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Written by Matt Boxshall (ThinkWell), Sarah Straubinger (ThinkWell), Kadidia Dissa Boro (ThinkWell Burkina Faso), Pierre-Marie Metangmo (ThinkWell Burkina Faso)

Despite many competing challenges, the Government of Burkina Faso continues to demonstrate its commitment to sexual and reproductive health rights. In July 2020, Burkina’s Ministry of Health (MoH) moved to improve equity and access to family planning (FP) by extending ‘Gratuité’ – a user fee exemption scheme for women and children under 5 years of age – to make FP services free of charge in all public facilities. ThinkWell has been supporting MoH to undertake routine analysis of free FP data. The analysis shows that the number of claims submitted has grown rapidly over the first three months of the program, primarily driven by demand for contraceptive implants. However, removing user fees does not appear to have increased overall uptake of FP in Burkina Faso, and it is unclear how the cost of reimbursing facilities for free services will be covered by the MoH.

Government commitment, backed by strong international support, has enabled relatively high uptake of FP in Burkina Faso by regional standards, but there is still much room for improvement. The national plan for accelerating FP targets a modern contraceptive prevalence rate of 32% by 2020, but recent data suggests that this target will not be achieved. Burkina’s very high total fertility rate (5.2 births per woman) contributes to environmental and security pressures in the region.

The Government of Burkina Faso adopted the Gratuité free health services policy in 2016 and announced its extension to include FP in 2018. Under Gratuité, public facilities nationwide provide a defined package of maternal, neonatal and child health (MNCH) services free of charge. Facilities replace lost income from user fees through equivalent payments from the government. The MoH’s 2018 decision to extend the scheme to include FP services was informed by evidence of improved access to MNCH services through Gratuité, as well as by the success of annual “free FP weeks”. A pilot of free FP within Gratuité ran from June to December 2019 in the Cascades and Centre-Ouest regions.

Despite the COVID-19 crisis, uptake of FP services remained stable in Burkina Faso, and in July 2020 the MoH decided to roll-out free FP services nationally. Intended for anyone who is sexually active, free FP benefits under Gratuité include FP counselling and provision of long- and short-acting contraceptive methods, as well as management of side effects and complications.

Analysis of initial FP Gratuité data shows increasing uptake of free services driven by demand for implants.  ThinkWell is partnering the Ministry of Health to conduct routine analysis of free FP claims data. Claims numbers have increased steadily between July and September 2020, with more than 80% of health districts reporting that they offered free FP services in September. Most claims are from primary level health facilities (95% from centre de soins et de promotion sociale) and rural locations (72%), suggesting that free services are reaching those most in need.  Contraceptive implants are the predominant free method, generating 72% of couple years of protection (CYPs), and perhaps signaling that the removal of fees is increasing access to long-acting revisable methods.

Although the number of free services is increasing, this does not translate into an increase in FP services overall. In the first quarter of roll-out, free services are simply replacing services paid out-of-pocket. Findings from the pilot suggest some potential reasons for this. A lack of demand creation and community sensitization may blunt the impact of the scheme. Providers’ limited understanding of the scheme’s reporting procedures may also reduce their willingness to offer free FP; as of September 2020, 20% of districts are yet to report FP claims into the e-Gratuité system.

An underlying issue, and a longer-term challenge, may be the impact of removing user fees on provider motivation. In Burkina Faso, the opportunity to generate immediate income for the facility through user fees may have encouraged a proactive offer of family planning services. The introduction of user fee exemptions schemes in other African countries has reduced health worker motivation. A review of the Gratuité scheme also identified that providers viewed the reporting system as complex, increasing administrative burden and undermining morale. Perceptions of late or inadequate payment from government have driven dissatisfaction with Gratuité among MNCH service providers, and such delays may contribute to poor provider motivation in similar schemes.

Inadequate budget provision for free FP also poses a critical challenge for the scheme. The cost of free FP services is increasing every month and reached 91 million CFA francs (roughly $167 thousand USD) in September 2020. Gratuité is funded by the state budget, which bears all direct health care expenses of the covered services. Provision of free MNCH services through the Gratuité worked well until budget cuts in 2018 caused shortfalls in payments to facilities and debts to the central medical store. In 2021, free FP will certainly cost the state more than a million dollars – not an impossible amount, but to date additional funds for FP have not been allocated. Uncertain and inadequate funding poses a challenge to the continued evolution of free FP and free MNCH services.

Despite these challenges, early results of Burkina Faso’s experiences providing free FP indicate that the scheme has potential to increase women’s choice and to improve access to FP. To improve performance, the Government of Burkina Faso should take steps to build awareness of FP in communities and facilities, maintain the motivation of providers, and ensure adequate budget allocation for FP services. The MoH has the opportunity to learn from these early successes and concerns to maximize value and impact as free FP continues to grow.

Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of SRHM as an organisation.