Keywords

Introduction

The health sector in Burkina Faso faces a number of problems: unequal access to health services, a lack of social safety nets to protect the poor, inefficiency in using existing resources, and weak mechanisms for coordinating partnerships (Rudasingwa et al. 2020). Only seven percent of Burkinabè feel that they benefit from social security, which increases the need of rural and poor households, especially women and children, to look for alternative sources of provision. Many rely on sources of support from family networks abroad (Ilboudo 2011; Ridde 2006). Within these transnational dynamics, the diaspora community in Italy formed a hometown association called “Association des Ressortissants de Niaogho en Italie” (ARNI), which manages projects for the Niaogho community. ARNI has a local partner called “Association pour le Developpement de Niaogho” (ADN). ARNI includes a women’s section that focuses on female issues such as mother-child health, pregnancy, and economic autonomy in Niaogho. One of ARNI’s main projects was to build a health center in Niaogho using financial remittances.

This chapter evaluates the transformative effects of collective remittances on the health sector and social resilience in Niaogho. Money transfers were also accompanied by social and cultural forms of remittances, such as knowledge, norms, and values, leading in sum to social change and a transformation of health practices. Regarding the transformative effects, my analysis focuses on gender dynamics. Furthermore, it explores how diaspora networks contribute to, complement, or disrupt the physical, economic, political, social, and sanitary assets of the local community. Two hypotheses structure my argument. First, I agree with the findings of Sikder et al. (2017, pp. 56–57) that diaspora networks function as a “critical ‘buffer’ to withstanding shocks and stresses” as well as social insurance for potential future crises through a diversification of social capital. Second, I argue that the increase in resilience of women with connections to the diaspora indirectly enhances resilience of other community members (especially in non-migrant households) because of a positive spillover effect of diaspora support and solidarity.

I understand diaspora as “any people or ethnic population that leave their traditional ethnic homelands, being dispersed throughout other parts of the world” (IOM 2004, p. 19). Transnationalism is conceptualized as “the processes by which immigrants build social fields that link together their country of origin and their country of settlement” (Glick Schiller et al. 1992, p. 1). Immigrant actors are understood as transmigrants who “develop and maintain multiple relations—familial, economic, social, organizational, religious, and political that span borders. Transmigrants take actions, make decisions, feel concerns, and develop identities within social networks that connect them to two or more societies simultaneously” (Glick Schiller et al. 1992, pp. 1–2).

Based on field research conducted between April 2018 and July 2020, I assessed the impact of two health centers called “Centre de Santé et de Promotion Sociale” (CSPS): CSPS 1 and CSPS 2 in the community of Niaogho in the Centre-Est region of Burkina Faso. CSPS 1 was established in the 1950s, while CSPS 2 was funded in 2015 by the diaspora community in Italy, including the provision of ambulances, a drugstore, and a dispensary in the rural municipality of Niaogho. This second health center now belongs to and is run by the Burkinabè government. Especially this diaspora-funded health center fundamentally changed access to healthcare services, health knowledge, and community resilience.

This chapter is organized as follows: First, I will summarize the history of migration from Niaogho to Italy to explain how a strong diaspora community developed there. I will then introduce my research questions and the methods I used to collect data during the field research before outlining my theoretical perspective. Finally, I will highlight the various forms of remittances received by community members in Niaogho and examine their effects on households and social resilience in the region.

Migration from Niaogho to Italy

Between 1967 and 1970, an agreement facilitated work migration of people from Burkina Faso to Italy (Sawadogo 2010; Zongo 2009, 2011). The agreement enabled the migrant workers to work in Italy for 90 days in the summer (Blion 1996), but the Italian administration also tolerated permanent migration to the industrial centers in the north. In the spring and summer, the migrants from Burkina Faso worked in the agriculture sector in the south of Italy, and during the autumn and winter in the factories in the region of Lombardy in the north. This migration was organized in a network of families, clans, villages, and friendships. Most of the time, men went abroad first and left behind women and children.

