of the respondents. With an average of FCFA 23051.62 (USD 39.18), the ultra-poor had to supplement a significant amount of out-of-pocket expenditure to receive formal healthcare services at public health facilities which were supposed to be free. The probability of incurring excessive out-of-pocket expenditure was negatively associated with being female (β = - 2.072, p = 0.00, ME = - 0.324; p = 0.000) and having an exemption card (β = - 1.787, p = 0.025; ME = - 0.279, p = 0.014).

CONCLUSIONS

User fee exemptions are associated with reduced out-of-pocket expenditure for the ultra-poor. Our results demonstrate the importance of free care and better implementation of existing exemption policies. The ultra-poor's elevated risk due to multi-morbidities and severity of illness need to be considered when allocating resources to better address existing inequalities and improve financial risk protection.