Access to health care for the ‘worst-off’ in Burkina Faso: 15 years of research
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![COMMUNITY BASED DEFINITION
• Widowed (OR = 1.40; CI 95% [1.10–1.78])
• Had no financial assistance from their household for
healthcare (OR = 1.58; CI 95% [1.26–1.97]
• Lived alone (OR = 1.28; CI 95% [1.01–1.63])
• Vision impairments (OR = 1.45; CI 95% [1.14–1.84]),
poor muscle strength & good mobility (OR = 1.73; CI
95% [1.28–2.33])
• Not determined by household income, self-reported
chronic illness, or previous use of services
Atchessi et al, 2014
Equitesante.org](https://image.slidesharecdn.com/riddeectm2015-150910164024-lva1-app6891/75/access-to-health-care-for-the-worstoff-in-burkina-faso-15-years-of-research-19-2048.jpg?cb=1670677244)
![Not enough to increase use of healthcare
• Use of health care services
– Exempted = 46.2%
– Non-Exempted = 42.1%
– OR = 1.1, CI 95% [0.80–1.51]), p=0,554
• Increased use regardless the exemption status (p <0.05)
o > 69 years of age (OR = 1.66, CI 95% [1.05–2.64])
o Male (OR = 1.44, CI 95% [0.99–2.08])
o Low-income HH (OR = 1.71, CI 95% [1.15–2.54])
o Received financial support to obtain healthcare (OR = 1.59, CI
95% [1.1–2.28]).
Equitesante.org
Atchessi et al, 2015](https://image.slidesharecdn.com/riddeectm2015-150910164024-lva1-app6891/75/access-to-health-care-for-the-worstoff-in-burkina-faso-15-years-of-research-28-2048.jpg?cb=1670677244)
Access to health care for the ‘worst-off’ in Burkina Faso: 15 years of research
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Presentation of Valéry Ridde at 9th European Congress on Tropical Medicine and International Health 08 September 2015
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Access to health care for the ‘worst-off’ in Burkina Faso: 15 years of research
- 1. Access to health care for the ‘worst-off’ in Burkina Faso: 15 years of research 9th European Congress on Tropical Medicine and International Health Valéry Ridde 08 September 2015 equitesante.org
- 3. RESEARCH QUESTIONS 1. WHY targeting the worst-off ? 2. HOW to target the worst-off ? 3. WHO are the worst-off ? 4. WHAT are the impact ? 5. CHALLENGES of targeting? Equitesante.org
- 5. CONTEXT • Poverty = 46% = < 0,6$/day • Extreme poverty = 9% • IRA/fever/Diarrheal = 50% • Assisted delivery = 66% • Inequalities of use Equitesante.org
- 6. WHY targeting the worst-off ? • 2000 : National health policy • 2007 : National subsidy for deliveries 2009 : National directive to use local cost- recovery funds • 2011 : National Health Strategy • 2012 : National Social Protection Policy • 2014/5 : National Health Insurance Equitesante.org
- 8. HOW to target the worst-off ? MT PMT CBT GT Equitesante.org
- 9. STATE LED COMMUNITY BASED HEALTH STAFF + CRITERIA Time period covered May 2004 to September 2005 November 2007 to 2012 June 2008 to September 2010 Services exempted Drugs at CSPS All services at CSPS and district hospital All services at CSPS and district hospital Criteria for selection No criteria provided Community-based definition of indigence 20 criteria Selection of beneficiaries Health workers at point of service Community at village level (pre-identification) Health workers at point of service (passive identification) Information to the beneficiaries At point of service Individual distribution of cards At point of service Funding and compensation mechanisms Ministry allocation of drugs No compensation Cost-recovery schemes used to finance exemption (Endogenous) Cost-recovery schemes used to finance exemption (Endogenous) Ridde et al, 2012 Equitesante.org
- 10. Equitesante.org
