Le non-recours aux services de soins prénatals : expériences de femmes vivant dans la commune rurale de Kokologho au Burkina Faso

Ce mémoire avec article tente de comprendre les motifs de non-recours aux services publics de soins prénatals selon la perspective des femmes âgées de 18 ans et plus vivant dans la commune rurale de Kokologho au Burkina Faso. Cette étude qualitative inspirée de l’ethnographie a utilisé différentes méthodes de collecte de données, dont l’observation participante, vingt-deux entrevues individuelles semi-dirigées avec des femmes qui sont en recours tardif aux soins prénatals et huit entrevues informelles avec des informateurs clés identifiés dans la communauté. Il ressort de l'analyse que le non-recours aux soins prénatals ne résulte pas seulement de facteurs liés à l’individu, mais de différents facteurs socioculturels, politiques et institutionnels. Nos résultats suggèrent que l’antagonisme des normes sociales entourant la grossesse et celles médicales, de même que les défaillances du système de soins et de la politique d’exemption des soins préventifs durant la grossesse entravent le recours effectif aux soins prénatals

Modélisation systémique des déterminants et processus de mise à l'échelle et de pérennisation d'innovations en santé : une étude qualitative de cas multiples au Burkina Faso et au Mali

En Afrique subsaharienne, beaucoup d'innovations en santé maternelle, néonatale et infantile (SMNI) sont confrontées à des fragilités environnementales, sociales, politiques, économiques, physiques, institutionnelles et elles évoluent souvent à petite échelle, de façon dispersée. Conséquemment, elles ne sont pas intégrées de façon durable dans les systèmes et organisations de ces pays. À cela s'ajoute le monopole d'une perspective techno-économique dans laquelle sont priorisées des approches verticales et rentables économiquement au désavantage de l'amélioration qualitative des pratiques et de la distribution équitable des impacts des innovations dans la société. De façon générale, il existe peu d'études scientifiques qui s'intéressent aux processus de mise à l'échelle ou de pérennisation des innovations et à leurs déterminants de succès et d'échec. S'inspirant de la théorie systémique et complexe et du paradigme des innovations sociales, cette thèse a modélisé les déterminants et les processus de mise à l'échelle et de pérennisation à partir d'une recherche empirique de trois innovations en SMNI : la chimioprévention du paludisme saisonnier (CPS) initiée par l'État burkinabé; les Caisses villageoises de solidarité santé (CVSS) et les Comités de femmes utilisatrices (CFU) initiés par la Fédération nationale des associations de santé communautaire (FENASCOM) au Mali. Un modèle conceptuel initial a été développé à partir de la revue de littérature et de la théorie systémique utilisée. Adoptant une méthodologie qualitative d'étude de cas multiples, chaque innovation a été étudiée comme un cas. Un ensemble de données a été collecté en utilisant différentes méthodes et sources d'information. Premièrement, d'août 2017 à juin 2018, nous avons réalisé une analyse documentaire (entrevues secondaires, rapports et notes d'organisation, etc.). Ensuite, de février à mai 2018, une immersion dans les deux pays a permis de mener des entrevues individuelles (n=45) et de groupe (n=34) auprès de personnes impliquées dans chaque innovation, de collecter des documents, de faire de l'observation non participante et de tenir un journal de bord. Enfin, l'analyse des données par contextualisation a été effectuée à l'aide du logiciel NVivo 11 pour comprendre l'évolution temporelle et spatiale des événements des cas étudiés ainsi que les raisons pour lesquelles ils ont pris une certaine tendance plutôt qu'une autre. La finalité était de conceptualiser des modèles qui émergent de l'objet d'étude. Pour chaque cas, nous avons observé des déterminants interdépendants qui sont : les valeurs, le leadership et la gouvernance, les ressources (humaines, matérielles et de connaissances), le financement, la simplification et l'adaptation des innovations. Ces déterminants se distinguent selon que l'innovation est soutenue par un bailleur de fonds ou par les communautés et ils évoluent selon les dynamiques internes et externes à l'innovation. Pour comprendre les conditions de réussite ou d'échec des processus étudiés, ces résultats suggèrent d'avoir une lecture systémique de ces déterminants en considérant leurs interactions et de les traiter comme un ensemble. À partir de ces résultats, nous avons pu modéliser les relations entre les différents processus d'une innovation (conception/adoption, mise en œuvre, mise à l'échelle, pérennisation) et l'environnement dans lequel elle évolue comme étant de type récursif et complexe. Ensuite, un modèle conceptuel intégrateur de la mise à l'échelle et de la pérennisation a été proposé. Il regroupe dans un continuum deux événements critiques que sont : (1) la stabilisation correspondant au maintien de l'innovation (ressources, structure, composantes, finalités des processus) et à l'ancrage institutionnel/communautaire de l'innovation ; (2) la résilience