How Burkina Faso cut its under-five mortality by 74%

Burkina Faso, one of the poorest countries in the world, cut its under-five mortality rate by 74% from 184 per 1,000 live births in 2003 to 48 per 1,000 live births in 2021 – despite growing insecurity in the country and the Sahel region as a whole.

Dr. S. Pierre Yameogo, Technical Secretary for Health Financing reforms in Burkina Faso's Ministry of Health, identified several key factors that drove this improvement in health outcomes for young children: investments in HIV and malaria prevention, as well as the provision of free health care to women and children under five.

Malaria has long been one of the leading killers of children under five in Burkina Faso. Health leaders began to shift that narrative in 2010, when they launched a series of robust national distribution campaigns for insecticide-treated bed nets to stop the spread of malaria. The 2010 campaign has since been followed, every two to three years, by supplementary campaigns to provide new insecticide-treated nets across the country. This effort increased the percentage of households with an insecticide-treated bed net from 56% in 2010 to 83% in 2021.

In 2014, the country also began providing children with seasonal malaria chemoprevention. At first, just over 300,000 children benefited from the treatment. But by 2020, the country was reaching all four million of the children under five it had targeted for treatment.

These efforts, combined with increased access to treatment, helped drive the malaria case fatality ratio for children under five down by more than 47% from 2013 to 2018.

Also, in 2010, the country implemented a national protocol for reducing mother-to-child transmission of HIV by testing all pregnant women twice during their pregnancy, and providing HIV-positive women with medication to reduce the risk of their child being infected. In 2012, the country adopted Option B+, a best practice for increasing child survival. Researchers have called Burkina Faso’s HIV programming "one of the most successful in Africa.” The country's initiatives helped it reduce mother-to-child transmission of HIV from 10% in 2006 to below 1% today.

The impact of these efforts to reduce HIV and malaria deaths were magnified by a historic policy change in 2016, when after about a decade of discussions, pilots, and preparation, the government implemented free essential health care for women and children under five at all public health facilities.

Health care user fees have been long been one source of funding for the health sector in Burkina Faso and beyond, despite the fact that a wide body of research has shown that user fees create a barrier to care, reduce access, and in the words of Dr. Margaret Chan, former director-general of the World Health Organization, "punish the poor".

“Before, patients had to pay for their consultation with the health care provider and then they had to pay for the medicine,” said Dr. Yameogo, who advocated so heavily for free health care that he earned the nickname “Dr. Free Care” among his ministry of health colleagues. “Even if they could afford to pay for transport to the hospital, medical examinations, hospitalization, and tests, sometimes they couldn’t afford to pay for the medicine prescribed.”

The removal of fees has doubled the number of contacts the average child has with the health system. Ministry of health data indicate that before 2016, the average child visited a health care provider about 1.7 times per year. Since the policy change, that average has jumped to between 2.6 to 3.3 visits per year. Those benefiting most from the program, ministry of health figures indicate, are poor and rural, with free care helping to reduce inequity.

The provision of free care for young children has also helped improve maternal health, said Dr. Yameogo. “Who brings the child to the health facility when they aren’t well?” asked Dr. Yameogo. “Most often, it is the mother. So, when she is in the clinic with her child, this is an opportunity for the mother to connect with the services available for free to her.”

Indeed, access to modern methods of family planning, for example, has increased from 9% in 2003 to 32% in 2021. Births in a health facility have increased from 38% in 2003 to 94% in 2021.

Free health care for children under five, when combined with free health care for women, create a virtuous cycle improving a broad range of health outcomes, said Dr. Yameogo, including a reduction in childhood stunting levels, which have been cut nearly in half from 43% in 2003 to 23% in 2021.

Further, researchers in Burkina Faso have found that free health care for women and children strengthens women’s empowerment by reinforcing “women's capability to make health decisions by eliminating the need for them to negotiate access to household resources … Other effects were also observed, such as increased self-esteem among women and greater respect within their marital relationship.”

Burkina Faso’s investment in providing free health care for women and children under five (which is almost entirely paid for by the government and not donors), was years in the making and is part of a global movement towards Universal Health Care.

The government had launched pilots to test subsidized care (with an 80% subsidy) for institutional deliveries, obstetric care, and newborn health care in 2006. This was supported by the European Union and its Humanitarian Aid Office (ECHO) through NGO pilot programs aimed at reducing malnutrition, with one key pathway being improving access to preventive and curative health care for women and children under five. The four main NGOs (Terre des Hommes, HELP, Action Against Hunger, and Save the Children) that implemented pilot projects also collaborated on building an evidence base and advocacy case to promote a policy shift in support of free care for women and children in Burkina Faso. Their timely policy briefs were instrumental in shaping the national conversation.

Their research and pilots also demonstrated that the elimination of user fees would increase access to and use of health facilities and save between 4,000 and 28,000 children’s lives each year, if rolled out nationally. The researchers also found that the removal of user fees was highly cost effective.

With this experience, and guided by research, the ministry of health, with support from UNICEF, ECHO, WHO, Amnesty International, and other partner NGOs developed its strategy for implementing free health care at the national level.

A national government crisis in 2015 and leadership change created conditions favorable to political change and the new government approved the free health care policy in early 2016.

“The government moved slowly and deliberately on the basis of very strong local and national evidence to make this policy shift,” said Valéry Ridde, a former University of Montreal professor who is now director of research at the French National Research Institute for Sustainable Development. Ridde lived in Burkina Faso and spent 10 years researching the policy shift in the country. “The lessons here for other countries are: making a huge policy shift like this takes time and requires systematic evidence, national ownership, and alignment of donors and partners.”

“Another key lesson,” added Ridde, “the team of NGOs and researchers supporting the government included a knowledge broker who helped connect decision makers with the research they needed. Decision makers and researchers don’t speak the same language and don’t work in the same time frames.”

To make free health care work, the government also had to strengthen its medical supply chain to ensure medicines were available, improve the national drug procurement system, and train more health care workers to meet the increased demand and maintain the quality of health service, said Ridde.

He cautioned that while each of these policies implemented by Burkina Faso’s leaders were beneficial, it is difficult to determine the impact of each on any particular health outcome.

Challenges to achieving UHC by 2030 and further improving health outcomes across Burkina Faso remain, said Dr. Yameogo. Approximately 1.7 million people in the country currently face difficulties in accessing basic health care and healthy food because of growing insecurity, which has forced the closure of 193 health facilities and destroyed, or put out of service, 28 ambulances, Dr. Yameogo said. This may slow further progress towards the country’s health goals and likely reverse these hard-won gains.

Burkina Faso follows many other sub-Saharan African countries in launching free health care policies including South Africa in 1994; Uganda in 2001; Zambia in 2005; Burundi, Liberia, and Senegal in 2006; and Ghana in 2008. “This shows that any country, even one with limited resources, can achieve UHC,” said Dr. Yameogo.