“The problem of the worst-off is dealt with after all other issues”: The equity and health policy implementation gap in Burkina Faso

In West Africa, the famous “implementation gap” concept applies to health policies. During the implementation of the Bamako Initiative (BI), the actors were drawn to policies solely for their orientation towards efficiency, thereby neglecting the equity aspects. This paper aims to present an in-depth understanding of this situation, developed through a case study and socio-anthropological fieldwork. The study is informed by a policy framework of analysis that integrates streams theory and the anthropology of development. Multiple sources of data were used: concept mapping (2), in-depth interviews (24), informal interviews (60), focus groups (4), document analysis, and field observation (7 months). The results indicate that the equity aspect of health policies was omitted during training on the use of proceedings from drug sales and user fees; donor agencies and NGOs were more preoccupied with efficiency than equity; the peripheral actors were not driven to ensure that indigents had free access to health care; society was not concerned with the sub-groups of the population; centralized decisions were taken without consultation, remained vague, and were not followed-up; and the concept of equity was perceived differently from those who devised policies. I offer a threefold explanation of why equity was neglected. First, the “windows of opportunity” for achieving equity goals were not seized, at least at the point that led to real change. Second, the policy entrepreneurs did not take on the task of coupling the problem streams with the solutions streams, which is necessary for a successful implementation. Third, the situation of the indigents did not exhibit the necessary characteristics for them to be considered a public problem. For scientific and social reasons it is urgent that we find a solution to halt the exclusion to health care among the poorest groups.