A suitable, consensual and participative process
The research results showed that the community-based selection process was perfectly adapted to the social context and well received by residents and health care workers. Thus, we showed that communities are able to identify the indigent in their villages. In rural areas, therefore, it is not necessarily useful to wait for a list of indigence criteria to be defined. However, the request from nurses, who have been asking for these criteria for the past 20 years, to scale up this pre-identification method to the entire district is additional proof of the relevance of the community-based approach.
Needs beyond access to health care
While indigence status did not lead to social stigmatization, the process revealed that access to health care was just one of many needs (not always perceived), even though the action research focused solely on that aspect. Indeed, the research action project focused on financial access to health care as a gateway to understanding why health services are used very little, if at all, by the indigent. It responded to a need that had long been widely expressed by those working in Burkina Faso’s health system and by residents, but never studied [9]. In fact, to our knowledge, this was the first time this type of community-based process had been tested and that indigence cards were distributed in rural areas. Therefore, it introduced a major innovation. However, researchers and stakeholders also quickly discovered the limitations of an action project centred on the financial determinants of access to care. By adapting a longitudinal case study method that is both qualitative and quantitative [12], we showed that the living conditions of a sample of 20 indigent people monitored for 12 months after receiving the card had fundamentally not changed. Also, their use of health centres was constrained in particular by very precarious health status, social isolation, lack of transportation and low priority given to health compared to their need to eat. Speaking about an indigent person, one interviewer observed, "He doesn't care about health care; he's thinking about where he'll get his next meal and where he'll sleep."
The scientific literature has long shown that geographic or social distance between patients and health care workers also affects use of services (not to mention, of course, the social determinants of health). The researchers were clearly aware of these facts but could not attempt to resolve all access issues in a single action research project because of the difficulty in finding ways to conduct research in this area and because of the chosen approach. However, the research in Ouargaye helped bring to light once again the two limitations of actions centred solely on financial access to health care: i) the use of services is constrained by aspects other than just payment for health care, and ii) the health of indigent people is affected by multiple factors outside of the health care system. While this is by no means a new scientific discovery, these results argue for the organization of more holistic and interdisciplinary action research projects to improve the living conditions of the worst-off. However, there again, we come up against the constraints of health research funding methods, which hardly favour this type of approach.
Stronger but limited local solidarity
The fact that the principle of solidarity was brought to light again through this endogenous funding was welcomed by all stakeholders. However, this local solidarity obviously has limits. Remember that in Burkina Faso, nearly half of the population (46%) lives on less than 280 F CFA (0.50 USD) per day. The communities made very few inclusion errors because they selected people who were truly very poor. On the other hand, in Ouargaye, they selected only a tiny portion of the poor population (0.36%) and the extremely poor population (0.78%), whereas the proportion of people in the country living below the extreme poverty line is 9% [13]. The results were approximately the same in Dori and Sebba, where the social context is very different but indigent coverage remained very low as well: 0.13% and 0.36% of the general population, respectively. The main explanation for this restricted selection is that the exemption is covered entirely by local funding. Taking into account their revenue-generating capacity, while the communities could have selected a few more indigents, it would not have been right to ask poor people to fund health care access for all the very poor people. The health centres’ annual profits could cover the needs of 1,800 indigents per year, which is not negligible, but would represent only 0.7% of the population of the Ouargaye district. Current efforts are already outstanding and show that local solidarity can be mobilized. However, the government, indisputably the supreme power, must guarantee health care access to indigent people. This action research project contributes to the development of knowledge on this issue in Africa [14, 15] and has shown that there is now a feasible, suitable and effective process for selecting indigent people. The government and its financial partners must now mobilize more resources to increase the coverage of support for indigent people. At a minimum, the 9% of the population considered to be extremely poor should be covered, and communities could be mobilized to identify these people. Moreover, an attempt should be made to implement a national equity fund financed by the government, its partners and local communities to support a greater number of indigent people.
A variety of knowledge transfer strategies
To ensure the results would be both useful and used, we developed multiple knowledge transfer strategies:
i) Very early involvement of potential users of the results in defining the action project and the outlines of the study: Beginning in the planning stage, all the main potential stakeholders in the action research project were involved (regional department of health, district management team, the Burkinabé Public Health Association, a key representative from the national health development program (PNDS), and health centre management committees).
ii) Involvement of local partners of the action research project in the processes of research and results presentation: Some members of the district management team and managers in the social action department were involved in many activities (choosing pilot project sites, informing and training community stakeholders in all the health centres, making and signing indigence cards, etc.).
iii) Presentation of results to communities and at national meetings of the Ministry of Health and stakeholders: It was not enough to present the results in scientific arenas; the research results were also shared at community forums (Figure 1), at district team meetings, and at meetings with all health care workers in the district, at the biannual conference of all of the country’s regional health directors and district chief medical officers, and at the national round table on social protection [Table ronde nationale sur la protection sociale] (http://sites.google.com/site/protectionsocialeauburkinafaso/), among others.
iv) Presentation of results at national, regional and international scientific conferences: To increase the number of dissemination processes, scientific presentations were given in Burkina Faso, Senegal, France, Canada, Switzerland, Belgium, etc. A workshop was specifically organized at the First Global Symposium on Health Systems Research held in Montreux in November 2010.
v) Organization of an international workshop in Burkina Faso: A workshop was organized in October 2010 to encourage stakeholders in the field to share their experiences and to increase the likelihood of getting decision-makers to integrate this issue into public policy. More than 60 people participated in the two-day workshop, and presentations were made on similar experiences in Burkina Faso, Cambodia, Ivory Coast, Ghana, Mali, Mauritania and Niger.
vi) Preparation and distribution of a policy brief: We know decision-makers do not always have time to read long reports or scientific articles. Therefore, we also prepared a short 1,500-word text (four pages with illustrations) summarizing the main results of this action research project. The document was translated into English and widely distributed, both as a hard copy version in Burkina Faso (In French) and as an electronic version across the networks interested in this topic.
vii) Production of a 26-minute documentary: We produced a documentary film to raise awareness of the issue of indigence and to have a visual tool that would attract attention. A film director from Niger, who had also produced a documentary on the issue of free health care for another one of our research projects, came to Ouargaye to give all the stakeholders involved an opportunity to express themselves. The film will be broadcast within the country and may also be used by the director in international competitions.
All of these knowledge transfer products are available online at: http://www.medsp.umontreal.ca/vesa-tc/indigents.htm.