Background: While numerous studies have shown the positive impact of free healthcare policies, the ethical issues raised by these policies in low-income countries have received little attention. In Burkina Faso, in July 2016, user fees were removed at healthcare facilities for children under 59 months of age and for “mothers”, i.e., for reproductive care. These eligibility criteria are, reportedly, sometimes difficult to comprehend or to enforce. The purpose of this study is twofold: 1) to understand the perceptions and practices of (...) health workers and beneficiaries regarding compliance with eligibility criteria for free care and 2) to explore the ethical tensions that have arisen and possible ways of resolving them. Methodology: In late 2018, a cross-sectional qualitative study was conducted in five rural communities in Boulsa, Burkina Faso. Semi-directed individual interviews were conducted with healthcare personnel (n=10) and mothers of young children (n=10) who were purposefully selected with the assistance of community health workers. Interviews were recorded and transcribed. A thematic content analysis was conducted on all materials. Themes were identified, discussed and reformulated between team members. Results: The study reveals the presence of practices to circumvent strict compliance with the eligibility criteria for free access. Common circumventing practices include hiding the exact age of children aged 60 months or older and using eligible persons for stockpiling drugs or for receiving a free consultation for the benefit of other household members. These practices result from ethical and economic tensions experienced by the beneficiaries. But they also raise ethical dilemmas for healthcare providers since they have to enforce compliance with the eligibility criteria while realizing the financially precarious position of the households. Informal mechanisms are introduced at the community level to reconcile the healthcare providers’ dissonance. Conclusion: The implementation of the user fee abolition policy in Burkina Faso is being carried out through local reinvention mechanisms to overcome ethical tensions related to the compliance with the eligibility criteria. (shrink)

The lack of primary healthcare integration has been identified as one of the main limits to programs’ efficacy in low- and middle-income countries. This is especially relevant to the Millennium Development Goals, whose health objectives were not attained in many countries at their term in 2015. While global health scholars and decision-makers are unanimous in calling for integration, the objective here is to go further and contribute to its promotion by presenting two of the most important challenges to be met (...) for its achievement: 1) developing a “crosswise approach” to implementation that is operational and effective; and 2) creating synergy between national programs and interventions driven by non-State actors. The argument for urgently addressing this double challenge is illustrated by drawing on observations made and lessons learned during a four-year research project evaluating the effects of interventions against malaria in Burkina Faso. The way interventions were framed was mostly vertical, leaving little room for local adaptation. In addition, many non-governmental organizations intervened and contributed to a fragmented and heteronomous health governance system. Important ethical issues stem from how interventions against malaria were shaped and implemented in Burkina Faso. To further explore this issue, a scoping literature review was conducted in August 2016 on the theme of integrated primary healthcare. It revealed that no clear definition of the concept has been advanced or endorsed thus far. We call for caution in conceptualizing it as a simple juxtaposition of different tasks or missions at the primary care level. It is time to go beyond the debate around selective versus comprehensive approaches or fragmentation versus cohesion. Integration should be thought of as a process to reconcile these tensions. In the context that characterizes many low- and middle-income countries today, better aid coordination and public health systems strengthening, as promoted by multisectoral approaches, might be among the best options to sustainably and ethically integrate primary healthcare interventions. (shrink)