- 11. Selected worst-off below the poverty line Ridde et al, BMC Public Health 2010, 10:631 • % 60 years old + (<0,001) • %of widow/ers (0,066) • Disability (0,004) • Health problem (<0,001) • Delayed /lack of funds (0,004) Equitesante.org Ridde et al, 2010
- 12. CB Targeting effectiveness FEW INCLUSION ERRORS • 0,17%/0,12 % non poor • 0,20%/0,15 % non extreme poor BUT VERY LOW COVERAGE • 0,36%/0,21% of poor • 0,78%/0,28% of extreme poor Equitesante.org
- 13. 2014 = PBF + EQUITY Equitesante.org
- 14. CBT : 8 DISTRICTS POP. WORST-OFF % Ouargaye 204 672 16 628 8,12% Tenkodogo 101 245 19 528 19,29% Kaya 286 456 22 939 8,01% Kongoussi 208 877 7 050 3,38% Gourcy 132 281 6 224 4,71% Ouahigouya 307 688 21 214 6,89% Batié 53 120 6 998 13,17% Diébougou 81 119 6 731 8,30% TOTAL 1 375 458 107 312 7,80% Equitesante.org
- 15. WHO are the worst-off ? Equitesante.org
- 16. “STREET” WORKERS DEFINTION • What are the criteria that enable you to say someone can be identified as indigent to be exempted from user fees ? Equitesante.org
- 17. WHO are the worst-off ? Equitesante.org Ridde et al, 2012
- 18. COMMUNITY BASED DEFINITION “someone who is extremely disadvantaged socially and economically, unable to look after him/herself and devoid of internal or external resources” Equitesante.org
- 19. COMMUNITY BASED DEFINITION • Widowed (OR = 1.40; CI 95% [1.10–1.78]) • Had no financial assistance from their household for healthcare (OR = 1.58; CI 95% [1.26–1.97] • Lived alone (OR = 1.28; CI 95% [1.01–1.63]) • Vision impairments (OR = 1.45; CI 95% [1.14–1.84]), poor muscle strength & good mobility (OR = 1.73; CI 95% [1.28–2.33]) • Not determined by household income, self-reported chronic illness, or previous use of services Atchessi et al, 2014 Equitesante.org
- 20. Distribution of indigents based on their distance from the HC Equitesante.org COGESs chose the people closest to HC Ridde, Bonnet et al, 2012
- 21. DISTANCE WAS A BARRIER TO SELECTION RED = density for indigents not retained by the COGESs Specialization in the selection according to the catchment areas Equitesante.org Ridde, Bonnet et al, 2012
- 22. Anxiety and Depression (2014) Equitesante.org 40,2% have more than 10 anxious/depressive symptoms 0 1 to 4 5 to 9 10 to 14 Pigeon-Gagné et al, 2015
- 23. SELF PERCEPTION (2014/03) HEALTH STATUS WORRY /ANXIETY SAD / DEPRESSED 0 10 20 30 40 50 60 70 80 oui un peu non SLEEP DISORDER 0 10 20 30 40 50 60 70 80 oui un peu non 0 10 20 30 40 50 60 70 80 oui un peu non Pigeon-Gagné et al, 2015 0 10 20 30 40 50 60 70 80 GOOD MODERATE POOR WORST-OFF GEN. POP. YES LITTLE NO YES LITTLE NOYES LITTLE NO
- 24. Health Care Access Equitesante.org • Health problem during the last 6 months = 69% (n=1141) • General Health care utilization : 48,8% to 77,8% • Health care utilization due to a mental health problem : 1,7% Atchessi et al, 2015
- 25. FACTORS ASSOCIATE WITH HEALTH CARE USE Atchessi et al, 2015 Equitesante.org
- 26. WHAT are the impact for the worst-off ? Equitesante.org
- 27. Equitesante.org
- 28. Not enough to increase use of healthcare • Use of health care services – Exempted = 46.2% – Non-Exempted = 42.1% – OR = 1.1, CI 95% [0.80–1.51]), p=0,554 • Increased use regardless the exemption status (p <0.05) o > 69 years of age (OR = 1.66, CI 95% [1.05–2.64]) o Male (OR = 1.44, CI 95% [0.99–2.08]) o Low-income HH (OR = 1.71, CI 95% [1.15–2.54]) o Received financial support to obtain healthcare (OR = 1.59, CI 95% [1.1–2.28]). Equitesante.org Atchessi et al, 2015
- 29. 2015 = PBF + EQUITY Equitesante.org
