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

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1 Evidene-based publi health, poliy and pratie A ommunity-based targeting approah to exempt the worst-off from user fees in Burkina Faso V Ridde, 1,2 M Yaogo, 3,4 Y Kafando, 5 O Sanfo, 6 N Coulibaly, 6 P A Nitiema, 6 A Biaba 5 1 Researh Centre of the University of Montreal Hospital Centre (CRCHUM), Canada; 2 Department of Soial and Preventive Mediine, University of Montréal, Canada; 3 Groupe de reherhe, d Expertise et de Formation en Santé pour le développement (GREFSaD), Burkina Faso; 4 Université Catholique de l Afrique de l Ouest-Unité Universitaire de Bobo-Dioulasso, Burkina Faso; 5 Soiété d étude et de reherhe en santé publique (SERSAP), Burkina Faso; 6 Ministère de la santé, Burkina Faso Correspondene to: Dr V Ridde, CRCHUM, International Health Unit, 3875 rue Saint-Urbain, Montréal, Québe, CANADA (H2W 1V1); valery.ridde@umontreal.a Aepted 31 July 2009 Published Online First 19 August 2009 ABSTRACT Bakground: To ontend with the risk of exlusion reated by user fees, those implementing the Bamako Initiative (BI) were asked to organise exemption shemes for the indigent. But those exemption shemes were never put in plae in Afria due to diffiulties identifying the indigent. An ation researh was implemented to test the hypothesis that a ommunity-based proess for seleting benefiiaries of user-fee exemptions in an Afrian environment of BI organisation is feasible. Methods: This study was arried out in 10 primary health entres (CSPS) in Burkina Faso. Village seletion ommittees (VSC) made lists of those worst-off, and the lists were validated by village hiefs, mayors, and health ommittees (COGES). A proess evaluation was implemented using doumentation analysis, aounting alulation, fous groups and in-depth interviews. Results: The 124 VSCs seleted 566 persons. The 10 COGESs retained 269 persons (48%), ie 2.81 per 1000 inhabitants. Exept for one CSPS, the annual profits from the user fee shemes ould support on average six times more indigents than the mean number seleted by the VSCs. Conlusions: In the rural Afrian ontext, villagers are apable of seleting those who should be exempted from user fees aording to their own perspetive. Thanks to the BI, health entres have a ertain finanial apaity to take are of the indigent. In a ommunity-based targeting approah using endogenous resoures generated from BI profits, loal pereptions of the health entres finanial viability, oupled with the hierarhial soial ontext, led to a very restritive seletion of andidates for exemption. Partiipants at the International Conferene on Primary Care Servies and Healthare Systems in Afria held April 28 30, 2008, in Ouagadougou (Burkina Faso) reaffirmed, as did the reent WHO Commission on Soial Determinants of Health, 1 2 the need for solutions to improve equity of aess to are. In West Afria, user fees have been implemented using a ommunity-based, deentralised approah in aordane with the priniples of the Bamako Initiative (BI) of To ontend with the risk of exlusion reated by user fees, those implementing the BI were asked to respet priniple #7, that is, to organise exemption shemes to help those unable to pay. 4 However, 20 years later, it is obvious that in Burkina Faso, 5 as elsewhere in Afria, 6 this type of system was never put in plae. One reason most often mentioned to justify this ination is the diffiulty of identifying who is to be exempted However, evidene on this subjet is quite rare, espeially in Afria. 9 To the author s knowledge, there has been no doumented experiene of any exemption mehanism within the ontext of BI in Afria, whereas most ountries have exemption systems that are supervised by the publi administration. However, only four of sub-saharan Afria s 34 ountries have a lear national poliy, with preise riteria, to support exemption measures. 10 Exemption systems organised by entral administrations do not really work. 11 For example, in three regional hospitals in Burkina Faso, only 32 women were exempted from fees, as indigents, between 1997 and 2002, ie 1.6% of Caesarean ases. 12 Therefore, many insist that identifying the benefiiaries of exemptions should be a matter left to loal assessment, lose to the ommunities and without heavy-handed and ostly tehnialities. However, little is known about suh ommunity-based shemes, and Afrian experienes are rare A review of 122 soial programmes (not only in health) that use targeting tehniques revealed that only 14 used a ommunity-based method. 