Is the process for selecting indigents to receive free care in Burkina Faso equitable?

In Burkina Faso, patients are required to pay for healthcare. This constitutes a barrier to access for indigents, who are the most disadvantaged. User fee exemption systems have been created to facilitate their access. A community-based initiative was thus implemented in a rural region of Burkina Faso to select the worst-off and exempt them from user fees. The final selection was not based on pre-defined criteria, but rather on community members' tacit knowledge of the villagers. The objective of this study was to analyze the equitable nature of this community-based selection process.

Based on a cross-sectional study carried out in 2010, we surveyed 1,687 indigents. The variables collected were those that determine healthcare use according to the Andersen-Newman model (1969): sociodemographic variables; income; occupation; access to financial, food or instrumental assistance; presence of chronic illness; and disabilities related to vision, muscle strength, or mobility. Bivariate analyses and logistic regression were performed.

User fee exemptions were given mainly to indigents who were widowed (OR = 1.40; CI 95% [1.10-1.78]), had no financial assistance from their household for healthcare (OR = 1.58; CI 95% [1.26-1.97], lived alone (OR = 1.28; CI 95% [1.01-1.63]), lived with their spouses, (OR = 2.00; CI 95% [1.35-2.96], had vision impairments (OR = 1.45; CI 95% [1.14-1.84]), or had poor muscle strength and good mobility (OR = 1.73; CI 95% [1.28-2.33]). The indigent selection was not determined by household income, self-reported chronic illness, or previous use of services.

The community selection process took into account factors related to social vulnerability and functional limitations. However, we cannot affirm that the selection process was perfectly equitable, as it was very restrictive due to the limited budget available and the State's lack of engagement in this matter. Exemption processes should be temporary solutions, and the State should make a commitment to move toward universal healthcare coverage.