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Kim E, Park YL, Lo YR, Keoprasith B, Panyakeo S. Sustaining essential health services in Lao PDR in the context of donor transition and COVID-19. Health Policy Plan 2024; 39:i131-i136. [PMID: 38253449 DOI: 10.1093/heapol/czad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 08/08/2023] [Indexed: 01/24/2024] Open
Abstract
Lao People's Democratic Republic (Lao PDR) aims at graduating from least developed country status by 2026 and must increase the level of domestic financing for health. This paper examines how the government has prepared for the decline of external assistance and how donors have applied their transition approaches. Adapting a World Health Organization (WHO) framework, reflections and lessons were generated based on literature review, informal and formal consultations and focus group discussions with the Lao PDR government and development partners including budget impact discussion. The government has taken three approaches to transition from external to domestic funding: mobilizing domestic resources, increasing efficiency across programs and prioritization with a focus on strengthening primary health care (PHC). The government has increased gradually domestic government health expenditures as a share of the government expenditure from 2.6% in 2013 to 4.9% in 2019. The Ministry of Health has made efforts to design and roll out integrated service delivery of maternal, newborn, child, and adolescent health services, immunization and nutrition; integrated 13 information systems of key health programs into one single District Health Information Software 2; and prioritized PHC, which has led to shifting donors towards supporting PHC. Donors have revisited their aid policies designed to improve sustainability and ownership of the government. However, the government faces challenges in improving cross-programmatic efficiency at the operational level and in further increasing the health budget due to the economic crisis aggravated during Coronavirus disease 2019 (COVID-19). Working to implement donor transition strategies under the current economic situation and country challenges, calls into question the criteria used to evaluate transition. This criterion needs to include more appropriate indicators other than gross national income per capita, which does not reflect a country's readiness and capacity of the health system. There should be a more country-tailored strategy and support for considering the context and system-wide readiness during donor transition.
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Affiliation(s)
- Eunkyoung Kim
- Health System Development team, World Health Organization Country Office for the Lao People's Democratic Republic, 125 Saphanthong Road, Unit 5, Ban Saphanthongtai, Sisattanak District, Vientiane Capital 0103, Lao People's Democratic Republic
| | - Yu Lee Park
- Health System Development team, World Health Organization Country Office for the Lao People's Democratic Republic, 125 Saphanthong Road, Unit 5, Ban Saphanthongtai, Sisattanak District, Vientiane Capital 0103, Lao People's Democratic Republic
| | - Ying-Ru Lo
- WHO Representative to Lao People's Democratic Republic, World Health Organization Country Office for the Lao People's Democratic Republic, 125 Saphanthong Road, Unit 5, Ban Saphanthongtai, Sisattanak District, Vientiane Capital 0103, Lao People's Democratic Republic
| | - Bounserth Keoprasith
- Department of Planning and Finance, Ministry of Health, Ban Thatkhao, Sisattanack District, Rue Simeuang, Vientiane Capital 0103, Lao People's Democratic Republic
| | - Suphab Panyakeo
- Department of Planning and Finance, Ministry of Health, Ban Thatkhao, Sisattanack District, Rue Simeuang, Vientiane Capital 0103, Lao People's Democratic Republic
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Appel I, Lohmann J, De Allegri M, Koulidiati JL, Somda S, Robyn PJ, Badolo H, Brenner S. Improving the readiness and clinical quality of antenatal care - findings from a quasi-experimental evaluation of a performance-based financing scheme in Burkina Faso. BMC Pregnancy Childbirth 2023; 23:352. [PMID: 37189035 DOI: 10.1186/s12884-023-05573-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 04/03/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND While maternal mortality has declined globally, it remains highest in low-income countries. High-quality antenatal care (ANC) can prevent or decrease pregnancy-related complications for mothers and newborns. The implementation of performance-based financing (PBF) schemes in Sub-Saharan Africa to improve primary healthcare provision commonly includes financial indicators linked to ANC service quality indicators. In this study, we examine changes in ANC provision produced by the introduction of a PBF scheme in rural Burkina Faso. METHODS This study followed a quasi-experimental design with two data collection points comparing effects on ANC service quality between primary health facilities across intervention and control districts based on difference-in-differences estimates. Performance scores were defined using data on structural and process quality of care reflecting key clinical aspects of ANC provision related to screening and prevention pertaining to first and follow-up ANC visits. RESULTS We found a statistically significant increase in performance scores by 10 percent-points in facilities' readiness to provide ANC services. The clinical care provided to different ANC client groups scored generally low, especially with respect to preventive care measures, we failed to observe any substantial changes in the clinical provision of ANC care attributable to the PBF. CONCLUSION The observed effect pattern reflects the incentive structure implemented by the scheme, with a stronger focus on structural elements compared with clinical aspects of care. This limited the scheme's overall potential to improve ANC provision at the client level after the observed three-year implementation period. To improve both facility readiness and health worker performance, stronger incentives are needed to increase adherence to clinical standards and patient care outcomes.
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Affiliation(s)
- Inke Appel
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany.
- Department of Gynecology and Obstetrics, Otto-Von-Guericke University, Magdeburg, Germany.
| | - Julia Lohmann
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
| | - Jean-Louis Koulidiati
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
- Institut Supérieur Des Sciences de La Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Serge Somda
- Centre Muraz, Institut National de Santé Publique (INSP), Bobo-Dioulasso, Burkina Faso
| | - Paul Jacob Robyn
- Health, Nutrition and Population Global Practice, World Bank, D.C., Washington, USA
| | - Hermann Badolo
- Centre Muraz, Institut National de Santé Publique (INSP), Bobo-Dioulasso, Burkina Faso
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany
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Fassinou LC, Ouoba J, Ngwasiri C, Romba I, Zoungrana-Yameogo WN, Bakiono F, Traoré IT, Hien H, Nagot N, Kirakoya-Samadoulougou F. Uptake of prevention of mother-to-child transmission cascade services in Burkina Faso between 2013 and 2020: are we on the right track? BMC Womens Health 2023; 23:126. [PMID: 36959578 PMCID: PMC10036241 DOI: 10.1186/s12905-023-02227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/13/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND The use of services to prevent mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) remains a serious challenge in sub-Saharan Africa. In the last decade, Burkina Faso has implemented numerous policies to increase the use of PMTCT services by pregnant women and their partners, as well as children. This study assesses trends in the uptake of PMTCT services in Burkina Faso from 2013 to 2020 in order to study the progress and gaps in achieving the national and international targets set for 2020. METHODS A repeated cross-sectional analysis was performed using data extracted from district health information software version 2. Percentages were computed for each PMTCT indicator and comparisons between the years were made using a chi-square test for trends with a significance threshold of 5%. Regions were not compared with each other. RESULTS The proportion of pregnant women who were tested and received their results significantly increased from 47.9% in 2013 to 84.6% in 2020 (p value < 0.001). Of the 13 regions in the country, only 1 region met the 95% national targets whereas, 6 regions met the 90% international targets for this indicator. The proportions of HIV-positive women receiving antiretroviral therapy (ART) increased from 90.8% in 2013 to 100% in 2020. In the same period, the proportion of exposed infants who received antiretroviral prophylaxis increased from 64.3% in 2013 to 86.8% in 2020. Only 3 regions reached the national and international targets for this indicator. A positive trend was also observed for the indicator related to screening at 2 months or later of exposed infants using Polymerase Chain Reaction (PCR) technic; with the rate rising from 7.4% in 2013 to 75.7% in 2020. However, for this indicator, the national and international targets were not achieved considering the national and regional settings. Concerning the women's partners, the proportion of those who tested for HIV increased from 0.9% in 2013 to 4.5% in 2020, with only 1 region that fully met the national target of 10% in 2020. The prevalence of HIV in this particular group was 0.5% in 2020. CONCLUSIONS PMTCT indicators show an increase from 2013 to 2020 but with a strong disparity between regions. National and international targets have not been achieved for any indicator; except for those related to women receiving ART. Strengthening strategies to effectively engage women and their partners on the use of PMTCT cascade services could help reduce mother-to-child transmission in Burkina Faso.
