Free but declining: the paradox of contraceptive uptake in Burkina Faso

In 2020, Burkina Faso expanded its national user fee exemption policy to include family planning services, with the objective of reducing financial barriers and increasing uptake of modern contraceptive methods. This study assesses the national and subnational trends in modern contraceptive uptake before and after the user fee exemption policy amongst women of reproductive age (WRA) in Burkina Faso.

To achieve this objective, we collected routine health facility and demographic data spanning the pre-intervention period (2016-2018) and the post-intervention period (2021-2024). Mixed-effects linear models examined district-level variations in modern contraceptive uptake, while descriptive analyses explored group differences and temporal trends in contraceptive uptake among WRA between 2021 and 2024.

At the national level, overall contraceptive uptake (all methods) declined by 3.26 percentage points between the pre- and post-policy periods (p < 0.01). The largest reductions were observed in Boucle du Mouhoun (-9.49 percentage points), Sahel (-8.6 percentage points), and Nord (-6.75 percentage points) regions (all p < 0.01). In the post-implementation period, modern contraceptive uptake among WRA declined by 3.6 percentage points nationally, with downward trend observed across all age groups but more pronounced among adult women. Modern contraceptive uptake among adult women declined by 4.5 percentage points, from 24.1% in 2021 to 19.6% in 2024. In contrast, adolescents experienced a smaller decline of 0.7 percentage points, from 16.3% to 15.6% over the same period (p < 0.01). Amongst women who sought care in health facilities in stable areas, modern contraceptive uptake declined by 3.4 percentage while security-challenged areas experienced a slightly higher decline of 3.6 percentage points, from 24.0% to 20.6% (p < 0.01). Similarly, facilities in urban areas experienced a lower decline (-1.1 percentage points) in modern contraceptive uptake compared to those in rural area (-5.2 percentage points (p < 0.01). Nearly one-third of health facilities reported stock-outs exceeding three months for some methods.

The removal of user fees for family planning services in Burkina Faso was insufficient to reverse declining modern contraceptive uptake with adult women and those living in rural and conflict-affected areas benefiting least. These findings highlight the need for complementary non-financial strategies to improve potential gains of the user fee exemption policy.