Germain SavadogopersName, Aurelia SouarèspersName, Ali SiépersName, Divya ParmarpersName, Gilles BibeaupersName, Rainer SauerbornpersName (2015date). “Using a community-based definition of poverty for targeting poor households for premium subsidies in the context of a community health insurance in Burkina Faso..” BMC Public Healthtitle·j.
Object of study — how community members in Nouna, Burkina Fasoterm·key, define povertyterm·key and povertyterm·key groups
Research question — which community-perceived povertyterm·key criteria could serve as indicators for measuring and alleviating povertyterm·key in the Nouna region
Contribution — a community-based definition of povertyterm·key, with criteria and povertyterm·key groups, usable for targetingterm·key insurance premium subsidiesterm·key
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | very low enrolment of poor households in a community health insurance scheme, mainly for financial reasons — “Enrolment among the poor households was very low throughout and financial barriers were mentioned as the main reason for not enrolling in the scheme [ 40 , 69 ].” | |
| claim-type | existence — “Community members in Nouna identified mainly three poverty groups: poor, intermediates and wealthy.” | |
| method — evidence | — “This is a descriptive and exploratory study using qualitative methods.” | |
| object of study — evidence | — “The participants were asked to discuss their ideas on poverty – how they define poverty, criteria they use to differentiate poverty groups and the terms they use for describing poverty.” | |
| research question — evidence | — “This paper aims to provide a new set of poverty criteria, based on community perception, which could be used to build systematic indicators for surveys aimed at measuring and alleviating poverty in the Nouna region.” | |
| contribution — evidence | — “The paper presents the definition, criteria and poverty groups defined by community members for targeting the poor in Nouna’s health district.” | |
| mechanism | community information Using community information lowers the cost of targeting the poor. — “Indeed, Rai showed how Governments and aid agencies could reduce the costs in targeting the poor by using community information [ 39 ].” | mechanisms[0] |
| sense | poverty (1970s definitions) - income or consumption below a defined threshold — “In the 1970s, definitions of poverty focused mainly on income [ 10 - 14 ] and were often based on a comparison of individuals’ income and consumption with some defined thresholds, below which individuals were considered poor [ 15 , 16 ].” | senses[0] |
| sense | poverty (Nouna community) - scarcity of basic needs, vulnerability, powerlessness, voicelessness and lack of social networks — “In general, poverty was seen in this study area as scarcity of basic needs, vulnerability, deprivation of capacities, powerlessness, voicelessness, indecent living conditions, and absence of social capital and community networks for support in times of need.” | senses[1] |
| sense | poor (focus-group rule) - anyone meeting at least one of the community's poverty criteria — “The FGD’s participants decided that anyone who fulfils at least one of the poverty criteria mentioned by them is defined as ‘poor’.” | senses[2] |
| relation | community wealth ranking —same-as→ CWR — In 2007, a method of self-assessment named community wealth ranking (CWR) was used to identify the poor households in each community [ 40 , 70 - 72 ]. — “In 2007, a method of self-assessment named community wealth ranking (CWR) was used to identify the poor households in each community [ 40 , 70 - 72 ].” | concept_edges[0] |
| weight | community wealth ranking —same-as→ CWR — 0.9 — “In 2007, a method of self-assessment named community wealth ranking (CWR) was used to identify the poor households in each community [ 40 , 70 - 72 ].” | concept_edges[0] |
| relation | community-based health insurance —same-as→ CBHI — In 2004, a community-based health insurance (CBHI) was launched in the Nouna’s health district in Burkina Faso with the main purpose of improving access to health care. — “In 2004, a community-based health insurance (CBHI) was launched in the Nouna’s health district in Burkina Faso with the main purpose of improving access to health care.” | concept_edges[1] |
| weight | community-based health insurance —same-as→ CBHI — 0.9 — “In 2004, a community-based health insurance (CBHI) was launched in the Nouna’s health district in Burkina Faso with the main purpose of improving access to health care.” | concept_edges[1] |
| relation | Focus Group Discussions —same-as→ FGD — Focus Group Discussions (FGD) were conducted in 41 villages and 24 sub-sectors of Nouna’s town, totaling 65 FGDs. — “Focus Group Discussions (FGD) were conducted in 41 villages and 24 sub-sectors of Nouna’s town, totaling 65 FGDs.” | concept_edges[2] |
| weight | Focus Group Discussions —same-as→ FGD — 0.9 — “Focus Group Discussions (FGD) were conducted in 41 villages and 24 sub-sectors of Nouna’s town, totaling 65 FGDs.” | concept_edges[2] |
| replication | original | |
| limitation | The invited knowledgeable participants gave their own perceptions, which may differ from the general community view. — “It was certain that the participants invited to take part in the discussions for the definition of poverty and poverty groups gave their own perceptions and concepts, which might be identical or slightly different from the general community view.” | limitations[0] |
| limitation | The study listed poverty criteria without building systematic survey indicators. — “Also, the study listed some relevant criteria referring to poverty within the community, without building systematic indicators for a poverty survey.” | limitations[1] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | 61 of 65 focus groups (94%) identified three poverty groups: poor, intermediate and wealthy households. — “The results showed that 61 (94%) FGDs identified mainly three poverty groups: poor, intermediates and wealthy households.” | content_tags.findings[0] |
