User fees abolition policy in Niger : comparing the under five years exemption implementation in two districts

Objective: Analysis of the implementation process for a national user fees abolition policy aimed at children under age five organized in Niger since October 2006. Methods: This was a study of contrasted cases.Twodistricts were selected, Keita and Abalak; Keita is supported by an international NGO. In 2009, we carried out socio-anthropological surveys in all the health facilities of both districts and qualitative interviews with 211 individuals. Results: Keita district launched the policy before Abalak did, and its implementation was more effective. The populations and the health workers of both districts were relatively well aware of the user fees abolition. Both districts experienced significant delays in the reimbursement of treatments provided free of charge in the health centres (9 months in Keita, 24 months in Abalak). The presence of the NGO compensated for the State’s shortcomings, particularly with respect to maintaining the drug supply, which became difficult because of payment delays. In Abalak, district officials reinstated user fees. Conclusions: The technical relevance of user fees abolition is undermined by the State’s lack of preparation for its funding and organizational management

Understanding the factors affecting the attraction and retention of health professionals in rural and remote areas: a mixed-method study in Niger

Abstract Background The critical shortage of human resources in health is a critical public health problem affecting most low- and middle-income countries, particularly in sub-Saharan Africa. In addition to the shortage of health professionals, attracting and retaining them in rural areas is a challenge. The objective of the study was to understand the factors that influence the attraction and retention of health professionals working in rural areas in Niger. Methods A mixed-method study was conducted in Tillabery region, Niger. A conceptual framework was used that included five dimensions. Three data collection methods were employed: in-depth interviews, documentary analysis, and concept mapping. In-depth interviews were conducted with three main actor groups: policy-makers and Ministry of Health officials (n = 15), health professionals (n = 102), and local health managers (n = 46). Concept mapping was conducted with midwifery students (n = 29). Multidimensional scaling and cluster analysis were performed to analyse the data from the concept mapping method. A content analysis was conducted for the qualitative data. Results The results of the study showed that the local environment, which includes living conditions (no electricity, lack of availability of schools), social factors (isolation, national and local insecurity), working conditions (workload), the lack of financial compensation, and individual factors (marital status, gender), influences the attraction and retention of health professionals to work in rural areas. Human resources policies do not adequately take into account the factors influencing the retention of rural health professionals. Conclusion Intersectoral policies are needed to improve living conditions and public services in rural areas. The government should also take into account the feminization of the medical profession and the social and cultural norms related to marital status and population mobility when formulating human resources management policies

Travelling models and the challenge of pragmatic contexts and practical norms: the case of maternal health

Abstract As in other areas of international development, we are witnessing the proliferation of ‘traveling models’ developed by international experts and introduced in an almost identical format across numerous countries to improve some aspect of maternal health systems in low- and middle-income countries. These policies and protocols are based on ‘miracle mechanisms’ that have been taken out of their original context but are believed to be intrinsically effective in light of their operational devices. In reality, standardised interventions are, in Africa and elsewhere, confronted with pragmatic implementation contexts that are always varied and specific, and which lead to drifts, distortions, dismemberments and bypasses. The partogram, focused antenatal care, the prevention of mother-to-child transmission of HIV or performance-based payment all illustrate these implementation gaps, often caused by the routine behaviour of health personnel who follow practical norms (and a professional culture) that are often distinct from official norms – as is the case with midwives. Experiences in maternal and child health in Africa suggest that an alternative approach would be to start with the daily reality of social and practical norms instead of relying on models, and to promote innovations that emerge from within local health systems