In this paper, the utilization of health services in the context of health system fragmentation in Burkina Faso is analyzed using household living condition survey data. The methodology explores the relationships between population health risk factors and health services utilization. The results of the analysis highlighted eight reference care providers in the Burkina Faso health system; thus, the probability of service use in the first level of the system, assumed to be its point of entry, is significantly and negatively associated with age and sex, with a lower probability for female gender. As a whole, the health risk factors positively influence the probability of service use at the higher levels of the health system and in the private sector. The results suggest that utilization of the traditional health sector remains predominated by the elderly. These results thus suggest the need for coordination of care across the levels of the public healthcare sector, on the one hand, and the presence of interaction and integration between the traditional or private sector and the public sector, on the other hand.
In Burkina Faso, the health system has a pyramid structure (see
from the CSPSs, and the regional hospital (CHR). On top of the health pyramid is the National University Hospital (CHN), which provides specialized care. This fragmentation of the health pyramid seems to correspond to a hierarchy of care. Alongside this public health sector, there are two coexisting care-providing sectors, namely the private sector and the traditional sector.
By analyzing the utilization of health services in this context of health system fragmentation in Burkina Faso, the main purpose of this paper is to highlight the potential challenges associated with this fragmentation and provide the basis on which future studies should be conducted. Indeed, [
We conducted a demand-side analysis focused on the utilization of health services by the population instead of healthcare provision to empirically study fragmentation and integration within the Burkina Faso health system. The paper is organized as follows: Section 2 briefly introduces the methodology and data; the main results are presented and discussed in Section 3, and Section 4 concludes the paper.
The health services utilization data analyzed in this paper was obtained from the survey of household living conditions in Burkina Faso in 1998. This survey was conducted by the National Institute of Statistics and Demography (INSD). One of the main objectives of the survey was to provide data at each of the 10 planning regions defined by the Ministry of economy and finance in order to enable economic analysis. To this end, the survey covered a sample of 8,500 households. The utilization of health services was determined according to the number of services used by persons who had a disease fifteen days prior to survey participation. The records in this database provided a sample pool including 44,941 observations (individual).
Pr % | Tradhealer | Privdoc | Privpharm | Privnurs | CHN | CHR | CMACM | CSPS | Private |
---|---|---|---|---|---|---|---|---|---|
Pr (y = 0) | 99.7443 | 99.8848 | 99.9842 | 99.9448 | 99.8564 | 99.8090 | 99.5707 | 98.3995 | 99.9085 |
Pr (y = 1) | 0.1136 | 0.0773 | 0.0110 | 0.0300 | 0.0789 | 0.0915 | 0.2431 | 0.7750 | 0.0552 |
Pr (y = 2) | 0.0616 | 0.0284 | 0.0032 | 0.0142 | 0.0316 | 0.0552 | 0.0821 | 0.4672 | 0.0284 |
Pr (y = 3) | 0.0521 | 0.0016 | 0.0016 | 0.0142 | 0.0189 | 0.0505 | 0.2036 | 0.0047 | |
Pr (y = 4) | 0.0095 | 0.0047 | 0.0047 | 0.0079 | 0.0142 | 0.0189 | 0.0710 | 0.0016 | |
Pr (y = 5) | 0.0047 | 0.0016 | 0.0032 | 0.0047 | 0.0126 | 0.0347 | |||
Pr (y = 6) | 0.0016 | 0.0016 | 0.0047 | 0.0016 | 0.0047 | 0.0237 | |||
Pr (y = 7) | 0.0016 | 0.0095 | 0.0079 | ||||||
Pr (y = 8) | 0.0016 | 0.0032 | 0.0016 | ||||||
Pr (y = 9) | 0.0032 | 0.0016 | 0.0016 | ||||||
Pr (y = 10) | 0.0016 | 0.0016 | 0.0032 | 0.0079 | 0.0016 | ||||
Pr (y = 11) | 0.0016 | ||||||||
Pr (y = 12) | |||||||||
Pr (y = 13) | 0.0016 | ||||||||
Pr (y = 14) | 0.0016 | ||||||||
Pr (y = 15) | 0.0032 | 0.0016 | 0.0016 | ||||||
Pr (y = 16) | 0.0016 | ||||||||
0.0071 | 0.0019 | 0.0002 | 0.0011 | 0.0030 | 0.0055 | 0.0088 | 0.0328 | 0.0015 | |
0.1789 | 0.0052 | 0.0004 | 0.0035 | 0.0109 | 0.1691 | 0.0322 | 0.2460 | 0.0039 | |
25.2472 | 2.7948 | 1.7141 | 3.1418 | 3.6673 | 30.8682 | 3.6796 | 7.5078 | 2.6581 |
Source: Author’s calculations using Stata.
