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The use of community health workers to administer prompt treatments is gaining popularity in most sub-Saharan African countries. Their performance is a key challenge because it varies considerably, depending on the context, while being closely associated with the effectiveness of case management strategies. What determines community health workers' performance is still under debate. Based on a realist perspective, a systematic review recently hypothesized that several mechanisms are associated with good performance and successful community interventions. In order to empirically investigate this hypothesis and confront it with the reality, we conducted a study in Burkina Faso, where in 2010 health authorities have implemented a national program introducing community case management of malaria. The objective was to assess the presence of the mechanisms in community health workers, and explore the influence of contextual factors. In 2012, we conducted semi-structured interviews with 35 community health workers from a study area established in two similar health districts (Kaya and Zorgho). Results suggest that they perceive most of the mechanisms, except the sense of being valued by the health system and accountability to village members. Analysis shows that drug stock-outs and past experiences of community health workers simultaneously influence the presence of several mechanisms. The lack of integration between governmental and non-governmental interventions and the overall socio-economic deprivation, were also identified as influencing the mechanisms' presence. By focusing on community health workers' agency, this study puts the influence of the context back at the core of the performance debate and raises the question of their ability to perform well in scaled-up anti-malaria programs. [ABSTRACT FROM AUTHOR]

With solid evidence that free healthcare increases the utilization of health services, Burkina Faso recently exempted all children under five and pregnant women from direct payment at health facilities. However, there is little insight into the capacity to maintain the gains attributable to free healthcare under routine conditions of implementation at the national scale. In particular, the repercussions of its interruption are unknown. The objective is to assess the effects of a sequence of natural interventions including the introduction, interruption and reintroduction of free healthcare on health-seeking practices and utilization of healthcare facilities by children under five. This is an embedded mixed methods study conducted in Kaya district, Burkina Faso. The quantitative component is based on a reversal longitudinal design. Pooled interrupted time-series analysis was performed to assess changes in the monthly number of visits from January 2005 to March 2015. Qualitative data were collected through in-depth interviews with health personnel and mothers to better understand the quantitative results. The results show that visits to health centres dropped immediately and significantly when free healthcare was interrupted (−146, CI 95% [-255; −37]). They increased again when free healthcare was reintroduced (+89, CI 95% [-11; 187]). Both urban and rural centres were affected. Self-medication and visits to traditional healers were reported more frequently during the withdrawal of free healthcare, and tensions between the population and health personnel increased. Implementation problems other than insufficient funding limited the coverage or intensity of free healthcare. While removing user fees could potentially improve mothers and children's health in Burkina Faso, this study shows that demand for healthcare remains highly sensitive to price changes. Gains in utilization attributable to free healthcare may vanish rapidly if user fees are reintroduced. It is essential to support an effective and sustainable implementation of this ambitious initiative. [ABSTRACT FROM AUTHOR]