How Burkina Faso used evidence in deciding to launch its policy of free healthcare for children under five and women in 2016

Abstract

In March 2016, the newly elected government of Burkina Faso decided on a major change in health financing policy: it abolished direct payment for healthcare for women and children under five. Unlike other countries in Africa, this decision took a long time, given that the first pilot projects for this policy instrument date from 2008. This article describes that political process and presents a reflexive analysis by two authors who were at the heart of events between 2008 and 2018. The analysis shows that, while the decision took a long time and certainly amounted to a policy paradigm shift, it was the result of a complex series of events and activities whose specific contributions are difficult to identify. Crucial to the decision was long-term funding of pilot projects to test the new policy instrument, associated with the generation of evidence mobilised through a myriad of knowledge transfer activities. Moreover, it took the continued mobilisation of advocacy coalitions, action to counter preconceived notions about this instrument, and the emergence of an essential window of opportunity-the 2014 popular uprising-for the decision to be possible. In this discussion, we generalise to the conceptual and theoretical levels, but also share practical lessons learned for those interested in engaging in evidence-informed decision-making. The main lessons are: recruit, train, and mobilise people and/or services responsible for knowledge transfer activities; identify and partner with political entrepreneurs early and regularly; be persistent and consistent in producing rigorous and useful knowledge; favour independent evaluation teams using mixed methods; train researchers in policy decision-making processes and decision-makers in knowledge production issues; adapt (content, format, vocabulary, language, etc.) the evidence to the needs of the knowledge users in close collaboration with researchers and disseminate it to target audiences; understand the sometimes different logics of researchers and decision-makers and encourage their interaction; to seize opportunities, regularly analyse the political decision-making processes specific to the national context as well as the social and political contexts favourable (or not) to decision-making.

Do Targeted User Fee Exemptions Reach the Ultra-Poor and Increase their Healthcare Utilisation? A Panel Study from Burkina Faso

“…User fees to pay for consultations, medications and laboratory work are still predominant at all levels of care in Burkina Faso [ 2 ]. According to the most recent Demographic and Health Survey, user fees are the most important barrier to healthcare access [ 3 ].…”

Effect of a prospective payment method for health facilities on direct medical expenditures in a low-resource setting: a paired pre-post study

“…In general, the introduction of a cost-reduction policy in most African countries has been motivated by a political agenda or occurred under pressure from international organizations without careful preparation ( Robert and Ridde, 2013 ; Ridde and Yaméogo, 2018 ). Policymakers have much less interest than researchers in the sustainability of these policies in general and, in particular, in the importance of the payment method for achieving policy objectives.…”

Policy learning and Universal Health Coverage in low- and middle-income countries

“…This experience was rich in reflexive (through the engagement of various stakeholders), bargaining (to accommodate divergent opinions and reach consensus through formal and informal discussion channels) and epistemic (the mentor giving expert advice only when requested) learnings. Learning generated through pilot schemes, as was the case for performance-based financing with Rwanda [88], Health Equity Funds in Cambodia [89], the RAMED in Morocco [82], or user fees removal policies in Burkina Faso [90], is also an interesting case. Policy actors and experts knew what they were looking for but they also acknowledged that there were many unknowns.…”