Utilization of healthcare services is analyzed using a count data model. However, events such as visits to a doctor or a specialist, or in short, utilization of health services, may be affected by recall bas, causing a correlation between the utilization of different healthcare services. For the modelling of correlated count data, [
To account for the overdispersion observed in our data, we use the [
with
Thus, letting
This equation represents the negative binomial distribution with
[
In this study, health status was assessed by applying the Goldberg scoring method to the General Health Questionnaire (GHQ). Thus, variables considered in the model included the area of residence, type of toilets, garbage disposal method and drinking water supply system (see
Income was predicted using the instrumental variables estimation method, as follows:
in which vector
Variables | Definition | Average | Standard deviation |
---|---|---|---|
Age | Age | 21.74635 | 18.86099 |
Inc_Hat | Predicted income | 51085.71 | 15314.68 |
GHQ | Health status | 10.19101 | 1.603733 |
Variables | Modality | Percentage | |
Sex | Sex | 0 (woman) | 48.88 |
1 (man) | 51.12 | ||
Marital | Marital status | 0 (married) | 38.17 |
1 (single) | 61.83 | ||
Disability | Disability | 0 (none) | 97.42 |
1 (yes) | 2.58 |
Source: Author’s calculations using Stata.
For the others modalities of health services in the Burkina Faso health system, our results highlight that sex and age as determinants of care services utilization are negatively and significantly correlated with the use of CSPS, considered to be the point of entry to the Burkina Faso health system. However, the probabilities of using higher levels of the health system were positively associated with the following risk factors: health status is associated with CMA/CM use; sex, age, and marital status are associated with CHR use; and marital status is associated with CHN use. Apart from the public sector of the health system, having received consultations from traditional healers is positively correlated with age, particularly among the elderly. As a whole, use of the private healthcare sector is positively correlated with the evaluated health risk factors.
Given these results, the reform in Burkina Faso aimed at making CSPSs a mandatory point of entry to the health system proves relevant and should be strengthened and accompanied by support measures designed primarily to optimize the waiting time of patients in CSPSs while decongesting facilities within the upper level of the health system, such as the CHR and the CMA/CM, thereby ensuring better coordination of care across the various providers in the health system. [
Tradhealer | Privdoc | Privnurs | Private | CSPS | CMACM | CHR | CHN | |
---|---|---|---|---|---|---|---|---|
Sex | −0.0719553 (0.2652173) | 0.227069 (0.5398661) | 1.552434 (0.6834249)** | 0.6987908 (0.5641232) | −0.5042776 (0.1898219)*** | 0.3405106 (0.3526252) | 1.775457 (0.4857976)*** | 0.2472755 (0.7179579) |
Age | −0.0377471 (0.0257776) | 0.0404845 (0.0516462) | 0.0525197 (0.0720559) | 0.3078499 (0.0668812)*** | 0.0124177 (0.0101395) | −0.0265204 (0.0241291) | 0.0781272 (0.0262977)*** | −0.007114 (0.0754369) |
(Age) 2 | 0.0008707 (0.0003882)** | −0.0002825 (0.0006294) | −0.0009103 (0.0008418) | −0.005012 (0.0009886)*** | −0.0002812 (0.0001412)** | 0.0002695 (0.0002636) | −0.0004068 (0.0002789) | 0.001478 (0.000924) |
Marital | −0.1550337 (0.37834) | 3.223739 (0.7234354)*** | 0.3750165 (1.00501) | 0.4969273 (0.5928282) | −0.0801855 (0.2698344) | −0.9926825 (0.4228223)** | 1.923734 (0.4429955)*** | 3.026969 (0.8151289)*** |
Disability | −2.904063 (0.9165538)*** | 4.432452 (1.261181)*** | 1.223668 (0.9791192) | 0.9959847 (0.9400392) | 0.4059046 (0.3937256) | −0.8801629 (0.7546487) | −0.5941607 (0.6009724) | −24.32502 (2.618974)*** |
GHQ | 0.0077351 (0.0620238) | 0.6463716 (0.2093823)*** | −0.1044198 (0.174481) | 0.107052 (0.1339821) | 0.0647375 (0.05204) | 0.2349497 (0.0847629)*** | −0.2200957 (0.128814)* | −0.1969951 (0.1711358) |
Inc_Hat | −2.24e−06 (9.54e−06) | 0.0000229 (0.0000182) | −0.0000269 (0.0000279) | −0.0000336 (0.0000154)** | 0.000011 (3.00e−06)*** | −0.0000191 (0.0000157) | −0.0000672 (0.000022)*** | −0.0000432 (0.000018)** |
C | −4.721349 (1.023232)*** | −18.64482 (2.749189)*** | −7.009871 (2.730883)*** | −10.68588 (2.230055)*** | −4.368481 (0.4906429)*** | −6.022566 (1.436937)*** | −3.728556 (2.091243)* | −6.126615 (2.600854)** |
−Log L | 1123.6165 | 152.48901 | 122.36702 | 218.09267 | 4612.4916 | 1004.8369 | 681.65423 | 211.75232 |
Source: Author’s calculation using Stata. Notes: Standard deviations are reported in parentheses. *, ** and *** indicate significance at 10%, 5% and 1% respectively.