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Affiliation(s)
- Lucresse Corine Fassinou
- Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso.
| | - Joël Ouoba
- Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso.
| | - Calypse Ngwasiri
- Centre for Research in Epidemiology, Biostatistics and Clinical Research of the School of Public Health, Université Libre de Bruxelles, Brussels, Belgique
| | - Issa Romba
- Secrétariat Permanent du Conseil National de lutte contre le Sida et les Infections Sexuellement Transmissibles, Ministère de la Santé, Burkina Faso
| | | | - Fidèle Bakiono
- Secrétariat Permanent du Conseil National de lutte contre le Sida et les Infections Sexuellement Transmissibles, Ministère de la Santé, Burkina Faso
| | - Isidore Tiandiogo Traoré
- Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
- Centre Muraz, Institut National de Santé Publique, Bobo-Dioulasso, Burkina Faso
| | - Hervé Hien
- Centre Muraz, Institut National de Santé Publique, Bobo-Dioulasso, Burkina Faso
| | - Nicolas Nagot
- Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, INSERM, University Antilles, Etablissement Français du Sang, Montpellier, France
| | - Fati Kirakoya-Samadoulougou
- Centre for Research in Epidemiology, Biostatistics and Clinical Research of the School of Public Health, Université Libre de Bruxelles, Brussels, Belgique
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Waithaka D, Gilson L, Barasa E, Tsofa B, Orgill M. Political Prioritisation for Performance-Based Financing at the County Level in Kenya: 2015 to 2018. Int J Health Policy Manag 2023; 12:6909. [PMID: 37579436 PMCID: PMC10125155 DOI: 10.34172/ijhpm.2023.6909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/17/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Performance based financing was introduced to Kilifi county in Kenya in 2015. This study investigates how and why political and bureaucratic actors at the local level in Kilifi county influenced the extent to which PBF was politically prioritised at the sub-national level. METHODS The study employed a single-case study design. The Shiffman and Smith political priority setting framework with adaptations proposed by Walt and Gilson was applied. Data was collected through document review (n=19) and in-depth interviews (n=8). Framework analysis was used to analyse data and generate findings. RESULTS In the period 2015-2018, the political prioritisation of PBF at the county level in Kilifi was influenced by contextual features including the devolution of power to sub-national actors and rigid public financial management structures. It was further influenced by interpretations of the idea of 'pay-for-performance', its framing as 'additional funding', as well as contestation between actors at the sub national level about key PBF design features. Ultimately PBF ceased at the end of 2018 after donor funding stopped. CONCLUSION Health reformers must be cognisant of the power and interests of national and sub national actors in all phases of the policy process, including both bureaucratic and political actors in health and non-health sectors. This is particularly important in devolved public governance contexts where reforms require sustained attention and budgetary commitment at the sub national level. There is also need for early involvement of critical actors to develop shared understandings of the ideas on which interventions are premised, as well as problems and solutions.
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Affiliation(s)
- Dennis Waithaka
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucy Gilson
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Benjamin Tsofa
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Health Systems Research Group, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Marsha Orgill
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Lohmann J, Koulidiati JL, Robyn PJ, Somé PA, De Allegri M. Why did performance-based financing in Burkina Faso fail to achieve the intended equity effects? A process tracing study. Soc Sci Med 2022; 305:115065. [PMID: 35636048 DOI: 10.1016/j.socscimed.2022.115065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 04/20/2022] [Accepted: 05/20/2022] [Indexed: 10/18/2022]
Abstract
In recent years, performance-based financing (PBF) has attracted attention as a means of reforming provider payment mechanisms in low- and middle-income countries. Particularly in combination with demand-side interventions, PBF has been assumed to benefit also the most vulnerable and disadvantaged groups. However, impact evaluations have often found this not to be the case. In Burkina Faso, PBF was coupled with specific equity measures to enhance healthcare utilization among the ultra-poor, but failed to produce the expected effects. Our study used the process tracing methodology to unravel the reasons for the lack of impact produced by the equity measures. We relied on published evidence, secondary data analysis, and findings from a qualitative study to support or invalidate the hypothesized causal mechanism, that is the reconstructed theory of change of the equity measures. Our findings show how various contextual, design, and implementation challenges hindered the causal mechanism from unfolding as planned. These included issues with the identification and exemption of the ultra-poor on the demand side, and with financial issues and considerations on the supply side. In broader terms, our findings underline the difficulty in improving access to care for the ultra-poor, given the multifaceted and complex nature of barriers to care the most vulnerable face. From a methodological point of view, our study demonstrates the value and applicability of process tracing in complementing other forms of evaluation for complex interventions in global health.
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Affiliation(s)
- Julia Lohmann
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, UK; Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, Germany.
| | - Jean-Louis Koulidiati
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, Germany.
| | - Paul Jacob Robyn
- Health, Nutrition and Population Global Practice, World Bank, Washington, D.C., USA.
| | | | - Manuela De Allegri
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Medical Faculty, Germany.
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Torbica A, Grainger C, Okada E, De Allegri M. How much does it cost to combine supply-side and demand-side RBF approaches in a single intervention? Full cost analysis of the Results Based Financing for Maternal and Newborn Health Initiative in Malawi. BMJ Open 2022; 12:e050885. [PMID: 35440444 PMCID: PMC9020314 DOI: 10.1136/bmjopen-2021-050885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To estimate the economic cost associated with implementing the Results Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative in Malawi. No specific hypotheses were formulated ex-ante. SETTING Primary and secondary delivery facilities in rural Malawi. PARTICIPANTS Not applicable. The study relied almost exclusively on secondary financial data. INTERVENTION The RBF4MNH Initiative was a results-based financing (RBF) intervention including both a demand and a supply-side component. PRIMARY AND SECONDARY OUTCOME MEASURES Cost per potential and for actual beneficiaries. RESULTS The overall economic cost of the Initiative during 2011-2016 amounted to €12 786 924, equivalent to €24.17 per pregnant woman residing in the intervention districts. The supply side activity cluster absorbed over 40% of all resources, half of which were spent on infrastructure upgrading and equipment supply, and 10% on incentives. Costs for the demand side activity cluster and for verification were equivalent to 14% and 6%, respectively of the Initiative overall cost. CONCLUSION Carefully tracing resource consumption across all activities, our study suggests that the full economic cost of implementing RBF interventions may be higher than what was previously reported in published cost-effectiveness studies. More research is urgently needed to carefully trace the costs of implementing RBF and similar health financing innovations, in order to inform decision-making in low-income and middle-income countries around scaling up RBF approaches.
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Affiliation(s)
- Aleksandra Torbica
- Department of Social and Political Sciences, Centre for Research for Health and Social Care Management, Bocconi University, Milano, Italy
| | | | - Elena Okada
- Options Consultancy Services Ltd, London, UK
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Heidelberg University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Germany
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Waithaka D, Cashin C, Barasa E. Is Performance-Based Financing A Pathway to Strategic Purchasing in Sub-Saharan Africa? A Synthesis of the Evidence. Health Syst Reform 2022; 8:e2068231. [PMID: 35666240 PMCID: PMC7613548 DOI: 10.1080/23288604.2022.2068231] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Many countries in sub-Saharan Africa have implemented performance-based financing (PBF) to improve health system performance. Much of the debate and analysis relating to PBF has focused on whether PBF “works”—that is, whether it leads to improvements in indicators tied to incentive-based payments. Because PBF schemes embody key elements of strategic health purchasing, this study examines the question of whether and how PBF programs in sub-Saharan Africa influence strategic purchasing more broadly within country health financing arrangements. We searched PubMed, Scopus, EconLit, Cochrane Database of Systematic Reviews, Google Scholar, Google, and the World Health Organization and World Bank’s repositories for studies that focused on the implementation experience or effects of PBF in sub-Saharan African and published in English from 2000 to 2020. We identified 44 papers and used framework analysis to analyze the data and generate key findings. The evidence we reviewed shows that PBF has the potential to raise awareness about strategic purchasing, improve governance and institutional arrangements, and strengthen strategic purchasing functions. However, these effects are minimal in practice because PBF has been introduced as narrow, often pilot, projects that run parallel to and have little integration with the mainstream health financing system. We concluded that PBF has not systematically transformed health purchasing in countries in sub-Saharan Africa but that the experience with PBF can provide valuable lessons for how system-wide strategic purchasing can be implemented most effectively in that region—either in countries that currently have PBF schemes and aim to integrate them into broader purchasing systems, or in countries that are not currently implementing PBF. We also concluded that for countries to pursue more holistic approaches to strategic health purchasing and achieve better health outcomes, they need to implement health financing reforms within or aligned with existing financing systems.
