1
|
Banke-Thomas A, Offosse MJ, Yameogo P, Manli AR, Goumbri A, Avoka C, Boxshall M, Eboreime E. Stakeholder perceptions and experiences from the implementation of the Gratuité user fee exemption policy in Burkina Faso: a qualitative study. Health Res Policy Syst 2023; 21:46. [PMID: 37280694 DOI: 10.1186/s12961-023-01008-3] [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: 01/16/2023] [Accepted: 05/18/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND In 2016, the Gratuité policy was initiated by the Government of Burkina Faso to remove user fees for maternal, newborn, and child Health (MNCH) services. Since its inception, there has not been any systematic capture of experiences of stakeholders as it relates to the policy. Our objective was to understand the perceptions and experiences of stakeholders regarding the implementation of the Gratuité policy. METHODS We used key informant interviews (KIIs) and focus group discussions (FGDs) to engage national and sub-national stakeholders in the Centre and Hauts-Bassin regions. Participants included policymakers, civil servants, researchers, non-governmental organizations in charge of monitoring the policy, skilled health personnel, health facility managers, and women who used MNCH services before and after the policy implementation. Topic guides aided sessions, which were audio recorded and transcribed verbatim. A thematic analysis was used for data synthesis. RESULTS There were five key themes emerging. First, majority of stakeholders have a positive perception of the Gratuité policy. Its implementation approach is deemed to have strengths including government leadership, multi-stakeholder involvement, robust internal capacity, and external monitoring. However, collateral shortage of financial and human resources, misuse of services, delays in reimbursement, political instability and health system shocks were highlighted as concerns that compromise the government's objective of achieving universal health coverage (UHC). However, many beneficiaries were satisfied at the point of use of MNHC services, though Gratuité did not always mean free to the service users. Broadly, there was consensus that the Gratuité policy has contributed to improvements in health-seeking behavior, access, and utilization of services, especially for children. However, the reported higher utilization is leading to some perceived increased workload and altered health worker attitude. CONCLUSIONS There is a general perception that the Gratuité policy is achieving what it set out to do, which is to increase access to care by removing financial barriers. While stakeholders recognized the intention and value of the Gratuité policy, and many beneficiaries were satisfied at the point of use, inefficiencies in its implementation undermines progress. As the country moves towards the goal of realizing UHC, reliable investment in the Gratuité policy is needed.
Collapse
Affiliation(s)
- Aduragbemi Banke-Thomas
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso.
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
- School of Human Sciences, University of Greenwich, London, United Kingdom.
| | - Marie-Jeanne Offosse
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | | | - Astrid Raissa Manli
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Aude Goumbri
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Cephas Avoka
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matt Boxshall
- ThinkWell Institute, 11 B.P. 1255 CMS 11 Ouagadougou, Quartier Ouaga 2000, près de la fondation Kimi, à 500 du boulevard Muammar Kadaffi, Ouagadougou, Burkina Faso
| | - Ejemai Eboreime
- Department of Psychiatry, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| |
Collapse
|
2
|
Houeninvo HG, Bello K, Hounkpatin H, Dossou JP. Developing and implementing National Health Insurance: learnings from the first try in Benin. BMJ Glob Health 2022; 7:bmjgh-2022-009027. [PMID: 36410785 PMCID: PMC9680139 DOI: 10.1136/bmjgh-2022-009027] [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: 03/19/2022] [Accepted: 08/07/2022] [Indexed: 11/23/2022] Open
Abstract
UNLABELLED In 2008, Benin government launched a national health insurance scheme, but this had been suspended in 2017. We aim to understand how existing ideas and institutions, stakeholders' behaviour and their interests shaped policy-making process and policy content, from its launch to its suspension. METHODS We used a case study design, framed by the policy triangle of Walt and Gilson. We collected data through document review, quantitative data extraction from routine information, and interviews with 20 key informants. We performed a content analysis using both complementarily deductive and inductive analysis. RESULTS This study confirms the keen interest for national health insurance scheme in Benin among various stakeholders. Compared with user fee exemption policies, it is considered as more sustainable, with a more reliable financing, and a greater likelihood to facilitate population's access to quality healthcare without financial hardships.Exempting the poor from paying health insurance premiums was however considered as an equitable mean to facilitate the extension of the health insurance to informal sector workers.The whole arrangements failed to deliver appropriate skills, tools, coordination and incentives to drive the policy implementers to make individual and organisational changes necessary to adjust to the objectives and values of the reform. These deficiencies compromised the implementation fidelity with unintended effects such as low subscription rate, low services utilisation and sustainability threats. CONCLUSION Supporting countries in documenting policy processes will ease learning across their tries for progressing towards Universal Health Coverage, as more than one try will be necessary.
