Assessing the efficiency of rural health centres in Burkina Faso: an application of Data Envelopment Analysis

Background  Effective health care provision benefits from the support of measurement techniques. Contrary to the situation in industrialised countries efficiency analyses in the health care sector in Africa are a very recent phenomenon. Hardly any of the existing studies was conducted at the level of primary care. Aim  The purpose of this study was twofold: (1) to evaluate the relative efficiency of health centres in rural Burkina Faso and (2) to investigate reasons for inefficient performance. Methods  Data Envelopment Analysis (DEA) was applied. To account for the situation in that country, the output-oriented approach was used in connection with different returns to scale assumptions. To identify the spatial effect of the catchment area on efficiency the Tobit model was applied. Results  According to constant returns to scale, 14 health centres were relatively efficient. The DEA projections suggest that the inefficient units were too big to be efficient. Tobit regression showed that the relatively efficient health centres are located close to villages in their catchment area. Conclusions  For ethical reasons it is not appropriate to try to improve the efficiency of health centres by closing some of them. Their efficiency can be improved and lives can be saved if access to health centres is enhanced. Funding: This study was supported by a research grant of the German Research Foundation (Deutsche Forschungsgemeinschaft).     

Illness reporting and demand for medical care in rural Burkina Faso

The issue of illness reporting in modelling demand for health care in low- and middle-income countries can be handled according to either of two conceptually-different constructs: (a) considering illness reporting behaviour as endogenous to demand; or (b) considering demand itself as the outcome of a sample selection phenomenon. In this paper, we take the second viewpoint and estimate the demand for medical care with an estimator that uses Heckman-type. Empirical estimates based on household survey data from rural Burkina Faso suggest that there are some implications of illness reporting behaviour for modelling the demand for medical care.     

Willingness-to-pay for community-based insurance in Burkina Faso

PURPOSE: To study the willingness-to-pay (WTP) for a proposed community-based health insurance (CBI) scheme in order to provide information about the relationship between the premium that is required to cover the costs of the scheme and expected insurance enrollment levels. In addition, factors that influence WTP were to be identified. METHODS: Data were collected from a household survey using a two-stage cluster sampling approach, with each household having the same probability of being selected. Interviews were conducted with 2414 individuals and 705 household heads. The take-it-or-leave-it (TIOLI) and the bidding game were used to elicit WTP. RESULTS: The average individual was willing to pay 2384 (elicited by the TIOLI) or 3191 (elicited by the bidding game) CFA (3.17 US dollars or 4.25 US dollars) to join CBI for him/herself. The head of household agreed to pay from 6448 (elicited by the TIOLI) or 9769 (elicited by the bidding game) CFA (8.6 US dollars or 13.03 US dollars) to join the health insurance scheme for his/her household. These results were influenced by household and individual ability-to-pay, household and individual characteristics, such as age, sex and education. The two methods yielded similar patterns of estimated WTP, in that higher WTP was obtained for higher income level, higher previous medical expenditure, higher education, younger people and males. A starting point bias was found in the case of the bidding game. CONCLUSIONS: Both TIOLI and bidding game methods can elicit a value of WTP for CBI. The value elicited by the bidding game is higher than by the TIOLI, but the two approaches yielded similar patterns of estimated WTP. WTP information can be used for setting insurance premium. When setting the premiums, it is important to consider differences between the real market and the theoretical one, and between the WTP and the cost of benefits package. The beneficiaries of CBI should be enrolled at the level of households or villages in order to protect vulnerable groups such as women, elders and the poor.     