| finding | Communities saw poverty as falling mainly on the elderly, then the ill and disabled, women, and orphans. — “Although community members believed that poverty makes no difference and could affect anybody in general, they recognized, nevertheless, that poverty tended to affect mainly the elders, followed by the ill and disabled people who could no longer work, the women, and finally orphans and children without support.” | content_tags.findings[1] |
| quantity | 7,807 — — “The database of NHDSS was used to identify all the 7,807 heads of household in 2009, in the settlement area of CBHI.” | content_tags.quantities[0] |
| key-terms | poverty, community-based definition of poverty, targeting, premium subsidies, community-based health insurance, community wealth ranking, focus group discussions, vulnerability, powerlessness, Burkina Faso |
| concept | household — the socio-economic unit in which individuals live together, share resources and jointly satisfy their needs under the authority of a HHH — “The household was defined as the socio-economic unit in which individuals live together, share resources and jointly satisfy their needs under the authority of a HHH [ 74 ].” | concepts[0] |
| concept | community wealth ranking — a method of self-assessment — “In 2007, a method of self-assessment named community wealth ranking (CWR) was used to identify the poor households in each community [ 40 , 70 - 72 ].” | concepts[1] |
| concept | CWR — community wealth ranking — “In 2007, a method of self-assessment named community wealth ranking (CWR) was used to identify the poor households in each community [ 40 , 70 - 72 ].” | concepts[2] |
| concept | community-based health insurance — not defined in this paper's own words; a local health insurance scheme run by and for a community, with yearly household membership — “In 2004, a community-based health insurance (CBHI) was launched in the Nouna’s health district in Burkina Faso with the main purpose of improving access to health care.” | concepts[3] |
| concept | CBHI — community-based health insurance — “In 2004, a community-based health insurance (CBHI) was launched in the Nouna’s health district in Burkina Faso with the main purpose of improving access to health care.” | concepts[4] |
| concept | Focus Group Discussions — not defined in this paper's own words; moderated group conversations used to gather shared views on a topic — “Focus Group Discussions (FGD) were conducted in 41 villages and 24 sub-sectors of Nouna’s town, totaling 65 FGDs.” | concepts[5] |
| concept | FGD — Focus Group Discussions — “Focus Group Discussions (FGD) were conducted in 41 villages and 24 sub-sectors of Nouna’s town, totaling 65 FGDs.” | concepts[6] |
| concept | Content analysis — aiming to categorize verbal data for the purpose of classification, summarization and tabulation — “The Content analysis, aiming to categorize verbal data for the purpose of classification, summarization and tabulation, was used to account for what was said by participants in the most possible objective and reliable way.” | concepts[7] |
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Using a community-based definition of povertyterm·key for targetingterm·key poor householdsterm·dom for premium subsidiesterm·key in the context of a community health insurance in Burkina Fasoterm·key.
Abstract One of the biggest challenges in subsidizing premiums of poor householdsterm·dom for community health insurance is the identification and selection of these householdsterm·dom. Generally, povertyterm·key assessments in developing countries are based on monetary terms. The householdterm·dom is regarded as poor if its income or consumption is lower than a predefined povertyterm·key cut-off. These measures fail to recognize the multi-dimensional character of povertyterm·key, ignoring community members’ perception and understanding of povertyterm·key, leaving them voiceless and powerless in the identification process. Realizing this, the steering committee of Nouna’s health insurance devised a method to involve community members to better define ‘perceived’ povertyterm·key, using this as a key element for the poor selection. The community-identified poor were then used to effectively target premium subsidiesterm·key for the insurance scheme.
The study was conducted in the Nouna’s Health District located in northwest Burkina Fasoterm·key. Participants in each village were selected to take part in focus-group discussions (FGDterm) organized in 41 villages and 7 sectors of Nouna’s town to discuss criteria and perceptions of povertyterm·key. The discussions were audio recorded, transcribed and analyzed in French using the software NVivo 9.
From the FGDterm on povertyterm·key and the subjective definitions and perceptions of the community members, we found that povertyterm·key was mainly seen as scarcity of basic needs, vulnerabilityterm·key, deprivation of capacities, powerlessnessterm·key, voicelessness, indecent living conditions, and absence of social capital and community networks for support in times of need. Criteria and povertyterm·key groups as described by community members can be used to identify poor who can then be targeted for subsidies.
Policies targetingterm·key the poorest require the establishment of effective selection strategies. These policies are well-conditioned by proper identification of the poor people. Community perceptions and criteria of povertyterm·key are grounded in reality, to better appreciate the issue. It is crucial to take these perceptions into account in undertaking community development actions which target the poor. For most community-based health insuranceterm·dom schemes with limited financial resources, using a community-based definition of povertyterm·key in the targetingterm·key of the poorest might be a less costly alternative.
The online version of this article (doi:10.1186/s12889-014-1335-4) contains supplementary material, which is available to authorized users.