Collapse
Affiliation(s)
| | - Kéfilath Bello
- Centre de recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Hashim Hounkpatin
- Centre de recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Jean-Paul Dossou
- Centre de recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| |
Collapse
|
3
|
Krishnaratne S, Hoyt J, Hamon JK, Ariko AB, Atayo C, Morukileng J, Spilotros N, Webster J. Acceptability of family planning in a changing context in Uganda: a realist evaluation at two time points. BMJ Open 2022; 12:e054277. [PMID: 35396286 PMCID: PMC8995957 DOI: 10.1136/bmjopen-2021-054277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES This study sought to understand, during an intervention which integrated family planning (FP) and immunisation, (1) if and how prevailing contextual factors influenced acceptability and use of modern contraceptive methods (MCMs) in a pastoral community in Uganda, (2) what mechanisms were triggered by these contextual factors (3) if these contextual factors changed between two time points 2 years apart and (4) the impact of contextual changes on mechanisms triggered and acceptability and use outcomes. DESIGN Qualitative realist evaluation over two time points. SETTING Government health facilities in Moroto District, Karamoja, Uganda. PARTICIPANTS 69 participants involved in the delivery and uptake of integrated FP and childhood immunisation services. INTERVENTION Integrated delivery of FP and childhood immunisation services offered to women accessing immunisation services in health facilities between January 2016 and December 2019. RESULTS Four key themes were identified that encompassed context and mechanisms influencing acceptability of MCMs across both time points of the evaluation. These were: (1) fear of side effects of MCMs; (2) preference for natural FP methods; (3) pastoral lifestyles in the community and (4) food insecurity. The context of these themes changed over time leading to the triggering of mechanisms with an overall increase in acceptability of MCMs over time. Key mechanisms of acceptability triggered included: affective attitude, intervention coherence, self-efficacy, perceived effectiveness and opportunity cost, leading to the development of three context-acceptability theories. CONCLUSIONS In this study, social and cultural norms played a strong role in influencing acceptability of the intervention. The context combined with intervention components were found to trigger several mechanisms that mapped to constructs of diffusion of innovations and acted as catalysts for mechanisms of acceptability. The context in which the intervention was implemented changed leading to the triggering of mechanisms and an increase in the perceived value and acceptability of MCM use.
Collapse
Affiliation(s)
- Shari Krishnaratne
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenna Hoyt
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jessie K Hamon
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Carol Atayo
- International Rescue Committee Uganda, Moroto, Uganda
| | - Job Morukileng
- Uganda Public Health Fellowship Programme, Kampala, Uganda
| | | | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
4
|
Seward N, Hanlon C, Hinrichs-Kraples S, Lund C, Murdoch J, Taylor Salisbury T, Verhey R, Shidhaye R, Thornicroft G, Araya R, Sevdalis N. A guide to systems-level, participatory, theory-informed implementation research in global health. BMJ Glob Health 2021; 6:e005365. [PMID: 34969685 PMCID: PMC8718460 DOI: 10.1136/bmjgh-2021-005365] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 12/03/2021] [Indexed: 12/17/2022] Open
Abstract
Implementation research is a multidisciplinary field that addresses the complex phenomenon of how context influences our ability to deliver evidence-informed healthcare. There is increasing realisation of the importance of applying robust implementation research to scale-up life-saving interventions that meet health-related sustainable development goals. However, the lack of high-quality implementation research is impeding our ability to meet these targets, globally. Within implementation research, theory refers to the proposed hypothesis and/or explanation of how an intervention is expected to interact with the local context and actors to bring about change. Although there is increasing interest in applying theory to understand how and why implementation programmes work in real-world settings, global health actors still tend to favour impact evaluations conducted in controlled environments. This may, in part, be due to the relative novelty as well as methodological complexity of implementation research and the need to draw on divergent disciplines, including epidemiology, implementation science and social sciences. Because of this, implementation research is faced with a particular set of challenges about how to reconcile different ways of thinking and constructing knowledge about healthcare interventions. To help translate some of the ambiguity surrounding how divergent theoretical approaches and methods contribute to implementation research, we draw on our multidisciplinary expertise in the field, particularly in global health. We offer an overview of the different theoretical approaches and describe how they are applied to continuously select, monitor and evaluate implementation strategies throughout the different phases of implementation research. In doing so, we offer a relatively brief, user-focused guide to help global health actors implement and report on evaluation of evidence-based and scalable interventions, programmes and practices.