Evaluation of pneumococcal meningitis clusters in Burkina Faso and implications for potential reactive vaccination

BackgroundTo better understand how to prevent and respond to pneumococcal meningitis outbreaks in the meningitis belt, we retrospectively examined Burkina Faso’s case-based meningitis surveillance data for pneumococcal meningitis clusters and assessed potential usefulness of response strategies.MethodsDemographic and clinical information, and cerebrospinal fluid laboratory results for meningitis cases were collected through nationwide surveillance. Pneumococcal cases were confirmed by culture, polymerase chain reaction (PCR), or latex agglutination; strains were serotyped using PCR. We reviewed data from 2011 to 2017 to identify and describe clusters of ≥ 5 confirmed pneumococcal meningitis cases per week in a single district. We assessed whether identified clusters met the 2016 WHO provisional pneumococcal meningitis outbreak definition: a district with a weekly incidence of >5 suspected meningitis cases/100,000 persons, >60% of confirmed meningitis cases caused by Streptococcus pneumoniae, and >10 confirmed pneumococcal meningitis cases.ResultsTwenty pneumococcal meningitis clusters were identified, with a maximum weekly incidence of 7 cases and a maximum duration of 4 weeks. Most identified clusters (15/20; 75%) occurred before nationwide introduction of 13-valent pneumococcal conjugate vaccine (PCV13) in October 2013. Most cases were due to serotype 1 (74%), 10% were due to PCV13 serotypes besides serotype 1, and 8 clusters had >1 serotype. While 6 identified clusters had a weekly incidence of >5 suspected cases/100,000 and all 20 clusters had >60% of confirmed meningitis cases due to S. pneumoniae, no cluster had >10 confirmed pneumococcal meningitis cases in a single week.ConclusionsFollowing PCV13 introduction, pneumococcal meningitis clusters were rarely detected, and none met the WHO provisional pneumococcal outbreak definition. Due to the limited cluster size and duration, there were no clear instances where reactive vaccination could have been useful. More data are needed to inform potential response strategies.     

Comparison of knowledge on stroke for stroke patients and the general population in Burkina Faso: a cross-sectional study

BackgroundIn many parts of Africa, there is limited information on awareness of symptoms of stroke, risk factors for stroke and willingness for stroke prevention, both in the general population and in people with stroke. Knowledge and preventive efforts for stroke in patients with a history of the illness are rarely investigated. This study aims to investigate awareness of stroke symptoms in stroke patients who were admitted to hospitals within 72 hours of a confirmed stroke event in Burkina Faso. This study also aims to investigate preventive behavior for stroke for the general population.MethodsFace-to-face interviews were conducted with the participants. The sample included 110 first-time stroke patients who had been admitted to one of three tertiary teaching hospitals in Burkina Faso within 72 hours and 750 participants from the general population, who were recruited through clustered sampling. Knowledge of stroke warning signs and current and future efforts on stroke prevention were also assessed.ResultsOnly 30.9% of the stroke patients believed that they were at risk before the stroke episode. Obvious warning signs were unfamiliar to both groups. Only 1.3% of the respondents from the general population group knew sudden weakness face arm or leg as a sign of stroke. For all future efforts in stroke prevention, stroke patients demonstrated significantly lower willingness to undertake behavioral changes than the general population. Sixty-six percent and 85% of the stroke patients and the general population, respectively, were willing to take steps to reduce blood pressure.ConclusionPublic education on stroke warning signs and strategies to increase willingness to engage in preventive behaviors are urgent in African countries. Strategies to improve public awareness for developing countries such as Burkina Faso should be designed differently from that of developed countries to incorporate local beliefs.     

Gender and HIV testing in Burkina Faso: An exploratory study

This study investigated the utilization of services around HIV testing in Burkina Faso through a survey that combined quantitative and qualitative data from 14 selected sites and 299 questionnaires. While some attitudes and behaviors towards HIV testing were similar for women and men, we found lower use of services by men, greater concerns about testing and disclosure on the part of women, and differences between men and women in motivations to test, and the experience of testing and its consequences. The results are discussed in the context of Burkina Faso and in terms of their implications for efforts to improve access to services around HIV.     

