Center for Applied Malaria Research and Evaluation, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 2323, New Orleans, LA 70112, USA.
Société d'Études et de Recherche en Santé Publique, 06 BP 9150 Ouagadougou, Burkina Faso.
Soc Sci Med. 2017 Jul;185:46-53. doi: 10.1016/j.socscimed.2017.05.040. Epub 2017 May 20.
With solid evidence that free healthcare increases the utilization of health services, Burkina Faso recently exempted all children under five and pregnant women from direct payment at health facilities. However, there is little insight into the capacity to maintain the gains attributable to free healthcare under routine conditions of implementation at the national scale. In particular, the repercussions of its interruption are unknown. The objective is to assess the effects of a sequence of natural interventions including the introduction, interruption and reintroduction of free healthcare on health-seeking practices and utilization of healthcare facilities by children under five. This is an embedded mixed methods study conducted in Kaya district, Burkina Faso. The quantitative component is based on a reversal longitudinal design. Pooled interrupted time-series analysis was performed to assess changes in the monthly number of visits from January 2005 to March 2015. Qualitative data were collected through in-depth interviews with health personnel and mothers to better understand the quantitative results. The results show that visits to health centres dropped immediately and significantly when free healthcare was interrupted (-146, CI [-255; -37]). They increased again when free healthcare was reintroduced (+89, CI [-11; 187]). Both urban and rural centres were affected. Self-medication and visits to traditional healers were reported more frequently during the withdrawal of free healthcare, and tensions between the population and health personnel increased. Implementation problems other than insufficient funding limited the coverage or intensity of free healthcare. While removing user fees could potentially improve mothers and children's health in Burkina Faso, this study shows that demand for healthcare remains highly sensitive to price changes. Gains in utilization attributable to free healthcare may vanish rapidly if user fees are reintroduced. It is essential to support an effective and sustainable implementation of this ambitious initiative.
有确凿证据表明，免费医疗服务会增加卫生服务的利用率，布基纳法索最近免除了所有五岁以下儿童和孕妇在卫生机构的直接付费。然而，对于在全国范围内常规实施条件下维持免费医疗服务所带来的收益的能力，我们知之甚少。特别是，中断免费医疗服务的后果尚不清楚。目的是评估一系列自然干预措施（包括免费医疗服务的引入、中断和重新引入）对五岁以下儿童的寻医行为和医疗设施使用的影响。这是在布基纳法索卡亚地区进行的一项嵌入式混合方法研究。定量部分基于反转纵向设计。采用汇总中断时间序列分析来评估 2005 年 1 月至 2015 年 3 月期间每月就诊次数的变化。通过对卫生人员和母亲进行深入访谈收集定性数据，以更好地理解定量结果。结果表明，免费医疗服务中断时，卫生中心的就诊量立即显著下降（-146，CI [-255；-37]）。当免费医疗服务重新引入时，就诊量再次增加（+89，CI [-11；187]）。城市和农村中心都受到影响。在免费医疗服务中断期间，更多地报告了自我用药和寻求传统治疗师的情况，并且民众和卫生人员之间的紧张关系加剧。除了资金不足之外，实施问题还限制了免费医疗服务的覆盖范围或强度。虽然取消用户费用可能会改善布基纳法索的母婴健康，但本研究表明，医疗服务的需求仍然对价格变化高度敏感。如果重新引入用户费用，免费医疗服务带来的利用率收益可能会迅速消失。支持这一雄心勃勃的倡议的有效和可持续实施至关重要。
