Why do women pay more than they should? A mixed methods study of the implementation gap in a policy to subsidize the costs of deliveries in Burkina Faso

Abstract

In 2007, Burkina Faso launched a public policy to subsidize 80% of the cost of normal deliveries. Although women are required to pay only the remaining 20%, i.e., 900 F CFA (1.4 Euros), some qualitative evidence suggests they actually pay more.

The aim of this study is to test and then (if confirmed) to understand the hypothesis that the amounts paid by women are more than the official fee, i.e., their 20% portion.

A mixed method sequential explanatory design giving equal priority to both quantitative (n = 883) and qualitative (n = 50) methods was used in a rural health district of Ouargaye.

Half (50%, median) of the women reported paying more than the official fee for a delivery. Health workers questioned the methodology of the study and the veracity of the women's reports. The three most plausible explanations for this payment disparity are: (i) the payments were for products used that were not part of the delivery kit covered by the official fee; (ii) the implementers had difficulty in understanding the policy; and (iii) there was improper conduct on the part of some health workers.

Institutional design and organizational practices, as well as weak rule enforcement and organizational capacity, need to be considered more carefully to avoid an implementation gap in this public policy.

Introduction

UNICEF (2009) has stated that 80% of maternal deaths could be avoided if known interventions were implemented. Thus, in the fight against maternal mortality, many voices have been raised deploring the fact that strategies known to be effective a priori are not being implemented, particularly in Africa (De Brouwere and Van Lerberghe, 2001, United Nations Secretary-General, 2010). One recommended intervention is to encourage women to use qualified personnel for deliveries. Proper care at deliveries could reduce the risks of maternal mortality and morbidity by 95% (Graham et al., 2001, World Health Organization, 2010a). Studies have shown that the financial barrier is one of several reasons for women's low recourse to qualified personnel for assisted deliveries (Nanda, 2002). Therefore it is now recommended that user fees for deliveries be eliminated (African Union, 2010, Richard et al., 2010, World Health Organization, 2010b).

However, it is not enough to follow internationally recognized recommendations by formulating public policies; these policies must also be effectively implemented, since, “if implementation fails, everything fails” (Chen, 2004). Indeed, other authors have asserted that “many evidence-based innovations fail to produce results when transferred to communities in the global south, largely because their implementation is untested, unsuitable or incomplete” (Madon, Hofman, Kupfer, & Glass, 2007). Moreover, meta-analyses have shown that the efficacy of interventions is generally subject to multiple distortion factors related to implementation, often in excess of 50% (Durlak & DuPre, 2008). Unfortunately, only 4% of publications on public policy implementation between 1933 and 2003 concern Africa (Saetren, 2005), and few of those were concerned with issues of equity in health (Gilson & Raphaely, 2008). In addition, scarcely any studies on health promotion or health policies in low-income countries refer directly to concepts and theories used in the study of public policies (Breton and De Leeuw, 2011, Gilson and Raphaely, 2008).