A delicate web: Household changes in health behaviour enabled by microcredit in Burkina Faso

Abstract

Providing microcredit to women in developing countries has long been highlighted as a simple and effective strategy for poverty reduction and health improvement. However, little is known about how microcredit enables changes in health behaviour. This knowledge is critical to further strengthen microcredit initiatives. This qualitative study, conducted in Burkina Faso, shows how microcredit can not only facilitate savings and investment strategies, but also lead to changes in household decision-making, enabling women to initiate health prevention, seek health treatment and manage health emergencies. Some changes led to increased household burdens for women that impeded health gains, such as administrative loan delays by the microcredit institution and reduced household contributions by the husband. Furthermore, the study highlighted the fragile nature of health gains, which may be eroded due to economic shocks on a household, such as crop failure, drought or illness.     

Education among orphans and non-orphans in an urban area of Burkina Faso

Abstract

Africa has long dealt with issues surrounding orphanhood and the fostering of children whose parents are no longer alive or available. With the increasing impact of HIV reflected demographically throughout the world, the sociodemographic situation of orphans in sub-Saharan Africa has only grown in visibility and importance. This paper compares orphans and non-orphans living in an urban area of Burkina Faso (Bobo-Dioulasso), with a special focus on school enrolment and delay. We found in univariate analysis that orphans and non‐orphans are equally likely to be enrolled in school, but orphans are more likely to be delayed. Once controlling for sociodemographic differences, however, orphans are not delayed significantly in school when compared with non-orphans. Results suggest that, while orphans may be at educational risk due to other concomitant sociodemographic factors, in this urban area orphan status alone does not significantly predict educational enrolment and short-term outcome.     

Measles outbreak in Burkina Faso, 2009: a case-control study to determine risk factors and estimate vaccine effectiveness

Objective

We investigated a large measles outbreak that occurred in 2009 in Burkina Faso in order to describe the epidemic, assess risk factors associated with measles, and estimate measles vaccine effectiveness.

Methods

We reviewed national surveillance and measles vaccine coverage data, and conducted a case–control study in three geographic areas. Case-patients were randomly selected from the national case-based measles surveillance database or, when a case-patient could not be traced, were persons in the same community who experienced an illness meeting the WHO measles clinical case definition. Controls were matched to the same age stratum (age 1–14 years or age 15–30 years) and community as case-patients. Risk factors were assessed using conditional logistic regression.

Results

Lack of measles vaccination was the main risk factor for measles in all three geographic areas for children aged 1–14 years (adjusted matched odds ratio [aMOR] [95% confidence interval (CI)], 19.4 [2.4–155.9], 5.9 [1.6–21.5], and 6.4 [1.8–23.0] in Bogodogo, Zorgho, and Sahel, respectively) and persons aged 15–30 years (aMOR [95% CI], 3.2 [1.1–9.7], 19.7 [3.3–infinity], 8.0 [1.8–34.8] in Bogodogo, Zorgho, and Sahel, respectively). Among children aged 1–14 years, VE of any measles vaccination prior to 2009 was 94% (95% CI, 45–99%) in Bogodogo, 87% (95% CI, 37–97%) in Zorgho, and 84% (95% CI, 41–96%) in Sahel. Main reasons for not receiving measles vaccination were lack of knowledge about vaccination campaigns or need for measles vaccination and absence during vaccination outreach or campaign activities.

Conclusion

These results emphasize the need for improved strategies to reduce missed opportunities for vaccination and achieve high vaccination coverage nationwide in order to prevent large measles outbreaks and to continue progress toward measles mortality reduction.     

Health insurance and health-seeking behavior: evidence from a randomized community-based insurance rollout in rural Burkina Faso

In 2004, a community-based health insurance (CBI) scheme was introduced in Nouna district, Burkina Faso, with the primary objective of improving access to facility-based health services. In order to overcome self-selection issues in the analysis of the behavioral effects of insurance, we combine four waves of the Nouna Health District Household Survey into a panel data set, and use the randomized timing of insurance rollout to estimate the causal effect of insurance coverage on health-seeking behavior. While we find a generally positive association between CBI affiliation and treatment seeking, we cannot reject the null that the introduction of health insurance does not have any effect on treatment seeking in general, and utilization of facility-based professional care, in particular. Low levels of health care provider satisfaction, poor perceived quality of care by enrollees, and ambiguity in the coverage level of the CBI benefit package appear to have contributed to these weak results. Our findings imply that the basic notion of insurance mechanically increasing facility-based professional care is not necessarily true empirically, and likely contingent on a large number of contextual factors affecting health-seeking behavior within households and communities.     