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Affiliation(s)
- Dennis Waithaka
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Cheryl Cashin
- Results for Development Institute, Washington, D.C, USA
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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Gage A, Bauhoff S. The effects of performance-based financing on neonatal health outcomes in Burundi, Lesotho, Senegal, Zambia and Zimbabwe. Health Policy Plan 2021; 36:332-340. [PMID: 33491082 PMCID: PMC8058947 DOI: 10.1093/heapol/czaa191] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 01/28/2023] Open
Abstract
Maternal and newborn care has been a primary focus of performance-based financing (PBF) projects, which have been piloted or implemented in 21 countries in sub-Saharan Africa since 2007. Several evaluations of PBF have demonstrated improvements to facility delivery or quality of care. However, no studies have measured the impact of PBF programmes directly on neonatal health outcomes in Africa, nor compared PBF programmes against another. We assess the impact of PBF on early neonatal health outcomes and associated health care utilization and quality in Burundi, Lesotho, Senegal, Zambia and Zimbabwe. We pooled Demographic and Health Surveys and Multiple Indicator Cluster Surveys and apply difference-in-differences analysis to estimate the effect of PBF projects supported by the World Bank on early neonatal mortality and low birthweight. We also assessed the effect of PBF on intermediate outputs that are frequently explicitly incentivized in PBF projects, including facility delivery and antenatal care utilization and quality, and caesarean section. Finally, we examined the impact among births to poor or high-risk women. We found no statistically significant impact of PBF on neonatal health outcomes, health care utilization or quality in a pooled sample. PBF was also not associated with better health outcomes in each country individually, though in some countries and among poor women PBF improved facility delivery, antenatal care utilization or antenatal care quality. There was no improvement on the health outcomes among poor or high-risk women in the five countries. PBF had no impact on early neonatal health outcomes in the five African countries studied and had limited and variable effects on the utilization and quality of neonatal health care. These findings suggest that there is a need for both a deeper assessment of PBF and for other strategies to make meaningful improvements to neonatal health outcomes.
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Affiliation(s)
- Anna Gage
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building 1, 11th Floor, Boston, MA 02115, USA
| | - Sebastian Bauhoff
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building 1, 11th Floor, Boston, MA 02115, USA
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Kuunibe N, Lohmann J, Hillebrecht M, Nguyen HT, Tougri G, De Allegri M. What happens when performance-based financing meets free healthcare? Evidence from an interrupted time-series analysis. Health Policy Plan 2021; 35:906-917. [PMID: 32601671 DOI: 10.1093/heapol/czaa062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2020] [Indexed: 11/12/2022] Open
Abstract
In spite of the wide attention performance-based financing (PBF) has received over the past decade, no evidence is available on its impacts on quantity and mix of service provision nor on its interaction with parallel health financing interventions. Our study aimed to examine the PBF impact on quantity and mix of service provision in Burkina Faso, while accounting for the parallel introduction of a free healthcare policy. We used Health Management Information System data from 838 primary-level health facilities across 24 districts and relied on an interrupted time-series analysis with independent controls. We placed two interruptions, one to account for PBF and one to account for the free healthcare policy. In the period before the free healthcare policy, PBF produced significant but modest increases across a wide range of maternal and child services, but a significant decrease in child immunization coverage. In the period after the introduction of the free healthcare policy, PBF did not affect service provision in intervention compared with control facilities, possibly indicating a saturation effect. Our findings indicate that PBF can produce modest increases in service provision, without altering the overall service mix. Our findings, however, also indicate that the introduction of other health financing reforms can quickly crowd out the effects produced by PBF. Further qualitative research is required to understand what factors allow healthcare providers to increase the provision of some, but not all services and how they react to the joint implementation of PBF and free health care.
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Affiliation(s)
- Naasegnibe Kuunibe
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany.,Department of Economics and Entrepreneurship Development, Faculty of Integrated development Studies, University for Development Studies, Wa Campus, Box 520, Wa, Upper West Region, Ghana
| | - Julia Lohmann
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany.,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Michael Hillebrecht
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Sectoral Department, Dag-Hammarskjöld-Weg 1-5, 65760 Eschborn, Germany
| | - Hoa Thi Nguyen
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany
| | | | - Manuela De Allegri
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany
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Zitti T, Fillol A, Lohmann J, Coulibaly A, Ridde V. Does the gap between health workers' expectations and the realities of implementing a performance-based financing project in Mali create frustration? Glob Health Res Policy 2021; 6:5. [PMID: 33526079 PMCID: PMC7852126 DOI: 10.1186/s41256-021-00189-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 01/25/2021] [Indexed: 11/24/2022] Open
Abstract
Background Performance-Based Financing (PBF), an innovative health financing initiative, was recently implemented in Mali. PBF aims to improve quality of care by motivating health workers. The purpose of this research was to identify and understand how health workers’ expectations related to their experiences of the first cycle of payment of PBF subsidies, and how this experience affected their motivation and sentiments towards the intervention. We pose the research question, “how does the process of PBF subsidies impact the motivation of health workers in Mali?” Methods We adopted a qualitative approach using multiple case studies. We chose three district hospitals (DH 1, 2 and 3) in three health districts (district 1, 2 and 3) among the ten in the Koulikoro region. Our cases correspond to the three DHs. We followed the principle of data source triangulation; we used 53 semi-directive interviews conducted with health workers (to follow the principle of saturuation), field notes, and documents relating to the distribution grids of subsidies for each DH. We analyzed data in a mixed deductive and inductive manner. Results The results show that the PBF subsidies led to health workers feeling more motivated to perform their tasks overall. Beyond financial motivation, this was primarily due to PBF allowing them to work more efficiently. However, respondents perceived a discrepancy between the efforts made and the subsidies received. The fact that their expectations were not met led to a sense of frustration and disappointment. Similarly, the way in which the subsidies were distributed and the lack of transparency in the distribution process led to feelings of unfairness among the vast majority of respondents. The results show that frustrations can build up in the early days of the intervention. Conclusion The PBF implementation in Mali left health workers frustrated. The short overall implementation period did not allow actors to adjust their initial expectations and motivational responses, neither positive nor negative. This underlines how short-term interventions might not just lack impact, but instil negative sentiments likely to carry on into the future.
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Affiliation(s)
- Tony Zitti
- Centre Population et Développement (Ceped), Institut de recherche pour le développement (IRD) et Université de Paris, Inserm ERL 1244, 45 rue des Saints-Pères, 75006, Paris, France. .,École doctorale Pierre Louis de santé publique, Université de Paris, Paris, France. .,ONG Miseli, Bamako, Mali.
| | - Amandine Fillol
- Centre Population et Développement (Ceped), Institut de recherche pour le développement (IRD) et Université de Paris, Inserm ERL 1244, 45 rue des Saints-Pères, 75006, Paris, France.,Ecole de santé publique de l'Université de Montréal, Montréal, Canada
| | - Julia Lohmann
- London School of Hygiene & Tropical Medicine, London, UK.,Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Abdourahmane Coulibaly
- ONG Miseli, Bamako, Mali.,Faculté de Médicine et d'Odontostomatologie, Université des Sciences, des Techniques et des Technologies, Bamako, Mali
| | - Valéry Ridde
- Centre Population et Développement (Ceped), Institut de recherche pour le développement (IRD) et Université de Paris, Inserm ERL 1244, 45 rue des Saints-Pères, 75006, Paris, France
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Beaugé Y, De Allegri M, Ouédraogo S, Bonnet E, Kuunibe N, Ridde V. Do Targeted User Fee Exemptions Reach the Ultra-Poor and Increase their Healthcare Utilisation? A Panel Study from Burkina Faso. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186543. [PMID: 32911868 PMCID: PMC7559284 DOI: 10.3390/ijerph17186543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/25/2020] [Accepted: 09/02/2020] [Indexed: 12/22/2022]
Abstract
Background: A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of user fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of user fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of user fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diébougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (β = −0.07; 95% CI = −0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.
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Affiliation(s)
- Yvonne Beaugé
- Heidelberg Institute for Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany; (M.D.A.); (N.K.)
- Correspondence: ; Tel.: +49-6221-56-35057; Fax: +49-6221-56-5948
| | - Manuela De Allegri
- Heidelberg Institute for Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany; (M.D.A.); (N.K.)
| | - Samiratou Ouédraogo
- The Canadian Institutes of Health Research (CIHR), Ottawa, ON K1A 0W9, Canada;
- National Public Health Institute of Quebec (INSPQ), Quebec City, QC G1V 5B3, Canada
- Department of Epidemiology, Biostatistics and Occupational Health (EBOH), Faculty of Medicine, McGill University, Montreal, QC H3A 1A2, Canada
| | - Emmanuel Bonnet
- French Institute for Research on Sustainable Development (IRD), Unité Mixte Internationale (UMI) Résiliences, 93143 Bondy, France;
| | - Naasegnibe Kuunibe
- Heidelberg Institute for Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany; (M.D.A.); (N.K.)
