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Background In Africa, health systems are poorly accessible, inequitable, and unresponsive. People rarely have either the confidence or the opportunity to express their opinions. In Burkina Faso, there is a political will to improve governance and responsiveness to create a more relevant and equitable health system. Given their development in Africa, information and communication technologies (ICTs) offer opportunities in this area. Methods This article presents the results of an evaluation of a toll-free call service coupled with an interactive voice server (TF-IVS) tested in Ouagadougou, Burkina Faso, to assess its relevance for improving health systems governance. The approach consisted of a 2-phased action research project to test 2 technologies: recorded messages and touch keypad. Using a concurrent mixed approach, we assessed the technological, social, and instrumental relevance of the service. Results The call service is available everywhere, 24 hours per day, seven days per week. The equipment and its physical location were not adequately protected against technological hazards. Of the 278 days of operation, 49 were non-functional. In 8 months, there were 13 877 calls, which demonstrated the popularity of ICTs and the ease of access to telephone networks and mobile technologies. The TF-IVS was free, anonymous, and multilingual, which fostered the expression of public opinion. However, cultural context (religion, ethnic culture) and fear of reprisals may have had a negative influence. In the end, questions remained regarding people’s capacity to use this innovative service. In the first trial, 49% of callers recorded their message and in the second, 48%. Touch key technology appeared more relevant for automated and real-time data collection and analysis, but there was no comprehensive strategy for translating the information collected into a response from healthcare actors or the government. Conclusion This study showed the relevance and feasibility of implementing a TF-IVS to strengthen health system responsiveness in one of the world’s poorest countries. Public opinion expressed through data collected in real-time is helpful for improving system responsiveness to meet care needs and enhance equity. However, the strategy for developing this tool must take into account the implementation context and the activities needed to influence the mechanisms of social responsibility (eg, information provision, citizen action, and state response).

Objective To identify the factors associated with non-medically indicated cesarean deliveries (NMIC) in Burkina Faso in centers where user fees for cesarean delivery were partially removed. Methods We carried out a criteria-based audit in 22 referral hospitals, using data from a 6-month prospective observational study, to assess the proportion of NMIC. Multivariate logistic regression analyses were used to identify factors associated with NMIC. Results The decision of cesarean delivery was not medically indicated in 24% of cases. The factors independently associated with NMIC were urban residence (adjusted OR 1.55; 95% CI, 1.12–2.12; P=0.006), spouse’s occupation other than breeder or farmer (aOR varying from 1.77 [95% CI, 1.19–2.62] to 2.15 [95% CI, 1.38–3.32] according to the profession), and cesarean decided by a general practitioner (aOR 1.61; 95% CI, 1.13–2.30; P=0.009). Conclusion The high percentage of unnecessary cesarean deliveries is in contrast to the unmet needs of women who still deliver outside health facilities. NMIC is associated with both socioeconomic determinants and medical factors. Hence, interventions are needed to improve the skills of healthcare professionals and awareness of women concerning the risks associated with unnecessary cesarean delivery.

Climate change is one of today's major challenges, and among the causes of population movement and international migration. Climate migrants impact health systems and how their ability to respond and adapt to their needs and patterns. To date, the resilience of health systems in the context of climate change has barely been explored. The purpose of this article is to show the importance of studying the relationship between climate change, migration, and the resilience of health systems from an interdisciplinary perspective. Resilience is an old concept, notably in the field of psychology, and is increasingly applied to the study of health systems. Yet, no research has analysed the resilience of health systems in the context of climate change. While universal health coverage is a major international goal, little research to date focused on the existing links between climate, migration, health systems and resilience. We propose an interdisciplinary approach relying on the concept of health system resilience to study adaptive and transformative strategies to articulate climate change, migration and health systems.

La mise en place des mecanismes de subvention ou de gratuite des soins appuyes par les ONG au Burkina Faso et au Niger a entraine une hausse importante de l’utilisation des services de sante de premiere ligne. Face a l’augmentation de la charge de travail percue par le personnel soignant, l’objectif de cette etude etait de mesurer leur charge de travail effective et d’estimer si les agents de sante etaient en mesure de faire face a la hausse engendree par cette augmentation. Nous avons utilise la methodeWISN recommande par l’OMS pour evaluer leur disponibilite en comparant, dans chaque pays, quatre centres de sante ou intervient une ONG par rapport a quatre autres centres de sante ou seule la politique de l’Etat est mise en place. Huit centres de centre ont ete concernes par cette etude au niveau de chaque pays en 2011. Au Burkina Faso, l’effectif du personnel etait superieur ou egal a l’effectif requis dans les huit centres de sante. Au Niger, trois centres de sante sur quatre du district sanitaire de Keita (presence d’ONG) presentaient un effectif en personnel inferieur ou egal a l’effectif requis (Wisn ratio ≤ 1). Par contre, a Abalak (absence d’ONG), les centres de sante presentaient des effectifs superieurs ou egaux aux effectifs requis (Wisn ratio ≥ 1). Cette etude montre que l’effectif en ressources humaines ne s’est pas adapte au Niger dans le cadre de la gratuite des soins soutenue par une ONG. Au Burkina Faso, cet effectif est actuellement suffisant pour faire face a la gratuite totale.