Background The fight against povertyterm·key remains a universal concern [ 1 - 4 ]. In most developing countries, povertyterm·key issues are mainly addressed with regard to the implementation of national strategic plans for povertyterm·key alleviation [ 5 - 9 ]. In the 1970s, definitions of povertyterm·key focused mainly on income [ 10 - 14 ] and were often based on a comparison of individuals’ income and consumption with some defined thresholds, below which individuals were considered poor [ 15 , 16 ]. New layers of complexity in the definition of povertyterm·key were added in the 1980s, including some non-monetary aspects [ 17 - 21 ]. Povertyterm·key is associated not only with insufficient income or weak consumption, but also with insufficient outcomes in respect to health, nutrition, literacy, deficient social relations, insecurity, low self-esteem and powerlessnessterm·key [ 22 - 29 ].
Increasingly, a qualitative approach to an understanding of povertyterm·key is emerging, involving the cultural and socio-economic aspects, along with the individual perceptions of population [ 30 - 33 ]. The complexity of measuring povertyterm·key mirrors the plural character of its definition [ 21 , 25 - 29 , 34 , 35 ]. This complexity increases where participatory methods are used and framed in building on the indicators of povertyterm·key defined by the target population [ 36 - 41 ]. Indeed in the 1990s, emphasis was put on how poor people themselves viewed their situation [ 20 , 39 , 42 ]. The local population that lives and works in the same community is in a position to observe the economic status of fellow community members over a long period and can be considered to be a better judge to assess levels of wealth [ 43 - 46 ].
It is now universally recognized that povertyterm·key is a complex and multidimensional issue [ 17 , 21 , 25 - 27 , 29 , 34 , 35 , 47 ]. It is generally defined in relation to a given context, which may be global, regional, national, local or individual [ 48 - 52 ]. It has become the norm not to limit research in that area by considering only the monetary aspects of povertyterm·key [ 35 ].
In the context of scarcity of resources, support for disadvantaged groups requires that the poor individuals are identified correctly and that their needs are well understood [ 20 , 53 - 55 ]. Acknowledging the ways a given community defines povertyterm·key may be critical in how members of the community choose coping strategies [ 56 - 58 ]. Community-based definitions of povertyterm·key were required in various rural settings to target poor people and to address povertyterm·key issues. Indeed, Rai showed how Governments and aid agencies could reduce the costs in targetingterm·key the poor by using community information [ 39 ]. Community concepts of povertyterm·key have been used to provide premium exemption in the Ghana National Health Insurance Scheme [ 46 ]. A community wealth rankingterm was performed in Nouna, Burkina Fasoterm·key, to target poor householdsterm·dom for enrolment subsidies [ 40 ]. Collins, in Niagara Falls, Canada, tried to understand povertyterm·key from those who are poor [ 55 ]. A series of researches put emphasis on the voices of the poor in addressing povertyterm·key issues [ 59 - 62 ]. In Indonesia, the poor were targeted using three approaches, among them community wealth rankingterm [ 63 ] Community Strategic Visioning was used as a method to define and address povertyterm·key in rural Montana [ 64 ].
In 2004, a community-based health insuranceterm·dom (CBHIterm·dom) was launched in the Nouna’s health district in Burkina Fasoterm·key with the main purpose of improving access to health care. The enrolment was at the householdterm·dom level and householdsterm·dom were required to renew their membership yearly [ 65 - 68 ]. Enrolment among the poor householdsterm·dom was very low throughout and financial barriers were mentioned as the main reason for not enrolling in the scheme [ 40 , 69 ]. In response to this, in 2006, the CBHIterm·dom steering committee decided to provide premium subsidiesterm·key to poor householdsterm·dom [ 40 ]. In 2007, a method of self-assessment named community wealth rankingterm (CWRterm) was used to identify the poor householdsterm·dom in each community [ 40 , 70 - 72 ].
The CWRterm’s method briefly entailed three sequential steps: First, a focus-group discussion (FGDterm) with knowledgeable people within the community was conducted to understand the key local criteria or characteristics of povertyterm·key and then to apply these criteria to identify main povertyterm·key groups in the community. Second, the householdsterm·dom ranking was conducted. In this exercise, cards with the names of householdterm·dom heads (HHH) were divided into three different color piles. This ranking of householdsterm·dom was performed separately by 3 key-informants, each one with a pile of card. These key informants were selected by the participants of the FGDterm as being knowledgeable of the socio-economic status of each HHH in the village or the Nouna’s sub-sector. In the last step, consensus among the key informants was reached. Three types of consensus were noted: Either there was an agreement in the rankings of householdsterm·dom, or a pairwise agreement; or again, the HHHs were selected by only one of the three key-informants. In that last case, the names of HHH were reviewed together by all the three key-informants, to ensure that they all agreed on their assigned rank. The list of selected HHHs for subsidies was elaborated and announced to the participants in the FGDterm [ 40 , 72 ].
The consensual community-based definition of povertyterm·key was the key-element used by each key-informant to classify the HHH in the predetermined povertyterm·key groups. The useful contribution of the community allowed the steering committee of the CBHIterm·dom scheme to use this method to identify poor householdsterm·dom for premium subsidiesterm·key to enroll in CBHIterm·dom.
