This blog has previously been published on Health Financing in Africa Le Blog.
Promise free maternal and child health care
This month the Council of Ministers in Burkina Faso, decided that from April 2016, the government will provide free healthcare for children under-five, pregnant women, deliveries and caesareans, and breast and uterine cancer screening.
This announcement is to be welcomed. Healthcare, and particularly delivery care, has been associated with catastrophic health expenditure in Burkina Faso and enormous social costs, exacerbating poverty. The promise to make maternal and child healthcare free continues the progress that Burkina Faso and many other countries in the region have been making towards extending coverage of essential care to vulnerable groups, including through removal of user fees for certain services. Pregnant women and young children are widely recognised as priority groups, with momentum derived initially from the Millennium Development Goals but now enshrined in the universal health coverage (UHC) goal within the Sustainable Development Goals.
Lessons learned
At this crucial stage, when new policies are being developed and piloted, it is important to remind ourselves of some of the important lessons learned through studies of the implementation and effects of previous user fee reforms in the region, including in Burkina Faso.
- Careful preparation is crucial. One of the strengths of the policy to subsidise 80% of the cost of deliveries, which Burkina Faso introduced in 2006, was that a period of pre-studies was undertaken, allowing for consultation and planning with stakeholders and staff; this should not be neglected in this new phase.
- The successful implementation of a financing policy depends on realistic budgeting to replace lost revenues at facility level and ensure a smooth flow of resources.
- To be effective, fee exemption requires investment in functionality of services; in our recent study in six districts in Burkina Faso, two had serious shortfalls in services and resources, including staff and critical equipment; this indicates the need for ongoing investment and monitoring.
- Communication is also critical. Staff need clear and simple guidelines, a system that supports and motivates them, and does not impose too much additional administrative work.
- Communities require good access to information. In our recent evaluation of the delivery subsidy policy, only 52% of recently delivered women had been aware of the policy. Creating awareness about policies is necessary to ensure that beneficiaries claim their entitlements.
- The success of fee exemption also hinges on the quality of healthcare services. Across the West African region, poor quality of care, especially in newborn care, has been a constraint to the successful implementation of previous fee exemption policies.
- The package of care on offer should be clear and cover the major risks to mothers and children’s health, including family planning, early loss of pregnancy and post-abortion care. There is also an ethical obligation, if cancer screening is offered, to provide access to counselling and treatment.
- Above all, monitoring of compliance with the policy at the frontline is essential. Research from numerous countries with similar policies has shown that the reduction of household expenditure following fee exemption has been substantial, but lower than expected. Households continue to pay for items that should have been covered, such as transport from peripheral health centres to hospitals, drugs, and laboratory tests. Informal payments to healthcare staff are also frequent. The poorest are most at risk in such a situation.
The Government of Burkina Faso is to be congratulated on taking measures to widen access to healthcare. But the devil is in the detail – making the benefits real for the population depends on careful next steps. As researchers, we stand ready to help in policy development and monitoring. There is a wide body of knowledge to draw on.
