布基纳法索基层工作者对豁免政策的了解和应用不足，危及全民健康覆盖目标的实现：来自横断面调查的证据。
Street-level workers' inadequate knowledge and application of exemption policies in Burkina Faso jeopardize the achievement of universal health coverage: evidence from a cross-sectional survey.
机构信息
CEPED, IRD, Université Paris Descartes, Inserm, équipe SAGESUD, 45, rue des Saints Pères, 75006, Paris, France.
IRD (French Institute For Research on Sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France.
出版信息
Int J Equity Health. 2018 Jan 8;17(1):5. doi: 10.1186/s12939-017-0717-5.
BACKGROUND
Street-level workers play a key role in public health policies in Africa, as they are often the ones to ensure their implementation. In Burkina Faso, the State formulated two different user-fee exemption policies for indigents, one for deliveries (2007), and one for primary healthcare (2009). The objective of this study was to measure and understand the determinants of street-level workers' knowledge and application of these exemption measures.
METHODS
We used cross-sectional data collected between October 2013 and March 2014. The survey targeted 1521 health workers distributed in 498 first-line centres, 18 district hospitals, 5 regional hospitals, and 11 private or other facilities across 24 districts. We used four different random effects models to identify factors associated with knowledge and application of each of the above-mentioned exemption policies.
RESULTS
Only 9.2% of workers surveyed knew of the directive exempting the worst-off, and only 5% implemented it. Knowledge and application of the delivery exemption were higher, with 27% of all health workers being aware of the delivery exemption directive and 24.2% applying it. Mobile health workers were found to be consistently more likely to apply both exemptions. Health workers who were facility heads were significantly more likely to know about the indigent exemption for primary health care and to apply it. Health workers in districts with higher proportions of very poor people were significantly more likely to know about and apply the delivery exemption. Nearly 60% of respondents indicated either 5% or 10% as the percentage of people they would deem adequate to target for exemption.
CONCLUSION
This quantitative study confirmed earlier qualitative results on the importance of training and informing health workers and monitoring the measures targeting equity, to ensure compliance with government directives. The local context (e.g., hierarchy, health system, interventions) and the ideas that street-level workers have about the policy instruments can influence their effective implementation. Methods for remunerating health workers and health centres also need to be adapted to ensure equity measures are applied to achieve universal healthcare.
背景
在非洲，基层工作者在公共卫生政策中发挥着关键作用，因为他们通常是确保政策实施的人。在布基纳法索，国家为贫困人口制定了两项不同的免费用药政策，一项是针对分娩（2007 年），另一项是针对初级保健（2009 年）。本研究的目的是衡量和理解基层工作者对这些豁免措施的知识和应用的决定因素。
方法
我们使用了 2013 年 10 月至 2014 年 3 月期间收集的横断面数据。调查对象为分布在 24 个区的 498 个一线中心、18 个区医院、5 个地区医院和 11 个私人或其他设施的 1521 名卫生工作者。我们使用了四种不同的随机效应模型来确定与上述豁免政策的知识和应用相关的因素。
结果
只有 9.2%的被调查工人知道为最贫困者免除费用的指令，只有 5%的人实施了该指令。对分娩豁免的认识和应用较高，所有卫生工作者中有 27%知道分娩豁免指令，24.2%的人实施了该指令。流动卫生工作者被发现更有可能同时应用这两项豁免。作为设施负责人的卫生工作者更有可能了解初级保健的贫困人口豁免政策并应用该政策。在贫困人口比例较高的地区，卫生工作者更有可能了解和应用分娩豁免。近 60%的受访者表示，他们认为 5%或 10%的人作为豁免的目标人群是足够的。
结论
这项定量研究证实了之前关于培训和告知卫生工作者以及监测公平措施的重要性的定性研究结果，以确保遵守政府指令。当地的情况（如等级制度、卫生系统、干预措施）和基层工作者对政策工具的看法会影响其有效实施。还需要调整卫生工作者和卫生中心的报酬方法，以确保实施公平措施以实现全民医疗保健。
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