This paper aims to provide a new set of povertyterm·key criteria, based on community perception, which could be used to build systematic indicators for surveys aimed at measuring and alleviating povertyterm·key in the Nouna region.
Targetingterm·key the poor using a community-based definition of povertyterm·key, as stated in the paper, could also be useful for most community health insurances in the region with limited financial resources. Finally, the paper attempts to contribute to the debate in the research area about how povertyterm·key should be defined. The alternative definitions of povertyterm·key provided by community members, that are not in purely financial terms, are highlighted. The paper presents the definition, criteria and povertyterm·key groups defined by community members for targetingterm·key the poor in Nouna’s health district.
Methods This is a descriptive and exploratory study using qualitative methods.
Study area Our study took place in 2009, in 41 villages and 7 sectors of Nouna’s town, located in Nouna’s Health Demographic Surveillance Site (NHDSS) with an area of 1756,244 km2. It should be noted that Nouna’s town is a semi-rural setting [ 73 ]. The NHDSS was established in Nouna’s Health District, which is one of the six districts of the health region of Mouhoun. The region is a dry orchard savannah and has a sub-Sahelian climate with a mean annual rainfall of 796 mm (range 483–1,083 mm) over the past five decades [ 73 ]. It covers the administrative boundaries of the province of Kossi with an area of 7464.44 km 2 . The NHDSS has 34 peripheral health facilities (CSPS) and a district hospital (CMA). The mostly rural population of the multi-ethnic Kossi’s province consists predominantly of subsistence farmers and cattle keepers [ 73 ]. The dilapidated road network made economic activity difficult throughout the province (see Additional file 1 ).
Study population The study target population consisted of all the HHH regardless of gender or membership status to the insurance scheme in the 41 villages and 7 sectors of Nouna’s town where CBHIterm·dom was implemented. The householdterm·dom was defined as the socio-economic unit in which individuals live together, share resources and jointly satisfy their needs under the authority of a HHH [ 74 ]. The database of NHDSS was used to identify all the 7,807 heads of householdterm·dom in 2009, in the settlement area of CBHIterm·dom. The main ethnic groups in the study setting were the Marka (38%), Bwaba (25%), Mossi (18%), Fulani (8%) and Samo (7%) [ 73 ]. The Dioula language serves as a lingua franca, permitting communication between the different ethnic groups in this region [ 73 ]. In terms of religious beliefs, the study population consists of Muslims, Catholics and Protestants.
Method Focus Group Discussionsterm (FGDterm) were conducted in 41 villages and 24 sub-sectors of Nouna’s town, totaling 65 FGDsterm. Seven sectors of Nouna’s town were divided into sub-sectors due to the large number of householdsterm·dom in these sectors. Size and composition of participants for the FGDterm The number of participants in FGDterm met the following premises: a small group (less than 4 participants) could be less productive because participants are more sensitive to the dynamic exchanges between them. On the other hand, a larger group (more than 12 participants) could be difficult to control with a high risk for participants to become shy, leading to the creation of sub-groups and to the deterioration of the conversation [ 75 , 76 ]. Thus, the FGDterm size was between 4 and 12 participants. On average, we had 10 participants per FGDterm.
The FGDterm participants had lived long enough in the community and had a good knowledge of the socio-economic status of each householdterm·dom. They could be opinion leaders like the chief of the village, religious leaders, elders, etc. They could also be leaders of associations or groups like farming cooperative, artisan groups and associations of women. The FGDterm participants included both men and women regardless of age, ethnicity and religion. The women in the NHDSS have previously been involved in mixed FGDterm, where both men and women participate, and therefore, were comfortable voicing their opinions in such discussions. Women represented about 1/3 of the participants in our FGDterm. b) Information strategies The Social Mobilization Unit of the CBHIterm·dom, operating at different levels (central and local), informed the community members about the community wealth rankingterm exercise and gave information about the venue and time when it would be undertaken in the village. Community members were also informed via local radio networks and door-to-door information was conveyed by local contacts of the CBHIterm·dom scheme. When appropriate, drummers were used for announcing the meetings in the villages. c) Running of FGDterm: The field workers in NHDSS knew the two main spoken languages (Dioula and Bwamu) in the study setting. They had extensive experience in conducting FGDterm in this region. After a consensus among the participants on the language, the principal investigator and field workers facilitated the discussions. The discussions were mainly conducted in Dioula, but we noticed that some participants felt more comfortable in giving their point of view in Bwamu, which is the second main spoken language.
The participants were asked to discuss their ideas on povertyterm·key – how they define povertyterm·key, criteria they use to differentiate povertyterm·key groups and the terms they use for describing povertyterm·key. Exchanges conducted with participants on various topics related to povertyterm·key were consensus-based. The main criteria provided by the participants to define povertyterm·key were listed and presented to them in order to get their consensus. d) Data analysis: The discussions during the FGDsterm were audio recorded and then translated and transcribed into French by transcribing agents knowledgeable in the two main local languages in which the FGDsterm were held. The transcripts were then typed by the Data Entry Unit of CRSN.