- 30. Worst-off exemptions directives (n=1365) Staff Knowledge • 9,18% (2,3% – 30,8%) • Head of CSPS : OR = 2.41*** Application • 4,98 % (0 % - 21,5%) • CHW : OR = 3.432** • Head of CSPS = OR = 7.55*** Equitesante.org
- 31. WHAT are the impact for public policies ? Equitesante.org
- 32. Equitesante.org
- 33. Equitesante.org
- 34. RESEARCH IMPACTS • PhD and MSc/MPH students • Scientific Articles and Books • 2007 = National Free delivery’s attention for the worst-off (20%) • 2009 = National directive • 2012 : National guideline and National social protection policy (20%) • 2014 : PBF + CBT in 10 districts • 2015 : Exemption (10%) for National Health Insurance Equitesante.org
- 36. “To address the problem of reach requires methods that actively connect the provision of health services to people who are otherwise invisible and thus unreachable” Equitesante.org
- 39. ACKNOWLEDGEMENTS Equitesante.org • MoH staff, communities, IDRC, CIHR, FRSQ, ECHO, WB, AGIR, HELP, Muraz, etc. • Kadio K, Kafando Y, Bonnet E, Atchessi N, Zunzunegi M-V, Simpore L, Bado A, Queuille L, Pigeon-Gagné E, Hunt M, Yaogo M, Samb O, Bonnet E, P-A Somé, Koulidiati J-J, Souares A De Allegri M, etc., etc.
- 40. THANKS YOU / MERCI equitesante.org @equitesante @valeryridde
Notes de l'éditeur
- When I start my research program I was young wth long hair… 2000 = master thesis with my first article at BWHO 15 years later = few books and papers about this, even book in french… I will try to summarize some of the major evidence that me and my colleague have.. Because we are a very large team, researchers, students, professional etc
- Scientific relevance to produce more evidence BUT also evidence to support policy decision-making All policy doc = want to target but do not know how
- You all know what are the challenges to improve the access to..
- Means testing (MT) = income or expenditure threshold Proxy Means Testing (PMT) = criteria that relate to income Participatory Wealth Ranking (PWR) = criteria defined by the community in focus group discussions Geographic Targeting (GT) = poverty clusters on the basis of aggregate poverty indicators A mix of processes
- Evaluation of 3 processus to target the WO
- Very low capacity to contribut at local level
- living in the most disadvantaged conditions
- Pie chart : 11,6%, 17,90% 30,30% et 40% Distribution :
- Quand on le fait avec nombre de sx = mêmes facteurs importants! VALÉRY : très intéressant, attention à l’interprétation car ici on est dans l’échantillon des indigents, ce qui veut dire que si on comparait avec des non indigents…. Mais cela montre bien aussi qu’il y a des sous-groupes chez les indigents !
- Donc seulement 3% sont aller consulter un type quelconque de soins pour les symptômes anxieux, dépressifs ou psychotiques!… ET un tiers de l’Échantillon n’en a pas parlé… Profil de quelqu’un qui ne parle pas de ses sx = ++ curieux…
- 29 VG 42,1 22,6 5,6 0,7
- formal (loti) and an informal (non-loti)
- in with no statistically significant association between the exemption status and the increased use of health care services (OR = 1.1, CI 95% [0.80–1.51]), p=0,554.
- Evaluation prévue en 2016, à suivre donc, sur un échantillon de 2000
- Après 5 années de recherche des progrès ont cependant été réalisés. L’expérience dans ce district a été reproduite dans trois autres districts du Burkina Faso et deux du Niger. Ces recherches ont aussi été prises en compte dans la nouvelle (2012) politique nationale de protection sociale et le référence national sur l’indigence. Un guide destiné aux communautés pour reproduire le processus participatif sera distribué à la fin de l’année 2012. Voir : http://www.biomedcentral.com/1472-698X/11/S2/S9