A seminal report of the IOM (2016) argued that after the sociopolitical crisis that occurred in the Ivory Coast in the 1990s, the emigration of Burkinabè from the Ivory Coast to Italy increased considerably. In 2015, 60,810 Burkinabè lived in Italy, more than 35,000 of whom were from the east of Burkina Faso, especially the district of Garango that comprises Béguédo, Niaogho, Boussouma, Lenga, and Bittou (IOM 2016). According to the former executive director of ARNI, about 4000 persons from Niaogho live in Italy today, more than 2000 of whom reside in the region of Lombardy—most of whom are members of ARNI.

Research Questions, Methods of Data Collection, and Theoretical Framework

Vulnerability is a reality in Burkina Faso: People suffer from poverty and a lack of infrastructure and economic perspectives. I define vulnerability as a cause of risk and a source of hazard that encompasses biophysical and social aspects (Cutter and Finch 2008; Heyman et al. 1991). Diverse forms of vulnerability may expose household or community members to health problems while at the same time preventing them from getting access to health services.

Research Questions

The objective of this study is to assess the transformative effects of financial and social remittances between the Italian diaspora and women in Niaogho and to understand their impact on vulnerability and health resilience. Thus, two research questions were formulated: First, what are the effects of remittances on health infrastructure and health behavior at a community level, especially toward women? Second, in what way did remittances strengthen or weaken community resilience? I argue that household members with a relationship to the diaspora are less vulnerable to healthcare problems because diaspora communities, transmigrants, and return migrants provide them with economic, social, and environmental capital that affects their health and increases their resilience. As Morse and McNamara (2013) showed, economic and social capital further the availability of and access to health resources, while environmental capital like housing, sleeping spaces, and places for food preparation helps to improve living conditions and to prevent some types of diseases such as respiratory illnesses and injuries.

Methods of Data Collection

To answer these research questions, I examined the influence of health infrastructure and knowledge transfer regarding mother and child health, pregnancy, health promotion, disease prevention, and curing diseases on community and household resilience. Of special interest here is women’s access to healthcare resources, information, and advice.

This research was designed as a cross-sectional study that includes both quantitative and qualitative methods. The process of data collection through interviews and focus group discussions (FGDs) was interactive and flexible, responding to the needs of the field (Al-Busaidi 2008; Legard et al. 2003). I mainly dealt with interview partners who did not finish primary or secondary school, especially in FDGs and interviews with return migrants. Many of them did not speak French, so field researchers translated the questions and conversations into Bissa. The primary data was complemented by secondary data such as written documents from NGO projects, national governments, the National Institute of Statistics and Demography (NISD), local administrations, and health centers.

Forty-seven interviews with experts were conducted in Burkina Faso (35) and Italy (12). These focused on the economic situation of the region of Central East of Burkina Faso, access to healthcare services, and reasons for outmigration. Ten individual in-depth interviews were carried out in Niaogho, Tenkodogo, Garango, and Ouagadougou with eight returnees from Italy, one from Gabon, and one from Equatorial Guinea. The interviewees were aged between 26 and 65. The interviews provided a collection of life histories on migration from household and family members. Their analysis helps to identify innovations brought by returned migrants, their social networks, their contributions to improve social justice, health-seeking behavior, and the norms and rules for the transmission of knowledge regarding health resilience (Murray 1998).

In addition, a household survey in Niaogho enabled us to understand which households use health facilities, and how and why they use them. Household members were randomly selected. The following determinants of health-seeking behavior were investigated according to socio-demographic, economic, and physical factors, namely financial accessibility, women’s autonomy, health service, and healthcare infrastructure (Shaikh 2012). The following variables were assessed in the questionnaire: age, gender, education, religion, ethnicity, family members, land and livestock possession, occupation, economic activities, assets and savings, income, health expenditure, food production and expenses, knowledge acquired, satisfaction with the health service, exchange with the diaspora, advice, mother and child health, family planning, participation in community activities, trust, and solidarity.

The survey included 224 heads of households in 8 villages (28 quartiers) within the rural municipality of Niaogho. Niaogho has around 23,000 inhabitants and around 3300 households (INSD 2017). Altogether 82.59 percent of the respondents were women (N = 185) and 17.41 percent men (N = 39). This is because migrants from the rural municipality of Niaogho are mainly male. However, there were also seasonal reasons: The survey took place during the rainy season when most of the remaining men were engaged in fieldwork and designated their spouses to answer the questions. Furthermore, the questionnaire, which addressed many points relating to health (especially reproductive health: prevention, prenatal and postnatal care, contraception, malaria, etc.) was quickly considered by men as a ‘women’s affair.’ In Burkina Faso, reproductive health issues are very often considered the responsibility of women, and the involvement of men in family planning is very low.

