Stakeholder perceptions and experiences from the implementation of the Gratuite user fee exemption policy in Burkina Faso: a qualitative study

BackgroundIn 2016, the Gratuite policy was initiated by the Government of Burkina Faso to remove user fees for maternal, newborn, and child Health (MNCH) services. Since its inception, there has not been any systematic capture of experiences of stakeholders as it relates to the policy. Our objective was to understand the perceptions and experiences of stakeholders regarding the implementation of the Gratuite policy.MethodsWe used key informant interviews (KIIs) and focus group discussions (FGDs) to engage national and sub-national stakeholders in the Centre and Hauts-Bassin regions. Participants included policymakers, civil servants, researchers, non-governmental organizations in charge of monitoring the policy, skilled health personnel, health facility managers, and women who used MNCH services before and after the policy implementation. Topic guides aided sessions, which were audio recorded and transcribed verbatim. A thematic analysis was used for data synthesis.ResultsThere were five key themes emerging. First, majority of stakeholders have a positive perception of the Gratuite policy. Its implementation approach is deemed to have strengths including government leadership, multi-stakeholder involvement, robust internal capacity, and external monitoring. However, collateral shortage of financial and human resources, misuse of services, delays in reimbursement, political instability and health system shocks were highlighted as concerns that compromise the government's objective of achieving universal health coverage (UHC). However, many beneficiaries were satisfied at the point of use of MNHC services, though Gratuite did not always mean free to the service users. Broadly, there was consensus that the Gratuite policy has contributed to improvements in health-seeking behavior, access, and utilization of services, especially for children. However, the reported higher utilization is leading to some perceived increased workload and altered health worker attitude.ConclusionsThere is a general perception that the Gratuite policy is achieving what it set out to do, which is to increase access to care by removing financial barriers. While stakeholders recognized the intention and value of the Gratuite policy, and many beneficiaries were satisfied at the point of use, inefficiencies in its implementation undermines progress. As the country moves towards the goal of realizing UHC, reliable investment in the Gratuite policy is needed.