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Background: Since September 2008, an intervention has made it possible to provide free care to children under five in public health facilities in two districts of Burkina Faso. This study evaluated the intervention's impact on household expenses incurred for services (consultations and medications) to the children targeted. Methods: The study is based on a survey of a representative panel of 1,260 households encountered in two waves, one month before and 12 months after the introduction of the intervention. The questions explored the illness episodes of all children under five in the 30 days before each wave. The analysis of health expenses incurred during an illness episode distinguished between total expenses and those incurred in public health facilities (charges for services and medications). Analyses based on multilevel simultaneous equation models were used to estimate the probability of spending and the amount spent, in a context where a large number of observations returned a count of zero. Results: The burden on household expenses was greatly alleviated under the intervention. Average expenditure dropped from US$11 per episode of care to less than US$2 after the intervention was implemented. The risk of incurring an expense at a public health facility was reduced by two-thirds. The facility users' savings were primarily related to medication purchases. In rural areas, where barriers to access health services are more acute, both poor and non-poor families benefited from the intervention. The probability of spending on medications dropped dramatically for both the poor and the non-poor under the exemption (-75 % vs.-77 %), and the reduction in expenses for medications generated by the intervention was comparable for both groups in relative values (-86 % vs.-89 %). Conclusion: User fees abolition at the point of service substantially alleviated the burden on household expenses. The intervention benefited both poor and non-poor families and provided financial protection. [ABSTRACT FROM AUTHOR]

Background: Inadequate public action in vulnerable communities is a major constraint for the health of poor and marginalized groups in low and middle-income countries (LMICs). The south Indian state of Kerala, known for relatively equitable provision of public resources, is no exception to the marginalization of vulnerable communities. In Kerala, women's lives are constrained by gender-based inequalities and certain indigenous groups are marginalized such that their health and welfare lag behind other social groups. The research: The goal of this socially-engaged, action-research initiative was to reduce social inequalities in access to health care in a rural community. Specific objectives were: 1) design and implement a community-based health insurance scheme to reduce financial barriers to health care, 2) strengthen local governance in monitoring and evidence-based decision-making, and 3) develop an evidence base for appropriate health interventions. Results and outcomes: Health and social inequities have been masked by Kerala's overall progress. Key findings illustrated large inequalities between different social groups. Particularly disadvantaged are lower-caste women and Paniyas (a marginalized indigenous group), for whom inequalities exist across education, employment status, landholdings, and health. The most vulnerable populations are the least likely to receive state support, which has broader implications for the entire country. A community based health solidarity scheme (SNEHA), under the leadership of local women, was developed and implemented yielding some benefits to health equity in the community—although inclusion of the Paniyas has been a challenge. The partnership: The Canadian-Indian action research team has worked collaboratively for over a decade. An initial focus on surveys and data analysis has transformed into a focus on socially engaged, participatory action research. Challenges and successes: Adapting to unanticipated external forces, maintaining a strong team in the rural village, retaining human resources capable of analyzing the data, and encouraging Paniya participation in the health insurance scheme were challenges. Successes were at least partially enabled by the length of the funding (this was a two-phase project over an eight year period). [ABSTRACT FROM AUTHOR]

Background: Systems to exempt the indigent from user fees have been put in place to prevent the worst-off from being excluded from health care services for lack of funds. Yet the implementation of these mechanisms is as rare as the operational research on this topic. This article analyzes an action research project aimed at finding an appropriate solution to make health care accessible to the indigent in a rural district of Burkina Faso. Research: This action research project was initiated in 2007 to study the feasibility and effectiveness of a community-based, participative and financially sustainable process for exempting the indigent from user fees. A interdisciplinary team of researchers from Burkina Faso and Canada was mobilized to document this action research project. Results and knowledge sharing: The action process was very well received. Indigent selection was effective and strengthened local solidarity, but coverage was reduced by the lack of local financial resources. Furthermore, the indigent have many other needs that cannot be addressed by exemption from user fees. Several knowledge transfer strategies were implemented to share research findings with residents and with local and national decision-makers. Partnership achievements and difficulties: Using a mixed and interdisciplinary research approach was critical to grasping the complexity of this community-based process. The adoption of the process and the partnership with local decision-makers were very effective. Therefore, at the instigation of an NGO, four other districts in Burkina Faso and Niger reproduced this experiment. However, national decision-makers showed no interest in this action and still seem unconcerned about finding solutions that promote access to health care for the indigent. Lessons learned: The lessons learned with regard to knowledge transfer and partnerships between researchers and associated decision-makers are: i) involve potential users of the research results from the research planning stage; ii) establish an ongoing partnership between researchers and users; iii) ensure that users can participate in certain research activities; iv) use a variety of strategies to disseminate results; and v) involve users in dissemination activities. [ABSTRACT FROM AUTHOR]

Background: In the Indian context, a household's caste characteristics are most relevant for identifying its poverty and vulnerability status. Inadequate provision of public health care, the near-absence of health insurance and increasing dependence on the private health sector have impoverished the poor and the marginalised, especially the scheduled tribe population. This study examines caste-based inequalities in households' out-of-pocket health expenditure in the south Indian state of Kerala and provides evidence on the consequent financial burden inflicted upon households in different caste groups. Methods: Using data from a 2003-2004 panel survey in Kottathara Panchayat that collected detailed information on health care consumption from 543 households, we analysed inequality in per capita out-of-pocket health expenditure across castes by considering households' health care needs and types of care utilised. We used multivariate regression to measure the caste-based inequality in health expenditure. To assess health expenditure burden, we analysed households incurring high health expenses and their sources of finance for meeting health expenses. Results: The per capita health expenditures reported by four caste groups accord with their status in the caste hierarchy. This was confirmed by multivariate analysis after controlling for health care needs and influential confounders. Households with high health care needs are more disadvantaged in terms of spending on health care. Households with high health care needs are generally at higher risk of spending heavily on health care. Hospitalisation expenditure was found to have the most impoverishing impacts, especially on backward caste households. Conclusion: Caste-based inequality in household health expenditure reflects unequal access to quality health care by different caste groups. Households with high health care needs and chronic health care needs are most affected by this inequality. Households in the most marginalised castes and with high health care need require protection against impoverishing health expenditures. Special emphasis must be given to funding hospitalisation, as this expenditure puts households most at risk in terms of mobilising monetary resources. However, designing protection instruments requires deeper understanding of how the uncovered financial burden of out-patient and hospitalisation expenditure creates negative consequences and of the relative magnitude of this burden on households. [ABSTRACT FROM AUTHOR]