The three FGDs in Italy included a women’s group of ARNI and two youth groups with Burkinabè migration background. The FGDs in Burkina Faso were conducted with a women’s group in Niaogho, with health and social workers of Niaogho, with community members, and with youth. For the FGDs, households were randomly selected with the intention of placing the findings in a more general context. The sample size for the focus groups in both countries was between 9 and 12 persons per FGD. The different FGDs helped to comprehend the interaction between ARNI and the community members of Niaogho. Moreover, I assessed the differences in health behavior in households with and without a connection to the diaspora as well as the relation between collective remittances, social capital, and transformations in community resilience.

Vignettes further explain healthcare-seeking behavior of households, the expenditures made, the corresponding attitudes, and the knowledge acquired. The vignette method enables an analysis of personalized short stories on sensitive topics (Gourlay et al. 2014; Hughes 1998) and offers a chance to compare the causal effects of individual experiences among household or community members during the FDG (Barter and Renold 2000; Guillermina 2006). The results of the vignettes are based on exchanges with the following focus groups: The first consisted of 12 women in Brescia and Prevalle aged 20 to 50. All the women were married and had children. Three had been born in Italy, the others in Burkina Faso, Ivory Coast, and Ghana. The second group comprised 9 women in Niaogho aged 18 to 65. All the women were married, five of whose husbands were in the diaspora, including three in Italy.

The results of the household survey were analyzed with SPSS 2015, while the qualitative data was manually coded and operationalized with ATLAS.ti.

Theoretical Framework: Remittances and Capital Theory

Peggy Levitt’s concept of social remittances describes how experiences and knowledge are shared and remitted between diaspora groups and members of their home community (Levitt 1996, 1998). On a community level, social remittances may result in a network of relationships intended to mobilize resources for collective actions and to reduce vulnerability (Bettin et al. 2014; Vari-Lavoisier 2020). On a household level, they influence norms, attitudes, and social practices of seeking health (Levitt 2001). Household members are thus the end users of the health infrastructure and healthcare services financed by the diaspora.

Social remittances are valorized in forms of social capital. Social capital is defined as “the sum of the resources, actual or virtual, that accrue to an individual or a group by virtue of possessing a durable network of more or less institutionalized relationships of mutual acquaintance and recognition” (Bourdieu and Wacquant 1992, p. 119). Receivers of social remittances enhance their standing within the community through their diaspora relations.

Wilson (2012) combined Bourdieu’s concept of capital theory with the model of community resilience and added environmental capital as a decisive factor in determining community resilience. Following his analysis, community resilience is generally defined as the capacity of a community to absorb disturbances and reorganize while undergoing change, but simultaneously retaining essentially the same function, structure, identity, and feedback (Wilson 2010). This concept helps to explore community connectedness, social system interactions, community solidarity, and the community’s connection to other geographical spaces (Cutter and Finch 2008). Community resilience can be understood as a “conceptual space at the intersection between economic, social and environmental capital” (Wilson 2012, p. 1220). Nevertheless, globalization can stimulate community stakeholders’ networks and therefore provide various resources to maximize community resilience (Chaskin 2008).

Remittances and Health at the Community Level

Remittances are the motor of social change and the transformation of health practices in Niaogho. They comprise money transfers, health infrastructure, advice, and knowledge exchange with the diaspora, resulting in individual changes in health behavior. Furthermore, the attitudes and lifestyles of return migrants, transmigrants, and the diaspora promote social innovation that may produce changes in beliefs, attitudes, and meanings.

The results of the household survey show that 85 households (38 percent) have at least one family member abroad while 139 households (62 percent) have no family members abroad. Furthermore, 10.3 percent of households (N = 23) have one family member in Italy. Around 27.7 percent of households (N = 62) have at least one family member in the diaspora, but not in Italy, including migrants from Niaogho who live in Ivory Coast, Ghana, Gabon, Equatorial Guinea, Algeria, Libya, and France.

