Using experience to create evidence: a mixed methods process evaluation of the new free family planning policy in Burkina Faso

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Study Justification:
– The study aims to evaluate the implementation of the new free family planning (FP) policy in Burkina Faso, which was introduced in 2019. This evaluation is important to identify obstacles and facilitators to implementation, assess the coverage of the policy, and investigate its influence on the perceived quality of FP services.
– The study provides valuable insights into the effectiveness of the policy and highlights areas for improvement. It can inform policy makers and program planners in Burkina Faso and other countries in Sub-Saharan Africa that are considering or implementing similar FP policies.
Study Highlights:
– The study found that implementation obstacles include insufficient communication, shortages of consumables and contraceptives, and delays in reimbursement from the government. However, previous experience with free healthcare policies, good acceptability in the population, and support from local associations were identified as facilitators.
– Six months after the introduction of the policy, only 50% of the surveyed participants knew about the free FP policy. Factors such as higher education level, being sexually active or in a relationship, having recently seen a healthcare professional, and possession of a radio significantly increased the odds of knowing.
– Despite the policy, 39% of the participants continued to pay for FP services due to stock shortages forcing them to buy their contraceptive products elsewhere. Increased waiting time and shorter consultations were also reported.
– The study highlights the need to address implementation issues to improve women’s access to contraception and increase awareness of the policy, particularly in the Cascades region.
Recommendations:
– Improve communication and awareness campaigns to increase knowledge of the free FP policy among the targeted population.
– Address stock shortages of consumables and contraceptives to ensure availability of FP services.
– Streamline reimbursement processes to reduce delays in payments to healthcare facilities.
– Address issues related to increased waiting time and shorter consultations to improve the quality of FP services.
Key Role Players:
– Ministry of Health: Responsible for policy development, coordination, and oversight.
– Healthcare workers: Involved in the delivery of FP services and implementation of the policy.
– Local associations: Provide support and advocacy for the policy implementation.
– Knowledge brokers: Assist in selecting participants for interviews and provide expertise in health matters.
Cost Items for Planning Recommendations:
– Communication and awareness campaigns: Budget for radio messages, community outreach activities, and information materials.
– Procurement of consumables and contraceptives: Allocate funds for purchasing and maintaining an adequate supply of FP products.
– Reimbursement system: Budget for administrative processes and timely payments to healthcare facilities.
– Training and capacity building: Provide resources for training healthcare workers on FP services and policy implementation.
– Monitoring and evaluation: Allocate funds for data collection, analysis, and reporting to assess the impact of the policy and identify areas for improvement.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides a comprehensive overview of the study design, methods, and results. The study used a mixed methods approach, including interviews and surveys, to evaluate the implementation of the free family planning policy in Burkina Faso. The obstacles and facilitators to implementation, coverage in the targeted population, and the policy’s influence on the perceived quality of family planning services were examined. The abstract provides specific details about the implementation issues, such as insufficient communication, shortages of consumables and contraceptives, and delays in reimbursement. It also highlights the main facilitators, including previous experience with free healthcare policies and support from local associations. The abstract concludes that six months after its introduction, the policy still has gaps in its implementation, as women continue to spend money for family planning services and have little knowledge of the policy, particularly in the Cascades region. The abstract suggests that addressing implementation issues could further improve women’s access to contraception. To improve the strength of the evidence, the abstract could provide more specific details about the sample size and demographics of the participants, as well as the statistical analysis methods used. Additionally, including information about the limitations of the study would provide a more balanced assessment of the evidence.