Collapse
Affiliation(s)
- Nadine Seward
- Centre for Implementation Science, Department of Health Service and Population Research, King's College London, London, UK
| | - Charlotte Hanlon
- Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, King's College London, London, UK
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Crick Lund
- King's College London, London, UK
- University of Cape Town, Rondebosch, South Africa
| | - Jamie Murdoch
- University of East Anglia Faculty of Medicine and Health Sciences, Norwich, UK
| | | | - Ruth Verhey
- Research Support Centre, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Rahul Shidhaye
- Pravara Institute of Medical Sciences, Loni, Maharashtra, India
| | | | | | - Nick Sevdalis
- Health Service & Population Research Department, King's College London, London, UK
| |
Collapse
|
5
|
Marchal B, Abejirinde IOO, Sulaberidze L, Chikovani I, Uchaneishvili M, Shengelia N, Diaconu K, Vassall A, Zoidze A, Giralt AN, Witter S. How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia. BMJ Open 2021; 11:e047948. [PMID: 34187826 PMCID: PMC8245474 DOI: 10.1136/bmjopen-2020-047948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/10/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt. METHODS Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders' assumptions on challenges and possible solutions for better TB control. Two participatory workshops were conducted with key actors, interspersed by reflection meetings within the research team and discussions with policymakers. Using concept mapping and causal mapping techniques, and drawing causal loop diagrams, we visualised how actors understood TB service provision challenges and the potential means by which a results-based financing (RBF) policy could address these. SETTING The study was conducted in Tbilisi, Georgia. PARTICIPANTS A total of 64 key actors from the Ministry of Labour, Health and Social Affairs, staff of the Global Fund to Fight AIDS, TB and Malaria Georgia Project, the National Centre for Disease Control and Public Health, the National TB programme, TB service providers and members of the research team were involved in the workshops. RESULTS Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organisational incentives, retraining service providers, clear redistribution of roles to support an integrated care model, and refinement of monitoring tools. Health system elements, such as effective referral systems and health information systems were highlighted as necessary for service improvement. CONCLUSIONS Developing policies that address complex issues requires methods that facilitate linkages between multiple stakeholders and between theory and practice. Such participatory approaches can be informed by realist evaluation principles and visually facilitated by causal loop diagrams. This approach allowed us leverage stakeholders' knowledge and expertise on TB service delivery and RBF to codesign a new policy.
