Search

International audience; The indigents have long been excluded from health policies in sub-Saharan Africa. Despite recent efforts by some countries to allow them free access to health services, they face a multitude of non-financial barriers that prevent them from accessing care. Interventions to address the multiple patient-level barriers to care, such as patient navigation interventions, could help reverse this trend. However, our scoping review showed that no navigation interventions in low-income countries targeted the indigents. The objective of this qualitative study is, therefore, to go beyond the lack of evidence and discuss relevant approaches to act in favor of health care equity. We interviewed 22 public health experts with the objective of finding out which actions related to patient navigation programs (identified in the scoping review for other target groups) could be relevant and/or adapted for the indigents. For each ability to access care described by Levesque and colleagues, we were thus able to list the potential opportunities and challenges of implementing each type of action for the indigents in sub-Saharan Africa. Overall, the experts all felt that patient navigation programs were very relevant to implement for the indigents. They emphasized the need for personalized follow-up and for holistic actions to consider the whole context of the situation of indigence. The recommendations made by the experts are valuable in guiding political decision-making, while leaving room for adaptation of the proposed guidelines according to different contexts.

ObjectiveTo examine the effects of high ambient temperature on infant feeding practices and childcare.DesignSecondary analysis of quantitative data from a prospective cohort study.SettingCommunity-based interviews in the commune of Bobo-Dioulasso, Burkina Faso. Exclusive breastfeeding is not widely practised in Burkina Faso.Participants866 women (1:1 urban:rural) were interviewed over 12 months. Participants were interviewed at three time points: cohort entry (when between 20 weeks’ gestation and 22 weeks’ postpartum), three and nine months thereafter. Retention at nine-month follow-up was 90%. Our secondary analysis focused on postpartum women (n=857).ExposureDaily mean temperature (°C) measured at one weather station in Bobo-Dioulasso. Meteorological data were obtained from publicly available archives (TuTiempo.net).Primary outcome measuresSelf-reported time spent breastfeeding (minutes/day), exclusive breastfeeding of infants under 6 months (no fluids other than breast milk provided in past 24 hours), supplementary feeding of infants aged 6–12 months (any fluid other than breast milk provided in past 24 hours), time spent caring for children (minutes/day).ResultsThe population experienced year-round high temperatures (daily mean temperature range=22.6°C–33.7°C). Breastfeeding decreased by 2.3 minutes/day (95% CI -4.6 to 0.04, p=0.05), and childcare increased by 0.6 minutes/day (0.06 to 1.2, p=0.03), per 1°C increase in same-day mean temperature. Temperature interacted with infant age to affect breastfeeding duration (p=0.02), with a stronger (negative) association between temperature and breastfeeding as infants aged (0–57 weeks). Odds of exclusive breastfeeding very young infants (0–3 months) tended to decrease as temperature increased (OR=0.88, 0.75 to 1.02, p=0.09). There was no association between temperature and exclusive breastfeeding at 3–6 months or supplementary feeding (6–12 months).ConclusionsWomen spent considerably less time breastfeeding (~25 minutes/day) during the hottest, compared with coolest, times of the year. Climate change adaptation plans for health should include advice to breastfeeding mothers during periods of high temperature.

BACKGROUND AND AIM: High ambient temperature is associated with reduced work capacity, disrupted sleep, and increased anxiety, which may impact on maternal caregiving behaviours and health-related ...

Background: In early March 2020, the COVID-19 pandemic hit West Africa. Countries in the region quickly set up crisis management committees and organised drastic measures to stem the spread of the coronavirus. The objective of this article is to analyse the epidemiological evolution of COVID-19 in seven Francophone West African countries (Benin, Burkina Faso, Côte d'Ivoire, Guinea, Mali, Niger, Senegal) as well as the public health measures decided upon during the first four months of the pandemic. Methods: Our method is based on quantitative and qualitative data from the pooling of information from a COVID-19 data platform and collected by a network of interdisciplinary collaborators present in the seven countries. Descriptive and spatial analyses of quantitative epidemiological data and content analyses of qualitative data on public measures and management committees were performed. Results: Attack rates for COVID-19 range from less than 10 per 100,000 inhabitants (Benin) to more than 45 per 100,000 inhabitants (Guinea). The spatio-temporal analysis shows three phases of incidence clusters. By the end of June 2020, case numbers had plateaued in some countries (Burkina Faso, Niger, Mali) while others continued to see the number of infections increasing (Benin, Côte d'Ivoire, Guinea, Senegal). The countries all reacted quickly to the crisis, in some cases before the first reported infection, and implemented public measures in a relatively homogeneous manner. None of the countries implemented country-wide lockdowns, but in some cases implemented partial or local containment measures. At the end of June 2020, countries began to lift certain restrictive measures, sometimes under pressure from the general population or from certain economic sectors. All the countries have adopted response plans and organized multiple crisis management committees, although their content and functioning have not always been transparent or easy to understand. Conclusion: Much research remains to be done in West Africa. It will be necessary to better understand the dynamics of the pandemic, which appears to be largely under control, as well as the effectiveness and implementation of the state responses, which have been rapidly formulated.