- Department of Economics and Entrepreneurship Development Studies, Faculty of Integrated Development Studies, University for Development Studies, P. O. Box 520, Wa, Upper West Region, Ghana
| | - Valéry Ridde
- French Institute for Research on sustainable Development (IRD), Centre Population et Développement (CEPED), Universités de Paris, ERL INSERM SAGESUD, 75006 Paris, France;
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Coulibaly A, Gautier L, Zitti T, Ridde V. Implementing performance-based financing in peripheral health centres in Mali: what can we learn from it? Health Res Policy Syst 2020; 18:54. [PMID: 32493360 PMCID: PMC7268714 DOI: 10.1186/s12961-020-00566-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 05/01/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Numerous sub-Saharan African countries have experimented with performance-based financing (PBF) with the goal of improving health system performance. To date, few articles have examined the implementation of this type of complex intervention in Francophone West Africa. This qualitative research aims to understand the process of implementing a PBF pilot project in Mali's Koulikoro region. Method We conducted a contrasted multiple case study of performance in 12 community health centres in three districts. We collected 161 semi-structured interviews, 69 informal interviews and 96 non-participant observation sessions. Data collection and analysis were guided by the Consolidated Framework for Implementation Research adapted to the research topic and local context. Results Our analysis revealed that the internal context of the PBF implementation played a key role in the process. High-performing centres exercised leadership and commitment more strongly than low-performing ones. These two characteristics were associated with taking initiatives to promote PBF implementation and strengthening team spirit. Information regarding the intervention was best appropriated by qualified health professionals. However, the limited duration of the implementation did not allow for the emergence of networks or champions. The enthusiasm initially generated by PBF quickly dissipated, mainly due to delays in the implementation schedule and the payment modalities. Conclusion PBF is a complex intervention in which many actors intervene in diverse contexts. The initial level of performance and the internal and external contexts of primary healthcare facilities influence the implementation of PBF. Future work in this area would benefit from an interdisciplinary approach combining public health and anthropology to better understand such an intervention. The deductive–inductive approach must be the stepping-stone of such a methodological approach.
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Affiliation(s)
- Abdourahmane Coulibaly
- Miseli Research NGO, Bamako, Mali. .,Faculty of Medicine and Odonto-Stomatology, Université des Sciences, des Techniques et des Technologies, Bamako, Mali. .,UMI 3189 Environnement, Santé, Sociétés (CNRS, UCAD, UGB, USTTB, CNRST), Dakar, Sénégal.
| | - Lara Gautier
- Department of Sociology, McGill University, Montreal, Canada.,Department of Social and Preventive Medicine, University of Montreal, Montreal, Canada
| | - Tony Zitti
- Miseli Research NGO, Bamako, Mali.,CEPED, Institute for Research on Sustainable Development, IRD-Université de Paris, ERL INSERM SAGESUD, Paris, France.,École doctorale Pierre Louis de santé publique: épidémiologie et sciences de l'information biomédicale, Université de Paris, Paris, France
| | - Valéry Ridde
- CEPED, Institute for Research on Sustainable Development, IRD-Université de Paris, ERL INSERM SAGESUD, Paris, France
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13
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Ravit M, Ravalihasy A, Audibert M, Ridde V, Bonnet E, Raffalli B, Roy FA, N’Landu A, Dumont A. The impact of the obstetrical risk insurance scheme in Mauritania on maternal healthcare utilization: a propensity score matching analysis. Health Policy Plan 2020; 35:388-398. [PMID: 32003810 PMCID: PMC7195851 DOI: 10.1093/heapol/czz150] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 01/24/2023] Open
Abstract
In Mauritania, obstetrical risk insurance (ORI) has been progressively implemented at the health district level since 2002 and was available in 25% of public healthcare facilities in 2015. The ORI scheme is based on pre-payment scheme principles and focuses on increasing the quality of and access to both maternal and perinatal healthcare. Compared with many community-based health insurance schemes, the ORI scheme is original because it is not based on risk pooling. For a pre-payment of 16-18 USD, women are covered during their pregnancy for antenatal care, skilled delivery, emergency obstetrical care [including caesarean section (C-section) and transfer] and a postnatal visit. The objective of this study is to evaluate the impact of ORI enrolment on maternal and child health services using data from the Multiple Indicator Cluster Survey (MICS) conducted in 2015. A total of 4172 women who delivered within the last 2 years before the interview were analysed. The effect of ORI enrolment on the outcomes was estimated using a propensity score matching estimation method. Fifty-eight per cent of the studied women were aware of ORI, and among these women, more than two-thirds were enrolled. ORI had a beneficial effect among the enrolled women by increasing the probability of having at least one prenatal visit by 13%, the probability of having four or more visits by 11% and the probability of giving birth at a healthcare facility by 15%. However, we found no effect on postnatal care (PNC), C-section rates or neonatal mortality. This study provides evidence that a voluntary pre-payment scheme focusing on pregnant women improves healthcare services utilization during pregnancy and delivery. However, no effect was found on PNC or neonatal mortality. Some efforts should be exerted to improve communication and accessibility to ORI.
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Affiliation(s)
- Marion Ravit
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
| | - Andrainolo Ravalihasy
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
| | - Martine Audibert
- Université Clermont Auvergne, CNRS, CERDI, 63000 Clermont-Ferrand, France
| | - Valéry Ridde
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
- Institut de Recherche en Santé Publique de Montréal (IRSPUM), Canada/Ecole de Santé Publique de Montréal (ESPUM), H3N 1X9, Montreal, Canada
| | - Emmanuel Bonnet
- UMR IDEES CNRS 6266, Université de Normandie/IRD RESILIENCE 236, 14000 Caen, France
| | - Bertille Raffalli
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
| | - Flore-Apolline Roy
- UMR IDEES CNRS 6266, Université de Normandie/IRD RESILIENCE 236, 14000 Caen, France
| | - Anais N’Landu
- Université Clermont Auvergne, CNRS, CERDI, 63000 Clermont-Ferrand, France
| | - Alexandre Dumont
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
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14
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Ridde V, Pérez D, Robert E. Using implementation science theories and frameworks in global health. BMJ Glob Health 2020; 5:e002269. [PMID: 32377405 PMCID: PMC7199704 DOI: 10.1136/bmjgh-2019-002269] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 11/20/2022] Open
Abstract
In global health, researchers and decision makers, many of whom have medical, epidemiology or biostatistics background, are increasingly interested in evaluating the implementation of health interventions. Implementation science, particularly for the study of public policies, has existed since at least the 1930s. This science makes compelling use of explicit theories and analytic frameworks that ensure research quality and rigour. Our objective is to inform researchers and decision makers who are not familiar with this research branch about these theories and analytic frameworks. We define four models of causation used in implementation science: intervention theory, frameworks, middle-range theory and grand theory. We then explain how scientists apply these models for three main implementation studies: fidelity assessment, process evaluation and complex evaluation. For each study, we provide concrete examples from research in Cuba and Africa to better understand the implementation of health interventions in global health context. Global health researchers and decision makers with a quantitative background will not become implementation scientists after reading this article. However, we believe they will be more aware of the need for rigorous implementation evaluations of global health interventions, alongside impact evaluations, and in collaboration with social scientists.
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Affiliation(s)
- Valéry Ridde
- CEPED, IRD (French Institute for Research on sustainable Development), Université de Paris, ERL INSERM SAGESUD, Paris, France
| | - Dennis Pérez
- Epidemiology Division, Pedro Kouri Tropical Medicine Institute (IPK), Havana, Cuba
| | - Emilie Robert
- ICARES and Centre de recherche SHERPA (Institut Universitaire au regard des communautés ethnoculturelles, CIUSSS du Centre-Ouest-de-l'Île-de-Montréal), Montreal, Quebec, Canada
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15
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Petross C, McMahon S, Lohmann J, Chase RP, Muula AS, De Allegri M. Intended and unintended effects: community perspectives on a performance-based financing programme in Malawi. BMJ Glob Health 2020; 5:e001894. [PMID: 32337084 PMCID: PMC7170427 DOI: 10.1136/bmjgh-2019-001894] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 11/04/2022] Open
Abstract
Background Several performance-based financing (PBF) evaluations have been undertaken in low-income countries, yet few have examined community perspectives of care amid PBF programme implementation. We assessed community members' perspectives of Support for Service Delivery Integration - Performance-Based Incentives ('SSDI-PBI'), a PBF intervention in Malawi, and explored some of the unintended effects that emerged amid implementation. Methods We conducted 30 focus group discussions: 17 with community leaders and 13 with mothers within catchment areas of SSDI-PBI implementing facilities. We analysed data using the framework approach. Results Community leaders and women had mixed impressions regarding the effect of SSDI-PBI on service delivery in facilities. They highlighted several improvements (including improved dialogue between staff and community, and cleaner, better-equipped facilities with enhanced privacy), but also persisting challenges (including inadequate and overworked staff, overcrowded facilities and long distances to facilities) related to services in SSDI-PBI-implementing facilities. Further, respondents described how four targeted service indicators related to maternal risk factor management, antenatal care (ANC) in the first trimester, skilled birth attendance and couple's HIV testing sparked unintended negative effects as experienced by women and communities. The unintended effects included women returning home for delivery, women feeling uncertain about their pregnancy status, women feeling betrayed or frustrated by the quality of care provided and partnerless women being denied ANC. Conclusion PBF programmes such as SSDI-PBI may improve some aspects of service delivery. However, to achieve system improvement, not only should necessary tools (such as medicines, equipment and human resources) be in place, but also programme priorities must be congruent with cultural expectations. Finally, facilities must be better supported to expect and then address increases in client load and heightened expectations in relation to services.