Collapse
Affiliation(s)
- Bruno Marchal
- Health Systems and Health Policy Research Group, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Ibukun-Oluwa Omolade Abejirinde
- Health Systems and Health Policy Research Group, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Lela Sulaberidze
- Research Unit, Curatio International Foundation, Tbilisi, Georgia
| | - Ivdity Chikovani
- Research Unit, Curatio International Foundation, Tbilisi, Georgia
| | | | - Natia Shengelia
- Research Unit, Curatio International Foundation, Tbilisi, Georgia
| | - Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Akaki Zoidze
- Research Unit, Curatio International Foundation, Tbilisi, Georgia
| | - Ariadna Nebot Giralt
- Health Systems and Health Policy Research Group, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| |
Collapse
|
6
|
Dossou JP, Van Belle S, Marchal B. Applying the Realist Evaluation Approach to the Complex Process of Policy Implementation-The Case of the User Fee Exemption Policy for Cesarean Section in Benin. Front Public Health 2021; 9:553980. [PMID: 34169051 PMCID: PMC8219213 DOI: 10.3389/fpubh.2021.553980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/07/2021] [Indexed: 11/13/2022] Open
Abstract
Realist evaluation is making inroads in the field of health policy and systems research to a large extent because of its good fit with complex issues. Until now, most realist studies focused on evaluating interventions or projects related to health care delivery, organization of health services, education, management, and leadership of health workers in high income countries. With this paper, we apply the realist approach to the study of national health policy implementation in a low resource country. We use the case of the user fee exemption policy for cesarean section in Benin, which we followed up from 2009 to 2018. We report on how realist evaluation can be applied for policy implementation research. We illustrate how we developed the initial programme theory-the starting point of any realist evaluation -, how we designed the study and data collection tools, and how we analyzed the data. For each step, we present current good practices, how we adapted them when needed, the challenges and the lessons learned. We report also on how the dynamic interactions between the central level (the national implementing agency) and the peripheral level (an implementing hospital) shaped the policy implementation. We found that at central level, availability of resources for a given policy is constantly challenged in the competitive national resource allocation arena. Key factors include the political power and the legitimacy of the group supporting the policy. These are influenced by the policy implementation structure, how the actual outputs of the implementation align with promises of the group supporting the policy and consequently how these outputs, the policy and its promoters are perceived by the community. We found that the service providers are key to the implementation, and that they are constrained or influenced by the dependability of the funding, their autonomy, their personal background, and the accountability arrangements. This study can inform the design and implementation of national health policies that involve interactions between central and operational level in other low-income countries.
Collapse
Affiliation(s)
- Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
- Complexity and Health Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sara Van Belle
- Health Policy Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruno Marchal
- Complexity and Health Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
7
|
Webster J, Krishnaratne S, Hoyt J, Demissie SD, Spilotros N, Landegger J, Kambanje M, Pryor S, Moseti E, Marcus S, Gnintoungbe M, Curry D, Hamon JK. Context-acceptability theories: example of family planning interventions in five African countries. Implement Sci 2021; 16:12. [PMID: 33435959 PMCID: PMC7805098 DOI: 10.1186/s13012-020-01074-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Family planning (FP) can lengthen birth intervals and potentially reduce the risk of foetal death, low birthweight, prematurity, and being small for gestational age. Effective FP is most easily achieved through access to and acceptability of modern contraceptive methods (MCMs). This study aimed to identify mechanisms of acceptability and the contexts in which they are triggered and to generate theories to improve the selection and implementation of effective interventions by studying an intervention integrating FP with childhood immunisation services. METHODS Qualitative interpretative synthesis of findings from realist evaluations of FP interventions in five African countries was guided by an analytical framework. Empirical mechanisms of acceptability were identified from semi-structured interviews and focus group discussions with key stakeholders (N = 253). The context in which these mechanisms were triggered was also defined. Empirical mechanisms of acceptability were matched to constructs of a theoretical framework of acceptability. Context-acceptability theories (CATs) were developed, which summarised constructs of acceptability triggered for specific actors in specified contexts. Examples of interventions that may be used to trigger acceptability for these actors were described. RESULTS Seven CATs were developed for contexts with strong beliefs in religious values and with powerful religious leaders, a traditional desire for large families, stigmatisation of MCM use, male partners who are non-accepting of FP, and rumours or experiences of MCM side effects. Acceptability mechanisms included alignment with values and beliefs without requiring compromise, actors' certainty about their ability to avoid harm and make the intervention work, and understanding the intervention and how it works. Additionally, acceptability by one group of actors was found to alter the context, triggering acceptability mechanisms amongst others. CONCLUSIONS This study demonstrated the value of embedding realist approaches within implementation research. CATs are transferable theories that answer the question: given the context, what construct of acceptability does an intervention need to trigger, or more simply, what intervention do we need to apply here to achieve our outcomes? CATs facilitate transfer of interventions across geographies within defined contexts.