Afin de fournir une protection sociale aux populations, le Burkina Faso a adopte, en 2012, sa premiere Politique nationale de la protection sociale (PNPS) qui integre les deux volets de la protection sociale (assurances sociales et filets sociaux). S’appuyant sur la theorie des courants de Kingdon (2003), cet article montre que la PNPS vise a repondre au probleme du deficit de protection sociale, source du renforcement des inegalites sociales, et de la degradation du climat social et politique. Le contexte mondial de promotion d’un socle de protection sociale (nouvelle orientation politique) a renforce la receptivite du gouvernement a l’elaboration d’une PNPS, en reponse au deficit de protection sociale. Les institutions internationales, sous l’impulsion de l’UNICEF, se sont regroupees en un reseau d’entrepreneurs politiques pour promouvoir cette solution qui cadre avec leur mandat, et vehiculer des idees de protection sociale qui coincident avec les attentes et les besoins du moment du gouvernement burkinabe (la solidarite nationale, la paix et la cohesion sociale). L’adoption de la PNPS represente les fondations d’un systeme de protection sociale pour le pays.

Au Burkina Faso, le Reseau d’appui aux mutuelles de sante et le ministere de l’Action sociale et de la Solidarite ont organise un programme de solidarite pour ameliorer l’acces aux soins des menages demunis. Cette recherche vise a comprendre l’emergence et la formulation de ce programme. Les resultats montrent que le programme repond a un besoin en connaissances sur la meilleure facon d’affilier les personnes demunies au « regime d’assurance maladie obligatoire » a travers les mutuelles de sante. Cependant, la formulation du programme privilegie des solutions plus profitables aux mutuelles qu’aux personnes demunies. Le deficit de concertation pendant la phase de formulation a laisse la latitude aux acteurs de decider dans le sens de leurs interets.

Introduction This paper aims to contribute to the discussion on how global health research (GHR) mentorship initiatives can best help prepare the next generation of GH researchers. To this end, the authors, a group of emerging researchers, share their experiences and perspectives of participating in the Global Health Research Capacity Strengthening (GHR-CAPS) program, a multidisciplinary GHR training and mentorship program in Quebec, Canada. # Discussion Based on their experiences, what is deemed most beneficial is interfacing with a diverse group of peers, learning and being guided from a community of mentors, actively engaging in research activities, having mentorship specific to GH, and being financially supported, especially through bursaries. Areas were also noted to better guide and support GHR emerging researchers. These included providing more support for navigating career transitions and developing a program of research, and removing geographical restrictions to access financial resources, including bursaries and small grants which can directly support the research of students and junior researchers. Overall, the trainees felt that participation in a mentorship program like GHR-CAPS yields multiple benefits including greater academic productivity, network expansion, increased professional confidence, and enhancement of knowledge and skills. It also provides a sense of belonging to something official and important and gives visibility to trainees' work. # Conclusion There is value-added to have mentorship programs like GHR-CAPS. GHR mentorship is optimized by having multiple sources of support for trainees and by implementing diverse strategies to meet trainees' needs and strengthen their capacity.