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Affiliation(s)
- Chisomo Petross
- University of Malawi, Kamuzu College of Nursing, Private Bag 1, Lilongwe, Malawi
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Shannon McMahon
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Julia Lohmann
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, Keppel Street, London WC1E 7HT, UK
| | - Rachel P Chase
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Adamson S. Muula
- Department of Public health, University of Malawi, College of Medicine, Blantyre 3, Malawi
- Africa Center of Excellence in Public Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
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16
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Nimpagaritse M, Korachais C, Meessen B. Effects in spite of tough constraints - A theory of change based investigation of contextual and implementation factors affecting the results of a performance based financing scheme extended to malnutrition in Burundi. PLoS One 2020; 15:e0226376. [PMID: 31929554 PMCID: PMC6957191 DOI: 10.1371/journal.pone.0226376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/25/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND From January 2015 to December 2016, the health authorities in Burundi piloted the inclusion of child nutrition services into the pre-existing performance-based financing free health care policy (PBF-FHC). An impact evaluation, focused on health centres, found positive effects both in terms of volume of services and quality of care. To some extent, this result is puzzling given the harshness of the contextual constraints related to the fragile setting. METHODS With a multi-methods approach, we explored how contextual and implementation constraints interacted with the pre-identified tracks of effect transmission embodied in the intervention. For our analysis, we used a hypothetical Theory of Change (ToC) that mapped a set of seven tracks through which the intervention might develop positive effects for children suffering from malnutrition. We built our analysis on (1) findings from the facility surveys and (2) extra qualitative data (logbooks, interviews and operational document reviews). FINDINGS Our results suggest that six constraints have weighted upon the intervention: (1) initial low skills of health workers; (2) unavailability of resources (including nutritional dietary inputs and equipment); (3) payment delays; (4) suboptimal information; (5) restrictions on autonomy; and (6) low intensity of supervision. Together, they have affected the intensity of the intervention, especially during its first year. From our analysis of the ToC, we noted that the positive effects largely occurred as a result of the incentive and information tracks. Qualitative data suggests that health centres have circumvented the many constraints by relying on a community-based recruitment strategy and a better management of inputs at the level of the facility and the patient himself. CONCLUSION Frontline actors have agency: when incentives are right, they take the initiative and find solutions. However, they cannot perform miracles: Burundi needs a holistic societal strategy to resolve the structural problem of child malnutrition. TRIAL REGISTRATION Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).
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Affiliation(s)
- Manassé Nimpagaritse
- Institut National de Santé Publique, Bujumbura, Burundi
- Health Economics Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Institut de Recherche Santé et Société, Université Catholique de Louvain, Clos Chapelle-aux-Champs, Bruxelles, Belgique
| | - Catherine Korachais
- Health Economics Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruno Meessen
- Health Economics Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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17
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Zitti T, Gautier L, Coulibaly A, Ridde V. Stakeholder Perceptions and Context of the Implementation of Performance-Based Financing in District Hospitals in Mali. Int J Health Policy Manag 2019; 8:583-592. [PMID: 31657185 PMCID: PMC6819625 DOI: 10.15171/ijhpm.2019.45] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 06/02/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To improve the performance of the healthcare system, Mali's government implemented a pilot project of performance-based financing (PBF) in the field of reproductive health. It was established in the Koulikoro region. This research analyses the process of implementing PBF at district hospital (DH) level, something which has rarely been done in Africa. METHODS This qualitative research is based on a multiple, explanatory, and contrasting case study with nested levels of analysis. It covered three of the 10 DHs in the Koulikoro region. We conducted 36 interviews: 12 per DH with council of circle's members (2) and health personnel (10). We also conducted 24 non-participant observation sessions, 16 informal interviews, and performed a literature review. We performed data analysis using the Consolidated Framework for Implementation Research (CFIR). RESULTS Stakeholders perceived the PBF pilot project as a vertical intervention from outside that focused solely on reproductive health. Local actors were not involved in the design of the PBF model. Several difficulties regarding the quality of its design and implementation were highlighted: too short duration of the intervention (8 months), choice and insufficient number of indicators according to the priority of the donors, and impossibility of making changes to the model during its implementation. All health workers adhered to the principles of PBF intervention. Except for members of the district health management team (DHMT) involved in the implementation, respondents only had partial knowledge of the PBF intervention. The implementation of PBF appeared to be easier in District 3 Hospital compared to District 1 and District 2 because it benefited from a pre-pilot project and had good leadership. CONCLUSION The PBF programme offered an opportunity to improve the quality of care provided to the population through the motivation of health personnel in Mali. However, several obstacles were observed during the implementation of the PBF pilot project in DHs. When designing and implementing PBF in DHs, it is necessary to consider factors that can influence the implementation of a complex intervention.
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Affiliation(s)
- Tony Zitti
- CEPED (UMR 196), Institut de Recherche pour le Développement, ERL INSERM SAGESUD, École doctorale Pierre Louis de santé publique, Université Sorbonne Paris Cité, Paris, France.,Miseli Research NGO, Bamako, Mali
| | - Lara Gautier
- Department of Social and Preventive Medicine, University of Montreal, Montreal, QC, Canada.,Public Health Research Institute, University of Montreal, Montreal, QC, Canada.,CESSMA (UMR 245), Institut de Recherche pour le Développement, Université Sorbonne Paris Cité, Paris, France
| | - Abdourahmane Coulibaly
- Miseli Research NGO, Bamako, Mali.,Faculty of Medicine and Odonto-Stomatology, Université des Sciences, des Techniques et des Technologies, Bamako, Mali
| | - Valéry Ridde
- CEPED (UMR 196), Institut de Recherche pour le Développement, ERL INSERM SAGESUD, Université Sorbonne Paris Cité, Paris, France
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Kuunibe N, Lohmann J, Schleicher M, Koulidiati JL, Robyn PJ, Zigani Z, Sanon A, De Allegri M. Factors associated with misreporting in performance-based financing in Burkina Faso: Implications for risk-based verification. Int J Health Plann Manage 2019; 34:1217-1237. [PMID: 30994207 DOI: 10.1002/hpm.2786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/13/2019] [Indexed: 11/06/2022] Open
Abstract
Performance-based financing (PBF) has been piloted in many low- and middle-income countries (LMICs) as a strategy to improve access to and quality of health services. As a key component of PBF, quantity verification is carried out to ensure that reported data matches the actual number of services provided. However, cost concerns have led to a call for risk-based verification. Existing evidence suggests misreporting is associated with factors such as complexity of indicators, high service volume, and accepted error margin. In contrast, evidence on the association of key facility characteristics with misreporting in PBF is scarce. We contributed to filling this gap in knowledge by combining administrative data from a large-scale pilot PBF program in Burkina Faso with data from a health facility assessment in the context of an impact evaluation of the intervention. Our results showed the coexistence of both overreporting and underreporting and that misreporting varied by service indicator and health district. We also found that the number of clinical staff at the facility, the population size in the facility catchment area, and the distance between the facility and the district administration were associated with the probability of misreporting. We recommend further research of these factors in the move towards risk-based verification. In addition, given that our analysis identified relevant associations, but could not explain them, we recommend further qualitative inquiry into verification processes.
