@article{fdi:010074059,
  title = {{T}he unintended consequences of combining equity measures with performance-based financing in {B}urkina {F}aso},
  author = {{T}urcotte-{T}remblay, {A}. {M}. and {D}e {A}llegri, {M}. and {G}ali-{G}ali, {I}. {A}. and {R}idde, {V}al{\'e}ry},
  editor = {},
  language = {{ENG}},
  abstract = {{B}ackground: {U}ser fees and poor quality of care contribute to low use of healthcare services in {B}urkina {F}aso. {T}he government implemented an innovative intervention that combines equity measures with performance-based financing ({PBF}). {T}hese health equity measures included a community-based selection of indigents to receive user fee exemptions and paying healthcare centres higher purchase prices for services provided to indigents. {R}esearch suggests complex interventions can trigger changes not targeted by program planners. {T}o date, however, there is a knowledge gap regarding the unintended consequences that can emerge from combining {PBF} with health equity measures. {O}ur objective is to document unintended consequences of the equity measures in this complex intervention. {M}ethods: {W}e developed a conceptual framework using the diffusion of innovations theory. {F}or the design, we conducted a multiple case study. {T}he cases were four healthcare facilities in one district. {W}e collected data through 93 semi-structured interviews, informal discussions, observation, as well as intervention documents. {W}e conducted thematic analysis using a hybrid deductive-inductive approach. {W}e also used secondary data to describe the monthly evolution of services provided to indigent and non-indigent patients before and after indigent cards were distributed. {T}ime series graphs were used to validate some results. {R}esults: {L}ocal actors, including members of indigent selection committees and healthcare workers, re-invented elements of the {PBF} equity measures over which they had control to increase their relative advantage or to adapt to implementation challenges and context. {S}ome individuals who did not meet the local conceptualization of indigents were selected to the detriment of others who did. {H}ealthcare providers believed that distributing free medications led to financial difficulties and drug shortages, especially given the low purchase prices and long payment delays. {H}ealthcare workers adopted measures to limit free services delivered to indigents, which led to conflicts between indigents and providers. {U}ltimately, selected indigents received uncertain and unequal coverage. {C}onclusions: {T}he severity of unintended consequences undermined the effectiveness and equity of the intervention. {I}f the intervention is prolonged and expanded, decision-makers and implementers will have to address these unintended consequences to reduce inequities in accessing care.},
  keywords = {{P}erformance-based financing ; {U}ser fee exemption ; {U}niversal health coverage ; {I}ndigents ; {U}nintended consequences ; {B}urkina {F}aso ; {M}ultiple-case study ; {BURKINA} {FASO}},
  booktitle = {},
  journal = {{I}nternational {J}ournal for {E}quity in {H}ealth},
  volume = {17},
  numero = {},
  pages = {art. 109 [19 ]},
  ISSN = {1475-9276},
  year = {2018},
  DOI = {10.1186/s12939-018-0780-6},
  URL = {https://www.documentation.ird.fr/hor/fdi:010074059},
}