As part of this special issue contributing to the development of knowledge on vulnerability and health in Africa, this article analyzes one example of a knowledge transfer strategy aimed at improving the use of research results that could help reduce the vulnerability of certain populations. In this case, since September 2008, the Non-Governmental Organization (NGO) Hilfe zur Selbsthilfe e.V. (HELP) has conducted a trial of subsidizing 100% of the costs of health care for vulnerable populations in two health districts of Burkina Faso. A scientific partnership was created to produce evidence on the intervention, and a knowledge transfer strategy was developed to promote the use of that evidence by stakeholders (decision-makers, people working in the health system, funding partners, etc.). The results showed that considerable efforts were invested in knowledge transfer activities and that these led to all types of use (instrumental, conceptual, persuasive). However, considerable variation in use was observed from one setting to another. This article presents some lessons to be drawn from this experience. (Global Health Promotion, 2013; 20 Supp. 1: 70-79).

This study based on qualitative research aims to assess the sustainability of the suppression of two healthcare payment subsidy interventions in favor of pregnant women, children under the age of five and indigents that occurred in three health districts in Burkina Faso. The results show the importance of the sustainability process mainly in organizational risk-taking and resource stabilization. These two elements were central to the difference in sustainability between the two interventions. This study also shows that the sustainability of an intervention is not reducible to the demonstration of its effectiveness. The other factors, which have not received much attention so far, but which have real influence, are : the nature of the interventions, the approach adopted in their implementation and the perception that leaders of the target organization have toward the interventions’ beneficiaries seeking to make them sustainable.

L’intervention subventionne le paiement des soins de santé des enfants de moins de cinq ans et des femmes enceintes dans deux districts du Burkina Faso. Une stratégie de recherches opérationnelles à multi-niveaux utilise des méthodes mixtes et associe l’analyse des effets à celle des processus. L’article propose une analyse des chances de succès de l’utilisation des données probantes. L’étude montre notamment qu’il faut associer chercheurs et décideurs le plus tôt possible et tout au long du processus, intéresser les intervenants aux activités de recherche et adapter la méthodologie en fonction des besoins des décideurs, de la rigueur scientifique et de la temporalité de la prise de décision.

Abstract: For many years, numerous attempts have been made to define empowerment, to identify its processes, and to suggest translations. Recently the debate has focussed on the complexity raised by its measurement and evaluation. The purpose of this article is to illustrate the contribution of Ninacs’s framework (2002) in evaluating empowerment, by presenting its application to the evaluation of a health promotion program in Haiti. The instrument designed based on this framework was valued by the evaluation participants, making possible a simple and useful visual representation of a complex and multidimensional concept.

INTRODUCTION: To reduce financial barriers to health care services presented by user fees Burkina Faso adopted a policy to subsidize deliveries and emergency obstetric care for the period 2006-2015. Deliveries and caesarean sections are subsidized at 80%; women must pay the remainder. The worst-off are fully exempted. METHODS The aim of this article is to document this policys entire process using a health policy analytical framework. Qualitative data are drawn from individual interviews (n = 113 persons) and focus groups conducted with 344 persons in central government three rural districts and one urban district. Quantitative data are taken from the national health information system in eight districts. RESULTS The policy was initiated in all districts concurrently before all the technical instruments were ready. The subsidy is paid by the national budget (US$60 million including US$10 million for the worst-off). Information activities implementation and evaluation support have been minimal because of insufficient funding. Health workers and lay people have not always had the same information such that the policy has not been uniformly applied. Coping strategies have been noted among health workers and the population but there has been no attempt to impede the policys implementation. At the time of the study fixed-rate reimbursement for delivery (output-based) and overestimation of input costs were financially advantageous to health workers (bonuses) and management committees (hoarding). Very few of the worst-off have been exempted from payment because selection processes and criteria have not yet been defined and most health workers are unaware of this possibility. The upward trend in assisted deliveries since 2004 continued after the policys introduction. CONCLUSIONS This ambitious policy expresses a strong political commitment but has not been adequately supported by international partners. Despite relatively tight administrative controls health workers have figured out how to take advantage of the system. Some of the policys instruments should be reviewed and clarified to improve its effectiveness.