13 Thus, this study presents the results of an ation researh the objetive of whih was to test the hypothesis that a ommunity-based proess for seleting benefiiaries of user-fee exemptions in an Afrian environment of BI organisation is feasible. In this study, the riterion for effetiveness is the apaity for members of the ommunity to implement a seletion proess. Clearly, before onsidering the effetiveness of the targeting (exlusion or inlusion error), there must first be a proess in plae. No sientifi evidene was found of the implementation of suh proesses in the BI ontext. Before providing evidene that the intervention made a differene in aess to health are for identified individuals, whih is the final goal of all exemption shemes, researh must show that the proess is feasible, as this has never been doumented in the literature. CONTEXT AND INTERVENTION Burkina Faso, ranked next-to-last in the 2007 Human Development Index, launhed the BI in The organisation of publi health are follows a lassial pyramidal model. First-ontat servie is omposed of primary health entres (CSPS) managed by a village health ommittee (COGES). Mediines are sold in the EGD (essential generi drug) depots of the CSPSs and the profits are managed by the COGESs. The COGESs use the profits for loal operating osts, inentive bonuses to governmental health staff, and salaries for ommunity managers of the EGD depots. The Soial Ation Ministry is responsible for the offiial exemption mehanism in Burkina Faso and for delivering the indigene ards. However, the bureaurats do not have the means to do surveys 10 J Epidemiol Community Health 2010;64: doi: /jeh

2 Evidene-based publi health, poliy and pratie to deide on the seletion of reipients, and the servies, whih are often unknown to the population, are only available in urban settings. This study was arried out in the Ouargaye Distrit ( inhabitants in 2006, 96% rural), a rural distrit engaged in subsistene agriulture. In the Centre-East region, where this distrit is loated, 55.2% of inhabitants were living below the poverty line in 2003, ompared to 46.4% nationwide. The rate of measles vaination is 65% for the distrit, as opposed to 71.1% nationwide. This ation researh was arried out in 10 of the distrit s 25 CSPSs (figure 1). The ation onsisted of asking the ommunities to selet the indigents who ould reeive total exemption from payment, to be finaned from the BI profits. The definition of the ontent of the ation and the hoie of the 10 CSPSs were made by the researh and distrit teams based on three riteria: ethis (not to inflit any finanial risk during a pilot projet); sustainability (using endogenous funds); and appropriateness (funtional COGESs, an ation that was partiipative and adapted to the ontext). Planning In 2003, the authors onduted a study aimed at understanding why exemption measures had not been implemented in Burkina Faso. One onlusion of that study was the need for ation researh to study ommunity exemption mehanisms. 5 The ation researh approah is, in fat, often reommended to introdue suh soial hange, inluding in Afria Thus, in a first step, the authors (VR) took advantage of a workshop led by the Canadian Coalition for Global Health Researh in July 2004 Figure 1 Distrit. Map of the Intervention J Epidemiol Community Health 2010;64: doi: /jeh

3 Evidene-based publi health, poliy and pratie in Canada to develop, with a researher (AN) from Burkina Faso, the broad lines of this ation researh. In a seond step, two workshops at the national and loal levels (led by the Publi Health Assoiation of Burkina, AB, and the Regional Diretor of Health, NC) were organised in Burkina Faso in Marh These workshops made it possible to develop the protool for the ation researh in a partiipatory manner with various national and loal stakeholders. Then a graduate student (a Burkinabé physiian) arried out a feasibility study in August 2005, whih suggested, in partiular, that the ommunities seletions be validated by the village hiefs. In a fourth step, the o-investigators met in November 2005 to finalise the protool and verify again the interest among deision-makers for suh a proess. The Minister of Health supported this study beause he had been asking sine 1992 for it to be organised. 