Burkina Faso has made substantial progress in women and children’s health and nutrition over the past two decades. Coverage of essential services has improved, and more children have been immunized and have benefited from treatment of malnutrition. However, the security situation severely disrupted in view of the upsurge and the multiplicity of armed attacks perpetrated in the country have impacted health service delivery in country’s six regions or around 50 percent of the country, leaving many women and children behind. The Global Financing Facility (GFF) is working with the government to strengthen the resilience of health systems and implement health financing reforms to expand coverage of quality services for vulnerable populations in those regions. These stepped-up efforts on equity are a critical part of Burkina Faso’s path towards achieving universal health coverage.
Progress Made but Challenges Remain
Burkina aso has made substantial progress in key health outcomes for women and children. Attended deliveries in health facilities rose from 66 to 84 percent between 2010 and 2015 while the number of women receiving four antenatal care visits increased from 28 to 38 percent between 2015 and 2017. In 2016, more than twice as many children under two were fully immunized (86 percent) compared to only 39 percent in 2003. From 2010 to 2015, under-five mortality dropped by more than a third (36 percent) and neonatal mortality by 28 percent. Maternal mortality fell slightly, and on average, women had less children while access to contraception almost doubled from 15 to 27 percent. Despite this progress, malnutrition continues to affect many children. While stunting declined from 25 to 21 percent wasting remained stagnant at 8.6 percent (Enquête Nutritionnelle Nationale).
Despite limited financial resources, Burkina Faso has increased domestic spending for health from US$17.45 to US$19.23 per capita between 2016 and 2017 with most of this spending (85 percent) allocated to primary and outpatient care. However, in the same period, total health spending as a share of the overall government expenditures dropped only slightly from 11 to 10 percent while the share of household out of pocket expenses remained flat at about a third of the overall spending. With support from the GFF, Burkina Faso is working to prioritize ways to expand access to services without putting families in financial hardship.
Focusing on Women and Children in Conflict-affected Areas
In recent years, political unrest and insurgency has disrupted health service delivery in the country’s Boucle du Mouhoun, Eastern-Center, Northern-Center-Nord, East, North and Sahel regions. Today, 6 of the 13 country’s regions are in a precarious state of security despite government efforts to curb the problem. As of June 30, 2020, approximately 1.3 million people are deprived of access to primary health care, the most affected being women and children up to 85 percent. Driven by a strong commitment to reach universal health coverage, the government worked with the GFF and partners to develop an investment case to prioritize and improve access to quality services for these vulnerable populations. The investment case is financed by a US$20 million GFF grant inked to an US$80 million World Bank investment, the Health Services Reinforcement Project.
Shaping a cohesive country platform
The GFF has helped the government to establish an inclusive stakeholder group of representatives from government ministries, health agencies, the private sector, donors, and civil society, led by the Minister of Health. This group collaborated to develop the initial investment case in 2019 that prioritized interventions to strengthen lagging health outcomes. Through dialogue and consultations, the GFF played a key role in empowering civil society to monitor progress and deliver on the objectives on the investment case.
Revising the investment case to reach those in need
Based on lessons learned, the government is revising the investment case to (i) better take into account resilience in order to provide the additional support needed in regions affected by insecurity; and (ii) take better account of financing reforms, in particular the financial protection of populations. The new investment case aims to expand an existing community-based health insurance program and provide free access to essential health services for mothers and young children. It will also include strategic purchasing of services to encourage health providers to increase both the volume and quality of services by linking payments to performance. The new investment case, which prioritizes closing access gaps, will also help mobilize resources for the country's gradual progress towards universal health coverage.
Prioritizing the most disadvantaged populations
The new plan prioritizes resources and high-impact interventions in six regions where maternal and child health lags the most and access to services are the lowest – Boucle de Mouhoun, Centre-Est, Est, Sahel, Nord, and Centre-Nord, which include the Northern regions that are home to those displaced by conflict. The focus is on building more resilient community health systems for continuous delivery of essential services to women and children. For example, in regions such as the Sahel, insecurity has forced health workers to be redeployed – resulting in major disruptions to service delivery. The region also has insufficient health facilities and a very low ratio of community health workers per capita – approximately 8.6 workers for every 10,000 people. Almost half of the population lives more than 10 kilometres away from a health facility, making access to services even more challenging.
Identifying funding gaps
The GFF and the Bill and Melinda Gates Foundation have supported the government to map resources to inform budget allocation decisions for 2020 and 2021. The mapping showed stronger alignment among partners, and an increase in donor financing and domestic resources to finance priorities. However, ;the data also revealed a funding gap of 30 percent – or an additional US$30 million needed by 2021 – mainly because the scope of activities and associated costs have expanded. The GFF will continue to work with the government on funding sustainability and to integrate annual assessments of funding allocations in line with the government’s own budget process.
Promoting Health Financing Reforms to Build Resilience
Under the new investment case the GFF will focus its support on a series of reforms to ensure equitable access to quality primary health care, especially in priority regions. These include delivering free health services to pregnant women and children under five by scaling up a new community health insurance program; upgrading performance-based contracts to improve quantity and quality of services; and strengthening community health systems.
- Improving social protection:the government will pay health insurance contributions for pregnant women and children under five, as well as for the poorest households. The government also plans to add family planning to the range of essential health services overed by the program
- Reforming strategic purchasing: the existing performance-contracting system will be reformed so that more women and children have access to additional health services. Under the revised scheme, health facilities will receive up-front funding and the services delivered will be monitored by non-governmental organizations. Reforms will also aim to increase the number of private health facilities offering services and medical supplies more accessible for women and children.
- Strengthening community health: focus will be placed on building more resilient community health systems by training competent health care professionals, increasing the number of women employed in facilities, and ensuring that facilities are adequately staffed.
Promote the use of better data in decision-making
The GFF is providing technical assistance to the government to strengthen the civil registration system, particularly in remote areas, to collect crucial information on vital statistics such as community health workers. To promote more and better data use in decision-making, the GFF has initiated a partnership with Countdown to 2030 to conduct annual and mid-term reviews of the country’s investment case. It also aims to build the capacity of the Institute of Population Sciences of the University of Ouagadougou to contribute to data analysis. Finally, the GFF and the World Bank are supporting the country’s population census to collect sociodemographic data and information on public infrastructure, including health facilities.
Realizing the Revised Investment Case: Next Steps
Building on earlier gains, Burkina Faso will monitor progress on key service delivery indicators and promote accountability and dialogue with all stakeholders. Together, these efforts will help strengthen the resilience of health systems to expand coverage of quality services for vulnerable populations.