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Targeting the worst-off for free health care: A process evaluation in Burkina Faso


  • Ridde, Valéry
  • Yaogo, Maurice
  • Kafando, Yamba
  • Kadio, Kadidiatou
  • Ouedraogo, Moctar
  • Bicaba, Abel
  • Haddad, Slim


Effective mechanisms to exempt the indigent from user fees at health care facilities are rare in Africa. A State-led intervention (2004-2005) and two action research projects (2007-2010) were implemented in a health district in Burkina Faso to exempt the indigent from user fees. This article presents the results of the process evaluation of these three interventions. Individual and group interviews were organized with the key stakeholders (health staff, community members) to document the strengths and weaknesses of key components of the interventions (relevance and uptake of the intervention, worst-off selection and information, financial arrangements). Data was subjected to content analysis and thematic analysis. The results show that all three intervention processes can be improved. Community-based targeting was better accepted by the stakeholders than was the State-led intervention. The strengths of the community-based approach were in clearly defining the selection criteria, informing the waiver beneficiaries, using a participative process and using endogenous funding. A weakness was that using endogenous funding led to restrictive selection by the community. The community-based approach appears to be the most effective, but it needs to be improved and retested to generate more knowledge before scaling up.

Suggested Citation

  • Ridde, Valéry & Yaogo, Maurice & Kafando, Yamba & Kadio, Kadidiatou & Ouedraogo, Moctar & Bicaba, Abel & Haddad, Slim, 2011. "Targeting the worst-off for free health care: A process evaluation in Burkina Faso," Evaluation and Program Planning, Elsevier, vol. 34(4), pages 333-342, November.
  • Handle: RePEc:eee:epplan:v:34:y:2011:i:4:p:333-342

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    References listed on IDEAS

    1. David Coady & Margaret Grosh & John Hoddinott, 2004. "Targeting of Transfers in Developing Countries : Review of Lessons and Experience," World Bank Publications, The World Bank, number 14902.
    2. Ir, Por & Bigdeli, Maryam & Meessen, Bruno & Van Damme, Wim, 2010. "Translating knowledge into policy and action to promote health equity: The Health Equity Fund policy process in Cambodia 2000-2008," Health Policy, Elsevier, vol. 96(3), pages 200-209, August.
    3. Davidson R. Gwatkin & Adam Wagstaff & Abdo S. Yazbeck, 2005. "Reaching the Poor with Health, Nutrition, and Population Services : What Works, What Doesn't, and Why," World Bank Publications, The World Bank, number 7393.
    4. Conning, Jonathan & Kevane, Michael, 2002. "Community-Based Targeting Mechanisms for Social Safety Nets: A Critical Review," World Development, Elsevier, vol. 30(3), pages 375-394, March.
    5. Bitran, Ricardo & Giedion, Ursula, 2003. "Waivers and exemptions for health services in developing countries," Social Protection and Labor Policy and Technical Notes 25987, The World Bank.
    6. Ridde, Valéry, 2008. ""The problem of the worst-off is dealt with after all other issues": The equity and health policy implementation gap in Burkina Faso," Social Science & Medicine, Elsevier, vol. 66(6), pages 1368-1378, March.
    7. Gilson, Lucy & Kalyalya, Denny & Kuchler, Felix & Lake, Sally & Oranga, Hezron & Ouendo, Marius, 2001. "Strategies for promoting equity: experience with community financing in three African countries," Health Policy, Elsevier, vol. 58(1), pages 37-67, October.
    8. Lucy Gilson & Steven Russell & Kent Buse, 1995. "The political economy of user fees with targeting: Developing equitable health financing policy," Journal of International Development, John Wiley & Sons, Ltd., vol. 7(3), pages 369-401, May.
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    Cited by:

    1. V. Ridde & I. Agier & A. Jahn & O. Mueller & J. Tiendrebéogo & M. Yé & M. De Allegri, 2015. "The impact of user fee removal policies on household out-of-pocket spending: evidence against the inverse equity hypothesis from a population based study in Burkina Faso," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 16(1), pages 55-64, January.


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