A community-based targeting approach to exempt the worst-off from user fees in Burkina Faso

Background: To contend with the risk of exclusion created by user fees, those implementing the Bamako Initiative (BI) were asked to organise exemption schemes for the indigent. But those exemption schemes were never put in place in Africa due to difficulties identifying the indigent. An action research was implemented to test the hypothesis that a community-based process for selecting beneficiaries of user-fee exemptions in an African environment of BI organisation is feasible. Methods: This study was carried out in 10 primary health centres (CSPS) in Burkina Faso. Village selection committees (VSC) made lists of those worst-off, and the lists were validated by village chiefs, mayors, and health committees (COGES). A process evaluation was implemented using documentation analysis, accounting calculation, focus groups and in-depth interviews. Results: The 124 VSCs selected 566 persons. The 10 COGESs retained 269 persons (48%), ie 2.81 per 1000 inhabitants. Except for one CSPS, the annual profits from the user fee schemes could support on average six times more indigents than the mean number selected by the VSCs. Conclusions: In the rural African context, villagers are capable of selecting those who should be exempted from user fees according to their own perspective. Thanks to the BI, health centres have a certain financial capacity to take care of the indigent. In a community-based targeting approach using endogenous resources generated from BI profits, local perceptions of the health centres' financial viability, coupled with the hierarchical social context, led to a very restrictive selection of candidates for exemption.