To improve the social protection of its population, Burkina Faso adopted a national policy in 2012. This paper analyses the process whereby this policy was formulated, looking at the issue from the standpoint of ‘policy design’ (Howlett and Mukherjee, 2014). Conducted in accordance with an inductive qualitative approach, the collection and analysis of the data show that this process of formulation has led neither to reflecting on the problem to be solved nor to identifying the specific needs of the beneficiaries. Nor has it led to evaluating the potential outcomes of the proposed solutions in order to choose the most appropriate ones. The authors are thus led to an empirical observation of ‘non-design’. This policy boils down to a document whose all-encompassing content brings together every conceivable action of social protection, without any arbitration. Three factors have contributed to this non-formulation: (1) the lack of clear government direction to guide discussions; (2) a weakness of support and of political will, resulting in a low degree of involvement in the process on the part of high-level decision makers; and (3) conceptual and technical misunderstandings on the part of national stakeholders in social protection—so much so that they have simply relied on the advice of international bodies. The government announced its intention of playing a leading role in the process of formulating this policy, but this was a purely rhetorical declaration. The study shows that leadership and political will have been lacking, particularly when it has come to channelling the respective interests of the stakeholders and managing the contradictions that hinder the formulation of a coherent policy adapted to the needs of the population.

Summary box King and Koski1 recently published a bold commentary in BMJ Global Health that defines global health as ‘ public health somewhere else ’. It raises important concerns about the justification, scope, efficiency and accountability of the field. We appreciate that the commentary compels us to reflect on the definition of global health, its application and how the field could be improved. We also agree that many of the issues highlighted by the authors (ie, political priorities driven by the North, expertise from the North being overvalued) do exist in some global health interventions. Many of us have heard of or witnessed disastrous situations caused by seemingly well-intentioned people. However, the problems described are not unavoidable or intrinsic characteristics of global health. Moreover, we believe the proposed definition of global health is not adequate to conceptualise the field. Rather than prompting improvements, it could result in mistrust towards global health and be a step backwards for the field. In the following, we contend that global health is more than just ‘ public health somewhere else ’ and argue that an inadequate definition entails risks for the …

Pour ameliorer la protection sociale de sa population, le Burkina Faso a adopte une politique nationale en 2012. Cet article analyse le processus de formulation de cette politique en s’appuyant sur la perspective du « policy design » (Howlett et Mukherjee, 2014). Menees conformement a la demarche qualitative inductive, la collecte et l’analyse des donnees montrent que ce processus de formulation n’a permis ni de mener une reflexion sur le probleme a resoudre, ni d’identifier les besoins specifiques des beneficiaires, ni d’evaluer les resultats potentiels des solutions proposees dans le but de choisir les plus appropriees. Les auteurs aboutissent donc a un constat empirique de « non-design ». Cette politique se resume a un document dont le contenu tous azimuts rassemble toutes les actions envisageables de protection sociale, sans aucun arbitrage. Trois facteurs ont favorise cette non-formulation : (1) le manque d’orientations gouvernementales claires pour guider les discussions ; (2) la faiblesse du soutien et de volonte politique – se traduisant par la faible implication des decideurs de haut niveau dans le processus ; et (3) les meconnaissances conceptuelle et technique des acteurs nationaux en matiere de protection sociale – si bien qu’ils se sont contentes d’avoir recours aux conseils des organismes internationaux. Le gouvernement a annonce son intention de jouer un role preponderant dans le processus de formulation de cette politique mais il s’est agit d’une declaration rhetorique. L’etude a en effet montre que le leadership et la volonte politique ont manque, notamment pour canaliser les interets respectifs des acteurs et gerer les contradictions qui font obstacle a la formulation d’une politique coherente et adaptee aux besoins de la population.