17 Content and implementation proess Implementation of the ation followed several steps: i) Information: All the administrative authorities of the distrit headquarters were informed, then a tour of the 10 CSPSs was organised to inform the loal and traditional authorities, as well as the COGES members and the health personnel. ii) Training: Beause implementation ativities are arried out by researhers in onjuntion with the members of the Distrit Health Team (DHT; SO), they were trained in order to implement the ation. Then, the health personnel and two people from eah COGES were also trained. After a presentation on the study, a workshop involving DHT members, researhers, ommunity member (COGES) and health staff allowed for onsensus to be reahed on a definition of the indigents who were to be seleted in the villages: someone who is extremely disadvantaged soially and eonomially, unable to look after himself (herself) and devoid of internal or external resoures. The term indigent was translated into the loal languages on a onsensual basis. iii) Creation of village seletion ommittees (VSC): VSCs made up of seven members were set up in eah of the 124 villages loated in the health areas of the 10 CSPSs. The membership, as designated by the COGESs after the training, had to respet a gender balane. To avoid any loal elite apture, the members ould not be administrative offiers, village hiefs or members of the COGESs. iv) Seletion of indigents: All the VSCs met several times. They made lists of the persons they onsidered to be indigent based only on the definition and without any predetermined riteria. The seletion unit was individuals. The proess of seletion was left under the deision of the members. The majority used their own knowledge of the population, ombined sometimes with field visits to households. In aordane with the loal ontext, this list was validated by the traditional hief of the village, the mayor, and finally the COGES, whih had the final word. v) Distribution of ards: Eah indigent reeived individually an exemption ard with his or her photo. This ard was validated by the Provinial Soial Ation Department. METHODS The objetive of this study is to desribe and analyse the proess of implementing the intervention. Through analysis, it was possible to identify the key harateristis of the intervention, ie its duration, the ost, the organisation of ommittees, the profiles of those seleted as indigents, the finanial apaity of the health entres, and finally, the pereptions of stakeholders. Reports and douments from the researh projet were analysed. Finanial apaity was alulated using a method previously used by researhers in the same ountry In eah CSPS, the aounting reords of the EGD depots were analysed from the expense books (purhase of EGDs, operating expenditures, et), reeipt books (sales of EGDs, user fees, grants, et), and ash reords (ash in the bank and in the safe), as well as the inventory reords of drug stoks. Sums aumulated sine the start of the BI orrespond to the treasury status. Annual profits orrespond to revenues (Expenditures + [initial EGD stok final EGD stok]). A qualitative study was undertaken to analyse the pereption of stakeholders onerning the proess by means of five fous group disussions (FGD) with male members of VCSs from the 10 CSPSs (n = 43), five FGDs with female members of VCSs (n = 31), one FGD with head nurses of nine CSPSs (n = 9), one FGD with managers of eight COGESs (n = 8), and three individual interviews with the oordinator of the ation researh and two members of the DHT. All the disussions and interviews were translated where neessary, reorded and then transribed using word proessing software. The data were analysed using ontent analysis. RESULTS Duration and ost The seletion of indigents by the VSCs and their validation took 45 days. The whole proess took 4 months. Some expenses were assumed by the DHT (photoopies, printing, transport). The amount spent on the ation (exluding the salary of the distrit-based researh oordinator) was F CFA (2300 J) paid by the researh projet. Composition of the VCSs Of the members of