Unraveling PBF effects beyond impact evaluation: results from a qualitative study in Cameroon

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 preexisting 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.sch_iih3pub5290pub

Les nouveaux usages thérapeutiques des compléments alimentaires chinois au Cameroun

Depuis les années 1990-2000, on assiste à la multiplication des filières commerçantes entre la Chine et le Cameroun qui engendre une baisse des prix de certains produits et une démocratisation de leur accès jusqu’alors réservé à une élite. L’arrivée des compléments alimentaires chinois a dans un premier temps engendré une augmentation de leur consommation, mais sans la baisse des prix que l’on peut constater pour de nombreux autres produits importés de Chine. L’engouement des Camerounais pour les compléments alimentaires chinois se comprend alors davantage dans une logique entrepreneuriale. Le marketing de réseau contrôle les prix, mais promet aux revendeurs un revenu conséquent grâce à cette activité. Progressivement, pourtant, ce commerce de produits coûteux à usage préventif se heurte à la réalité du pouvoir d’achat des Camerounais. La consommation des compléments alimentaires chinois se poursuit à la faveur d’une transformation de leurs usages. Abandonnant le préventif pour le thérapeutique, les compléments alimentaires se font alors une place dans le pluralisme médical au Cameroun. Cette transformation de l’usage des compléments alimentaires apparaît au travers de l’émergence de « boutiques » à mi-chemin entre des commerces et des cabinets médicaux. En revenant sur les étapes de la biographie de ces produits chinois au Cameroun, nous mettons en évidence une dynamique qui leur est spécifique en raison de leur coût et de leur mode de distribution.Since 1990-2000, there has been an increase in the number of trade channels between China and Cameroon, which has led to a fall in the price of certain products and a democratization of access to them, which had previously been reserved for an elite. The arrival of Chinese dietary supplements initially led to an increase in their consumption, but without the price drop that can be observed for many other products imported from China. The enthusiasm of Cameroonians for Chinese dietary supplements is therefore best understood within an entrepreneurial logic. Network marketing controls prices, but promises resellers a substantial income from this activity. Gradually, however, this trade of expensive products for preventive use will come up against the reality of Cameroonians’ purchasing power. The consumption of Chinese dietary supplements will continue as their uses change. Abandoning the preventive for the therapeutic, food supplements are now making a place for themselves in the medical pluralism in Cameroon. This transformation in the use of food supplements is reflected in the emergence of « shops » that are halfway between businesses and medical practices. By going back over the stages in the biography of these Chinese products in Cameroon, we highlight a dynamic that is specific to them because of their cost and their mode of distribution