renvoyant aux capacités d'adaptation, de transformation, d'apprentissage et d'appropriation de l'innovation. Cette thèse propose de nouvelles avenues théoriques et des recommandations pour la pratique en santé publique et communautaire qui reconnaissent les particularités contextuelles des pays à faible ressource, comme le Burkina Faso et le Mali. Spécifiquement, elle suggère que la mise à l'échelle et la pérennisation devraient être considérées comme un impératif dans les processus d'innovation pour lutter contre les inégalités sociales grandissantes dans les pays d'Afrique. Elles pourraient également favoriser des changements durables dans les systèmes, les politiques, les conditions de vie des personnes et la société en général. Pour cela, certains principes forts sont à valoriser dans les processus d'innovation, tels que la participation de toutes les parties prenantes ; le caractère dynamique et récursif des processus et des pratiques ; la mise en œuvre des pratiques inclusives axées sur l'équité, la qualité et l'équilibre des pouvoirs.In sub-Saharan Africa, many innovations in maternal, newborn, and child health (MNCH) are faced with environmental, social, political, economic, physical, and institutional vulnerabilities and often evolve on a small scale. Consequently, they are not sustainably integrated into these countries' systems and organizations. Furthermore, a techno-economic perspective prioritizes vertical and cost-effective approaches rather than the qualitative improvement of practices and equitable distribution of the impacts of innovations in society. Few studies focus on the processes of scaling up or sustainability of innovations and their determinants of success and failure. Based on systemic and complexity theory and the perspective of social innovation, this thesis proposes to model the determinants and processes of scaling up and sustainability based on empirical research on three innovations in MNCH: Seasonal malaria chemoprevention (SMC) initiated by the Burkinabe State, the Village health solidarity funds (CVSS) and Women's committees of health care services users (CFU) initiated by the National Federation of Community Health Associations (FENASCOM) in Mali. An initial conceptual model was developed based on the literature review and systemic theory. We adopted a qualitative multiple case study methodology, with each innovation constituting a case. A data set was collected using different sources of information. We conducted a documentary analysis (secondary interviews, reports, organizational notes, and more) from August 2017 to June 2018. From February to May 2018, individual (n=45) and group (n=34) interviews were conducted with stakeholders involved in each innovation in both countries while collecting documents, engaging in non-participant observation, and keeping a logbook. We completed a contextualization analysis with NVivo 11 software to understand the temporal and spatial evolution of the events studied and specific trends developed. The purpose was to conceptualize patterns that emerge from the studied phenomena. For each case, we observed interdependent determinants: values, leadership and governance, resources (financial, human, material, and knowledge), funding, simplification, and the adaptation of innovations. These determinants vary depending on whether innovation is supported by an external funder or by the community. They evolve according to the internal and external dynamics of the innovation. These results suggest a systemic understanding of these determinants by considering their interactions and treating them as a whole to understand the conditions for the success or failure of the processes studied. From these results, we were able to specify that the relationships between the different processes of innovation (conception/adoption, implementation, scaling up, and sustainability) and the environment in which the innovation evolves are recursive and complex. Then, we proposed a conceptual model integrating scaling up and sustainability. It encompasses a continuum of two critical events: (1) stabilization corresponding to the maintenance of resources, the structure of the innovation and its components, the purposes of the processes, and the institutional/community anchoring the innovation, and (2) resilience, or the capacity of the innovation's adaptation, transformation, learning, and appropriation. This thesis proposes new theoretical avenues and recommendations for practices that recognize the contextual particularities of resource-poor countries such as Burkina Faso and Mali. Specifically, it suggests that scaling up and sustainability should be imperative in innovation processes to address growing social inequalities in African countries. This approach could improve sustainable systems, policies, people's living conditions, and society. To this end, decision-makers should value certain principles in innovation processes, such as the participation of all stakeholders, the dynamic and recursive nature of processes and practices, and the implementation of inclusive practices focused on equity, quality, and power balance