The Content analysisterm, aiming to categorize verbal data for the purpose of classification, summarization and tabulation, was used to account for what was said by participants in the most possible objective and reliable way. Two levels were considered for the content analysisterm, one was descriptive about the data and the other interpretative about what the data meant.
After reading the transcripts, semantic units, or themes, were extracted, based on the frequency of use by participants to express an idea or opinion. These themes were subsequently classified into categories, or containers, related to the objectives of the study. In our study, the categories were consistent with the povertyterm·key criteria as defined by the community members.
The manual coding method was used to label data in Nvivo. First, some emerging themes in terms of the frequency of use were put into containers called free nodes. Then, from the text, the related recurrent themes were dragged and dropped into the nodes. Some free nodes, therefore, were grouped into tree nodes according to the research objectives. Some direct, representative and relevant quotations were used verbatim within the text to enlighten emerging themes. The software NVivo 9.2 (QSR property limited. From 1999 to 2011) was used for this qualitative analysis. Analysis was done by the principal investigator. e) Ethical approval The study protocol was approved by the institutional Research Ethics Committee of CRSN (2005–005/CLE/CRSN) and as a component of D2 project by the ethical committee of the University of Heidelberg (Medical school) under the number (130/2002). FGDterm participants’ consent was obtained before the start of each FGDterm. Emphasis was on the confidentiality of data within each village, in order to avoid information leaking from one village to another, and also to avoid disclosing information about poorest householdsterm·dom.
Results In general, povertyterm·key was seen in this study area as scarcity of basic needs, vulnerabilityterm·key, deprivation of capacities, powerlessnessterm·key, voicelessness, indecent living conditions, and absence of social capital and community networks for support in times of need. The definition of povertyterm·key was mostly associated to the geographical, social and cultural contexts of daily life by the participants. A HHH and farmer in the village of Barakuy reported: ‘The wealthy in one village may be considered poor if we change the benchmark’ (Male, HHH, 41 years old). This assertion was also raised by several participants in many other villages. The complexity of povertyterm·key issues was also raised when we tried to define and identify those poor or wealthy. The village’s informer in Bourasso who participated in many activities and studies implemented in the village stated ‘In a meeting if you ask the poor to raise their hand, no one will do it. In the meantime if you direct the question to the wealthy ones, the behaviour will be the same’ (Male, 48 years old).
Local names and meanings of povertyterm·key The word povertyterm·key, when translated into local languages, carried different connotations. In their local languages, communities used words that were full of meaning in their ways of designating poor and rich people. The names provided to point out a poor person were basically a description of the situation or the behavior of that person. According to the various ethnic groups, the commonly used names and meanings given to poor people are listed in Table 1 . Table 1 Local names full of meanings of povertyterm·key Local languages Local names of the poor Translation into English « literal » and « meanings » Local name of the wealthy Translation into English « literal » et « meanings » Dioula Dêssêbagato «dêssê = has tried in vain/ bagato = person » « the one who is not able, who has not succeed, who has failed» Nafolotigui « nafolo = wealth/tigui = owner » « The one who has wealth, who has the fortune » Faantan (word from Faangatan) « faanga = authority, power/ tan = lack » Faanman (word from Faangaman) «faanga = authority, power/ man = owner » « the one who is leader, who has power and wealth » « The one who is powerless, who has nothing» Tiguèlankoro «tiguê = hands/ lankoro = empty » Séétigui « sée = capability, power/ tigui = owner » « the one who is able, who has power » « the one who owns nothing » Fintigui « fin = thing/ tigui = owner » « the owner, the one who has wealth» waritigui « wari = money/ tigui = owner» « the one who has money, the wealthy » Marka Paantan (word from Paangatan) « paanga = authority, power/ tan = lack » Paaman (word from Paangaman) «paanga = authority,power/man = owner » « the one who is leader, who has power and wealth » « the one who owns nothing, who is a needy» Pinti « pin = thing/ ti = owner » « the owner » Moré Nongsoaba « nongo = tribulation/ soaba = owner » « the one who,suffer, who is a needy» Raakanre(word from Rahawakanre) «kanre = prosperity/ rahawa = the man » « the one who thrives, who has happiness» Taalga « taalga = a needy» « the one who has nothing, who has to beg to survive » Liguidisoaba «liguidi = money/ soaba = owner » « the one who has money, who is wealthy » Arzeksoaba « arzeka = fortune, prosperity/ soaba = owner » « the one who thrives, who can afford » Bwamu Baabasso « baaba = needy/ so = owner » « the one who is a needy, who has to beg to survive » Séébasso « sééba = capability, power/so = owner » « the one who is able » Fioro « fio = needy/ ro = owner » Biobasso «bioba = thing/ so = owner » « the owner, the one who has wealth » « the one who is a needy, who has to beg to survive » Fulani Taalka « taalga = needy» Djomdjawdi « djawdi = wealth/djom = owner » « the one who has nothing, who is a needy » « the one who has wealth, who has power» Missikina « Missi = beef/kina = lack » « the one who doesn’t own beef » Djomnadjê « nadjê = beef/djom = owner » « the one who owns beefs » Nyaagoodo « Nyaagaade = needy/ do = owner » « the one who is a needy » Samo Douoba (word from Dounbamba) « doun = will/bamba = non achieved » « the one who cannot solve his own problem without any support» Padina « Pa = money/ dina = owner » « the one who has money, who is wealthy» Number and types of povertyterm·key groups identified The participants in the FGDsterm were asked to identify the numbers and types of povertyterm·key groups in their villages or Nouna’s sub-sectors. The results showed that 61 (94%) FGDsterm identified mainly three povertyterm·key groups: poor, intermediates and wealthy householdsterm·dom. Only 3 (5%) FGDsterm referred to two povertyterm·key groups: poor and wealthy; and 1 FGDterm listed four types of povertyterm·key groups: very poor, poor, intermediate and wealthy.