Introduction : afin de proteger les indigents de l’exclusion des services de sante du fait du paiement direct, une recherche action a ete mise en œuvre au Burkina Faso. Par une approche communautaire, des comites villageois de selection (CVS) ont identifie les indigents devant beneficier de l’exemption du paiement des services dans les formations sanitaires. A l’issue d’une etude quantitative sur les depenses de consommation des menages selectionnes (dans le but d’evaluer l’efficacite du ciblage communautaire), nous avons fait un constat. En effet, certaines personnes ciblees sont dans des menages de niveau economique eleve. La presente recherche a pour but de comprendre pourquoi ces personnes ont ete selectionnees par les CVS.Methodes : l’approche est qualitative exploratoire a visee descriptive, complementaire et subsequente a une etude quantitative. Des recits de vie et des entretiens individuels ont ete realises aupres de 54 indigents selectionnes par un echantillonnage aleatoire stratifie. L’analyse thematique de contenu a ete effectuee.Resultats : les indigents identifies par la communaute sont le plus souvent des personnes âgees, incapables de travailler pour se prendre en charge en raison du poids de l’âge ou d’une maladie chronique. Toutefois certains d’entre eux ont un niveau de consommation non pauvre. Cela s’explique par le fait qu’ils beneficient de la solidarite locale pour les besoins alimentaires. Cependant, les difficultes quant a l’acces aux soins de sante demeurent.Discussion : la communaute percoit la pauvrete au-dela de l’aisance economique. La dimension sociale de la pauvrete (dont l’incapacite de l’individu a participer pleinement a la vie de la communaute) a largement determine l’identification d’indigents dans des menages dont le niveau economique est a priori eleve. Le processus communautaire a permis de retenir ces personnes qui, sur la base des elements contextuels, n’ont pas forcement acces aux ressources des menages pour des soins de sante.

In West Africa, health system funding rarely involves cross-subsidization among population segments. In some countries, a few community-based or professional health insurance programs are present, but coverage is very low. The financial principles underlying universal health coverage (UHC) sustainability and solidarity are threefold: 1) anticipation of potential health risks; 2) risk sharing and; 3) socio-economic status solidarity. In Burkina Faso, where decision-makers are favorable to national health insurance, we measured endorsement of these principles and discerned which management configurations would achieve the greatest adherence.We used a sequential exploratory design. In a qualitative step (9 interviews, 12 focus groups), we adapted an instrument proposed by Goudge et al. (2012) to the local context and addressed desirability bias. Then, in a quantitative step (1255 respondents from the general population), we measured endorsement. Thematic analysis (qualitative) and logistic regressions (quantitative) were used.High levels of endorsement were found for each principle. Actual practices showed that anticipation and risk sharing were not only intentions. Preferences were given to solidarity between socio-economic status (SES) levels and progressivity. Although respondents seemed to prefer the national level for implementation, their current solidarity practices were mainly focused on close family. Thus, contribution levels should be set so that the entire family benefits from healthcare.Some critical conditions must be met to make UHC financial principles a reality through health insurance in Burkina Faso: trust, fair and mandatory contributions, and education.

The use of community health workers to administer prompt treatments is gaining popularity in most sub-Saharan African countries. Their performance is a key challenge because it varies considerably, depending on the context, while being closely associated with the effectiveness of case management strategies. What determines community health workers' performance is still under debate. Based on a realist perspective, a systematic review recently hypothesized that several mechanisms are associated with good performance and successful community interventions. In order to empirically investigate this hypothesis and confront it with the reality, we conducted a study in Burkina Faso, where in 2010 health authorities have implemented a national program introducing community case management of malaria. The objective was to assess the presence of the mechanisms in community health workers, and explore the influence of contextual factors. In 2012, we conducted semi-structured interviews with 35 community health workers from a study area established in two similar health districts (Kaya and Zorgho). Results suggest that they perceive most of the mechanisms, except the sense of being valued by the health system and accountability to village members. Analysis shows that drug stock-outs and past experiences of community health workers simultaneously influence the presence of several mechanisms. The lack of integration between governmental and non-governmental interventions and the overall socio-economic deprivation, were also identified as influencing the mechanisms' presence. By focusing on community health workers' agency, this study puts the influence of the context back at the core of the performance debate and raises the question of their ability to perform well in scaled-up anti-malaria programs.

To increase the financial access to health care for indigents, an action research was conducted in Burkina Faso. Based on a community approach, village committees identified indigents who were exempt from payment of health care fees. Quantitative analysis of the food expenditure of selected households (to assess the efficacy of the community-based selection) showed that some of the indigents selected came from households with a high economic level. This research was designed to explain why these people were identified by the Village Selection Committees (VSC).This study was based on a qualitative exploratory descriptive approach, complementary and subsequent to a quantitative study. Life stories and individual interviews were conducted with stratified random sampling of 54 indigents. Thematic content analysis was performed.Indigents identified by the community are usually elderly, unable to work because of old age or chronic illness. However, some of them came from households with a high level of consumption, which can be explained by the fact that they benefit from community aid for their food needs. However, they present persistent difficulties of access to health care.The community perceives poverty in terms other simply economic aspects. The social dimension of poverty (including the inability to fully participate in community life) has a major impact on the choice of the CVS, leading to the selection of indigents from households that appear to have a high economic level. This community process which takes into account contextual factors, identified these people who do not necessarily have access to the household resources for health care.