However, kinship is not the only relationship of exchange: Although only 38 percent of the households queried have family members in the diaspora, 59 percent of the respondents noted that they exchange ideas and knowledge with their relatives, friends, and neighbors in the diaspora. Some household members also stated that they receive information and advice on how to cure diseases; between 61.3 percent and 88.3 percent of respondents affirmed that they are satisfied with the advice received from the diaspora. As communication means have developed and fees are being reduced, this exchange has become easier, cheaper, and broader.

During their visits to Niaogho, diaspora members give advice regarding nutrition and health to their household members. Advice is also received from husbands and other family members such as sisters, aunts, and cousins, although advice regarding dietary preferences and healthy nutrition is sometimes difficult to apply as they are part of cultural habits and require financial resources. This is why the women’s section of ARNI finances dietary training activities and teaches—along with local midwives—how to cook dishes for babies.

Development of Health Infrastructure in Niaogho

The first health center in Niaogho, CSPS 1, was built in the 1950s during the colonial period and is today run by the government. In 2015, ARNI and its Italian partners in Forlì-Cesena built a second health center, CSPS 2, with a drugstore and a dispensary. This new health center enabled the district health authorities to reorganize their health services and to divide Niaogho into two sanitary areas. Today, the two sanitary areas of the rural municipality of Niaogho serve more than 30,000 inhabitants. The diaspora project greatly changed the health provision structure in Niaogho, providing more health workers, infirmaries for the treatment and cure of diseases, and delivery rooms. Furthermore, the diaspora established a network between health workers in Niaogho, Italian nurses, and NGOs who work in the two health centers for two weeks or one month. Besides health facilities, ARNI supports local institutions such as the forestry department and schools.

Both health centers are frequented by the community members of Niaogho. CSPS 2 receives some patients from other villages because it is closer to them. Since the recruitment of community-based health workers in 2017, the workload of nurses and midwives has been reduced. Furthermore, health behaviors have changed: Tables 10.1 and 10.2

Table 10.1 Number of prenatal consultations in CSPS 1
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Table 10.2 Number of prenatal consultations in CSPS 2
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show that health centers provide more prenatal and postnatal consultations, more assisted births, and less deliveries at home, thus reducing the rate of mother-child mortality. For the time period from 2014 to 2018, it is significant that no woman gave birth without assistance. The number of infants in regular consultation increased and the number of malnourished children was reduced.

The tables show the importance of visiting health centers and the role of midwives in prenatal and postnatal care. Their awareness-raising messages have a positive impact on the behavior of women in Niaogho, as shown by their frequent recourse to health facilities in the event of illness or pregnancy and childbirth. Health centers are also places where women discuss their issues with health workers and acquire health knowledge.

Trust, Health Practices, and Knowledge Transfer in Households With and Without a Connection to the Diaspora

A significant transformative effect can be found with regard to changing practices in the context of contraception and prenatal and postnatal advice. Regarding decisions to use contraception, around 10.27 percent (N = 23) of respondents stated that the husbands living in Italy had made this decision, while about 87.05 percent (N = 195) of respondents stated that the decision to use contraception was a joint decision. The FGDs revealed a new influence of men in family planning. Traditionally, these topics were regarded as a women’s issue, but nowadays numerous interventions and awareness programs in the health sector in Burkina Faso are trying to integrate men in the mother and child healthcare programs. Even men living abroad now take an interest in family planning practices and the attitudes of their wives in Niaogho. This can lead to conflict in religious and traditional families, where parents and in-laws are of different opinions.

It takes trust to confide in health workers, not only for the people of Niaogho. Trust is an important component of health-seeking behavior, and trust and health outcomes mutually affect each other in the wellbeing of patients. Without trust in health workers, patients would not visit any health center on a regular basis. In the context of trust, the results concerning CSPS 1 and CSPS 2 and household members with or without a connection to the diaspora are striking. The findings show that respondents with a connection to the diaspora trust the government-run CSPS 1 health center slightly less (47.05 percent) than respondents without a connection to the diaspora (56.83 percent) (Table 10.3).