Relative povertyterm·key criteria for each povertyterm·key group The links between the identified povertyterm·key groups and the related criteria is summarized in Table 2 . Table 2 Relative povertyterm·key criteria for each povertyterm·key group Povertyterm·key groups Very poor Poor Intermediate Wealthy Criteria Has insufficient food ++ + Has nothing ++ + Is not in good health status preventing to work ++ + Is unable to solve his own problem by himself ++ + Has no money ++ + Is unable fill his medical prescriptions ++ + Has no social network ++ + Is not owner of livestock ++ + Wear poor clothes and live in poor conditions ++ + Is very old and without support ++ + Has no poultry ++ + Has enough food + ++ Can do or get anything + ++ Is in good health status + ++ Is able to solve his own problem and help somebody else + ++ Has enough money + ++ Is owner of livestock + ++ Has nice clothes and good living conditions + ++ Can use health services + ++ +: The cross indicates that a link exists between the criterion and the povertyterm·key group. ++: The two crosses indicate that a strong link exists between the criterion and the povertyterm·key group. The shaded area: indicates that the criterion is not related to the povertyterm·key group.
Poor group The criteria that defined a person as poor were mainly: Has insufficient food, has nothing, is not in good health status preventing work, is unable to solve his own problems by himself. Besides this main group of povertyterm·key criteria, some others were also mentioned by community members to refer to the poor: has no money, is unable to fill his medical prescriptions, has no social network, is not an owner of livestock, wears poor clothes and lives in poor conditions, is very old and without any support, and has no poultry. The FGDterm’s participants decided that anyone who fulfils at least one of the povertyterm·key criteria mentioned by them is defined as ‘poor’.
All these criteria contributed to making the poor powerlessnessterm·key, voicelessness and vulnerable. Some criteria were classified as “others” and were related to the misfortune, the lack of means of transportation and the disappointment of the poor people. The above information were translated into an algorithm to define povertyterm·key in the study area (see Figure 1 ). Figure 1 Algorithm of the definition of povertyterm·key by community in Nouna, Burkina Fasoterm·key. →: contributes to. ↔: are interconnected.
Not having a sufficient daily meal for a householdterm·dom was identified as the criterion which mainly emerged from the discussions with the participants to designate the poor. This was stated by many participants, among them a farmer in the village of Boune who said: ‘The poor is the one who cannot get his daily meal and eat his fill’ (Farmer, male, 54 years old). Beside insufficient food, the absence of ownership, translated into having nothing by community members, was mentioned several times. Povertyterm·key was also related to the poor health status of the householdterm·dom’s head. Indeed, in order to perform their farming activities for most of them, the HHHs needed to be in good physical and mental health. Otherwise, they were considered poor, as pointed out by a farmer in the village of Bourasso: ‘The poor is the one who is lying down, who cannot do anything and who cannot even get up to work’ (Farmer, male, 49 years old). The poor were also seen as unable to solve their own problems, making them dependent on the community. A female HHH and farmer in the Village of Dara raised the fact that the poor had no point of view in the main decisions of the village, otherwise, even if they gave their opinion, it was not considered: ‘When you are poor, you are not considered, nobody wants to invite you for the meetings in the village; you rather stay at home because they will never consider what you would have said even if you were there’ (Female, HHH, 37 years old).
The percentage in the use of these criteria by community members to designate the poor during the 65 FGDsterm are showed by Figure 2 . Figure 2 Percentage in the use of criteria to define povertyterm·key.
Intermediate group The intermediate HHH were those who had their daily meal, those who did not need to beg, in respect to food, materials of agricultural work, means of travel, etc. This group is characterized by those who have sufficient means for themselves, but may not be able to help needy ones: This was illustrated by a male, local head of CBHIterm·dom in the village of Labarani: ‘People in intermediate group can get their daily food; they are not considered poor, but they are not however considered rich’ (Male, 39 years old).
Wealthy group The last group is composed of the wealthy householdsterm·dom that are characterized by the opposite of all that was cited for the preceding groups.
From the debates with community members, it came up that the wealthy fulfilled at least one of the following wealth criteria: is able to solve his own problem and help someone else, has enough money, is owner of livestock, has enough food, can do or get anything.