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Affiliation(s)
- Naasegnibe Kuunibe
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
| | - Julia Lohmann
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
| | - Michael Schleicher
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
| | - Jean-Louis Koulidiati
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
| | - Paul Jacob Robyn
- Health, Nutrition and Population Unit, World Bank, Washington, DC, USA
| | | | - Adama Sanon
- Ministère de la santé, Ouagadougou, Burkina Faso
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
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Pérez D, Van der Stuyft P, Ridde V, Lefèvre P. To the bone: Comment on "I wanted a skeleton … they brought a prince": A qualitative investigation of factors mediating the implementation of a Performance Based Incentive program in Malawi. SSM Popul Health 2019; 7:100305. [PMID: 31297432 PMCID: PMC6598832 DOI: 10.1016/j.ssmph.2018.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/01/2018] [Accepted: 10/07/2018] [Indexed: 11/15/2022] Open
Abstract
Recently, McMahon and colleagues set out to build on a widely-used fidelity framework, assessing the role of moderating factors during the implementation of performance-based financing programs in Malawi. Their attempt draws again the attention to the importance of approaching real word implementation issues from a theoretical perspective. It also highlights the importance of fidelity assessment within process evaluation of health programs. In this comment we argue that theoretical developments in the field of implementation science in global health would benefit from an accurate understanding of existing conceptual frameworks as well as from taking into account all contemporary contributions.
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Affiliation(s)
- Dennis Pérez
- Department of Epidemiology, Tropical Medicine Institute “Pedro Kouri”, Havana City, Cuba
- Public Health Research Institute, Montreal University, Montreal, Canada
| | | | - Valéry Ridde
- Public Health Research Institute, Montreal University, Montreal, Canada
- Centre Population et Développement, Institute de Recherche pour de Développement, Université Paris Descartes, Paris, France
| | - Pierre Lefèvre
- Freelance Consultant in Global Health, Brussels, Belgium
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20
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Zizien ZR, Korachais C, Compaoré P, Ridde V, De Brouwere V. Contribution of the results-based financing strategy to improving maternal and child health indicators in Burkina Faso. Int J Health Plann Manage 2018; 34:111-129. [PMID: 30113703 DOI: 10.1002/hpm.2589] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 01/22/2018] [Accepted: 06/29/2018] [Indexed: 11/10/2022] Open
Abstract
In response to the poor performance of its public health care provision, Burkina Faso decided, to implement results-based financing (RBF). This strategy relies on a strategic purchase of the quantity and quality of services provided by health workers, monitored by a set of indicators. However, there is a lack of evidence on its effects. The objective of this article is to appreciate the effect of RBF on a set of maternal and child health (MCH) indicators in Burkina Faso. The study design is quasi-experimental comparative with a control group before and after the implementation of the RBF. To estimate the effect of RBF, we used two methods of analysis: (1) the segmented regression to measure the effect of RBF in the health districts (HD) implementing RBF (RBF HD) and (2) the difference-in-difference test to estimate the effect of RBF considering the differences in mean between RBF HD and HD that did not implement RBF (non-RBF HD). We found among five indicators studied that only the postnatal consultation coverage in RBF HD was significantly higher (7.68%; P = 0.04) than in the non-RBF HD. Overall, our findings do not clearly demonstrate the effectiveness of RBF in improving MCH indicators in Burkina Faso.
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Affiliation(s)
- Zawora Rita Zizien
- Direction Régionale de la Santé des Cascades, Ministère de la Santé, Banfora, Burkina Faso
| | - Catherine Korachais
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Philippe Compaoré
- Service Technique du Financement Basé sur les Résultats, Ministère de la Santé, Ouagadougou, Burkina Faso
| | - Valéry Ridde
- University of Montreal Public Health Research Institute (IRSPUM), Montreal, QC, Canada.,IRD (French Institute for Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Université Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
| | - Vincent De Brouwere
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Ridde V, Gautier L, Turcotte-Tremblay AM, Sieleunou I, Paul E. Performance-based Financing in Africa: Time to Test Measures for Equity. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2018; 48:549-561. [PMID: 29932352 DOI: 10.1177/0020731418779508] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Over the past 15 years, hundreds of millions of dollars have been invested in reforms founded on performance-based financing (PBF) in low- and middle-income countries. While evidence on its effectiveness and efficiency is still controversial, there appears to be an emerging consensus that equity has not been adequately considered. In this article, we show how PBF-type interventions in Africa have not sufficiently taken into account equity of access to care for the worst-off and their financial protection. In reviewing the history of health reforms in Africa, we show that this omission is nothing new. We suggest that strategic purchasing and PBF-type actions would benefit from being implemented in ways that promote equity and the financial protection of populations in Africa. Without such a reorientation of reforms, it will be impossible to achieve universal health coverage by 2030.
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Affiliation(s)
- Valéry Ridde
- 1 CEPED, IRD, Université Paris Descartes, Inserm, équipe SAGESUD, Paris, France.,2 University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada
| | - Lara Gautier
- 2 University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada.,3 Centre d'Etudes en Sciences Sociales sur les Mondes Africains, Américains et Asiatiques (CESSMA), French Institute for Research on Sustainable Development (IRD), Université Sorbonne Paris Cité
| | | | - Isidore Sieleunou
- 2 University of Montreal Public Health Research Institute (IRSPUM), Montreal, Canada
| | - Elisabeth Paul
- 4 Université de Liège, Faculty of Social Sciences, Liège, Belgium
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Mwase T, Brenner S, Mazalale J, Lohmann J, Hamadou S, Somda SMA, Ridde V, De Allegri M. Inequities and their determinants in coverage of maternal health services in Burkina Faso. Int J Equity Health 2018; 17:58. [PMID: 29751836 PMCID: PMC5948792 DOI: 10.1186/s12939-018-0770-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/29/2018] [Indexed: 11/30/2022] Open
Abstract
Background Poor and marginalized segments of society often display the worst health status due to limited access to health enhancing interventions. It follows that in order to enhance the health status of entire populations, inequities in access to health care services need to be addressed as an inherent element of any effort targeting Universal Health Coverage. In line with this observation and the need to generate evidence on the equity status quo in sub-Saharan Africa, we assessed the magnitude of the inequities and their determinants in coverage of maternal health services in Burkina Faso. Methods We assessed coverage for three basic maternal care services (at least four antenatal care visits, facility-based delivery, and at least one postnatal care visit) using data from a cross-sectional household survey including a total of 6655 mostly rural, poor women who had completed a pregnancy in the 24 months prior to the survey date. We assessed equity along the dimensions of household wealth, distance to the health facility, and literacy using both simple comparative measures and concentration indices. We also ran hierarchical random effects regression to confirm the presence or absence of inequities due to household wealth, distance, and literacy, while controlling for potential confounders. Results Coverage of facility based delivery was high (89%), but suboptimal for at least four antenatal care visits (44%) and one postnatal care visit (53%). We detected inequities along the dimensions of household wealth, literacy and distance. Service coverage was higher among the least poor, those who were literate, and those living closer to a health facility. We detected a significant positive association between household wealth and all outcome variables, and a positive association between literacy and facility-based delivery. We detected a negative association between living farther away from the catchment facility and all outcome variables. Conclusion Existing inequities in maternal health services in Burkina Faso are likely going to jeopardize the achievement of Universal Health Coverage. It is important that policy makers continue to strengthen and monitor the implementation of strategies that promote proportionate universalism and forge multi-sectoral approach in dealing with social determinants of inequities in maternal health services coverage.
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Affiliation(s)
- Takondwa Mwase
- Institute of Public Health, Faculty of Medicine, Heidelberg University, INF 130.3, Heidelberg, Germany.
| | - Stephan Brenner
- Institute of Public Health, Faculty of Medicine, Heidelberg University, INF 130.3, Heidelberg, Germany
| | - Jacob Mazalale
- University of Malawi, Chancellor College, PO Box 280, Zomba, Malawi
| | - Julia Lohmann
- Institute of Public Health, Faculty of Medicine, Heidelberg University, INF 130.3, Heidelberg, Germany
| | - Saidou Hamadou
- University of Montreal Public Health Research Institute (IRSPUM), 7101 Avenue de Parc, Room 3060, Montreal, QC H3N 1X9, Canada
| | - Serge M A Somda
- Centre MURAZ 2054 Avenue Mamadou KONATE, 01 B.P. 390, Bobo-Dioulasso 01, Burkina Faso
| | - Valery Ridde
- University of Montreal Hospital Research Centre (CRHHUM), 850 Saint Denis, 3rd Floor, Montreal, QC, H2X 0A9, Canada
| | - Manuela De Allegri
- Institute of Public Health, Faculty of Medicine, Heidelberg University, INF 130.3, Heidelberg, Germany
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Lohmann J, Muula AS, Houlfort N, De Allegri M. How does performance-based financing affect health workers' intrinsic motivation? A Self-Determination Theory-based mixed-methods study in Malawi. Soc Sci Med 2018; 208:1-8. [PMID: 29751178 DOI: 10.1016/j.socscimed.2018.04.053] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 04/25/2018] [Accepted: 04/27/2018] [Indexed: 11/26/2022]
Abstract
"Intrinsic motivation crowding out", the erosion of high-quality, sustainable motivation through the introduction of financial incentives, is one of the most frequently discussed but yet little researched potential unfavorable consequence of Performance-based Financing (PBF). We used the opportunity of the introduction of PBF in Malawi to investigate whether and how PBF affected intrinsic motivation, using a mixed-methods research design theoretically grounded in Self-Determination Theory (SDT). The quantitative component served to estimate the impact of PBF on intrinsic motivation, relying on a controlled pre- and post-test design, with data collected from health workers in 23 intervention and 10 comparison facilities before (March/April 2013; n = 70) and approximately two years after (June/July 2015; n = 71) the start of the intervention. The qualitative component, relying on in-depth interviews with health workers in selected intervention facilities one (April 2014; n = 21) and two (September 2015; n = 20) years after the start of PBF, served to understand how PBF did or did not bring about change in intrinsic motivation. Specifically, it allowed us to examine how the various motivation-relevant elements and consequences of PBF impacted health workers' basic psychological needs for autonomy, competence, and relatedness, which SDT postulates as central to intrinsic motivation. Our results suggest that PBF did not affect health workers' overall intrinsic motivation levels, with the intervention having had both positive and negative effects on psychological needs satisfaction. To maximize positive PBF effects on intrinsic motivation, our results underline the potential value of explicit strategies to mitigate unintended negative impact of unavoidable design, implementation, and contextual challenges, for instance by building autonomy support activities into PBF designs.