Table 10.3 Trust in the health workers at CSPS 1
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Overall, both groups have more trust in CSPS 2, probably due to the better services it provides. Interestingly, with regard to the variable connection to the diaspora, the households without a connection to the diaspora trust CSPS 2 more (74.82 percent) than households with a connection to the diaspora (51.76 percent) (Table 10.4).

Table 10.4 Trust in the health workers at CSPS 2
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The findings further show that household members without a connection to the diaspora complain less about the quality of services provided. Moreover, they do not use private health centers because of a lack of financial means and they frequently use traditional medicines. By contrast, most households with connections to the diaspora are critical of health workers and complain more. Due to financial remittances, they are able to more often use private healthcare services, which are more expensive, have reduced waiting times, and provide better quality. Furthermore, money from abroad enables them to buy medicines and to pay fees for ambulances, surgery, and X-rays.

For both groups, the development of health infrastructures reinforces knowledge about and practices concerning malaria, infectious diseases, mother-child health, and hygiene. The circulation and acceptance of health knowledge requires trust in the health services, which is given for both CSPS 1 and CSPS 2. Knowledge regarding the prevention of malaria and mother-child healthcare were highly valued by the women who participated in this study. Due to increased access, district health authorities observed changes in the use of health services in Niaogho since the opening of CSPS 2. For example, some women reported having acquired important knowledge on hygiene, the prevention of malaria, infectious diseases, the treatment of diarrhea, and mother-child healthcare. Health workers mentioned that knowledge regarding the prevention of malaria, prenatal care, and waterborne diseases is more easily accepted and incorporated into daily life than other topics (see also McKenzie and Rapoport 2005).

In Niaogho, this knowledge transfer works at an interpersonal level (individual household members with a connection to the diaspora), an organizational level (ARNI), and an institutional level (health centers). Other levels may include interaction between community members during cultural and social activities such as weddings, baptisms, and village celebrations, where information and experiences are exchanged. The level of knowledge transfer may arouse different perceptions and provoke different types of outcomes.

The findings suggest that households with a connection to the diaspora have more health-promoting attitudes and behaviors than households without a connection to the diaspora. Undoubtedly, relatives abroad give practical advices. However, a health worker at CSPS 2 rated the influence of awareness-raising activities so high that they leveled the difference between households with and without a connection to the diaspora: “as far as knowledge is concerned, I think there is no difference between households with a relative abroad and those without, because of the awareness-raising activities” (Health Worker CSPS 2, Niaogho 2019). This shows the transformative effects of awareness-raising campaigns, yet the question whether these effects are based on collective remittances remains unanswered.

It is important to note that not all health knowledge comes from having a connection to the diaspora, be it on a personal or organizational level like ARNI. Some nurses even argue that the positive results of health indicators toward mother and child health is due to two local health insurance funds, which were established by the Burkinabè government in 2015 to promote universal health coverage (Rudasingwa et al. 2020). These funds aim at improving the equity and access to healthcare services for prenatal care and mother-child care, especially free healthcare for pregnant women and children aged 0 to 5. We can see that the forms and origins of health knowledge are contested.

Health knowledge is disseminated through personal interactions. Transmigrants, the diaspora, and return migrants have a high impact on the transformation of health practices, because they are multipliers, especially when back home (Van Houte 2016). Migrants obtain social standing through their economic and biographical success abroad as well as through education, new skills, and contacts in the host country (Levitt and Lamba-Nieves 2011). However, international migration has also led to conflicts between those who left and those who stayed: Transmigrants are frequently ostracized as “white men” in Niaogho, for example, when they talk about hygiene to their household members and friends. Some people in Niaogho feel insulted and stigmatized as uncivilized and backward by the diaspora community’s awareness campaigns. The local respondents often stated that they feel patronized and instrumentalized when enlightened with messages on hygiene, and some are suspicious that the health advice also contains political messages. Van Houte (2016) defined remittances as inherently controversial, ambivalent, and disruptive. In the case of Niaogho, the social remittances from Italy are also embedded in neocolonial structures, affecting the appropriation or rejection of remittances and consequently reducing resilience.