Background: In 2019, Burkina Faso was one of the first countries in Sub-Saharan Africa to introduce a free family planning (FP) policy. This process evaluation aims to identify obstacles and facilitators to its implementation, examine its coverage in the targeted population after six months, and investigate its influence on the perceived quality of FP services. Methods: This process evaluation was conducted from November 2019 through March 2020 in the two regions of Burkina Faso where the new policy was introduced as a pilot. Mixed methods were used with a convergent design. Semi-directed interviews were conducted with the Ministry of Health (n = 3), healthcare workers (n = 10), and women aged 15–49 years (n = 10). Surveys were also administered to the female members of 696 households randomly selected from four health districts (n = 901). Results: Implementation obstacles include insufficient communication, shortages of consumables and contraceptives, and delays in reimbursement from the government. The main facilitators were previous experience with free healthcare policies, good acceptability in the population, and support from local associations. Six months after its introduction, only 50% of the surveyed participants knew about the free FP policy. Higher education level, being sexually active or in a relationship, having recently seen a healthcare professional, and possession of a radio significantly increased the odds of knowing. Of the participants, 39% continued paying for FP services despite the new policy, mainly because of stock shortages forcing them to buy their contraceptive products elsewhere. Increased waiting time and shorter consultations were also reported. Conclusion: Six months after its introduction, the free FP policy still has gaps in its implementation, as women continue to spend money for FP services and have little knowledge of the policy, particularly in the Cascades region. While its use is reportedly increasing, addressing implementation issues could further improve women’s access to contraception.