Improving poor women's access to maternity care: Findings from a primary care intervention in Burkina Faso

To date, there has been little progress in reducing wealth inequities in access to maternity care. This paper describes the results of a maternal health intervention in Burkina Faso that was aimed at increasing access to skilled maternity care by improving availability and quality of maternity care, particularly at primary care health facilities, and promoting its use before, during, and after delivery. Post-intervention data show a large overall increase in use of facility-based maternity care in the intervention district, particularly at primary care facilities, but little change in the comparison district. In addition, large wealth inequities in the use of professional care during childbirth were almost eliminated in the intervention district while they increased in the comparison district—both among all women, and among the subset of women who reported experiencing complications during delivery. Study results suggest that efforts to upgrade maternity services at primary care facilities may be key for improving poor women's access to and use of skilled care during childbirth.     

Paying the price: the cost and consequences of emergency obstetric care in Burkina Faso

Substantial healthcare expenses can impoverish households or push them further into poverty. In this paper, we examine the cost of obstetric care and the social and economic consequences associated with exposure to economic shocks up to a year following the end of pregnancy in Burkina Faso. Burkina Faso is a low-income country with poor health outcomes and a poorly functioning health system. We present an inter-disciplinary analysis of an ethnographic study of 82 women nested in a prospective cohort study of 1013 women. We compare the experiences of women who survived life-threatening obstetric complications ('near-miss' events) with women who delivered without complications in hospitals. The cost of emergency obstetric care was significantly higher than the cost of care for uncomplicated delivery. Compared with women who had uncomplicated deliveries, women who survived near-miss events experienced substantial difficulties meeting the costs of care, reflecting the high cost of emergency obstetric care and the low socioeconomic status of their households. They reported more frequent sale of assets, borrowing and slower repayment of debt in the year following the expenditure. Healthcare costs consumed a large part of households' resources and women who survived near-miss events continued to spend significantly more on healthcare in the year following the event, while at the same time experiencing continued cost barriers to accessing healthcare. In-depth interviews confirm that the economic burden of emergency obstetric care contributed to severe and long-lasting consequences for women and their households. The necessity of meeting unexpectedly high costs challenged social expectations and patterns of reciprocity between husbands, wives and wider social networks, placed enormous strain on everyday survival and shaped physical, social and economic well-being in the year that followed the event. In conclusion, we consider the implications of our findings for financing mechanisms for maternity care in low-income settings.     

Twelve months of implementation of health care performance‐based financing in Burkina Faso: A qualitative multiple case study

To improve health services' quantity and quality, African countries are increasingly engaging in performance‐based financing (PBF) interventions. Studies to understand their implementation in francophone West Africa are rare. This study analysed PBF implementation in Burkina Faso 12 months post‐launch in late 2014. The design was a multiple and contrasted case study involving 18 cases (health centres). Empirical data were collected from observations, informal (n = 224) and formal (n = 459) interviews, and documents. Outside the circle of persons trained in PBF, few in the community had knowledge of it. In some health centres, the fact that staff were receiving bonuses was intentionally not announced to populations and community leaders. Most local actors thought PBF was just another project, but the majority appreciated it. There were significant delays in setting up agencies for performance monitoring, auditing, and contracting, as well as in the payment. The first audits led rapidly to coping strategies among health workers and occasionally to some staging beforehand. No community‐based audits had yet been done. Distribution of bonuses varied from one centre to another. This study shows the importance of understanding the implementation of public health interventions in Africa and of uncovering coping strategies.     