Besides the main criteria, the wealthy were also designated by another category of criteria: has enough food, can do or get anything, is in good health status, wear nice clothes and good life condition, can use health services.
Some criteria of wealth classified as “others” referred to: Has modern transportation means like motorcycle and car and has built a house in block. Wealthy people are self-sufficient in their life. They are able to cope with their own problems and those from needy ones, said a housewife in Lei’s Village. ‘In our village, if you see someone who can solve his own problem and additionally can support poor is called wealthy’ (Female, 35 years old).
‘The livestock are part of the wealth, since money is not a tree that can be planted and reap the fruit. These are things that we can barter or we sell them to get enough money and become wealthy’ (Male, 43 years old). This assertion, which highlights the ownership of livestock as evidence of wealth, was from a male and HHH who was both a farmer and stockbreeder in Diamasso’s village.
Likewise, community members put great emphasis on the importance of health in their everyday life as noted a farmer and chief of Solimana village. ‘The wealthy is the one who is healthy since health is the most important wealth’ (Male, 61 years old). They also focused on school knowledge and monthly wages for those in the sectors of Nouna town to designate the wealthy. A jobless man without any school degree, asserted: ‘For us, someone who can be called wealthy is the one who has monthly pay, who has some school knowledge’ (Male, 36 years old).
The following Figure 3 showed the percentage in the use of these criteria by community members to designate the wealthy during the 65 FGDsterm implemented. Figure 3 Percentage in the use of criteria to define wealthy.
Relative povertyterm·key criteria for each povertyterm·key group When we applied the local definition of povertyterm·key provided by the community members, the groups most exposed to povertyterm·key were identified. Although community members believed that povertyterm·key makes no difference and could affect anybody in general, they recognized, nevertheless, that povertyterm·key tended to affect mainly the elders, followed by the ill and disabled people who could no longer work, the women, and finally orphans and children without support.
Discussion Discussing povertyterm·key issues in a community is a very sensitive subject and needs to be approached with great caution. Mckendrick stated, in the case of UK, that talking about povertyterm·key is never neutral and the language may be sexist, ageist, racist or homophobic if not used appropriately [ 77 , 78 ]. Some other authors also noted the sensitive nature of povertyterm·key [ 79 - 82 ].
Community members in Nouna identified mainly three povertyterm·key groups: poor, intermediates and wealthy. We noted that only one FGDterm indicated 4 povertyterm·key groups including the very poor. But on the other side, no FGDterm mentioned the wealthiest group as a povertyterm·key group to be considered since they rejected the fact that there were wealthiest people among them. We also noted that these community members did not make any great difference between the poor and the very poor. For them the two groups faced the same difficulties with only slight differences. The Food and Agriculture Organization of the United Nations (FAO), in a study implemented in the Horn of Africa, also found three povertyterm·key groups: the lowest levels of Wealth Index, the intermediate Wealth Index and the high Wealth Index [ 83 ]. Kalisa in Rwanda studied the characterization of farming systems in southern Rwanda and found three wealth categories among the farmers: Well-off farmer, Intermediate farmer and the Poor farmer [ 84 ].
The community-based definition of povertyterm·key that we used in our study allowed us to better understand povertyterm·key from the view of the community. Souares, in Nouna, targeted the poor householdsterm·dom for insurance enrolment subsidies by using a community-based definition of povertyterm·key [ 40 ]. The same exercise was performed in Ghana by Aryeetey who also used the community concepts of povertyterm·key to provide premium exemptions in Ghana National Health insurance scheme [ 46 ]. Many other authors have also used this community-based definition of povertyterm·key to target the poor [ 39 , 55 , 63 , 80 ].
Making community central to the definition of perceived povertyterm·key was guided by the fact that community members might have a better feeling for povertyterm·key and might understand all the arguments for that. This was also mentioned by some other authors [ 43 , 46 , 85 , 86 ].
We were convinced that the povertyterm·key criteria provided by community members reflected a realistic situation experienced by them. They were the ones concerned with povertyterm·key issues, so they were the ones in the best position to express what they felt in their own words and languages.
Most of the criteria highlighted in our study referring to the poor, like the insufficient daily meal, the ill-health …etc., were also mentioned in the study of Aryeetey in Ghana. ‘The poorest were unable to afford three meals daily and meals were often made up of cooked cassava…’[ 46 ]. She also indicated, as we mentioned in our study, that it was common to see the poorest wearing miss-matched old plastic bathroom slippers and worn out, often dirty clothes.
In our study we pointed out that poor people were sometimes excluded from the main decision making because of their povertyterm·key status. This situation was also noticed by Aryeetey in Ghana. ‘The poorest people were usually not included in group decision making processes either at the family or community level’ [ 46 ].
Our study showed, as did several other authors, that involving community members in the definition of povertyterm·key may allow poor people to make their voices heard [ 20 , 59 , 60 , 86 - 90 ], as they are often not considered in their own society. This situation of marginalization was highlighted in 2010 by Salmen [ 91 , 92 ]. Narayan in 2000 [ 54 ] recognized that economically marginalized groups also tend to be socially marginalized. In Kenya, Cameroon, Gabon and Zambia, he reported previously that poor people felt powerless and that they were generally voiceless [ 93 ].
