Pro-poor health policy in Burkina Faso

Exploring the Implementation Gap of a Pro-
poor Health Policy: the National Subsidy for
Deliveries in Burkina Faso

Ridde V., Kouanda S., Yameogo M., Kadio K, Bado A., Haddad S.

ISEQH, Cartegena, Sept 28, 2011

Gilson and Raphaely (2008)

“more work on
implementation, and
specifically, the challenges
of implementing equity-
oriented policies.”

© UdeM / VR-SH 2011 2

Global Campaign for the Health MDGs 2009
Free quality services for women and
children at the point of use and other
access barriers removed

African Union 2010 (Kampala) :
User fees abolition for pregnant women
and children under 5 years

© UdeM / VR-SH 2011

Background; Burkina Faso (WHO 2010)

• Maternal mortality in 2008 = 560/100,000
• Assisted deliveries from 47% in 2006 to 76% in 2010
• 7 nurses/midwifes for 10.000 inhabitants
• Inequalities in access in 2005
• Poor: AD =39%
• Less poor AD = 91%
• Health expenditures in 2008:
• 5.9% GDP; Total HE per capita = 37$; OOPS = 93%
• HH selling assets and borrowing:
• Q1 = 70% vs Q5 = 50% (WHS 2003)


Public policy subsidies for emergency
obstetric and neonatal care (2006-2007)

• Subsidies:
• 60%-80% of C-sec / deliveries costs
• 100% of C-sec / deliveries costs for worst-off
• 100% of the cost of evacuation (PHC to Hosp)

• Funding:
• National budget. Provision: 30 B. F (2006-2015)
• Indigence fund: 5 B F (needs of 23% of exp. deliveries).

• Remaining payments (user fees):
• 900 F (1.4 E) / normal delivery in a PHC
• 11,000 F (17 E) / C-sec
• 0 F for the worst off
© UdeM / VR-SH 2011 5

Study objectives

• To evaluate the benefits distribution of
the national maternal healthcare subsidy
policy in terms of medical expenses for
deliveries and financial protection of
households
• To understand these results

© UdeM / VR-SH 2011 6

Study design :

• Explanatory sequential mixed methods
design
• QUANT => QUAL
• Equal priority to both QUANT and
QUAL methods

© UdeM / VR-SH 2011 7

QUANTITATIVE STRAND

• Health facility survey: assisted normal deliveries.
• Recall period : 6 Weeks

• Household surveys 2006 – 2010 (independent samples)

Survey 2006
Policy 2010

HH S1 N=1170
X
HH S2 N=1035

• Amount paid for facility–based delivery (normal delivery)


Health expenditures per delivery (2006 – 2010)

MEAN MEDIAN

© UdeM / VR-SH 2011 9

Distribution of HE across groups (2006 – 2010)


Global change in the prevalence of high HE (2006 standards)

© UdeM / VR-SH 2011 11

Change in the prevalence of outliers (2006 standards)

© UdeM / VR-SH 2011 12

HE needs adjusted share in the consumption per
income groups (2006-2010)

Q1 Q5


Prevalence of “zero-cost” episodes per
income group

© UdeM / VR-SH 2011 14

Implementation gap for normal deliveries in 2010 (n=883)

Grand mean =
1.863 F CFA

Official fee = 900 F CFA

15

QUALITATIVE STRAND

• Population : “policy-makers” (Lipsky) = implementors
1 - Focus group with all health centre managers (n=33)
• Extreme case studies approach
• quantitative results guide the selection of qualitative data sources
• four health centres where the highest average reported payments
2 - In depth interviewed
• healthcare workers ( n=10)
• community leaders (n= 8)
• the director of reproductive health and the former chief medical
officer of the district (n=2)
• Inductive/thematic qualitative analysis

© UdeM / VR-SH 2011 16

FIRST : SURPRISE AND DENIAL

1. criticized the women’s capacity to respond to questions
about expenses :
• “Really, that gap, there, it surprises me. I wonder if, on
the day of the questioning, the women really understood”
nuser
1. methodology and validity of the data was called into
question :
• “Did you require them to show you the receipt? Didn’t the
people questioned, really only say what they wanted to
say?” nurse
1. would be reimbursed:
• “…and our parents, there, they think when they tell you
this, you’ll reimburse them,” midwife.

© UdeM / VR-SH 2011 17

IMPLEMENTATION GAP


IMPLEMENTATION GAP

• Lack of policy understanding
•« We have a serious trouble to understand
the subsidies policy » Nurse
 lack of support to the implementers
 inadequate information
 intentional strategy
• Improper conduct on the part of health workers
•« the problem is concerning the rest of the
items from the kit » Nurse


Policy of subsidizing 80% of the direct costs
of normal deliveries

• Very effective in reducing household costs;
• Was progressive, with women in the bottom quintile
benefiting more than those in the top quintile;
• The prevalence of households with excessive spending on
deliveries was very significantly reduced;

© UdeM / VR-SH 2011 21

Lessons learned for improving the
implementation of fees subsidization policies

• Involve street-level workers in defining the policy’s
content;
• Test the policy’s implementation and instruments before
scaling up nationally;
• Regularly update the policy’s operating manual to correct
any errors and ambiguities;
• Make the manual’s contents accessible and adapted to all
levels of the health system and for all the health workers
involved;
• Keep the population informed about the policy’s content
and procedures;
• Carry out regular population surveys to find out whether
the policy is actually benefiting its target population .
© UdeM / VR-SH 2011 22

An “endogenous approach” for the evaluation of the
effects on the risk of catastrophic expenditures

• Endogenous threshold based on the existing distribution
• Sk2006 = Q3 + k* (Q3-Q1); 0.5<= k <=1.5
• If HEi>Sk, i is at risk of catastrophic expenditure

Q3

Q1

See = Mukherje, S., Haddad, S., & Narayana, D. (2011). International Journal of Equity Health, 10.

© UdeM / VR-SH 2011 24

Pro-poor health policy in Burkina Faso

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