Transformative Effects of Remittances on Community Resilience

International migration enables a transfer of social capital and fosters changes in traditional communities, in daily practices of health behavior, and in attitudes and perceptions of health (Buch and Kuckulenz 2010; De Haas 2007). In the projects initiated by ARNI, transmigrants and return migrants remit social as well as economic and environmental capital. Social capital is derived from receiving financial as well as social remittances and increases community resilience. The effects of social capital for resilience can be examined according to the categories of bonding, bridging, and linking (Putnam 2000; Woolcock 2001). In the case of Niaogho, the bonding and bridging effects are dominant.

Bonding effects can be seen in the increase of health-seeking awareness on a household level in term of advice, material and financial assistance, and emotional support. Financial support reduces economic vulnerabilities. For example, remittances enable pregnant women to visit gynecologists and obstetricians in the city in case of medical emergency. These services do not exist in Niaogho. Furthermore, diaspora women during their stay in Niaogho provide local women with prenatal and postnatal alimentations, healthy eating plans, and nutritious foods.

The emotional support provided by sisters, cousins, sisters-in-law, and aunts to their female relatives encompasses advice and sharing experiences and feelings and may lessen the stress of pregnant women. Information on nutrition, health, and safety practices during pregnancy and on baby hygiene foster knowledge about prenatal and postnatal care among family members, friends, and neighbors who belong to the same network.

At the household level, the bonding social capital is strong because migrants from Niaogho first help their family members there through individual projects. Women with a connection to the diaspora privilege people who belong to their family network (cousins, sisters, and aunts). Thus, the social capital they generate may create exclusion and could be negative for community cohesion because it is monopolized by in-group members with a connection to the diaspora.

Bridging effects can be found when the women’s section of ARNI encourages the participation of other women’s associations in Niaogho to join in their activities on health awareness. They thus go beyond their own families and bridge their remittance transfers to all community members in Niaogho.

Other bridging effects include the cooperation between ARNI’s women’s section and the health and social workers at both health centers. Health centers have become places where different women’s organizations meet, share activities, and exchange advice. The presence of some diaspora women during the information campaigns of the health and social workers in Niaogho may heighten trust in health workers and therefore improve health-seeking behavior like accepting advice on nutrition, mother-child care, and hygiene (including breastfeeding, control of the weight of newborns, child malnutrition, and complementary foods).

These collective social remittances increase access to health services and knowledge. They generate positive effects on collective learning through exchange and communication and lead to changes in health practices. Additionally, social remittances cause bridging effects by co-empowering rural communities and enhancing their resilience.

Positive Effects of Remittances at the Household and Community Level

The positive and negative effects of remittances have been noted at both the household and community levels (Cumming et al. 2005). Beyond doubt, remittances have increased the use of healthcare services in Niaogho, and findings show that the diaspora shapes and prepares community members to accept changes and integrate new behavior into their everyday routines. Households with connections to the diaspora are more open to health treatments because they are better informed. However, they are less trusting and respectful toward health and social workers. Additionally, they use private health services or go to higher levels of healthcare in the city to look for cures—even without referrals from nurses in Niaogho.

Financial and social remittances influence the health-seeking behavior of household members with a connection to the diaspora: They care more about their health than household members without a connection to the diaspora and consume health services more often. During the FDGs in Niaogho, they stated unambiguously that they felt freer to talk about health in health centers and were more aware of their health and wellbeing. Furthermore, they indicated a self-rated health gradient.

The positive effects on health behavior are often generated by social interactions with return migrants and transmigrants, enabling the introduction of hygiene knowledge such as washing hands and waste management as well as improved housing conditions and sanitary devices like latrines. This effect is enhanced by the high esteem transmigrants and return migrants hold in their communities of origin, although—as mentioned—their social standing is not undisputed in the Niaogho community.

At the community level, key informants and health workers stated that the most visible positive impact of diaspora projects has been the improvement of prenatal and antenatal care, as well as malaria prevention. The social remittance practices of diaspora women foster the establishment of social capital, consisting of high-quality networks and social relationships. Thus, diaspora women can generate resources for collective actions intended to engender positive outcomes (Baum et al. 2000; Levitt 1998). Moreover, some diaspora women stated that they had learned about herbal medicine from women in Niaogho. Although the remittance transfer between Italy and Niaogho is predominantly one-way, there are a few exceptional cases of mutuality, like the exchange of traditional knowledge (see also Levitt and Lamba-Nieves 2011).