The free FP policy was introduced as a pilot in the Cascades and Centre-Ouest regions in June 2019 by the Government of Burkina Faso (see Fig. 1). These areas comprise a total population of ~ 2.5 million, mostly (> 80%) located in rural areas, and present a fertility rate of around six children per woman [21, 22]. The policy applied to all public health facilities and covered 100% of the cost of FP consultations and counseling, tests and examinations, and contraceptives themselves (injectables, implants, copper intrauterine devices, emergency contraceptive pills, condoms, surgical methods, and a range of natural methods). Management of side effects and transport to the reference health facility for medical evacuations were also covered, as were all FP-related medical procedures (e.g., installation and removal of implants) and consumables (gloves, syringes, swabs, disinfectants, etc.). The goal is for women who are sexually active to pay nothing for any aspect of FP. Map of study area. The four health districts are displayed in blue. Main roads are shown as grey lines The introduction of free FP followed a national policy implemented in July 2016 that removed user fees for maternal and child healthcare services [23]. Both interventions use the same third-party reimbursement mechanisms and follow similar administrative and reporting procedures. As such, the free FP policy was conceptualized as a functional scale-up of the national user fee removal policy [24]. The implementation process was therefore facilitated and consisted mainly of informing health personnel through official channels of the extension of free procedures to family planning-related services. Dissemination activities in the population were also planned through radio messages and awareness campaigns in the communities by healthcare providers. This study was conducted between November 2019 and March 2020 in two separate phases (see Fig. 2). This study was conducted with the use of a mixed method design as per Creswell and Clark [25]. A mixed methods design was chosen in order to benefit from knowledge that comes from both qualitative and quantitative research as well as the integration of these two approaches [25]. First, a qualitative exploratory phase was undertaken to gain insight into the policy implementation process and refine research questions and instruments. Second, a qualitative and quantitative field data collection phase was conducted. Data was triangulated during the analysis using a convergent mixed method design, which was used to assess the coverage and implementation level of the free FP policy among the targeted population (Objective 2). Study design and collection phases The other two objectives, to investigate the presence of obstacles or facilitators to implementation and to assess the policy’s influence on the perceived quality of FP services, were pursued qualitatively. This was intentional, since it was necessary to gain an in-depth understanding of these topics and explore emerging themes—which is particularly suitable to qualitative research [26, 27]. To attain a variety of perspectives, qualitative investigations focused on three levels of policy implementation: (i) the central level, with the Ministry of Health (MoH); (ii) the peripheral level, with HCWs; and (iii) the community level, with direct beneficiaries of the policy. Moore’s conceptual framework for process evaluations of complex interventions guided this implementation study (see Additional file 1: Appendix S1) [28]. The specific components of Moore’s conceptual framework studied in this evaluation are process (Objective 1), fidelity and reach (Objective 2), and outcomes (Objective 3). The study took place in the context of rising insecurity in the country caused by terrorist attacks [29]. It was also conducted shortly after a nationwide strike had paralyzed non-essential activities in health facilities for several weeks. In October 2019, official documents (national planning and implementing strategy textbooks, information guides for health authorities, policy statements) were collected to gather as much information as possible before conducting interviews. In November 2019, semi-structured individual interviews (n = 3) were conducted in the capital Ouagadougou with program planners within the MoH involved in developing the free FP policy. The participants were conveniently selected with the assistance of a well-known knowledge broker for health matters in Burkina Faso. Interviews took place in MoH actors’ offices. They were conducted in French by LB, were supervised by a local researcher trained in qualitative research (AB), and lasted 30–60 min. Field notes were taken during the interviews, which were audio-recorded. After three interviews, information collected was deemed sufficient to form a good understanding of how implementation of free FP had been planned. Data was interpreted based on the review of planning documents, field notes and audio recordings, and with feedback from the other research team members. The fact that many researchers on the team had been involved for several years with the MoH in studies on free healthcare policies enriched this exploratory phase. This study’s quantitative component was embedded in another ongoing research project that aimed to evaluate the impacts of the national policy that removed health center user fees for pregnant women and children under five in 2016. Questions specific to the free FP policy were added to the original survey. The quantitative component was mostly designed to pursue Objective #2 of the present study: assessing the coverage and implementation level of the free FP policy among the targeted population. The coverage dimension was explored by assessing the beneficiaries’ knowledge of the FP policy and its associated factors, while the implementation level was examined by considering the presence of residual costs related to FP. The sampling procedures were derived from those of the USAID Demographic and Health Surveys program. A two-stage cluster sampling was carried out in four out of 10 health districts: Leo and Tenado (Centre-Ouest) and Sindou and Banfora (Cascades). These districts were purposively selected based on two criteria: They contained health facilities located in rural areas, and they were secure (not having experienced any attacks since at least 2016). Using the enumeration areas as defined by the Demographic and Health Surveys Program in these four districts, 29 were randomly selected with a probability proportional to the size of their population. In the second stage, 24 households per unit were randomly selected with equal probability. The target sample size of households was 696. Only households with ≥ 1 woman aged 15–49 were eligible. Ineligible households and households that could not be found were replaced by the nearest one. The survey took place in March 2020, after a five-day training for the interviewers. A questionnaire adapted from the standardized Demographic and Health Survey was administered to all consenting women aged 15–49 years from the selected households. It was administered in the local language by female interviewers with prior experience in community-based surveys. Although the standardized questionnaire already covered the participants’ sociodemographic characteristics and use of FP services, some questions were added to record out of pocket payments for FP services covered by the policy and the participants’ knowledge of the free PF policy. Responses were collected electronically on tablets using Commcare software (Dimagi, Cambridge, USA). Questionnaire data was automatically uploaded to a secure server then extracted and cleaned using Stata 14.0 (StataCorp, College Station, TX). Descriptive analysis was performed on three key variables related to the implementation of the free FP policy. The coverage of this policy was first assessed by estimating the proportion of targeted women who know that FP was now officially free of charge at health facilities. Secondly, contraceptive use (and moment of procurement) was measured by categorizing women according to their current use of contraceptives (yes/no) and the moment they last procured them, i.e., before or after the policy had been implemented. Thirdly, the costs associated with the respondent’s last FP visit to the health facility were analyzed by the time of the visit (before or after the introduction of the free policy) and broken down by type of service. All statistical analyses were conducted in open-source R statistical software V3.5.2. Maps were produced using the open-source software QGIS v3.8.1 Zanzibar. A multivariable logistic regression model with robust variance estimators was used to investigate factors related to knowledge of FP policy. The difference in the proportion of participants who paid for FP services before and after the introduction of the free policy was estimated by Chi-square tests of homogeneity of variance. The threshold for statistical significance was set at 0.05 (bilateral tests). The qualitative component consisted of semi-directed individual interviews with health personnel and female community members. For convenience and logistical reasons, the qualitative research took place only in the district of Banfora, where five public health facilities were selected based on their location (accessible rural areas) and their type (health facilities without maternity services were excluded). In each health center, the head nurse and another member of the health staff (preferably a midwife) were individually interviewed (n = 10). With their assistance, households or groups of households with women of reproductive age were identified in the catchment area, and two women were selected in the community surrounding each health facility (n = 10). Selection was stratified by age, with one female community member  20; these participants were from different households. To be selected, female community members had to be currently using FP. Data was collected in January 2020. For community members, the interviews took place outside of their home, in a secluded location that guaranteed the confidentiality of the respondents. For health personnel, interviews took place in a private room at the health facility. An interview guide specific to the type of the participant and with open-ended questions was used during the discussion (see Additional file 1). The interviews were conducted in French or in Djoula (depending on the participant’s preference) by a single female researcher with extensive training in qualitative research. Interviews with health personnel and women lasted 30–50 min and 15–30 min, respectively. They were recorded, transcribed verbatim and translated into French by an assistant. The field researcher listened to the original audio recordings and validated the transcripts. The research team members met once. Ten interviews were conducted with each type of participant and, with feedback from the researcher and her field notes, data saturation was considered to be reached. A content analysis technique was carried out on the qualitative data. The transcripts were read several times for thorough understanding. The text was entirely segmented, and a mixed inductive and deductive coding was used: deductive because the coding grid was first established based on Moore’s conceptual framework, and inductive because new codes were created for emerging themes [28]. The concepts from the framework which were used in the deductive coding grid were: process (obstacles and facilitators to the implementation), fidelity (payment for services or methods of FP), reach (knowledge of the intervention), and outcomes (perceived quality of care) [28]. Double coding was performed by two authors on a sample of the material to confirm the reliability of the final coding grid. Coding was conducted by LB and CB, as well as the thematic analysis. Peer debriefing was conducted with members of the research team, LB, CB and SC to derive themes from the codes. The interview results were triangulated with the data collected in the qualitative exploratory phase. The analysis was performed using QDA Miner software (QDA Miner 5.0). Integration of qualitative and quantitative data for the convergent design was carried out specifically for Objective 2 of our study: assessing coverage and implementation level of the free FP policy among the targeted population by investigating knowledge of the FP policy and residual costs related to FP. For this objective, quantitative and qualitative results were analyzed in parallel to study the same object before being integrated. A resulting comparison strategy was used by comparing the qualitative and quantitative components and identifying and interpreting divergences and convergences [25]. This interpretation was carried out to expand our understanding of conclusions on the free FP policy. For example, qualitative results were used to confirm our quantitative finding and explain specific quantitative results (expenditures on FP and knowledge level of the new policy). All participants provided informed written consent for both the qualitative and quantitative data collections. For the quantitative phase, consent was recorded on the tablet where the questionnaire was conducted. The questionnaire and the interviews were administered individually in a secluded area to preserve the confidentiality of participants. Participants aged 15–17 years old were considered mature minors and consented as adults. All the study procedures, including those for obtaining consent, were approved by the Comité d’éthique de la recherche en sciences de la santé at University of Montreal (Certificate #CERSES-20-146-D) and by the Comité d’éthique pour la Recherche en Santé in Burkina Faso (Deliberation #2018-6-075). The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript.