Background: In most African countries, indigents treated at public health centres are supposed to be exempted from user fees. In Africa, most of the available knowledge has to do with targeting processes in rural areas, and little is known about how to select the worst-off in an urban area. In rural communities of Burkina Faso, trials of participatory community-based selection of indigents have been effective. However, the process for selecting indigents in urban areas is not yet clear. Methods: This study evaluates a community-funded participatory indigent selection process in both a formal (loti) and an informal (non-loti) neighbourhood in the urban setting of Burkina Faso’s capital. This was an exploratory study to evaluate the processes and effectiveness of participatory targeting. We conducted individual interviews (n = 26) and analyzed secondary qualitative data (eight focus groups, 16 individual interviews). We also used the results of a socioeconomic survey (carried out by the Ouaga HDSS in 2011) of all the households established in the areas, including those of selected indigents. Results: The coverage of indigent targeting was very low: 0.33% (loti) and 0.22% (non loti). In the non loti neighbourhood, the level of poverty among people selected was higher than the mean level of the poor who were not selected. Some indigents selected in the loti neighbourhood were not among the worst-off. The process was difficult to organize in the loti neighbourhood; people knew each other less well and were not very available, and there were cases of collusion. The process worked well in the non loti neighbourhood. Conclusions: This intervention research provides new evidence about the feasibility of a community-based selection process in an urban setting in Africa by comparing two different urban settings. The participatory community-based selection process appeared to be suitable for the non loti neighbourhood, but other targeting strategies need to be found for loti areas. Specific budgets need to be allocated to increase the coverage of indigent targeting.

Over recent decades, Burkina Faso has improved the geographic accessibility of its health centres. However, patients are still required to pay point-of-service user fees, which excludes the most vulnerable from access to care. In 2010, 259 village committees in the Ouargaye district selected 2649 indigents to be exempted from user fees. The 26 health centre management committees that fund this exemption retained 1097 of those selected indigents. Spatial analysis showed that the management committees retained the indigents who were geographically closer to the health centres, in contrast to the selections of the village committees which were more diversified. Using village committees to select indigents would seem preferable to using management committees. It is not yet known whether the management committees’ selections were due to a desire to maximize the benefits of exemption by giving it to those most likely to use it, or to the fact that they did not personally know the indigents who were more geographically distant from them, or that some villages are not represented at the management committees.

Background Systems to exempt the indigent from user fees have been put in place to prevent the worst-off from being excluded from health care services for lack of funds. Yet the implementation of these mechanisms is as rare as the operational research on this topic. This article analyzes an action research project aimed at finding an appropriate solution to make health care accessible to the indigent in a rural district of Burkina Faso. Research This action research project was initiated in 2007 to study the feasibility and effectiveness of a community-based, participative and financially sustainable process for exempting the indigent from user fees. A interdisciplinary team of researchers from Burkina Faso and Canada was mobilized to document this action research project. Results and knowledge sharing The action process was very well received. Indigent selection was effective and strengthened local solidarity, but coverage was reduced by the lack of local financial resources. Furthermore, the indigent have many other needs that cannot be addressed by exemption from user fees. Several knowledge transfer strategies were implemented to share research findings with residents and with local and national decision-makers. Partnership achievements and difficulties Using a mixed and interdisciplinary research approach was critical to grasping the complexity of this community-based process. The adoption of the process and the partnership with local decision-makers were very effective. Therefore, at the instigation of an NGO, four other districts in Burkina Faso and Niger reproduced this experiment. However, national decision-makers showed no interest in this action and still seem unconcerned about finding solutions that promote access to health care for the indigent. Lessons learned The lessons learned with regard to knowledge transfer and partnerships between researchers and associated decision-makers are: i) involve potential users of the research results from the research planning stage; ii) establish an ongoing partnership between researchers and users; iii) ensure that users can participate in certain research activities; iv) use a variety of strategies to disseminate results; and v) involve users in dissemination activities.

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.