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Int J Equity Health. 2018 Sep 24;17(1):109. doi: 10.1186/s12939-018-0780-6.

The unintended consequences of combining equity measures with performance-based financing in Burkina Faso.

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University of Montreal Public Health Research Institute, 7101 Avenue du Parc, Room 3060, Montreal, QC, H3N 1X9, Canada.
School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC, H3N 1X9, Canada.
Institute of Public Health, Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
Association Action Gouvernance Intégration Renforcement (AGIR), Ouagadougou, Burkina Faso.
Association Zama Forum pour la Diffusion des Connaissances et des Expériences Novatrices en Afrique (Zama Forum / ADCE-Afrique), Bobo-Dioulasso, Burkina Faso.
University of Montreal Public Health Research Institute, 7101 Avenue du Parc, Room 3060, Montreal, QC, H3N 1X9, Canada.
IRD (French Institute for Research on Sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France.



User fees and poor quality of care contribute to low use of healthcare services in Burkina Faso. The government implemented an innovative intervention that combines equity measures with performance-based financing (PBF). These 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. Research suggests complex interventions can trigger changes not targeted by program planners. To date, however, there is a knowledge gap regarding the unintended consequences that can emerge from combining PBF with health equity measures. Our objective is to document unintended consequences of the equity measures in this complex intervention.


We developed a conceptual framework using the diffusion of innovations theory. For the design, we conducted a multiple case study. The cases were four healthcare facilities in one district. We collected data through 93 semi-structured interviews, informal discussions, observation, as well as intervention documents. We conducted thematic analysis using a hybrid deductive-inductive approach. We 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. Time series graphs were used to validate some results.


Local 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. Some individuals who did not meet the local conceptualization of indigents were selected to the detriment of others who did. Healthcare providers believed that distributing free medications led to financial difficulties and drug shortages, especially given the low purchase prices and long payment delays. Healthcare workers adopted measures to limit free services delivered to indigents, which led to conflicts between indigents and providers. Ultimately, selected indigents received uncertain and unequal coverage.


The severity of unintended consequences undermined the effectiveness and equity of the intervention. If the intervention is prolonged and expanded, decision-makers and implementers will have to address these unintended consequences to reduce inequities in accessing care.


Burkina Faso; Indigents; Multiple-case study; Performance-based financing; Unintended consequences; Universal health coverage; User fee exemption

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