Burkina Faso

The Context 

Strong, formalized community health programs can save lives, but they are often underfunded, disjointed, poorly managed, and understocked. In Burkina Faso, many people lack access to basic healthcare and more than 10% of children died before their 5^th birthday in 2019, according to the Lancet. Data from IHME shows that the highest causes of mortality in the overall population are malaria, lower respiratory infections, neonatal disorders, and diarrheal diseases—health issues commonly treated by CHWs. The security situation in Burkina Faso exacerbates these health challenges; many health facilities are closing in affected regions and staff are leaving their posts. Improving the national community health program is critical to ensuring that people have access to the quality healthcare they need. 

Burkina Faso’s government is keenly interested in improving community health and making it more accessible to reaching its goal, under Presidential Directive, of universal health coverage. However, it needs support and technical expertise to design, launch, and sustain comprehensive improvements. A study in 2016 found that Burkina Faso’s community health program had no effect on under five child mortality, citing inadequate supervision, compensation, and supplies as some of the main challenges.

The Solution 

The government of Burkina Faso has requested long-term support from Living Goods to ensure that these challenges are addressed and that access to quality, community-based healthcare is improved through the integration of our innovative, digitally enabled performance management approach. Living Goods’ approach has traditionally been to work locally, prove our model, and then expand our reach to collaborate with the national government to promote broader adoption—but our entry point in Burkina Faso is through collaboration with the central government on a national scope of work. In 2020, after observing Living Goods’ work in Kenya and Uganda, Burkina Faso’s Ministry of Health (MoH) requested our support in assessing their community health performance management approach and digital tools. Based on Living Goods’ assessment, the Burkina Faso Government decided to embark on the digitalization of their national community health system with the integration of performance management best practices.  

Under an initial three-year agreement with the MoH, Living Goods will provide technical assistance to both strengthen community healthcare and integrate it into the primary healthcare system while fostering an enabling environment for long term, government-led sustainability. We will set up a “learning site” in two districts as a center of excellence showcasing effective community health and testing new approaches. On top of the evidence generated in the learning site, Living Goods will in two additional regions provide “implementation support” by helping put operational best practices in place by supporting supervisors, managers, and government teams to optimize performance and cost-effectively improve care. Burkina Faso will serve as a model globally, catalyzing an abundance of learnings that will be leveraged by other countries as they work to improve their own community health systems.   

Living Goods’ Approach

Living Goods has been identified as one of the few actors on the community health stage with a scalable approach to cost-effectively improving health outcomes. Commitment to learning and innovating has also enabled evolution in our approach. Focusing on long-term sustainability, Living Goods works hand in hand with Burkina Faso’s national government and a variety of key stakeholders to bolster the enabling environment and equip them with the tools needed to transform the community health system.

Living Goods serves as the technical lead to Burkina Faso’s government to ensure integration of sound performance management principles. In alignment with WHO’s guidelines for optimized community health, Living Goods’ digital performance management approach focuses on four “DESC” pillars:

• Digitally enabled: The existing digital tool for CHWs in Burkina Faso is not widespread, is only used for data collection, and is not integrated with the facility or government systems. Based on our learnings in Kenya and Uganda, Living Goods is providing technical support for the development of CommCare-based digital tools that will act as a job aid, support in data collection, and enable data use while integrating with relevant systems. This will support the entire Community Health System, including: CHW service provision in communities by asking guiding questions; delivering messages for behavior change and patient education; and driving accurate diagnoses, treatments and/or referrals as well as effective supervision. Data-driven task lists and real-time dashboards will drive better health performance, quality assurance, and accuracy, while providing governments with valuable insight for policy and budgeting. Finally, the tool will ensure continuation of care by enabling access to patient records at health facilities.
• Equipped: Only CHWs beyond 5km of health facilities are allowed to carry essential medicines, and stockouts are frequent. At the same time, refresher trainings for CHWs are uncommon. Living Goods has recognized the importance of conducting regular refresher trainings for CHWs to insure they are providing quality care and utilizing their resources appropriately. Through Living Goods’ support, CHWs will be equipped with training, medications, and tools to diagnose and treat illnesses and to provide other essential health services. The digital tool will identify knowledge or quality gaps as topics for follow-up trainings and track inventory to ensure CHWs are fully stocked.
• Supervised: CHW supervisors are located at the facility level in Burkina Faso. Infrequent direct interaction with the CHWs they supervise and limited insight into the work being done make effective supervision difficult. Living Goods’ approach fosters supportive supervision as critical for motivating, mentoring, and monitoring CHWs. The digital tool provides supervisors with a dashboard for monitoring CHW performance and identifying when follow-up is needed. These digitally enabled performance management insights ensure high-quality service delivery. Living Goods will build capacity of government supervisors, adapting those best practices to the local context. The government has also asked Living Goods to test a peer supervision approach to strengthen supervision efficacy and to potentially roll out in insecure region where health facilities are not functional.
• Compensated: Burkina Faso’s government recognizes the value of compensating CHWs for the valuable services they provide and have committed to a payment of $35 per month. However, this compensation is set at a static rate and very often delayed due to logistical constraints. With the knowledge that effective compensation is critical to engage, motivate, and empower CHWs, Living Goods is promoting guidelines and tools that will overcome the existing barriers. Our experience shows that linking some compensation to the achievement of clearly defined health targets can deliver greater impact, and thus we intend to test this approach in one learning site in Burkina Faso in the medium term to show the government the value of reforming the compensation structure.

Theory of Change 

Living Good’s objective is to improve access to quality, community-based healthcare by integrating our innovative DESC principles into Burkina Faso’s national community health program. To achieve this, Living Goods will: 

1. Establish a successful model of digitally enabled performance management for community health in Burkina Faso. Co-creating with the MoH, Living Goods’ DESC principles and best practices will be embedded into the approach and design of the digital tool for CHWs and supervisors. This tool will integrate with the national health database to build the digital health infrastructure. The data from this digital tool will support supervision and compensation by providing performance insight and ensuring CHWs are equipped by identifying training topics and tracking supplies. After extensive user testing and human-centered design research, Living Goods will launch a learning site in 2 districts to implement gold standard community health in Burkina Faso and to test new approaches that could support future policy change—resulting in an effective community health program to guide scaling in new regions.  
2. Create an enabling environment for improved government-led community health. Living Goods will support government to integrate a community health performance management approach using DESC principles, cost the digitally enabled community health program, and mobilize sustainable resources for the national scaleup. We will also enable government to use data from the digital tool for policy and budgeting decisions conducive to improving community health. To sustain project gains and initiate the approach in new regions, Living Goods will foster ownership and empower MoH staff at all levels with the training, tools, and support needed. Finally, we will work closely with other partners and key stakeholders to ensure alignment around a single roadmap for this work. 

By providing a strong approach and creating an enabling environment, this project will lay the groundwork for long-term, government-led scale up, enabling all communities in Burkina Faso to access the essential healthcare they need.  

Promoting Learning 

Living Goods is committed to ensuring comprehensive monitoring, learning, and adaptation throughout this process. We will establish a national baseline through close collaboration with the government and Global Fund to measure progress. A long-term consultant will be recruited to foster learning and ensure that findings are not only promoted within Burkina Faso, but also at the global level so that other countries can use these findings as they seek to improve their own community health systems.