Analysis of the policymaking process in Burkina Faso's health sector: Case studies of the creation of two health system support units

Background: Burkina Faso has made a number of health system policy decisions to improve performance on health indicators and strengthen responsiveness to health-related challenges. These included the creation of a General Directorate of Health Information and Statistics (DGISS) and a technical unit to coordinate performance-based financing (CT-FBR). We analysed the policymaking processes associated with the establishment of these units, and documented the factors that influenced this process. Method: We used a multiple-case study design based on Kingdon's agenda-setting model to investigate the DGISS and CT-FBR policymaking processes. Data were collected from interviews with key informants (n = 28), published literature, policy documents (including two strategic and 230 action plans), and 55 legal/regulatory texts. Interviews were analysed using thematic qualitative analysis. Data from the documentary analysis were triangulated with the qualitative interview data. Results: Key factors influencing the policymaking processes associated with the two units involved the 'problem' (problem identification), 'policy' (formation of policy proposals), and 'politics' (political climate/change) streams, which came together in a way that resulted in proposals being placed on the decision agenda. A number of problems with Burkina Faso's health information and financing systems were identified. Policy proposals for the DGISS and CT-FBR units were developed in response to these problems, emerging from several sources including development partners. Changes in political and public service administrations (specifically the 2008 appointment of a new Minister of Health and the establishment of a new budget allocation system), with corresponding changes in the actors and interests involved, appeared key in elevating the proposals to the decision agenda. Conclusions: Efforts to improve performance on health indicators and strengthen responsiveness to health-related challenges need focus on the need for a compelling problem, a viable policy, and conducive politics in order to make it to the decision agenda.