Based on the provided information, here are some potential innovations that could be recommended to improve access to maternal health:

1. Strengthen Communication: Address the insufficient communication obstacle by implementing targeted communication strategies to raise awareness about the free family planning policy. This could include radio messages, community awareness campaigns, and information dissemination through healthcare providers.

2. Improve Supply Chain Management: Address the shortages of consumables and contraceptives by implementing effective supply chain management systems. This could involve regular monitoring of stock levels, forecasting demand, and ensuring timely procurement and distribution of contraceptives to health facilities.

3. Streamline Reimbursement Process: Address the delays in reimbursement from the government by streamlining the reimbursement process. This could involve establishing clear guidelines and timelines for reimbursement, improving administrative and reporting procedures, and providing training and support to healthcare workers involved in the reimbursement process.

4. Enhance Provider Training: Provide training to healthcare workers on the new free family planning policy, its benefits, and the services covered. This could help ensure that healthcare workers are knowledgeable about the policy and can effectively communicate it to their patients.

5. Increase Community Engagement: Engage local associations and community leaders to support and promote the free family planning policy. This could involve partnering with community-based organizations, conducting community outreach programs, and involving community leaders in policy implementation and advocacy efforts.

6. Address Stock Shortages: Address the issue of stock shortages forcing women to buy contraceptive products elsewhere by improving the availability and accessibility of contraceptives in health facilities. This could involve strengthening supply chain management, increasing the stock of contraceptives in health facilities, and ensuring regular resupply.

7. Improve Service Delivery: Address the reported increased waiting time and shorter consultations by improving the efficiency and quality of service delivery. This could involve optimizing appointment scheduling, increasing the number of healthcare providers, and implementing client-centered approaches to care.