the 124 VCSs, less than 2% were members of the COGESs or religious leaders. Women made up 44% of the members, but only 15% of the VSCs had more than three women among the seven members. Seletion of indigents The 124 VSCs seleted 566 persons. The 10 COGESs retained 269 persons (48%), ie 2.81 per 1000 inhabitants (table 1). Less than 5% of the VSCs seleted more than 10 persons, and 15% of them did not selet any. Half the indigents were women (134/ 269) and 63% of the indigents were more than 50 years old. Finanial apaity of the EGD depots Savings ahieved sine the launhing of the BI (table 2, olumn b) make it possible theoretially to support between 290 and 4400 indigents per year in the oming years, depending on the CSPS (hypothesis based on one primary health are onsultation per year per person). Exept for one CSPS, the annual profits (olumn d) ould support indigents per year. The mean number of indigents seleted by the VSCs represent on average 17% of the finanial apaity. Health entres are thus able to support more than six times the number of indigents seleted in the intervention (table 2, olumn f). Stakeholders pereptions The ation was well reeived by the stakeholders. They onsidered that it was benefiial for the worst-off, aording to their own ( emi ) riteria. It was a useful inentive for making the COGESs legal responsibility towards the indigent a onrete reality. One riterion for the effetiveness of this ation was the fat that it was ommunity-based and partiipative, beause, as one VSC member remarked, there have been other interventions 12 J Epidemiol Community Health 2010;64: doi: /jeh

4 Evidene-based publi health, poliy and pratie Table 1 Indigents seleted per CSPS CSPS Total population (a) Total number of villages per VSC indigents seleted by the VSCs (b) Rate of seletion (ø) (b/a) indigents retained by the COGESs () Rate of validation COGES/CVS (%) (/b) Final seletion rate (ø) (/a) Bittin Boudangou Bousgou Kongloré Méné Ouargaye Sangha Vaongho Yondé Yourga Total that helped the indigent, but their approah was not like this one, whih is muh more ommunity-entred. It was also aepted beause it respeted the soial ontext by requiring validation of the lists and by hoosing as VCS members people who were very involved in the ommunity. In the VCSs, the seletion proess was onsensual. However, the fat that the COGESs only retained half the indigents an be explained aording to members of COGES essentially by their fear of using up their aumulated funds and the fat that they do not really know the status of their finanial situation. Some COGESs expressed a lak of onfidene in the seletion arried out by the VCSs and felt they were not rigorous enough in their seletion. Some hallenges still need to be addressed: ensuring the ontinuity of the exemption in the health pyramid; having more time and resoures for reating the VSCs, providing better information to the COGESs about their finanial margins of manoeuvre so that an informed deision an be taken on the number of indigents, and avoiding the risk of soial stigmatisation. DISCUSSION The first limitation of this study was that it was still not possible to assess the effetiveness of the targeting. The riterion of effetiveness presented at the beginning of this study was foused on the ommunity s apaity to atually implement the proess. The present study thus demonstrated that this was possible. Further researh will be required to verify whether the targeting was effetive in seleting the worst-off (inlusion or exlusion error) and enabling them to use health are servies. Nevertheless, it an be said that it was effetive from the point of view of the VSC members who seleted the persons they onsidered to be indigent, but not as muh from the perspetive of the researhers and health professionals, who expeted a larger number of people to be seleted. To use the terminology of anthropology, 19 this study revealed the emi effetiveness more than the eti effetiveness of the intervention. The seond limitation is that the estimate of the finanial apaity to support the indigent is based on a hypothesis of only one visit per year and does not take into aount possible fees for more ostly treatments, partiularly in hospital. That being said, support to the indigent is onsidered, in the real intervention, as overing all fees, inluding ases transferred to hospitals. The third limitation, assoiated with the preeding one, is that this intervention only partly improves the affordability of health servies, without ating upon availability and aeptability. 