Collapse
Affiliation(s)
- Jayne Webster
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK.
| | - Shari Krishnaratne
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenna Hoyt
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | | | | | | | | | - Jessie K Hamon
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
8
|
Hamon JK, Krishnaratne S, Hoyt J, Kambanje M, Pryor S, Webster J. Integrated delivery of family planning and childhood immunisation services in routine outreach clinics: findings from a realist evaluation in Malawi. BMC Health Serv Res 2020. [PMID: 32838774 DOI: 10.1186/s12913-020-05571-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Family planning (FP) needs among postpartum women in low- and middle-income countries remain largely unmet. Integrating FP with childhood immunisation services could partially reduce this unmet need by creating multiple opportunities for timely contact with FP services during the 12 months following childbirth. METHODS A realist evaluation of an intervention integrating FP and childhood immunisation services in routine outreach clinics in two rural districts of Malawi was conducted. A Context-Mechanism-Outcome (CMO) framework was used to describe the drivers of the intervention. A detailed programme theory was developed based on the analysis of semi-structured interviews and focus group discussions with 50 stakeholders. RESULTS A total of 9 core mechanisms were identified, which centred on constructs of access. Findings revealed that on the demand side, women were motivated to attend outreach clinics due to shorter travel distances; they felt confident they could access FP services and use contraceptive methods covertly if needed; and when supported by their husband, they were empowered to take up the use of contraceptive methods. On the supply side, providers were empowered through the training they received to provide integrated services; they were confident in their ability to provide essential services; and they were motivated by teamwork and by the recognition they received for their work. Additionally, some providers were found to be unwilling to walk long distances to reach remote clinics, which was seen to negatively affect the availability of services. CONCLUSIONS The delivery of integrated FP and childhood immunisation services in the context of routine outreach clinics in rural Malawi was seen to trigger mechanisms of accessibility and to improve the acceptability and availability of FP services. However, further research is needed to understand how the integration of these services in a routine outreach clinic setting may affect other dimensions of accessibility, including the approachability, appropriateness and affordability of services.
Collapse
Affiliation(s)
- Jessie K Hamon
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Shari Krishnaratne
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Jenna Hoyt
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | | | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| |
Collapse
|
9
|
Hamon JK, Krishnaratne S, Hoyt J, Kambanje M, Pryor S, Webster J. Integrated delivery of family planning and childhood immunisation services in routine outreach clinics: findings from a realist evaluation in Malawi. BMC Health Serv Res 2020; 20:777. [PMID: 32838774 PMCID: PMC7447579 DOI: 10.1186/s12913-020-05571-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Family planning (FP) needs among postpartum women in low- and middle-income countries remain largely unmet. Integrating FP with childhood immunisation services could partially reduce this unmet need by creating multiple opportunities for timely contact with FP services during the 12 months following childbirth. METHODS A realist evaluation of an intervention integrating FP and childhood immunisation services in routine outreach clinics in two rural districts of Malawi was conducted. A Context-Mechanism-Outcome (CMO) framework was used to describe the drivers of the intervention. A detailed programme theory was developed based on the analysis of semi-structured interviews and focus group discussions with 50 stakeholders. RESULTS A total of 9 core mechanisms were identified, which centred on constructs of access. Findings revealed that on the demand side, women were motivated to attend outreach clinics due to shorter travel distances; they felt confident they could access FP services and use contraceptive methods covertly if needed; and when supported by their husband, they were empowered to take up the use of contraceptive methods. On the supply side, providers were empowered through the training they received to provide integrated services; they were confident in their ability to provide essential services; and they were motivated by teamwork and by the recognition they received for their work. Additionally, some providers were found to be unwilling to walk long distances to reach remote clinics, which was seen to negatively affect the availability of services. CONCLUSIONS The delivery of integrated FP and childhood immunisation services in the context of routine outreach clinics in rural Malawi was seen to trigger mechanisms of accessibility and to improve the acceptability and availability of FP services. However, further research is needed to understand how the integration of these services in a routine outreach clinic setting may affect other dimensions of accessibility, including the approachability, appropriateness and affordability of services.
Collapse
Affiliation(s)
- Jessie K Hamon
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Shari Krishnaratne
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Jenna Hoyt
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | | | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|