Targeting the worst-off for free health care: a process evaluation in Burkina Faso

Effective mechanisms to exempt the indigent from user fees at health care facilities are rare in Africa. A State-led intervention (2004-2005) and two action research projects (2007-2010) were implemented in a health district in Burkina Faso to exempt the indigent from user fees. This article presents the results of the process evaluation of these three interventions. Individual and group interviews were organized with the key stakeholders (health staff, community members) to document the strengths and weaknesses of key components of the interventions (relevance and uptake of the intervention, worst-off selection and information, financial arrangements). Data was subjected to content analysis and thematic analysis. The results show that all three intervention processes can be improved. Community-based targeting was better accepted by the stakeholders than was the State-led intervention. The strengths of the community-based approach were in clearly defining the selection criteria, informing the waiver beneficiaries, using a participative process and using endogenous funding. A weakness was that using endogenous funding led to restrictive selection by the community. The community-based approach appears to be the most effective, but it needs to be improved and retested to generate more knowledge before scaling up.     

Analysis of the implementation of a social protection initiative to admit the poorest of the poor to mutual health funds in Burkina Faso

To enable mutual health funds to extend coverage to poor people, the Mutual Health Support Network (Réseau d’appui aux mutuelles de santé – RAMS) in 2012 launched an initiative in collaboration with the Ministry of Social Action and Solidarity (ministère de l’Action sociale et de la Solidarité nationale – MASSN) in Burkina Faso. This article reveals difficulties in the initiative's implementation, which resulted in the continued exclusion of poor people from health services. Poor people were required not only to make co‐payments, but also to accept a limitation of coverage to three episodes of illness per year. Additional challenges to service takeup were the geographical distance of the homes of some beneficiaries covered by a mutual fund agreement from a health centre and the failure by some health workers and managers of pharmacies to recognize the mutual membership card. A formal framework was lacking that brought together all the actors involved in planning and implementing the initiative. Those involved did not all have the same information. Each structure performed the tasks within its scope, according to its own interests, but without consulting the other parties, and there was no platform for discussing implementation difficulties.