20 Table 2 Finanial apaity of EGD depots to support indigents, per CSPS CSPS indigents retained by the COGES (a) Funds available at 1 Marh 2007 (F CFA) (b) indigents that ould be supported ( = b/1500 F) Finanial apaity to provide support (a/) Aounting benefits in F CFA (1/03/07 to 28/02/08) (d) indigents that ould be supported per year (e = d/1500 F) Finanial apaity per year vs number of indigents retained (f = e/a) Bittin % Boudangou % Bousgou % Kongloré % NA Méné % Ouargaye % NA NA NA Sangha % NA Vaongho % Yondé % Yourga % Total (10 heath entres) % Mean per health entre EGD, essential generi drugs. b, Money in the bank + money in the safe (treasurer) + ash on hand (EDG manager). d, Revenues (Expenditures + [initial EGD stok final EGD stok]). NA, data not available. 655 F CFA = 1 Euro Average ost per outpatient onsultation = 1500 F CFA (hypothesis of one visit per year per person). J Epidemiol Community Health 2010;64: doi: /jeh

5 Evidene-based publi health, poliy and pratie The exemption redues only diret osts for the indigent, but they are sometimes also the furthest away (geographially and soially) from health entres and often disempowered. The intervention showed, for example, that the seleted indigents also asked for food to take their mediations, whih were now free. Suh an intervention, just in the health are setor, annot pretend to redue poverty or the soial inequalities of health. Nevertheless, the authors believe this experiene of targeting ould now be useful to other publi servies (food seurity, eduation, et) in distributing aid targeted to the worst-off that ould omplement this aess to health are servies. However, there remains a serious need for produing data on this subjet in Afria, as suh studies are still too rare. In fat, an analysis of publiations on targeting programs between 1985 and 2003 shows that less than 10% of those programmes were implemented in sub-saharan Afrian ountries. 13 To the authors knowledge, this is the first study on ommunity-based exemption shemes in the ontext of the BI in Afria. The study offers good news and bad news. The good news is that it is feasible to implement priniple #7 of the BI (as a proess) and to adapt it to the ontext. The seletion of individuals pereived as indigent by the ommunity using a ommunity-based proess was not very ostly and was appreiated by the stakeholders. With respet to gender, the importane assigned to inluding women in the preparation phase and the diretive to ensure an equitable distribution of VSC members ontributed most definitely to a gender-balaned seletion of indigents, whih testifies to the feasibility of gender-balaned interventions alled for in this ontext. 21 The bad news is the stringeny of the final verdits of the ommunities in seleting indigents only 3/1000, or 6/1000 if retaining the numbers seleted by the VSCs. In Cambodia, in a very different ontext, a ommunity-based targeting approah retained 16% of the population to reeive exemptions, knowing that the funding was external. 22 In the same region, it appears that pre-identifiation by the ommunity would be more effetive for seleting the worst-off (very poor) than the poor. 23 In Burkina, this restritive seletion an be attributed to soial and tehnial reasons. Soially, beause their vision of soial justie (equity) is more egalitarian than Rawlsian (and its maximin priniple: the maximum for those who have the minimum), people are more apt to seek soial peae and onsensus The seletion of indigents was made on the basis of a double burden, eonomi (lak of finanial means) and soial (lak of support) beause the situation is that of a ountry ranked next-to-last in the Human Development Index. In a ontext of widespread poverty, it is extreme poverty that makes the differene for the population. The region s soial organisation is very hierarhial and to be labelled indigent an sometimes dishonour the family, the authors were told. This soial hypothesis had been advaned in a study of three pilot projets in Afria. 