Background While more and more West African countries are implementing public user fees exemption policies, there is still little knowledge available on this topic. The long time required for scientific production, combined with the needs of decision-makers, led to the creation in 2010 of a project to support implementers in aggregating knowledge on their experiences. This article presents a transversal analysis of user fees exemption policies implemented in Benin, Burkina Faso, Mali, Niger, Togo and Senegal. Methods This was a multiple case study with several embedded levels of analysis. The cases were public user fees exemption policies selected by the participants because of their instructive value. The data used in the countries were taken from documentary analysis, interviews and questionnaires. The transversal analysis was based on a framework for studying five implementation components and five actors’ attitudes usually encountered in these policies. Results The analysis of the implementation components revealed: a majority of State financing; maintenance of centrally organized financing; a multiplicity of reimbursement methods; reimbursement delays and/or stock shortages; almost no implementation guides; a lack of support measures; communication plans that were rarely carried out, funded or renewed; health workers who were given general information but not details; poorly informed populations; almost no evaluation systems; ineffective and poorly funded coordination systems; low levels of community involvement; and incomplete referral-evacuation systems. With regard to actors’ attitudes, the analysis revealed: objectives that were appreciated by everyone; dissatisfaction with the implementation; specific tensions between healthcare providers and patients; overall satisfaction among patients, but still some problems; the perception that while the financial barrier has been removed, other barriers persist; occasionally a reorganization of practices, service rationing due to lack of reimbursement, and some overcharging or shifting of resources. Conclusions This transversal analysis confirms the need to assign a great deal of importance to the implementation of user fees exemption policies once these decisions have been taken. It also highlights some practices that suggest avenues of future research.

Background Since 2006, Burkina Faso has subsidized the cost of caesarean sections to increase their accessibility. Caesareans are performed by obstetricians, general practitioners, and nurses trained in emergency surgery. While the national caesarean rate is still too low (only 2 % in 2010), 12 to 24 % of caesareans performed in hospital are, in fact, not medically indicated. The objective of this study is to evaluate the effectiveness and analyze the implementation of a multi-faceted intervention to lower the rate of non-medically indicated caesareans in Burkina Faso. Methods This study combines a multicentre cluster randomized controlled trial with an implementation analysis in a mixed-methods approach. The evidence-based intervention will consist of three strategies to improve the competencies of maternity teams: 1) clinical audits based on objective criteria; 2) training of personnel; and 3) decision-support reminders of indications for caesareans via text messages. The unit of randomization and of intervention is the public hospital equipped with a functional operating room. Using stratified randomization on hospital type and staff qualifications, 11 hospitals have been assigned to the intervention group and 11 to the control group. The intervention will cover 1 year. Every patient who delivered by caesarean during a 6-month period in the year preceding the intervention and the 6 months following its end will be included in the trial. The change in the rate of non-medically indicated caesareans is the main criterion by which the intervention’s impact will be assessed. To analyze the intervention process, a longitudinal qualitative study consisting of deliberative workshops and individual in-depth interviews will be conducted. The target outcome is a 50 % reduction in the rate of non-medically indicated caesareans. Discussion This study will provide evidence regarding the effectiveness of a multi-faceted intervention for reducing non-medically indicated caesareans in a low-income country. By combining qualitative and quantitative methods, the study’s findings will allow understanding the factors that could influence the intervention process and ultimately the intended outcomes. Trial registration The DECIDE trial is registered on the Current Controlled Trials website under the number ISRCTN48510263 on January 28, 2014. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1112-8) contains supplementary material, which is available to authorized users.

Background In 2006, the Parliament of Burkina Faso passed a policy to reduce the direct costs of obstetric services and neonatal care in the country’s health centres, aiming to lower the country’s high national maternal mortality and morbidity rates. Implementation was via a “partial exemption” covering 80% of the costs. In 2008 the German NGO HELP launched a pilot project in two health districts to eliminate the remaining 20% of user fees. Regardless of any exemptions, women giving birth in Burkina Faso’s health centres face additional expenses that often represent an additional barrier to accessing health services. We compared the total cost of giving birth in health centres offering partial exemption versus those with full exemption to assess the impact on additional out-of-pocket fees. Methods A case–control study was performed to compare medical expenses. Case subjects were women who gave birth in 12 health centres located in the Dori and Sebba districts, where HELP provided full fee exemption for obstetric services and neonatal care. Controls were from six health centres in the neighbouring Djibo district where a partial fee exemption was in place. A random sample of approximately 50 women per health centre was selected for a total of 870 women. Results There was an implementation gap regarding the full exemption for obstetric services and neonatal care. Only 1.1% of the sample from Sebba but 17.5% of the group from Dori had excessive spending on birth related costs, indicating that women who delivered in Sebba were much less exposed to excessive medical expenses than women from Dori. Additional out-of-pocket fees in the full exemption health districts took into account household ability to pay, with poorer women generally paying less. Conclusions We found that the elimination of fees for facility-based births benefits especially the poorest households. The existence of excessive spending related to direct costs of giving birth is of concern, making it urgent for the government to remove all direct fees for obstetric and neonatal care. However, the policy of completely abolishing user fees is insufficient; the implementation process must have a thorough monitoring system to reduce implementation gaps.