Assessing changes in costs of maternal postpartum services between 2013 and 2014 in Burkina Faso.

INTRODUCTION: In Africa, a majority of women bring their infant to health services for immunization, but few are checked in the postpartum (PP) period. The Missed opportunities for maternal and infant health (MOMI) EU-funded project has implemented a package of interventions at community and facility levels to uptake maternal and infant postpartum care (PPC). One of these interventions is the integration of maternal PPC in child clinics and infant immunization services, which proved to be successful for improving maternal and infant PPC. AIM: Taking stock of the progress achieved in terms of PPC with the implementation of the interventions, this paper assesses the economic cost of maternal PPC services, for health services and households, before and after the project start in Kaya health district (Burkina Faso). METHODS: PPC costs to health services are estimated using secondary data on personnel and infrastructure and primary data on time allocation. Data from two household surveys collected before and after one year intervention among mothers within one year PP are used to estimate the household cost of maternal PPC visits. We also compare PPC costs for households and health services with or without integration. We focus on the costs of the PPC intervention at days 6-10 that was most successful. RESULTS: The average unit cost of health services for days 6-10 maternal PPC decreased from 4.6 USD before the intervention in 2013 (Jan-June) to 3.5 USD after the intervention implementation in 2014. Maternal PPC utilization increased with the implementation of the interventions but so did days 6-10 household mean costs. Similarly, the household costs increased with the integration of maternal PPC to BCG immunization. CONCLUSION: In the context of growing reproductive health expenditures from many funding sources in Burkina Faso, the uptake of maternal PPC led to a cost reduction, as shown for days 6-10, at health services level. Further research should determine whether the increase in costs for households would be deterrent to the use of integrated maternal and infant PPC.

Integration of postpartum care into child health and immunization services in Burkina Faso: findings from a cross-sectional study.

BACKGROUND: The Missed Opportunities for Maternal and Infant Health (MOMI) project, which aimed at upgrading maternal and infant postpartum care (PPC), implemented a package of interventions including the integration of maternal PPC in infant immunization services in 12 health facilities in Kaya Health district in Burkina Faso from 2013 to 2015. This paper assesses the coverage and the quality of combined mother-infant PPC in reproductive, maternal, newborn and child health services (RMNCH). METHODS: We conducted a mixed methods study with cross-sectional surveys before and after the intervention in the Kaya health and demographic surveillance system. On the quantitative side, two household surveys were performed in 2012 (N = 757) and in 2014 (N = 754) among mothers within one year postpartum. The analysis examines the result of the intervention by the date of delivery at three key time points in the PPC schedule: the first 48 h, days 6-10 and during weeks 6-8 and beyond. On the qualitative side, in depth interviews, focus group discussions and observations were conducted in four health facilities in 2012 and 2015. They involved mothers in the postpartum period, facility and community health workers, and other stakeholders. We performed a descriptive analysis and a two-sample test of proportions of the quantitative data. The qualitative data were recorded, transcribed and analysed along the themes relevant for the intervention. RESULTS: The findings show that the WHO guidelines, in terms of content and improvement of maternal PPC, were followed for physical examinations and consultations. They also show a significant increase in the coverage of maternal PPC services from 50% (372/752) before the intervention to 81% (544/672) one year after the start of the intervention. However, more women were assessed at days 6-10 than at later visits. Integration of maternal PPC was low, with little improvements in history taking and physical examination of mothers in immunization services. While health workers are polyvalent, difficulties in restructuring and organizing services hindered the integration. CONCLUSION: Unless a comprehensive strategy of integration within RMNCH services is implemented to address the primary health care challenges within the health system, integration will not yield the desired results.

A cross-sectional mixed study of the opportunity to improve maternal postpartum care in reproductive, maternal, newborn, and child health services in the Kaya health district of Burkina Faso.

OBJECTIVE: To propose a rationale to improve maternal postpartum care in reproductive, maternal, newborn, and child health (RMNCH) services. METHODS: We conducted a cross-sectional mixed study in the Kaya health district in Burkina Faso based on two data collection exercises conducted between December 2012 and May 2013. A household survey of 757 mothers in their first year after delivery was processed. It was complemented with a qualitative analysis using in-depth interviews with key informants, focus group discussions with mothers, and participant observation. RESULTS: Postpartum services showed serious weaknesses. Overall, 52% (n=384) of mothers did not receive any maternal postpartum care; however among them, 47% (n= 349) received infant postpartum care. CONCLUSION: We suggest the integration of maternal postpartum care in RMNCH services as a key step to improving postpartum care. The intervention would require the overcoming of challenges related to the quality and cost of services, and to reaching the poor populations with low education and a high parity.

Malaria prevention measures in Burkina Faso: distribution and households expenditures.