The differences in characteristics between health-care users and non-users: implication for introducing community-based health insurance in Burkina Faso

The purposes of this study are to describe the characteristics of different health-care users, to explain such characteristics using a health demand model and to estimate the price-related probability change for different types of health care in order to provide policy guidance for the introduction of community-based health insurance (CBI) in Burkina Faso. Data were collected from a household survey using a two stage cluster sampling approach. Household interviews were carried out during April and May 2003. In the interviewed 7,939 individuals in 988 households, there were 558 people reported one or more illness episodes; two-thirds of these people did not seek professional care. Health care non-users display lower household income and expenditure, older age and lower perceived severity of disease. The main reason for choosing no-care and self-care was ‘not enough money’. Multinomial logistic regression confirms these observations. Higher household cash-income, higher perceived severity of disease and acute disease significantly increased the probability of using western care. Older age and higher price-cash income ratio significantly increased the probability of no-care or self-care. If CBI were introduced the probability of using western care would increase by 4.33% and the probability of using self-care would reduce by 3.98%. The price-related probability change of using western care for lower income people is higher than for higher income although the quantity changed is relatively small. In conclusion, the introduction of CBI might increase the use of medical services, especially for the poor. Co-payment for the rich might be necessary. Premium adjusted for income or subsidies for the poor can be considered in order to absorb a greater number of poor households into CBI and further improve equity in terms of enrolment. However, the role of CBI in Burkina Faso is rather limited: it might only increase utilisation of western health care by a probability of 4%.     

"The problem of the worst-off is dealt with after all other issues": the equity and health policy implementation gap in Burkina Faso

In West Africa, the famous "implementation gap" concept applies to health policies. During the implementation of the Bamako Initiative (BI), the actors were drawn to policies solely for their orientation towards efficiency, thereby neglecting the equity aspects. This paper aims to present an in-depth understanding of this situation, developed through a case study and socio-anthropological fieldwork. The study is informed by a policy framework of analysis that integrates streams theory and the anthropology of development. Multiple sources of data were used: concept mapping (2), in-depth interviews (24), informal interviews (60), focus groups (4), document analysis, and field observation (7 months). The results indicate that the equity aspect of health policies was omitted during training on the use of proceedings from drug sales and user fees; donor agencies and NGOs were more preoccupied with efficiency than equity; the peripheral actors were not driven to ensure that indigents had free access to health care; society was not concerned with the sub-groups of the population; centralized decisions were taken without consultation, remained vague, and were not followed-up; and the concept of equity was perceived differently from those who devised policies. I offer a threefold explanation of why equity was neglected. First, the "windows of opportunity" for achieving equity goals were not seized, at least at the point that led to real change. Second, the policy entrepreneurs did not take on the task of coupling the problem streams with the solutions streams, which is necessary for a successful implementation. Third, the situation of the indigents did not exhibit the necessary characteristics for them to be considered a public problem. For scientific and social reasons it is urgent that we find a solution to halt the exclusion to health care among the poorest groups.     

Contribution of the results‐based financing strategy to improving maternal and child health indicators in Burkina Faso

In response to the poor performance of its public health care provision, Burkina Faso decided, to implement results‐based financing (RBF). This strategy relies on a strategic purchase of the quantity and quality of services provided by health workers, monitored by a set of indicators. However, there is a lack of evidence on its effects. The objective of this article is to appreciate the effect of RBF on a set of maternal and child health (MCH) indicators in Burkina Faso. The study design is quasi‐experimental comparative with a control group before and after the implementation of the RBF. To estimate the effect of RBF, we used two methods of analysis: (1) the segmented regression to measure the effect of RBF in the health districts (HD) implementing RBF (RBF HD) and (2) the difference‐in‐difference test to estimate the effect of RBF considering the differences in mean between RBF HD and HD that did not implement RBF (non–RBF HD). We found among five indicators studied that only the postnatal consultation coverage in RBF HD was significantly higher (7.68%; P = 0.04) than in the non–RBF HD. Overall, our findings do not clearly demonstrate the effectiveness of RBF in improving MCH indicators in Burkina Faso.