Using systems thinking to understand the scale-up and sustainability of health innovation: a case study of seasonal malaria chemoprevention processes in Burkina Faso

Background Scale-up and sustainability are often studied separately, with few studies examining the interdependencies between these two processes and the implementation contexts of innovations towards malaria prevention and control. Researchers and implementers offer much more attention to the content of innovations, as they focus on the technological dimensions and the conditions for expansion. Researchers have often considered innovation a linear sequence in which scaling up and sustainability represented the last stages. Using systems thinking in this manuscript, we analyze complex scaling and sustainability processes through adopting and implementing seasonal malaria chemoprevention (SMC) in Burkina Faso from 2014 to 2018. Methods We conducted a qualitative case study involving 141 retrospective secondary data (administrative, press, scientific, tools and registries, and verbatim) spanning from 2012 to 2018. We complemented these data with primary data collected between February and March 2018 in the form of 15 personal semi-structured interviews with SMC stakeholders and non-participant observations. Processual analysis permitted us to conceptualize scale-up and sustainability processes over time according to different vertical and horizontal levels of analysis and their interconnections. Results Our results indicated six internal and external determinants of SMC that may negatively or positively influence its scale-up and sustainability. These determinants are effectiveness, monitoring and evaluation systems, resources (financial, material, and human), leadership and governance, adaptation to the local context, and other external elements. Our results revealed that donors and implementing actors prioritized financial resources over other determinants. In contrast, our study clearly showed that the sustainability of the innovation, as well as its scaling up, depends significantly on the consideration of the interconnectedness of the determinants. Each determinant can concurrently constitute an opportunity and a challenge for the success of the innovation. Conclusion Our findings highlight the usefulness of the systemic perspective to consider all contexts (international, national, subnational, and local) to achieve large-scale improvements in the quality, equity, and effectiveness of global health interventions. Thus, complex and systems thinking have made it possible to observe emergent and dynamic innovation behaviors and the dynamics particular to sustainability and scaling up processes. -- Keywords : Scale-up ; Sustainability ; Innovation ; Africa ; Burkina Faso ; Malaria ; Seasonal malaria chemoprevention ; Systems thinking

A conceptualisation of scale-up and sustainability of social innovations in global health: a narrative review and integrative framework for action

Background The scale-up and sustainability of social innovations for health have received increased interest in global health research in recent years; however, these ambiguous concepts are poorly defined and insufficiently theorised and studied. Researchers, policymakers, and practitioners lack conceptual clarity and integrated frameworks for the scale-up and sustainability of global health innovations. Often, the frameworks developed are conceived in a linear and deterministic or consequentialist vision of the diffusion of innovations. This approach limits the consideration of complexity in scaling up and sustaining innovations. Objective By using a systems theory lens and conducting a narrative review, this manuscript aims to produce an evidence-based integrative conceptual framework for the scale-up and sustainability of global health innovations. Method We conducted a hermeneutic narrative review to synthetise different definitions of scale-up and sustainability to model an integrative definition of these concepts for global health. We have summarised the literature on the determinants that influence the conditions for innovation success or failure while noting the interconnections between internal and external innovation environments. Results The internal innovation environment includes innovation characteristics (effectiveness and testability, monitoring and evaluation systems, simplification processes, resource requirements) and organisational characteristics (leadership and governance, organisational change, and organisational viability). The external innovation environment refers to receptive and transformative environments; the values, cultures, norms, and practices of individuals, communities, organisations, and systems; and other contextual characteristics relevant to innovation development. Conclusion From these syntheses, we proposed an interconnected framework for action to better guide innovation researchers, practitioners, and policymakers in incorporating complexity and systemic interactions between internal and external innovation environments in global health. -- Keywords : Scale-up ; sustainability ; social innovation ; narrative review ; global health ; systems thinking.hinking

Practice of diagnostic hysteroscopy after myomectomy in the prevention of intrauterine adhesions: experience of Ouakam military hospital (Dakar, Senegal)