BACKGROUND: The provision of insecticide-treated nets (ITNs) is widely accepted in Burkina Faso thanks to large-scale national distribution campaigns. However, household also use other methods of prevention. Thus far, there is little knowledge about the expenditures of these malaria prevention methods, particularly in combination with the national interventions. This paper presents the utilization levels and expenditures of malaria prevention tools in Burkina Faso and explores the potential inequality in ownership. METHODS: The analysis is based on a cross-sectional survey, conducted during the 2010 high transmission season from July to September in the Nanoro Health and Demographic Surveillance Site. Following a systematic sampling technique, the survey covers 500 households with children under 5 years of age from 24 villages. In the survey, households were asked about expenditures on malaria prevention methods in the month preceding the survey. This includes expenditure on coils, indoor spraying, aerosols, repellents, herbs, cleaning of the environment and clearing of the vegetation. The data analysis was conducted with SPSS taking into account the socio-economic status (SES) of the household to examine any differences in the utilization of the prevention method and expenditure quintiles. An asset-based index, created through principal components analysis (PCA), was used to categorize the households into quintiles. FINDINGS: Of the households surveyed, 45% used one preventive measure in the past month; 29% used two measures; and 25% used three or more measures. A significant association was found between the number of prevention measures and the SES of the household (p < 0.05). The majority of households owned at least one insecticide treated net (ITN) (98%). Among households that used ITN, 53.8% used methods other than bed nets. The majority of households paid nothing for malaria prevention. CONCLUSION: Most of the households received bed nets and other preventive method for free. There is equity in expenditures across SES groups. Free distribution of ITNs ensured that there was equity in ITN ownership among households. More research on the possibility of increasing access to other locally relevant methods of malaria control that proved to be effective is need.

What criteria guide national entrepreneurs' policy decisions on user fee removal for maternal health care services? Use of a best-worst scaling choice experiment in West Africa.

OBJECTIVE: Several countries in sub-Saharan Africa have implemented policies to remove or reduce user fees. Our aim was to identify criteria guiding such decisions among national policy entrepreneurs, those who link up problem definition, solution development and political processes. METHODS: We administered a best-worst scaling (BWS) experiment to 89 policy entrepreneurs, asking them to identify the most and the least important criteria on a series of predefined sets. Sets were compiled using a Balance Incomplete Block Design which generated random combinations of all 11 criteria included in the experiment. In turn, those had emerged from a prior set of focus group discussions organized among policy entrepreneurs. Ordered logit models were used to investigate the value of single criteria as well as heterogeneity of preferences. RESULTS: Political commitment was identified as the most important criterion guiding policy decisions on user fee abolition or reduction to the overall sample, but particularly so for more experienced respondents aged over 50 years. International pressure and donor money were identified as least important while equity and institutional capacity were deemed of relatively little importance. Respondents more involved in advising on policy than on formulating policy rated economic issues such as financial sustainability and cost-effectiveness as less important. CONCLUSIONS: It is feasible to apply BWS experiments in low-income countries, although whether the technique can be adjusted to elicit preferences among non-literate respondents in these settings is unclear.

Willingness to pay for maternal health outcomes: are women willing to pay more than men?

BACKGROUND: Only a limited number of studies have specifically sought to analyse and try to understand sex differences in willingness to pay (WTP). OBJECTIVE: To identify the role of sex in determining monetary values placed upon improvements in maternal health in Burkina Faso, West Africa. METHODS: A contingent valuation survey using the bidding game method was conducted in the district of Nouna in 2005; a sample of 409 male heads of households and their spouses were asked their WTP for a reduction in the number of maternal deaths in the Nouna area. Ordinary least squares regression analysis was employed to examine the determinants of WTP. RESULTS: Men were willing to pay significantly more than women (3127 vs 2273 West African francs), although this represented a significantly smaller proportion of their annual income (4% vs 11%). In the multivariate analyses of all respondents there was a significant positive relationship between WTP values and both starting bid and whether there had been a previous maternal complication in the respondent's household. However, there was a significant negative relationship between WTP and female sex. Once interactions between sex and income were taken into account, income did affect valuations, with a positive relationship between higher-income women and WTP values. CONCLUSION: In absolute terms, men were willing to pay more than women, while women were willing to pay a greater proportion of their income. Differences between men and women in their WTP, both in absolute terms and in terms of proportion of income, can be explained by a household effect. Future studies should distinguish between individual income and command over decision making with respect to use of individual and household income, and gain further insight into the strategies used by respondents in answering bidding game questions.

Assessing the costs and cost-effectiveness of a skilled care initiative in rural Burkina Faso.

OBJECTIVES: The objectives of this study were to assess the cost-effectiveness of a skilled attendance strategy (the Skilled Care Initiative, SCI) in enhancing maternal health care in a remote, rural district of Burkina Faso and to analyse more broadly the costs and cost patterns of maternal health provision in the intervention and comparison districts. METHODS: The approach used was to cost the standard provision of maternal care, to analyse the main cost structures, and to derive cost estimates per facility. The additional costs attributable to SCI were identified. Several measures of cost-effectiveness or performance were calculated, including cost per delivery and utilisation. RESULTS: If the increase in deliveries in Ouargaye between 2004 and 2005 is attributed solely to the stimulus of demand for skilled care by the SCI community mobilisation and behavioural communication change activities, the incremental cost per delivery was $164 international dollars. This compares with an average cost per delivery in Health Centres across the two districts of $214 international dollars. However, if a broader measure of SCI costs is used, the incremental cost per delivery increases markedly, to $1306 international dollars. At the level of individual Health Centres, utilisation is a better measure of performance than cost per delivery and Health Centres in Ouargaye are utilised more than in Diapaga. CONCLUSIONS: Demand side actions, such as community mobilisation and behavioural communication change activities, can be as important in improving skilled care at delivery as investment in health facilities, assuming there is some spare capacity, as has been the case in Burkina Faso. These conclusions have important potential implications for planning and resource allocation to achieve safer delivery for all women in Burkina Faso.