Women seeking modern healthcare in sub-Saharan Africa (SSA) are faced with numerous supply-side and demand-side barriers. They have to pay out of pocket, a significant challenge when they have already to cope with poor living conditions [1
] and travel long distances to health facilities, especially for specialized services which are only available in urban centers [3
]. In addition, poor road conditions and the underdevelopment of public transport, coupled with a lack of money to pay for them, often make transportation to health facilities difficult to organize [6
]. While the cited studies have documented the independent effects of these barriers on women's health-seeking behavior, this study focuses on capturing the overall burden they impose.
Beyond the mere existence of barriers, it is the ability to overcome them that most likely influences health-seeking behavior. Other things being equal, health service utilization in SSA is higher among wealthy women [15
], probably because they are more able to cover healthcare costs. However, an economically poor African woman may still manage to obtain some healthcare if she has an effective safety net [7
]. At household and individual levels, women's ability to mobilize the resources needed to obtain healthcare depends not only on their personal and their household's wealth, but also on household functioning and living arrangements. Due to gender norms, procuring money for healthcare may depend on the willingness of the husband or household head to allocate household resources for this purpose, if such resources are available. Furthermore, in some African societies women need to obtain their husband's consent or the consent of other decision-makers before visiting a health center; in certain circumstances, they may not be allowed to travel alone or may feel uncomfortable doing so. Some women are unable or not allowed to use common transportation means (a bicycle or a motorcycle), even when these are available and the women know where to go to obtain appropriate care [24
]. Healthcare seeking behavior can be expected to be sensitive to these gender-related factors.
There is a widespread awareness that access to healthcare is difficult for most African women and may be further hampered by gender-related constraints [27
]. However, the burden and risk of exclusion women face remain unquantified due to the lack of an appropriate instrument for measuring their ability to overcome barriers to healthcare. In current research practice, inequalities in access to healthcare and risk of exclusion are often indirectly estimated by comparing patterns of achieved utilization
between socio-economic groups of individuals [34
]. Although these indirect evaluations have contributed to identifying groups who likely fail to receive needed care, utilization-based estimations of disadvantage are potentially problematic for at least two reasons. First, having utilized is not always synonymous of abilities to afford healthcare because users may have engaged themselves into catastrophic expenses1
to acquire care [23
]. Second, non-utilization is not necessarily due to inability to use because individuals may prefer alternative sources
of care [23
]. In SSA, this may occur, for instance, when the health problem is thought to be solvable only by traditional healing [43
evaluation of abilities
is needed to gain a better understanding of healthcare seeking behavior. In particular, looking at women's own evaluation of their ability to overcome healthcare barriers should help distinguish between capability-related and preference-related influences. The importance of this distinction is highlighted in the capability framework
. This conceptual guide starts from the premise that a fair assessment of people's actions and quality of life should focus on analyzing what they are able to do or to be (their capabilities) rather than on what they actually accomplish (their achievements) [47
]. Focusing on achievements may lead to distorted jugement because achievements are outcomes of available possibilities on one hand, and of individual preferences on the other hand. Two people with comparable achievents may still have unequal advantages if they have unequal achivement opportunities from which they can choose one over another [47
A source of publicly available and internationally comparable data, the Demographic and Health Surveys (DHS), has recently introduced seven questionnaire items aiming directly at barriers that women of reproductive age may face when seeking healthcare. The questions address difficulties related to getting permission, going alone, finding transport, preferring a female health worker and covering the costs [50
]. The data collected in SSA have so far mainly been used in the official DHS country reports. Some of the reports evaluate each of the seven items individually, others collapse them into a single dichotomous variable, yielding the proportion of women reporting difficulties with at least one of the seven aspects of access to care (see for example [51
]). We found only a single study [55
] that combined the information from the seven items to create an index of "mother's personal barriers" from principal components analysis, unfortunately without providing further details.
In this study, we use the DHS questions from the most recent available survey of Burkina Faso [52
]. Burkina Faso is a poor landlocked country in West Africa, characterized by, among other things, weakly developed transportation facilities and a public healthcare system with low geographical coverage, applying user fees, and lack of collective health financing systems and mechanisms to prevent exclusion from healthcare [56
]. Qualified health professionals are found mainly in a few urban centers, and there is a general lack of these professionals. Rural areas, in which more than 80% of the country's population lives, are underserved. As in many other SSA countries, most women (74%) are illiterate[58
], underrepresented in the labor market [59
] and often economically dependent on their husbands. Households members, including spouses, do not usually pool their income [60
]. There is gender-specific allocation of activities and responsibilities and women are generally expected to respect their husbands' authority [61
], including when they need healthcare.
We combine the new DHS questions to develop a continuous synthetic index of the women's capabilities to access healthcare. We evaluate whether this index is a reliable and valid measure of women's perceived ability to overcome common barriers to seeking modern healthcare in the context of SSA.