Background: Surgical treatment of myomas may be the cause of some complications, including intrauterine adhesions. The objective of the study was to evaluate the incidence of intrauterine adhesions in patients who underwent myomectomy by laparotomy or hysteroscopic resection.Methods: We carried out a prospective single center study from August 1st 2016 to May 31st 2017 in the gynaecological and obstetrical department of Ouakam the Military Hospital (Senegal). We included patients who underwent myomectomy by laparotomy with opening of the uterine cavity or myomectomy by hysteroscopy. A diagnostic hysteroscopy was performed to search post-operative intrauterine adhesions. For each patient, we studied the socio-demographic aspects, the surgical approach, the delay of diagnostic hysteroscopy, the appearance of uterine cavity and the tolerance of hysteroscopy.Results: 54 patients underwent the diagnostic hysteroscopy. The mean age was 36 years old. The main indication of myomectomy was menorrhagia. 37 patients underwent myomectomy by laparotomy and 17 by hysteroscopy. Each case was followed by a post-operative diagnostic hysteroscopy with a mean delay time of 58 days. We found post-operative intrauterine adhesions in 7 patients (5 in the laparotomy group and 2 in hysteroscopy group).Conclusions: Early diagnostic hysteroscopy after myomectomy should be done in our context to reduce post-operative intrauterine adhesions and preserve the patient’s fertility

The role of mutuals and community-based insurance in social health protection systems: International experience on delegated functions

L’architecture institutionnelle sur laquelle repose la protection sociale de la santé varie selon les pays, de même que les acteurs et organismes impliqués. Dans certains pays, les sociétés mutualistes et organismes d’assurance maladie communautaire jouent un rôle central. Dans les années 1990, ces structures ont été promues, notamment parce qu’elles constituaient un moyen d’étendre la couverture de la sécurité sociale, en particulier en Afrique subsaharienne. Aujourd’hui, l’adoption du Programme de développement durable à l’horizon 2030 et une nouvelle volonté politique de parvenir à la couverture universelle ont conduit à s’interroger sur le rôle des mutuelles et organismes d’assurance maladie communautaire. Toutefois, peu d’études ont été consacrées à leur place dans les systèmes nationaux de sécurité sociale. Cette étude exploratoire, qui repose sur l’analyse de 49 documents couvrant 18 pays répartis dans le monde entier, est axée sur la délégation de fonctions en faveur des mutuelles/organismes d’assurance maladie communautaire dans les systèmes nationaux de protection sociale de la santé. Ses résultats révèlent la dynamique de cette délégation au fil du temps et des processus de mise en œuvre. Ils mettent en lumière des pistes de réflexion de nature à éclairer la formulation de l’action publique. -- Mots-clés : Mutualité ; protection sociale ; santé ; régimes de sécurité sociale ; assurance maladie; international

Feasibility and safety of integrating mass drug administration for helminth control with seasonal malaria chemoprevention among Senegalese children: a randomized controlled, observer-blind trial

BACKGROUND: The overlap in the epidemiology of malaria and helminths has been identified as a potential area to exploit for the development of an integrated control strategy that may help to achieve elimination of malaria and helminths. A randomized, controlled, observer-blind trial was conducted to assess the feasibility and safety of combining mass drug administration (MDA) for schistosomiasis and soil transmitted helminths (STH) with seasonal malaria chemoprevention (SMC) among children living in Senegal. METHODS: Female and male children aged 1-14 years were randomized 1:1:1, to receive Vitamin A and Zinc on Day 0, followed by SMC drugs (sulfadoxine-pyrimethamine and amodiaquine) on Days 1-3 (control group); or praziquantel and Vitamin A on Day 0, followed by SMC drugs on Days 1-3 (treatment group 1); or albendazole and praziquantel on Day 0, followed by SMC drugs on Days 1-3 (treatment group 2). Safety assessment was performed by collecting adverse events from all children for six subsequent days following administration of the study drugs. Pre- and post-intervention, blood samples were collected for determination of haemoglobin concentration, malaria microscopy, and PCR assays. Stool samples were analyzed using Kato-Katz, Merthiolate-iodine-formalin and PCR methods. Urine filtration, PCR and circulating cathodic antigen tests were also performed. RESULTS: From 9 to 22 June 2022, 627 children aged 1-14 years were randomized into the three groups described above. Mild, transient vomiting was observed in 12.6% (26/206) of children in treatment group 2, in 10.6% (22/207) in group 1, and in 4.2% (9/214) in the control group (p = 0.005). Pre-intervention, the geometric mean value of Plasmodium falciparum parasite density was highest among children who received albendazole, praziquantel with SMC drugs. Post-intervention, the parasite density was highest among children who received SMC drugs only. Children who received praziquantel and SMC drugs had a lower risk of developing severe anaemia than their counterparts who received SMC drugs alone (OR = 0.81, 95% CI 0.13-5.00, p = 0.63). CONCLUSIONS: Integration of MDA for helminths with SMC drugs was safe and feasible among Senegalese children. These findings support further evaluation of the integrated control model. TRIAL REGISTRATION: The study is registered at Clinical Trial.gov NCT05354258

