The unintended consequences of combining equity measures with performance-based financing in Burkina Faso

Abstract

Background: User fees and poor quality of care contribute to low use of healthcare services in Burkina Faso. The government implemented an innovative intervention that combines equity measures with performance-based financing (PBF). These health equity measures included a community-based selection of indigents to receive user fee exemptions and paying healthcare centres higher purchase prices for services provided to indigents. Research suggests complex interventions can trigger changes not targeted by program planners. To date, however, there is a knowledge gap regarding the unintended consequences that can emerge from combining PBF with health equity measures. Our objective is to document unintended consequences of the equity measures in this complex intervention.

Methods: We developed a conceptual framework using the diffusion of innovations theory. For the design, we conducted a multiple case study. The cases were four healthcare facilities in one district. We collected data through 93 semi-structured interviews, informal discussions, observation, as well as intervention documents. We conducted thematic analysis using a hybrid deductive-inductive approach. We also used secondary data to describe the monthly evolution of services provided to indigent and non-indigent patients before and after indigent cards were distributed. Time series graphs were used to validate some results.

Results: Local actors, including members of indigent selection committees and healthcare workers, re-invented elements of the PBF equity measures over which they had control to increase their relative advantage or to adapt to implementation challenges and context. Some individuals who did not meet the local conceptualization of indigents were selected to the detriment of others who did. Healthcare providers believed that distributing free medications led to financial difficulties and drug shortages, especially given the low purchase prices and long payment delays. Healthcare workers adopted measures to limit free services delivered to indigents, which led to conflicts between indigents and providers. Ultimately, selected indigents received uncertain and unequal coverage.

Conclusions: The severity of unintended consequences undermined the effectiveness and equity of the intervention. If the intervention is prolonged and expanded, decision-makers and implementers will have to address these unintended consequences to reduce inequities in accessing care.

Keywords: Burkina Faso; Indigents; Multiple-case study; Performance-based financing; Unintended consequences; Universal health coverage; User fee exemption.

Fig. 1

Conceptual model

Fig. 2

Facility 1 - Total number of new consultations for patients classified as indigents or non-indigents seen in curative care. Note: As shown by the qualitative data, the curves representing non-indigents are likely to include individuals who should have received user fee exemptions but were requested to pay, either because they did not possess an indigent card or because healthcare workers refused to recognize their indigent status. Similarly, the curves representing indigents may include individuals who received indigent cards even though they did not truly meet the local conceptualization of indigents

Fig. 3

Facility 2 - Total number of new consultations for patients classified as indigents or non-indigents seen in curative care

Fig. 4

Average number of new consultations for patients classified as indigents or non-indigents seen in curative care in PBF3 facilities (n = 7) within the study district. Note: Healthcare centres (n = 7) for which the intervention arm was not specified in the database were excluded. PBF ceased to fund services delivered to indigent children under five once the free healthcare policy began in June 2016 because it covered their user fees and medications