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Abstract

Introduction and rationale

The ultra-poor are the most vulnerable and underserved population in sub-Saharan Africa with limited access to health care services. Producing scientific evidence on the exemption from user fees for this population is considered highly relevant also in light of the agenda of sustainable development and the focus on leaving no one behind. Nevertheless, the ultra-poor have remained an underrepresented group in the scientific landscape, primarily because of the difficulties in reaching them. The study contributed to filling this gap by estimating the effects of user fee exemptions on healthcare utilization, their potential to protect the ultra-poor from financial hardship and the cost implications to the healthcare system when providing first-level services through user fee exemptions to the ultra-poor nationwide. The ultra-poor had been targeted and exempted within the context of the performance-based financing intervention in Burkina Faso. Ultra-poor were selected based on a community-based approach and provided with an exemption card allowing them to access healthcare services free of charge. Specifically, the first study objective was to establish the effect of user fee exemptions on the utilisation of healthcare services. The second study objective was to assess the level of out-of- pocket expenditure and factors associated with excessive out-of-pocket expenditure among the ultra-poor. The third study objective was to estimate the capital and recurrent cost of providing one first-level curative consultation to the exempted ultra-poor and estimate the cost and healthcare budget impact for a national scale-up. 121

Materials and methods

In line with the study objectives mentioned above, the thesis consists of three components. The first study component relied on a panel data set of 1652 randomly selected ultra-poor from Diébougou, Gourcy, Kaya and Ouargaye health district. Logistic regression was applied on the end line data to identify factors associated with the receipt of user fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. The second study component consisted of a descriptive analysis of out-of- pocket expenditure on formal healthcare services using cross-sectional data from the Diébougou district only. Multivariate logistic regression was performed to investigate the factors related to excessive out-of-pocket expenditure among the ultra-poor. For study component three, the author conducted a micro-costing study by extracting resource consumption data from the medical records of 1380 ultra-poor patients in 15 CSPS in Diébougou in 2016. Using the derived recurrent cost per the first-level consultation, the author conducted a budget impact analysis for providing first-level consultations to the exempted ultra-poor nationwide, considering different thresholds of health service utilisation and population coverage.

Results

First, the study found that out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diébougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation ( = 0.07; 95% CI = 0.45; 0.32; p = 0.73). Second, the study detected that with an average of FCFA 23051.62 (USD 39.18), the ultra- poor had to supplement a significant amount of out-of-pocket expenditure to receive formal healthcare services at public health facilities, although services were supposed to be free. The probability of incurring excessive out-of-pocket expenditure was negatively associated with being female (β = − 2.072, p = 0.00, ME = − 0.324; p = 0.000) and having an exemption card 122 (β = − 1.787, p = 0.025; ME = − 0.279, p = 0.014). Third, the study estimated the capital cost of providing one first-level curative consultation to the ultra-poor to range between USD 0.59 - USD 0.61 and the recurrent cost between USD 2.58 and USD 5.00, accumulating to a total of USD 3.17 - USD 5.61. A nationwide delivery of first-level services to the bottom 6 % of the population, assuming 0.25 healthcare contacts per capita per year, would result in an annual expense between USD 832,225.81 and USD 1,614,197.26. This annual expense represents 0.22 to 0.43 per cent of the Burkinabè health budget. However, the expected annual expense was very sensitive to changes in the health utilization rate and population coverage.

Conclusions and recommendations

The study provides evidence that targeted user fee exemptions for the ultra-poor need to be better designed and implemented to effectively increase health service utilisation. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access. The study further demonstrated that user fee exemptions are yet associated with reduced out-of-pocket expenditure for the ultra-poor, showing the importance of free care for this marginalised population. The ultra-poor people's elevated risk due to multi-morbidities and severity of illness need to be considered when allocating resources to address existing inequalities better and improve financial risk protection. Last, the study found that providing first-level services for the exempted ultra-poor at the national level is likely to be affordable. To further advance towards leaving no one behind, Burkina Faso could consider piloting a capitation-based system to remunerate primary healthcare providers for providing first-level services to the ultra-poor.