L’innovation en santé est-elle perçue comme étant technologique ou sociale ? Une réflexion conceptuelle dans le domaine de la santé publique

Les innovations en santé se produisent dans différents services, organisations et communautés. De plus, elles font face à de multiples logiques institutionnelles, qui sont souvent contradictoires. La logique du marché axée principalement sur la rentabilité et sur la création de la valeur économique à travers les innovations détient le monopole dans les systèmes d’innovation actuels. Cette orientation s’appuie sur une vision techno-économique de l’innovation, selon laquelle les technologies sont considérées comme une fin en soi. Par conséquent, la valeur économique de l’innovation est privilégiée par rapport à sa valeur sociale. Cette perspective dominante comporte différents défis et enjeux dans le domaine de la santé publique et communautaire, où maints acteurs concourent et ont des intérêts divergents. Cet article s’intéresse de près à la notion d’innovation dans le but de clarifier sa signification et de repenser ses différentes orientations paradigmatiques, notamment techno-économique et sociale. La discussion portera sur l’intérêt de l’innovation sociale comme paradigme à promouvoir dans le domaine de la santé publique.Health innovations occur in different services, organizations and communities. Also, they are confronted with multiple institutional logics, which are often contradictory. The market logic focused primarily on profit and the creation of economic value through innovations holds the monopoly in current innovation systems. This orientation is based on a techno-economic vision of innovation in which technologies are considered as an end in themselves. Consequently, the economic value of innovation is privileged over the social one. This dominant perspective involves various challenges and issues in the field of public and community health, where many actors compete and have divergent interests. This article takes a close look at the notion of innovation in order to clarify its meaning, and to rethink its different paradigmatic orientations, notably techno-economic and social. The discussion will study the interest of social innovation as a paradigm to promote in the field of public health

Practice of diagnostic hysteroscopy after myomectomy in the prevention of intrauterine adhesions: experience of Ouakam military hospital (Dakar, Senegal)

Background: Surgical treatment of myomas may be the cause of some complications, including intrauterine adhesions. The objective of the study was to evaluate the incidence of intrauterine adhesions in patients who underwent myomectomy by laparotomy or hysteroscopic resection.Methods: We carried out a prospective single center study from August 1st 2016 to May 31st 2017 in the gynaecological and obstetrical department of Ouakam the Military Hospital (Senegal). We included patients who underwent myomectomy by laparotomy with opening of the uterine cavity or myomectomy by hysteroscopy. A diagnostic hysteroscopy was performed to search post-operative intrauterine adhesions. For each patient, we studied the socio-demographic aspects, the surgical approach, the delay of diagnostic hysteroscopy, the appearance of uterine cavity and the tolerance of hysteroscopy.Results: 54 patients underwent the diagnostic hysteroscopy. The mean age was 36 years old. The main indication of myomectomy was menorrhagia. 37 patients underwent myomectomy by laparotomy and 17 by hysteroscopy. Each case was followed by a post-operative diagnostic hysteroscopy with a mean delay time of 58 days. We found post-operative intrauterine adhesions in 7 patients (5 in the laparotomy group and 2 in hysteroscopy group).Conclusions: Early diagnostic hysteroscopy after myomectomy should be done in our context to reduce post-operative intrauterine adhesions and preserve the patient’s fertility