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Affiliation(s)
- Julia Lohmann
- Institute of Public Health, Medical Faculty, Heidelberg University, Germany.
| | - Adamson S Muula
- Department of Public Health, College of Medicine, University of Malawi, Malawi
| | | | - Manuela De Allegri
- Institute of Public Health, Medical Faculty, Heidelberg University, Germany
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De Allegri M, Bertone MP, McMahon S, Mounpe Chare I, Robyn PJ. Unraveling PBF effects beyond impact evaluation: results from a qualitative study in Cameroon. BMJ Glob Health 2018; 3:e000693. [PMID: 29607103 PMCID: PMC5873544 DOI: 10.1136/bmjgh-2017-000693] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 01/28/2018] [Accepted: 02/14/2018] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Performance-based financing (PBF) has acquired increased prominence as a means of reforming health system purchasing structures in low-income and middle-income countries. A number of impact evaluations have noted that PBF often produces mixed and heterogeneous effects. Still, little systematic effort has been channelled towards understanding what causes such heterogeneity, including looking more closely at implementation processes. METHODS Our qualitative study aimed at closing this gap in knowledge by attempting to unpack the mixed and heterogeneous effects detected by the PBF impact evaluation in Cameroon to inform further implementation as the country scales up the PBF approach. We collected data at all levels of the health system (national, district, facility) and at the community level, using a mixture of in-depth interviews and focus group discussions. We combined deductive and inductive analytical techniques and applied analyst triangulation. RESULTS Our findings indicate that heterogeneity in effects across facilities could be explained by pre-existing infrastructural weaknesses coupled with rigid administrative processes and implementation challenges, while heterogeneity across indicators could be explained by providers' practices, privileging services where demand-side barriers were less substantive. CONCLUSION In light of the country's commitment to scaling up PBF, it follows that substantial efforts (particularly entrusting facilities with more financial autonomy) should be made to overcome infrastructural and demand-side barriers and to smooth implementation processes, thus, enabling healthcare providers to use PBF resources and management models to a fuller potential.
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Affiliation(s)
- Manuela De Allegri
- Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Maria Paola Bertone
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Shannon McMahon
- Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | | | - Paul Jacob Robyn
- Health, Nutrition, and Population Unit, The World Bank, Washington, District of Columbia, USA
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Paul E, Albert L, Bisala BN, Bodson O, Bonnet E, Bossyns P, Colombo S, De Brouwere V, Dumont A, Eclou DS, Gyselinck K, Hane F, Marchal B, Meloni R, Noirhomme M, Noterman JP, Ooms G, Samb OM, Ssengooba F, Touré L, Turcotte-Tremblay AM, Van Belle S, Vinard P, Ridde V. Performance-based financing in low-income and middle-income countries: isn't it time for a rethink? BMJ Glob Health 2018; 3:e000664. [PMID: 29564163 PMCID: PMC5859812 DOI: 10.1136/bmjgh-2017-000664] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 01/01/2023] Open
Abstract
This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.
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Affiliation(s)
- Elisabeth Paul
- Tax Institute, Université de Liège, Liège, Belgium
- Faculty of Social Sciences, Université de Liège, Liège, Belgium
| | - Lucien Albert
- International Health Unit, University of Montreal, Montreal, Quebec, Canada
| | - Badibanga N'Sambuka Bisala
- Expert in district health systems based on primary healthcare, Groupe d'Appui à la Recherche et Enseignement en Santé Publique, Mbuji-Mayi, Democratic Republic of the Congo
| | - Oriane Bodson
- Faculty of Social Sciences, Université de Liège, Liège, Belgium
| | - Emmanuel Bonnet
- Résiliences, Research Institute for Development (IRD), Bondy, France
| | - Paul Bossyns
- Health Sector Thematic Unit, Belgian Development Agency (ENABEL), Brussels, Belgium
| | | | - Vincent De Brouwere
- Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
| | - Alexandre Dumont
- CEPED, Research Institute for Development (IRD), Paris Descartes University, INSERM, Paris, France
| | | | - Karel Gyselinck
- Health Sector Thematic Unit, Belgian Development Agency (ENABEL), Brussels, Belgium
| | - Fatoumata Hane
- Department of Sociology, Université Assane Seck, Ziguinchor, Senegal
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
| | | | | | | | - Gorik Ooms
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Oumar Mallé Samb
- Global Health, Department of Health Sciences, Université du Québec en Abitibi-Témiscamingue, Quebec City, Quebec, Canada
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Laurence Touré
- Anthropologist, Research Association Miseli, Bamako, Mali
| | | | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium
| | | | - Valéry Ridde
- CEPED, Research Institute for Development (IRD), Paris Descartes University, INSERM, Paris, France
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Bodson O, Barro A, Turcotte-Tremblay AM, Zanté N, Somé PA, Ridde V. A study on the implementation fidelity of the performance-based financing policy in Burkina Faso after 12 months. Arch Public Health 2018; 76:4. [PMID: 29344354 PMCID: PMC5764025 DOI: 10.1186/s13690-017-0250-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 12/08/2017] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Performance-based financing (PBF) in the health sector has recently gained momentum in low- and middle-income countries (LMICs) as one of the ways forward for achieving Universal Health Coverage. The major principle underlying PBF is that health centers are remunerated based on the quantity and quality of services they provide. PBF has been operating in Burkina Faso since 2011, and as a pilot project since 2014 in 15 health districts randomly assigned into four different models, before an eventual scale-up. Despite the need for expeditious documentation of the impact of PBF, caution is advised to avoid adopting hasty conclusions. Above all, it is crucial to understand why and how an impact is produced or not. Our implementation fidelity study approached this inquiry by comparing, after 12 months of operation, the activities implemented against what was planned initially and will make it possible later to establish links with the policy's impacts. METHODS Our study compared, in 21 health centers from three health districts, the implementation of activities that were core to the process in terms of content, coverage, and temporality. Data were collected through document analysis, as well as from individual interviews and focus groups with key informants. RESULTS In the first year of implementation, solid foundations were put in place for the intervention. Even so, implementation deficiencies and delays were observed with respect to certain performance auditing procedures, as well as in payments of PBF subsidies, which compromised the incentive-based rationale to some extent. CONCLUSION Over next months, efforts should be made to adjust the intervention more closely to context and to the original planning.
