Effect of interrupting free healthcare for children: Drawing lessons at the critical moment of national scale-up in Burkina Faso Thomas Druetz a, * , Abel Bicaba b , Telesphore Some b , Seni Kouanda c , Antarou Ly d , Slim Haddad d, e a Center for Applied Malaria Research and Evaluation, School of Public Health and Tropical Medicine, Tulane University,1440 Canal Street, Suite 2323, New Orleans, LA 70112, USA b Soci et ed’  Etudes et de Recherche en Sant e Publique, 06 BP 9150 Ouagadougou, Burkina Faso c Biomedical and Public Health Department, Institut de Recherche en Sciences de la Sant e, Ouagadougou 03 BP 7192, Burkina Faso d Faculty of Medicine, Laval University, 1050 Avenue de la M edecine, Qu ebec, Qu ebec G1V 0A6, Canada e Laval University Medical Research Center (CHUQ), Saint-Sacrement Hospital, 1050, Chemin Sainte-Foy, Qu ebec, Qu ebec G1S 4L8, Canada article info Article history: Received 15 August 2016 Received in revised form 16 May 2017 Accepted 17 May 2017 Available online 20 May 2017 Keywords: Burkina Faso User fees removal Free healthcare Inequities in health Access to treatment Treatment-seeking practices Mixed methods study Interrupted time-series abstract With solid evidence that free healthcare increases the utilization of health services, Burkina Faso recently exempted all children under five and pregnant women from direct payment at health facilities. However, there is little insight into the capacity to maintain the gains attributable to free healthcare under routine conditions of implementation at the national scale. In particular, the repercussions of its interruption are unknown. The objective is to assess the effects of a sequence of natural interventions including the introduction, interruption and reintroduction of free healthcare on health-seeking practices and utili- zation of healthcare facilities by children under five. This is an embedded mixed methods study con- ducted in Kaya district, Burkina Faso. The quantitative component is based on a reversal longitudinal design. Pooled interrupted time-series analysis was performed to assess changes in the monthly number of visits from January 2005 to March 2015. Qualitative data were collected through in-depth interviews with health personnel and mothers to better understand the quantitative results. The results show that visits to health centres dropped immediately and significantly when free healthcare was interrupted (À146, CI 95% [-255; À37]). They increased again when free healthcare was reintroduced (þ89, CI 95% [-11; 187]). Both urban and rural centres were affected. Self-medication and visits to traditional healers were reported more frequently during the withdrawal of free healthcare, and tensions between the population and health personnel increased. Implementation problems other than insufficient funding limited the coverage or intensity of free healthcare. While removing user fees could potentially improve mothers and children's health in Burkina Faso, this study shows that demand for healthcare remains highly sensitive to price changes. Gains in utilization attributable to free healthcare may vanish rapidly if user fees are reintroduced. It is essential to support an effective and sustainable implementation of this ambitious initiative. © 2017 Elsevier Ltd. All rights reserved. 1. Introduction In March 2016, Burkina Faso adopted a national policy titled “Free Healthcare for Mothers and Children under Five” (Gouvernement du Burkina Faso, 2016). The national scale-up in Burkina Faso has already begun and is planned to be completed by June 2016. The policy echoes recommendations to abolish direct payment in health facilities that have been recently formulated by the major global health actors (Robert and Ridde, 2013). Notably, this strategy has been endorsed by the African Union since 2013 (African Union, 2010). “Free Healthcare for Mothers and Children under Five” builds upon the successful implementation of free healthcare for pregnant women and children under five years of age in six Burkinabe dis- tricts (Minist ere de la Sant e, 2015b). These initiatives were applied between 2008 and 2015 by non-governmental organizations (NGOs) with the financial support of the European Community * Corresponding author. E-mail addresses: tdruetz@tulane.edu (T. Druetz), bicaba_tg@yahoo.fr (A. Bicaba), some_tele@yahoo.fr (T. Some), skouanda@irss.bf (S. Kouanda), antarou.ly.1@ulaval.ca (A. Ly), slim.haddad@fmed.ulaval.ca (S. Haddad). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed http://dx.doi.org/10.1016/j.socscimed.2017.05.040 0277-9536/© 2017 Elsevier Ltd. All rights reserved. Social Science & Medicine 185 (2017) 46e53