Negative Effects of Remittances at the Household and Community Level

ARNI health projects have induced a dependency on financial remittances similar to international development assistance projects. This dependency is negative for self-determined initiatives for resilience and especially affects the women left behind.

Niaogho women regret that the cooperation with the women from ARNI is short-term and takes place only during the holidays. This indicates that the diaspora engagement is perceived rather as a short-term effect than a long-term commitment. Moreover, Niaogho women who do not belong to this network complain that they are left out and not informed about activities of ARNI’s women’s association. The diaspora support leaves out household members who are socially distant (Piché 2013). In order to reduce negative social cohesion due to the implementation of its projects, ARNI fosters interactions to generate participation among community, government, local institutional, and external stakeholders.

As regards gender dynamics, it is important to highlight that 87 percent (N = 77) of household heads with a connection to the diaspora are women, who live in Niaogho with their children and without their husbands. Most of these women live with their in-laws, where they face certain restrictions. For example, they feel reduced to the role of reproduction, which makes it problematic for them to use contraception. The head nurse of CSPS 2 stated:

[I]t is because of the practices of the diaspora that our indicators on family planning are falling down. Women [whose husbands are abroad] refuse to join us because their husbands are not in Niaogho. This means that migrants do not want their wives to do family planning. When we [health and social workers] go out for family sensitization, women do not even listen to us. Here, if you do family planning it is perceived as if you want to go out [with another man]. The parents of migrants do not accept that the wives of their children or brothers who are abroad adhere to family planning. Often, it is at night that some women come to the CSPS to adhere to this practice. (Head of Health Worker CSPS 2).

Obviously, the women who are left behind suffer because of rigid family hierarchies, the absence of their husbands, and the reduction of their social contacts. The diaspora seems to be powerless in promoting autonomy, self-esteem, and social justice for the women left behind (O’Neil et al. 2017). Rather, as the statement above indicates, the opposite is the case. The results further suggest a decreasing dependency upon the community in favor of institutional support through the health centers and private healthcare. If help from outside is fast and efficient, there is no need to turn to other community members.

Conclusion

The transformative effects of remittances in health-seeking behavior have become evident in various aspects. The diaspora association ARNI funded the second health clinic, CSPS 2, which has made a significant contribution especially to the health and wellbeing of women in Niaogho, as we can see from the rising number of prenatal and antenatal consultations and assisted births as well as in a growing awareness of contraception. Further effects include health prevention, the provision of medication, and incentives to visit health centers in general. In both health centers, the people of Niaogho have a positive and trusting relationship with the healthcare services and seek treatment and advice.

We can furthermore see differences in health behavior in households with and without a connection to the diaspora. People without a connection to the diaspora accept both health centers, trust them, and make use of their services. People with a connection to the diaspora are more open to health treatment and are better informed, but they use the health centers less and seek private health services instead because they can afford to do so due to financial remittances. With regard to gender, the health centers enable women, especially, to use contraception, sometimes against the will of their (in-law) families.

Remittances function as transformative drivers of community resilience in Niaogho, as was analyzed here through the concept of bonding and bridging effects of social capital (Putnam 2000; Woolcock 2001). Bonding social capital based on transnational ties contributed to the circulation of experience, information, and best practices regarding mother and child health, and not just between close family members and neighbors. The activities of ARNI in health centers established relationships between women’s associations and health social workers. These activities enhanced bridging social capital amongst different women’s groups in Niaogho, producing positive outcomes for attitudes to health. Overall, with its projects, ARNI has reduced the bonding social capital at the community level, whereas the bridging capital at the individual level has increased because of the transfer of social capital by diaspora members, affecting especially the position of the women left behind.

Overall, individual (household level) and collective (community level) remittances have increased resilience in Niaogho through greater equality in access to health centers, better healthcare services, and a transfer of knowledge and social capital with bonding and bridging effects. However, these processes have also led to dependencies on financial remittances from abroad, reducing self-determined initiatives for resilience and especially affecting the women left behind.