These innovations aim to address the identified obstacles and facilitators to the implementation of the free family planning policy in Burkina Faso and improve women’s access to maternal health services.
AI Innovations Description
The recommendation to improve access to maternal health based on the described study is to address the implementation obstacles identified in the evaluation. These obstacles include insufficient communication, shortages of consumables and contraceptives, and delays in reimbursement from the government. By addressing these issues, the free family planning (FP) policy can be implemented more effectively and improve access to maternal health.

To address the obstacle of insufficient communication, it is important to develop a comprehensive communication strategy that reaches both healthcare workers and the targeted population. This strategy should include clear and consistent messaging about the free FP policy, its benefits, and where and how to access FP services. Communication channels such as radio messages, awareness campaigns, and community engagement activities should be utilized to ensure that the information reaches the intended audience.

To address the issue of shortages of consumables and contraceptives, it is crucial to strengthen the supply chain management system. This can be done by improving forecasting and procurement processes, ensuring adequate stock levels at health facilities, and establishing mechanisms for timely distribution of contraceptives. Collaboration with relevant stakeholders, such as the Ministry of Health and supply chain management agencies, is essential to address this issue effectively.

Delays in reimbursement from the government can be addressed by streamlining administrative and reporting procedures. This may involve simplifying the reimbursement process, ensuring timely disbursement of funds, and providing training and support to healthcare workers on the reimbursement procedures. It is important to establish clear guidelines and accountability mechanisms to ensure that reimbursements are processed efficiently.

By addressing these implementation obstacles, the free FP policy can be more effectively implemented, leading to improved access to maternal health services. This, in turn, can contribute to reducing maternal mortality and improving overall maternal health outcomes in Burkina Faso.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthen Communication: Address the obstacle of insufficient communication by implementing targeted awareness campaigns and disseminating information about maternal health services, including family planning, through various channels such as radio, community health workers, and local associations.

2. Improve Supply Chain Management: Address the obstacle of shortages of consumables and contraceptives by implementing effective supply chain management systems to ensure a consistent and reliable availability of these essential resources in health facilities.

3. Streamline Reimbursement Processes: Address the obstacle of delays in reimbursement from the government by streamlining the reimbursement processes, ensuring timely payments to healthcare providers for the services they provide.

4. Enhance Training and Capacity Building: Provide training and capacity building programs for healthcare workers to improve their knowledge and skills in providing maternal health services, including family planning. This can help ensure the provision of high-quality services and increase the acceptability of these services among women.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed using a combination of quantitative and qualitative data collection methods. Here is a brief outline of a possible methodology:

1. Baseline Data Collection: Collect baseline data on the current status of access to maternal health services, including family planning, in the target population. This can include information on knowledge and awareness of available services, utilization rates, barriers to access, and quality of care.

2. Intervention Implementation: Implement the recommended interventions, such as targeted awareness campaigns, supply chain management improvements, and training programs for healthcare workers. Ensure proper monitoring and documentation of the implementation process.

3. Data Collection Post-Intervention: Collect data after the implementation of the interventions to assess their impact on improving access to maternal health services. This can include measuring changes in knowledge and awareness, utilization rates, availability of contraceptives, and healthcare provider satisfaction.

4. Quantitative Analysis: Analyze the quantitative data using statistical methods to quantify the impact of the interventions. This can involve comparing pre- and post-intervention data to identify any significant changes in access to maternal health services.

5. Qualitative Analysis: Analyze the qualitative data collected through interviews and focus groups to gain a deeper understanding of the experiences and perceptions of the target population and healthcare providers regarding the interventions. This can provide valuable insights into the effectiveness of the interventions and any additional factors influencing access to maternal health services.

6. Integration of Findings: Integrate the findings from the quantitative and qualitative analyses to provide a comprehensive assessment of the impact of the interventions on improving access to maternal health services. Identify key lessons learned and recommendations for further improvement.

7. Dissemination of Results: Share the findings with relevant stakeholders, including policymakers, healthcare providers, and community members, to inform decision-making and facilitate the implementation of evidence-based strategies to improve access to maternal health services.

It is important to note that this is a general outline, and the specific methodology may vary depending on the context and resources available for the evaluation.

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