9 Tehnially, the (equitable) utilisation of endogenous resoures generated by BI user fees is not promoted, 7 and therefore that idea definitely hindered the seletion of indigents. The COGESs were in onflit of interest, as no third-party purhaser was involved. The effetiveness of the Cambodian experienes an be explained, in part, by signifiant funding that went beyond the loal ontributive apaity (table 2) and was mostly exogenous in origin Conlusion This experiene teahes us that in the Afrian ontext of the BI, deision-makers who want to inrease servie utilisation among the worst-off should definitely onsider two possible solutions, What is already known on this subjet User fees exemption shemes must be implemented to help those unable to pay. Exemption systems organised by entral administrations do not really work. Little is known about ommunity-based exemption shemes in Afria. What this study adds The seletion of indigent people using a ommunity-based proess in Burkina Faso was feasible, not very ostly and appreiated by the stakeholders. Health entres had the apaity to take on six times more indigent people than the ommunity seleted. The seletion was very restritive (only 3/1000) for soial (vision of soial justie and extreme poverty) and tehnial reasons (utilisation of endogenous resoures and onflit of interest). Poliy impliations Afrian States ould require that a minimum number of indigents be seleted by the ommunity on the basis of a perentage of annual profits thanks to user fees shemes. Community-based targeting approahes should be tested where support for the worst-off ould be funded by a thirdparty purhaser. beause there is still insuffiient data 9 26 and experiene 27. First, although endogenous resoures may be limited, they do exist (thanks to the BI) and ommunities an selet individuals whom they onsider indigent ( emi effetiveness). Also, the State ould legally require (and even enfore, by aompanying measures) that a minimum number of indigents be seleted on the basis of a perentage of annual profits. The present researh showed, in fat, that the health entres had the apaity to take on six times more indigent persons than the ommittees seleted. Exlusion error ould be redued by inreasing the number of benefiiaries. Seond, a ommunity-based targeting approah should be tested where support for the worst-off ould be funded by a third-party purhaser like the Health Equity Funds. Further studies need to be undertaken, partiularly in Afria, to evaluate the effetiveness of suh mehanisms in seleting the worst-off and improving their aess to are. Aknowledgements: This study desribes a ollaborative proess and is therefore based on the work of many people. We would like to thank the Assoiation Burkinabé de Santé Publique and all our olleagues in the DHT, head nurses, members of COGESs and CVSs, as well as the people in all the villages who took part in the proess. The feasibility study arried out by Dr Yonaba was espeially helpful. Critial readings of a preliminary draft of this text by Bruno Meessen, Fabienne Rihard and Béatrie Nikiema helped larify the arguments presented. Thanks to Donna Riley for translation and editing support. The researh was aepted by the ethis ommittees in Burkina Faso and Canada. Funding: This ation researh was made possible through funding from the International Development Researh Centre (IDRC) in Canada. Valéry Ridde urrently holds a researh fellowship from the Fonds de Reherhe en Santé du Québe (FRSQ). Competing interests: None. 14 J Epidemiol Community Health 2010;64: doi: /jeh

6 Evidene-based publi health, poliy and pratie Ethis approval: Canada and Burkina Faso ethis ommittees. Provenane and peer review: Not ommissioned; externally peer reviewed. REFERENCES 1. Gilson L, Doherty J, Loewenson R, et al. Challenging inequity through health systems. Final report Knowledge Network on Health Systems. WHO Commission on the Soial Determinants of Health. Equinet. CHP. LSHTM 2007: WHO. Closing the gap in a generation Health equity through ation on the soial determinants of health. Commission on Soial Determinants of Health FINAL REPORT. Geneva: World Health Organization, 2008: M Pake B, Hanson K, Mills A. Implementing the Bamako Initiative in Afria, a review and five ase studies: London Shool of Hygiene and Tropial Mediine PHP Department Publiation UNICEF. The Bamako Initiative: rebuilding