Abstract
Until 2010, Burkina Faso was an exception to the international trend of abolishing user fees for antiretroviral treatment (ART). Patients were still expected to pay 1,500F CFA (2 Euros) per month for ART. Nevertheless, many non-governmental organizations (NGOs) exempted patients from payment. The objective of this study was to investigate how NGOs selected the beneficiaries of payment exemptions for government-provided ART and rationed out complementary medical and psychosocial services.For this qualitative study, we conducted 13 individual interviews and three focus group discussions (n = 13 persons) with program staff in nine NGOs (4,000 patients), two NGO coordinating structures and one national program. These encounters were recorded and transcribed, and their content was thematically analyzed. The results were presented to the NGOs for feedback.Results indicate that there are no concrete guidelines for identifying patients warranting payment exemptions. Formerly, ART was scarce in Burkina Faso and the primary criterion for treatment selection was clinical. Our results suggest that this scarcity, mediated by an approach we call sociotherapeutic rationality (i.e. maximization of clinical success), may have led to inequities in the provision of free ART. This approach may be detrimental to assuring equity since the most impoverished lack resources to pay for services that maximize clinical success (e.g. viral load) that would increase their chances of being selected for treatment. However, once selected into treatment, attempts were made to ration-out complementary services more equitably.This study demonstrates the risks entailed by medication scarcity, which presents NGOs and health professionals with impossible choices that run counter to the philosophy of equity in access to treatment. Amid growing concerns of an international funding retreat for ART, it is important to learn from the past in order to better manage the potentially inequitable consequences of ART scarcity.
Highlights
Like the direct payment of healthcare services in Africa [1], financial access to antiretroviral treatment (ART) has been the subject of numerous debates and considerable research [2,3]
The objective of this study is to shed light upon how non-governmental organizations (NGOs) selected the beneficiaries of payment exemptions for ART and how they rationed out complementary services
Our respondents sometimes invoked the “pay it forward” principle, i.e., since the NGOs received ARVs at no cost, they felt the people living with HIV/ AIDS (PLWHA) should not have to pay either. Given that these NGOs had provided treatment for free since the beginning, one coordinator said, they “could not see how they could backtrack “. Even though they knew “some people can afford to pay for treatment“, this coordinator continued, it was the idea of payment itself that was inconceivable. “[Clearly,] we do not agree with this national policy,” another coordinator said
Summary
Like the direct payment of healthcare services in Africa [1], financial access to antiretroviral treatment (ART) has been the subject of numerous debates and considerable research [2,3]. Until 2010, Burkina Faso was an exception to this trend of abolishing fees for ART, despite evidence demonstrating that treatment costs and the costs of complementary services such as laboratory monitoring are important barriers to care [7]. This was somewhat expected for Burkina Faso, as policy-makers have been relatively reticent about all forms of payment exemption. Even when the State occasionally consents to strongly subsidize a program, such as artemisinin-based combination therapies (ACT) and delivery care, it continues to resist completely removing userfees This is the case despite the African Union calling for free delivery care and under-five medical consultations [9]
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