private healthcare providers have often been considered to generate additional costs in healthcare or health insurance systems. In the case of Burkina Faso, for example, [
The health system in Burkina Faso has a pyramid structure. Thus, we analyze the utilization of healthcare within this system by highlighting system fragmentation and its associated challenges. This paper suggests the need for integration between the various providers in the system. In line with this need, recent empirical research has focused on essential aspects required for integration of a fragmented system. Using a qualitative approach, Shevski and Sheiman (2014) performed a conceptual assessment of fragmentation and integration, arguing that the key attributes of integration were teamwork, coordination and continuity of care.
In Burkina Faso, some steps have been taken towards continuity of care, namely encouraging use of the first level of care provision as the point of entry to the health system. However, research conducted on fragmented and highly integrated systems should consider all dimensions of integration to improve the efficiency of healthcare provision.
Traoré, O. (2016) Utilization of Health Services in the Burkina Faso Health System: Empirical Evidence of Health System Fragmentation and Integration. Modern Economy, 7, 1555-1563. http://dx.doi.org/10.4236/me.2016.713139
Variables | Categories | Values |
---|---|---|
Area of residence | Plotted land | 0 |
Unplatted land | 1 | |
Type of toilets | Flush/pit latrine | 0 |
Pit latrine | 1 | |
Ordinary/sanplat latrine | 2 | |
Open/bush latrine | 3 | |
Others | 4 | |
Waste disposal system | Tank | 0 |
Garbage | 1 | |
Pit | 2 | |
Individual waste stockpile | 3 | |
Public dumping site | 4 | |
Street | 5 | |
Drinking water supply | Clean tap water within the home | 0 |
Shared tap water within the home | 1 | |
Borehole water | 2 | |
Public standpipe water | 3 | |
Tubewell water | 4 | |
Ordinary well water | 5 | |
River or stream water | 6 | |
Others | 7 |
Source: Built from the INSD’s 1998 survey data base.
Income | Coefficients |
---|---|
Sex | 18223.1 |
(4309.241)*** | |
Age | −20.77243 |
(398.4953) | |
Age2 | 2.183776 |
(6.473623) | |
cnss | 74370.49 |
(7553.925)*** | |
carfo | 60121.51 |
(4547.017)*** | |
cnasur | 144672.1 |
(42662.96)*** | |
carsur | 69458.61 |
(24899.28)*** | |
GHQ | −2862.264 |
(1166.529)* | |
irevtran | 1466.717 |
1376.788 | |
building type | −23246.97 |
(5330.731)*** | |
livestock | 42.67347 |
27.65797 | |
_cons | 61034.01 |
(17127.12)*** | |
obs | 10172 |
F(11. 10160) | 39.13 |
Prob> F | 0.0000 |
R-squared | 0.0118 |
Source: Author’s calculation using Stata. Notes: Standard deviations are reported in parentheses. *, ** and *** indicate significance at 10%, 5% and 1% respectively. CNSS: National Social Security Fund; CARFO: Independent Civil Servants’ Pension Fund; cnasur: variable for CNSS + insurance; carsur: variable for CARFO + insurance; irevtran: variable for transitory income.