health systems. New York: UNICEF- The Bamako Initiative Management Unit, 1995: Ridde V. The problem of the worst-off is dealt with after all other issues : The equity and health poliy implementation gap in Burkina Faso. So Si Med 2008;66: Gilson L, Kalyalya D, Kuhler F, et al. The equity impats of ommunity finaning ativities in three Afrian ountries. Int J Health Plann Manage 2000;15: Ridde V. Fees-for-servies, ost reovery, and equity in a distrit of Burkina Faso operating the Bamako Initiative. Bull World Health Org 2003;81: Gilson L, Kalyalya D, Kuhler F, et al. Strategies for promoting equity: experiene with ommunity finaning in three Afrian ountries. Health Poliy 2001;58: Noirhomme M, Thomé J-M. Les fonds d équité, une stratégie pour améliorer l aès aux soins des plus pauvres en Afrique? In: Dussault G, Fournier P, Letourmy A, eds. L Assurane maladie en Afrique franophone: Améliorer l aès aux soins et lutter ontre la pauvreté. Washington: Banque mondiale, 2006: Waelkens M-P. Exemptions for ost reovery systems in sub-saharan Afria: A review of poliies and praties. London: A dissertation submitted to the Division of International Health, Liverpool Shool of Tropial Mediine, Bitran R, Giedion U. Waivers and exemptions for health servies in developing ountries. Final draft. World Bank 2002: Biaba A, Ouedraogo J, Ki S, et al. Aès aux urgenes hirurgiales et équité. Ouagadougou: ABSP, CRDI, UdM, 2003: Coady D, Grosh M, Hoddinott J. Targeting of Transferts in Developing Countries: Review of Lessons and Experiene. Washington: World Bank, IFPRI, Conning J, Kevane M. Community Based Targeting Mehanisms for Soial Safety Nets: A Critial Review. World Dev 2002;30: Reason P, Bradbury H, eds. Handbook of Ation Researh. Partiipative Inquiry and Pratie. London-Thousand Oaks-New Delhi: Sage Publiations, Sott V, Stern R, Sanders D, et al. Researh to ation to address inequities: the experiene of the Cape Town Equity Gauge. Int J Equity Health 2008;7: Ministère de la Santé. Doument national sur le renforement des soins de santé primaires au Burkina Faso; projet de démarrage de l Initiative de Bamako. Ouagadougou: Comité préparatoire de l Initiative de Bamako, 1992: Galland B, Fontaine D, Rasidy K. Évaluer la viabilité des entres de santé. Fasiule 1: Guide méthodologique ReMeD, AFVP, CIDR, Medius Mundi Frane, Coopération Française Olivier de Sardan J-P. La rigueur du qualitatif. Les ontraintes empiriques de l interprétation soio-anthropologique. Louvain-la-Neuve: Aademia Bruylant, Thiede M, Akweongo P, MIntyre D. Exploring the dimensions of aess. In: MIntyre D, Mooney G, eds. The eonomis of health equity. Cambridge: Cambridge University Press, 2007: Nikièma B, Haddad S, Potvin L. Women bargaining to seek healthare: norms, domesti pratives, and impliations in rural Burkina Faso. World Development 2008;36: Noirhomme M, Meessen B, Griffiths F, et al. Improving aess to hospital are for the poor: omparative analysis of four health equity funds in Cambodia. Health Poliy Plan 2007;22: Ir P, Deoster K, Hardeman W, et al. Challenges in identifying the poor: An assessment of household eligibility for Health Equity Fund after four years of preidentifiation in Oddar Meanhey, Cambodia. In: Meessen B, Pei X, Criel B, et al., eds. Health and Soial Protetion: experienes from Cambodia, China and Lao PDR. Anvers: Studies in Health Servies Organisation & Poliy, : Ridde V. Equity and health poliy in Afria: using onept mapping in Moore (Burkina Faso). BMC Health Serv Res 2008;8: Yaogo M. La mobilisation physique et finanière dans le adre du développement loal: exemples pris dans les provines du Bazéga, du Boulgou et du Zoundweogo. Ouagadougou, ACE/RECIT, Etude n 3 [wwwae-reitorg/rapport_ae/etude0003pdf] Lagarde M, Palmer N. Evidene from systemati reviews to inform deision making regarding finaning mehanisms that improve aess to health servies for poor people. Geneva: The Alliane for Health Poliy and Systems Researh, 2006: Meessen B, Pei X, Criel B, et al., eds. Health and Soial Protetion: experienes from Cambodia, China and Lao PDR. Anvers: Studies in Health Servies Organisation & Poliy, 2008: Bigdeli M, Annear PL. Barriers to aess and the purhasing funtion of health equity funds: lessons from Cambodia. Bull World Health Org 2009;87: J Epidemiol Community Health 2010;64: doi: /jeh