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Reflections on the Unintended Consequences of the Promotion of Institutional Pregnancy and Birth Care in Burkina Faso.

ABSTRACT: The policy of institutional delivery has been the cornerstone of actions aimed at monitoring and achieving MDG 5. Efforts to increase institutional births have been implemented worldwide within different cultural and health systems settings. This paper explores how communities in rural Burkina Faso perceive the promotion and delivery of facility pregnancy and birth care, and how this promotion influences health-seeking behaviour. A qualitative study was conducted in South-Western Burkina Faso between September 2011 and January 2012. A total of 21 in-depth interviews and 8 focus group discussions with women who had given birth recently and community members were conducted. The data were analyzed using qualitative content analysis and interpreted through Merton's concept of unintended consequences of purposive social action. The study found that community members experienced a strong pressure to give birth in a health facility and perceived health workers to define institutional birth as the only acceptable option. Women and their families experienced verbal, economic and administrative sanctions if they did not attend services and adhered to health worker recommendations, and reported that they felt incapable of questioning health workers' knowledge and practices. Women who for social and economic reasons had limited access to health facilities found that the sanctions came with increased cost for health services, led to social stigma and acted as additional barriers to seek skilled care at birth. The study demonstrates how the global and national policy of skilled pregnancy and birth care can occur in unintentional ways in local settings. The promotion of institutional care during pregnancy and at birth in the study area compromised health system trust and equal access to care. The pressure to use facility care and the sanctions experienced by women not complying may further marginalize women with poor access to facility care and contribute to worsened health outcomes.

SUBMITTER: Melberg A

PROVIDER: S-EPMC4892534 | biostudies-literature | 2016

REPOSITORIES: biostudies-literature

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Reflections on the Unintended Consequences of the Promotion of Institutional Pregnancy and Birth Care in Burkina Faso.

Melberg Andrea A Diallo Abdoulaye Hama AH Ruano Ana Lorena AL Tylleskär Thorkild T Moland Karen Marie KM

PloS one 20160603 6

The policy of institutional delivery has been the cornerstone of actions aimed at monitoring and achieving MDG 5. Efforts to increase institutional births have been implemented worldwide within different cultural and health systems settings. This paper explores how communities in rural Burkina Faso perceive the promotion and delivery of facility pregnancy and birth care, and how this promotion influences health-seeking behaviour. A qualitative study was conducted in South-Western Burkina Faso be ...[more]

PMID: 27258012

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Project description:BackgroundUser 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.MethodsWe 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.ResultsLocal 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.ConclusionsThe 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.

Project description:BackgroundPerformance-based financing (PBF) is promoted to improve the quality and quantity of healthcare services in low-income countries. Despite the complexity of the intervention, little attention has been given to studying its unintended consequences. Our objective is to increase evidence on the unintended consequences of PBF in Burkina Faso.MethodsUsing the diffusion of innovations theory, we conducted a multiple case study. The cases were 6 healthcare facilities in two districts. Between April 2015 and 2016, we collected data through 101 semi-structured interviews, discussions, observations, and documents. We conducted thematic analysis using a hybrid deductive-inductive approach. Secondary data was used to illustrate the evolution of reported services. We conducted a cross-case synthesis to identify the results arising independently from more than 1 case.ResultsA desirable unintended consequence of PBF was that 3 facilities limited the sale of non-prescribed medication to encourage patients to consult. Undesirable unintended consequences were found in the majority of facilities including fixation on measures rather than on underlying objectives, the pursuit of narrow and less relevant performance indicators, gaming, and teaching trainees improper practices. Providers in all facilities deliberately manipulated medical registers and documents, such that the reported quantity and quality of care differed from what was actually delivered. While most participants indicated that PBF was more advantageous than previous practices, the long payment delays were a source of dissatisfaction and demotivation across all facilities. Dissatisfaction also emerged in relation to the distribution of subsidies and the non-attribution of quality points for services delivered by certain staff considered "unqualified" in guidelines. Results in many facilities revealed suboptimal planning, a perception of the intervention as "budgetivorous," as well as tensions related to the principle of managerial autonomy.ConclusionPBF led to numerous unintended consequences that could undermine the intervention's effectiveness. The findings contribute to a more comprehensive picture of the consequences of implementing PBF. Policy-makers can use the results of this study to devise effective strategies before, during and after the implementation of the intervention to minimize undesirable unintended consequences and promote desirable ones.

Project description:OBJECTIVE: The World Health Organization (WHO) has recommended a universal antiretroviral therapy (ART) for all HIV-infected children before the age of two since 2010, but this implies an early identification of these infants. We described the Prevention of Mother-to-Child HIV Transmission (PMTCT) cascade, the staffing and the quality of infrastructures in pediatric HIV care facilities, in Ouagadougou, Burkina Faso. METHODS: We conducted a cross-sectional survey in 2011 in all health care facilities involved in PMTCT and pediatric HIV care in Ouagadougou. We assessed them according to their coverage in pediatric HIV care and WHO standards, through a desk review of medical registers and a semi-structured questionnaire administered to health-care workers (HCW). RESULTS: In 2011, there was no offer of care in primary health care facilities for HIV-infected children in Ouagadougou. Six district hospitals and two university hospitals provided pediatric HIV care. Among the 67 592 pregnant women attending antenatal clinics in 2011, 85.9% were tested for HIV. The prevalence of HIV was 1.8% (95% Confidence Interval: 1.7%-1.9%). Among the 1 064 HIV-infected pregnant women attending antenatal clinics, 41.4% received a mother-to-child HIV transmission prevention intervention. Among the HIV-exposed infants, 313 (29.4%) had an early infant HIV test, and 306 (97.8%) of these infants tested received their result within a four-month period. Among the 40 children initially tested HIV-infected, 33 (82.5%) were referred to a health care facility, 3 (9.0%) were false positive, and 27 (90.0%) were initiated on ART. Although health care facilities were adequately supplied with HIV drugs, they were hindered by operational challenges such as shortage of infrastructures, laboratory reagents, and trained HCW. CONCLUSIONS: The PMTCT cascade revealed bottle necks in PMTCT intervention and HIV early infant diagnosis. The staffing in HIV care and quality of health care infrastructures were also insufficient in 2011 in Ouagadougou.

Dataset Information

Reflections on the Unintended Consequences of the Promotion of Institutional Pregnancy and Birth Care in Burkina Faso.

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Reflections on the Unintended Consequences of the Promotion of Institutional Pregnancy and Birth Care in Burkina Faso.

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