In the 41 villages where our study took place, the concepts of monetary incomes and expenses remain little utilized. So using community concepts to define povertyterm·key was more informative for our study than using a monetary assessment.
The same observation was made by Saul in 1999. The community’s way of defining povertyterm·key is, thus, very important and quite relevant, in so far as the main determinants of formal povertyterm·key assessment, such as incomes and expenses, are not generally well-known in monetary terms in this rural context [ 94 ]. Coudouel also found in her research that measuring intrahousehold allocations and inequality was difficult, since the available data typically failed to directly capture individual spending and consumption [ 95 ].
Alatas found in Indonesia that the results of community-based methods were more strongly correlated with individual community members’ self-assessments of their own status than a metric of povertyterm·key based purely on consumption [ 63 ]. This has also been highlighted by Chambers and Salmen [ 37 , 92 ].
Our study also highlighted, as Chambers did, some aspects of povertyterm·key referring to “vulnerabilityterm·key and powerlessnessterm·key”, which are not captured in conventional surveys [ 36 , 37 , 96 , 97 ]. The scarcity of basic needs as referring to the poor was also indicated by many authors [ 7 , 91 , 98 - 100 ].
We might assert about the process aimed at targetingterm·key the poor, that using the understanding of “who was poor” and “what were the defined povertyterm·key groups” provided by community members as key-elements for the selection of those poor, was less costly in terms of time and resources. Chambers, in 1994, published that this community-based method appeared to be an important cost-effective alternative to the normal surveys, particularly with regard to the time and budget used for the surveys [ 37 ].
We would like to mention three implications regarding our research. The first implication is the important role and place of community members in defining ‘perceived’ povertyterm·key and towards povertyterm·key alleviation in Nouna health district. Povertyterm·key was mainly defined by community members outside traditional economic descriptions, this should lead policies in Burkina Fasoterm·key to put greater emphasis on the contribution of Community in defining povertyterm·key and targetingterm·key poor for povertyterm·key alleviation. The contribution of the paper to the debate about how povertyterm·key should be defined, might then be considered. The second implication is that, using community-based definitions of povertyterm·key in targetingterm·key the poor for subsidies or exemption within a community, may be cost-effective for organizations, like community-based health insurancesterm·dom, with limited financial resources. The third implication is that our research provides a new set of povertyterm·key criteria as seen and perceived by the community that could be used to build systematic indicators for surveys aiming to measure and alleviate povertyterm·key in the Nouna region. Indeed, Burkina Fasoterm·key in its Strategy for Accelerated Growth and Sustainable Development (SCADD) from 2011 through 2015, which replaced the Povertyterm·key Reduction Strategy Paper, aims to alleviate extreme povertyterm·key and hunger as specific objective number 2 [ 101 ]. Our research could help Burkina Fasoterm·key policy-makers better target the poor and more effectively address povertyterm·key issues in community areas.
We are confident that any policy or program addressing povertyterm·key issues in a specific community should consider how that specific community defines povertyterm·key.
Some limitations of our study should be mentioned, since we made the choice of inviting knowledgeable people within the community to discuss on its behalf. It was certain that the participants invited to take part in the discussions for the definition of povertyterm·key and povertyterm·key groups gave their own perceptions and concepts, which might be identical or slightly different from the general community view. Also, the study listed some relevant criteria referring to povertyterm·key within the community, without building systematic indicators for a povertyterm·key survey. Some nuances between povertyterm·key groups ‘poor vs. very poor’ and ‘intermediate vs. wealthy’ were not easy to define by community members.
Conclusion The definition of povertyterm·key by community members to be used in the targetingterm·key of the poor, seems to be one of the most adequate ways in a setting where people live in a community, sharing daily realities, like in Nouna’s health district. For most community-based health insuranceterm·dom schemes with limited financial resources, and particularly the CBHIterm·dom in Nouna, using a community-based definition of povertyterm·key in the targetingterm·key of the poorest might be a less costly alternative.
Our study allowed us to elicit a new set of criteria that could be used to build systematic indicators for surveys aiming to measure and alleviate povertyterm·key in the Nouna region. This research could help Burkina Fasoterm·key policy-makers better target the poor and more effectively address povertyterm·key issues in community areas, by taking into account the perceptions and criteria of povertyterm·key as seen and defined by these communities in addition to applying the unified questionnaire on basic welfare indicators already in use in the country.
In the context of establishing subsidies for the poor in a particular community, the involvement of this community in defining who is eligible and the targetingterm·key of these eligible people may appear to be an essential element for the acceptance of the potential subsidies.
Indeed the targetingterm·key of the poor in Nouna’s health district, using community definition of povertyterm·key, aimed to provide insurance premium subsidiesterm·key to those selected as poor.
We assert that policies aiming at povertyterm·key aleviation in a given community, should consider the contribution of that community in defining and aleviating povertyterm·key. Our study attempts to contribute to the debate in area of research about how povertyterm·key should be defined.