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Affiliation(s)
- Oriane Bodson
- ARC Effi-Santé, Political Economy and Health Economy, Faculty of Social Sciences, University of Liege, Place des orateurs, 3 (B31) – Quartier Agora, 4000 Liege, Belgium
| | - Ahmed Barro
- Action-Gouvernance-Intégration-Renforcement Association/Groupe de travail en Santé et Développement (AGIR/SD), Ouagadougou, Burkina Faso
| | - Anne-Marie Turcotte-Tremblay
- University of Montreal Public Health Research Institute (IRSPUM) and University of Montreal School of Public Health (ESPUM), 7101 avenue du Parc, 3rd Floor, Montréal, Québec, H3N 1X9 Canada
| | - Nestor Zanté
- Action-Gouvernance-Intégration-Renforcement Association/Groupe de travail en Santé et Développement (AGIR/SD), Ouagadougou, Burkina Faso
| | - Paul-André Somé
- Action-Gouvernance-Intégration-Renforcement Association/Groupe de travail en Santé et Développement (AGIR/SD), Ouagadougou, Burkina Faso
| | - Valéry Ridde
- University of Montreal Public Health Research Institute (IRSPUM) and University of Montreal School of Public Health (ESPUM), 7101 avenue du Parc, 3rd Floor, Montréal, Québec, H3N 1X9 Canada
- CEPED, IRD, Université Paris Descartes, INSERM, équipe SAGESUD, 45 Rue des Saints-Pères, 75006 Paris, France
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Ridde V, Leppert G, Hien H, Robyn PJ, De Allegri M. Street-level workers' inadequate knowledge and application of exemption policies in Burkina Faso jeopardize the achievement of universal health coverage: evidence from a cross-sectional survey. Int J Equity Health 2018; 17:5. [PMID: 29310690 PMCID: PMC5759863 DOI: 10.1186/s12939-017-0717-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Street-level workers play a key role in public health policies in Africa, as they are often the ones to ensure their implementation. In Burkina Faso, the State formulated two different user-fee exemption policies for indigents, one for deliveries (2007), and one for primary healthcare (2009). The objective of this study was to measure and understand the determinants of street-level workers' knowledge and application of these exemption measures. METHODS We used cross-sectional data collected between October 2013 and March 2014. The survey targeted 1521 health workers distributed in 498 first-line centres, 18 district hospitals, 5 regional hospitals, and 11 private or other facilities across 24 districts. We used four different random effects models to identify factors associated with knowledge and application of each of the above-mentioned exemption policies. RESULTS Only 9.2% of workers surveyed knew of the directive exempting the worst-off, and only 5% implemented it. Knowledge and application of the delivery exemption were higher, with 27% of all health workers being aware of the delivery exemption directive and 24.2% applying it. Mobile health workers were found to be consistently more likely to apply both exemptions. Health workers who were facility heads were significantly more likely to know about the indigent exemption for primary health care and to apply it. Health workers in districts with higher proportions of very poor people were significantly more likely to know about and apply the delivery exemption. Nearly 60% of respondents indicated either 5% or 10% as the percentage of people they would deem adequate to target for exemption. CONCLUSION This quantitative study confirmed earlier qualitative results on the importance of training and informing health workers and monitoring the measures targeting equity, to ensure compliance with government directives. The local context (e.g., hierarchy, health system, interventions) and the ideas that street-level workers have about the policy instruments can influence their effective implementation. Methods for remunerating health workers and health centres also need to be adapted to ensure equity measures are applied to achieve universal healthcare.
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Affiliation(s)
- Valéry Ridde
- CEPED, IRD, Université Paris Descartes, Inserm, équipe SAGESUD, 45, rue des Saints Pères, 75006 Paris, France
- IRD (French Institute For Research on Sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
| | - Gerald Leppert
- German Institute for Development Evaluation (DEval), Fritz-Schäffer-Str. 26, 53113 Bonn, Germany
| | - Hervé Hien
- Centre MURAZ, Bobo-Dioulasso, Burkina Faso
| | - Paul Jacob Robyn
- Health, Nutrition and Population Global Practice, The World Bank, 701 18th St NW, Washington, DC 20006 USA
| | - Manuela De Allegri
- Institute of Public Health, Medical Faculty, Heidelberg University, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
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Ridde V, Yaogo M, Zongo S, Somé P, Turcotte‐Tremblay A. Twelve months of implementation of health care performance-based financing in Burkina Faso: A qualitative multiple case study. Int J Health Plann Manage 2018; 33:e153-e167. [PMID: 28671285 PMCID: PMC5900741 DOI: 10.1002/hpm.2439] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 11/18/2022] Open
Abstract
To improve health services' quantity and quality, African countries are increasingly engaging in performance-based financing (PBF) interventions. Studies to understand their implementation in francophone West Africa are rare. This study analysed PBF implementation in Burkina Faso 12 months post-launch in late 2014. The design was a multiple and contrasted case study involving 18 cases (health centres). Empirical data were collected from observations, informal (n = 224) and formal (n = 459) interviews, and documents. Outside the circle of persons trained in PBF, few in the community had knowledge of it. In some health centres, the fact that staff were receiving bonuses was intentionally not announced to populations and community leaders. Most local actors thought PBF was just another project, but the majority appreciated it. There were significant delays in setting up agencies for performance monitoring, auditing, and contracting, as well as in the payment. The first audits led rapidly to coping strategies among health workers and occasionally to some staging beforehand. No community-based audits had yet been done. Distribution of bonuses varied from one centre to another. This study shows the importance of understanding the implementation of public health interventions in Africa and of uncovering coping strategies.
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Affiliation(s)
- Valéry Ridde
- University of Montreal Public Health Research Institute (IRSPUM)MontrealQCCanada
- University of Montreal School of Public Health (ESPUM)MontrealQCCanada
| | - Maurice Yaogo
- Université Catholique de l'Afrique de l'Ouest—Unité Universitaire à Bobo‐DioulassoBobo‐DioulassoBurkina Faso
- Association Zama Forum pour la Diffusion des Connaissances et des Expériences novatrices en Afrique (Zama Forum/ADCE—Afrique)Bobo‐DioulassoBurkina Faso
| | - Sylvie Zongo
- Institut des Sciences des Sociétés (INSS‐CNRST)OuagadougouBurkina Faso
| | - Paul‐André Somé
- Association Action Gouvernance Intégration Renforcement (AGIR)OuagadougouBurkina Faso
| | - Anne‐Marie Turcotte‐Tremblay
- University of Montreal Public Health Research Institute (IRSPUM)MontrealQCCanada
- University of Montreal School of Public Health (ESPUM)MontrealQCCanada
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Seppey M, Ridde V, Touré L, Coulibaly A. Donor-funded project's sustainability assessment: a qualitative case study of a results-based financing pilot in Koulikoro region, Mali. Global Health 2017; 13:86. [PMID: 29216877 PMCID: PMC5721604 DOI: 10.1186/s12992-017-0307-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 10/24/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Results-based financing (RBF) is emerging as a new alternative to finance health systems in many African countries. In Mali, a pilot project was conducted to improve demand and supply of health services through financing performance in targeted services. No study has explored the sustainability process of such a project in Africa. This study's objectives were to understand the project's sustainability process and to assess its level of sustainability. METHODS Sustainability was examined through its different determinants, phases, levels and contexts. These were explored using qualitative interviews to discern, via critical events, stakeholders' ideas regarding the project's sustainability. Data collection sites were chosen with the participation of different stakeholders, based on a variety of criteria (rural/urban settings, level of participation, RBF participants still present, etc.). Forty-nine stakeholders were then interviewed in six community health centres and two referral health centres (from 11/12/15 to 08/03/16), including health practitioners, administrators, and those involved in implementing and conceptualizing the program (government and NGOs). A theme analysis was done with the software © QDA Miner according to the study's conceptual framework. RESULTS The results of this project show a weak level of sustainability due to many factors. While some gains could be sustained (ex.: investments in long-term resources, high compatibility of values and codes, adapted design to the implementations contexts, etc.) other intended benefits could not (ex.: end of investments, lack of shared cultural artefacts around RBF, loss of different tasks and procedures, need of more ownership of the project by the local stakeholders). A lack of sustainability planning was observed, and few critical events were associated to phases of sustainability. CONCLUSIONS While this RBF project aimed at increasing health agents' motivation through different mechanisms (supervision, investments, incentives, etc.), these results raise questions on what types of motivation could be more stable and what could be the place of local stakeholders in the project; all this with the aim of more sustained and efficient results.
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Affiliation(s)
- Mathieu Seppey
- Université de Montréal, École de santé publique (ESPUM), P.O. Box 6128, Succursale Centre-Ville, Montréal, Québec, H3C 3J7 Canada
- Institut de Recherche en Santé Publique de l’UdeM (IRSPUM), 7101 Avenue du Parc, Office 3187-03, Montréal, Québec, H3N 1X9 Canada
| | - Valéry Ridde
- Université de Montréal, École de santé publique (ESPUM), P.O. Box 6128, Succursale Centre-Ville, Montréal, Québec, H3C 3J7 Canada
- Institut de Recherche en Santé Publique de l’UdeM (IRSPUM), 7101 Avenue du Parc, Office 3187-03, Montréal, Québec, H3N 1X9 Canada
| | - Laurence Touré
- MISELI (Association Malienne de Recherche et Formation en Anthropologie des Dynamiques Locales), cité el-Farako, BP E5448 Bamako, Mali
| | - Abdourahmane Coulibaly
- MISELI (Association Malienne de Recherche et Formation en Anthropologie des Dynamiques Locales), cité el-Farako, BP E5448 Bamako, Mali
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