27 research outputs found
Le financement basé sur les résultats au Bénin et au Sénégal : Un levier pérenne de changement de pratiques des agents de santé ?
Le financement basĂ© sur les rĂ©sultats (ou FBR) est depuis prĂšs de vingt ans largement implantĂ© dans les pays Ă revenu faible et intermĂ©diaire avec lâobjectif de motiver les personnels de santĂ© Ă augmenter la quantitĂ© et amĂ©liorer la qualitĂ© des soins prodiguĂ©s. NĂ©anmoins, lâapproche de FBR souffre toujours dâun manque de donnĂ©es probantes (et cohĂ©rentes) quant Ă ses effets, et dâune insuffisante comprĂ©hension des facteurs motivationnels qui en expliquent la prĂ©sence ou lâabsence. Cette recherche doctorale entend contribuer Ă combler ce manquement. Elle vise Ă explorer le potentiel de changement de pratiques des agents de santĂ© impliquĂ©s dans le FBR au BĂ©nin et au SĂ©nĂ©gal, et Ă mettre au jour les multiples facteurs explicatifs sous-jacents Ă lâĆuvre dans la rĂ©alisation de ces changements. LâoriginalitĂ© de notre recherche est multiple. Elle combine deux pays dâĂ©tude, analyse plusieurs programmes de FBR, avec un accent original sur la question de la pĂ©rennitĂ© des effets du FBR au BĂ©nin. Elle se base Ă©galement sur lâarticulation de mĂ©thodes de recherche qualitative (recherches documentaires, observations participantes, entretiens semi-directifs) et quantitative (analyses statistiques). Elle mobilise, enfin, un cadre dâanalyse original et dynamique â le I-Change model.
Il ressort de notre Ă©tude de terrain que le FBR permet, selon les agents de santĂ© interrogĂ©s, de changer certaines de leurs pratiques, mĂȘme si les modifications dĂ©crites ne sont pas systĂ©matiques. En ce qui concerne le SĂ©nĂ©gal, ces changements ne sâaccompagnent pas dâune amĂ©lioration systĂ©matique des indicateurs de santĂ©, mĂȘme lorsque le FBR est combinĂ© Ă un appui Ă la demande au travers dâun mĂ©canisme de transfert monĂ©taire conditionnel. Notre Ă©tude dĂ©montre que le potentiel du FBR Ă influer sur les pratiques des agents de santĂ© ne sâexplique pas uniquement par lâincitant financier, qui constitue pourtant un Ă©lĂ©ment central dans la stratĂ©gie de diffusion des approches de financement de type results-based. En effet, de nombreux leviers de changement de pratiques des agents de santĂ© â matĂ©riels comme immatĂ©riels â ont Ă©tĂ© identifiĂ©s, alors que dâautres nâont pas Ă©tĂ© activĂ©s, ou du moins pas toujours entiĂšrement. La seconde enquĂȘte de terrain au BĂ©nin, respectivement 9 et 12 mois aprĂšs lâarrĂȘt des programmes FBR, a montrĂ© une tendance gĂ©nĂ©rale au « relĂąchement » progressif du « sĂ©rieux », de la « rigueur » professionnelle, de mĂȘme quâune dĂ©sactivation de certains leviers de changement de pratiques du FBR. Les programmes de FBR bĂ©ninois nâont pas eu dâeffets pĂ©rennes. Par ailleurs, nos Ă©tudes de terrain ont montrĂ© que le contexte dâimplantation des programmes FBR joue un rĂŽle crucial â pouvant ĂȘtre facilitateur ou entravant â dans lâatteinte et le maintien de ses rĂ©sultats.
Ensemble, ces constats remettent en cause lâidĂ©e que le FBR peut constituer une approche efficace pour rĂ©pondre aux dysfonctionnements des systĂšmes de santĂ©. Ils appellent plutĂŽt une mise en Ćuvre coordonnĂ©e des programmes de FBR avec les diffĂ©rentes rĂ©formes engagĂ©es ou Ă engager au sein des systĂšmes de santĂ© nationaux (portant notamment sur la rĂ©munĂ©ration des ressources humaines pour la santĂ© et le financement du plateau technique). Une mise en Ćuvre qui devrait sâinscrire dans une rĂ©flexion de fond sur les dĂ©fis relatifs tant Ă lâoffre et quâĂ la demande de soins.Performance-based financing (PBF) has been widely implemented in low- and middle-income countries with the aim of incentivizing health service providers and the health workforce to improve the quantity and quality of care for nearly twenty years now. However, the PBF approach continues to face a lack of (relevant) evidence regarding its effects, and a limited understanding of the motivational factors that explain the presence or absence of its effects. This doctoral research intends to address this gap. It aims to explore the potential for change in health workersâ practices through PBF in Benin and Senegal, and uncover the multiple explanatory factors underlying these changes. The originality of our research is manifold. It combines two study countries, analyzes several PBF programs and does so, with an original emphasis on the question of the sustainability of PBF effects in Benin. The research is based on the articulation of qualitative (documentary research, participant observation, semi-structured interviews) and quantitative (statistical analyzes) research methods, and mobilizes an original and dynamic analytical framework - the I-Change model.
Our field study shows that, according to the health workers interviewed, PBF allows to change some of their practices, even if the observed changes are not systematic. In the case of Senegal, these changes are not accompanied by a systematic improvement of health indicators, even when the PBF is combined with demand-side programs through a conditional cash transfer (CCT) scheme. From our study, it also emerges that the potential of PBF to change health workersâ practices cannot be only explained by the financial incentive, which is central in results-based approaches dissemination strategy. Indeed, many levers for changing health workersâ practices - both tangible and intangible - have been identified, while other potential levers of change have not been activated, at least not always fully. The second field study conducted in Benin, 9 and 12 months after the end of PBF programs respectively, showed a general trend towards a gradual ârelaxationâ of âseriousnessâ, of professional ârigorâ, and a deactivation of certain levers for change of PBF. The PBF programs in Benin did not have lasting effects. In addition, our field studies have shown that the context in which PBF programs are implemented plays a crucial role - which can be facilitating or hindering - in achieving and sustaining the results of PBF programs.
Taken together, these observations challenge the idea that PBF can constitute an effective approach to respond to dysfunctional health systems â or at least they call for the implementation of PBF programs coordinated with the various reforms initiated or to be initiated within the national health systems (particularly relating to human resources for health remuneration and technical equipment funding), and forming part of an in-depth reflection on supply and demand of care challenges.Projet dâActions de Recherche ConcertĂ©es (ARC) « Effi-SantĂ© » « Innovative and Efficient Health Financing Systems: Towards Universal Health Coverage in Developing Countries
Are pilot programmes able to give rise to sustainable health system effects? The case of performance-based financing in Benin
Background: Sustainability, understood as âthe continuation of benefits from a development intervention after major development assistance has been completedâ, is a major performance criterion of development programmes. Performance-based financing (PBF) was implemented in Benin between 2012 and 2017, with support from four donors and along two models. However, insufficient demonstrated results and lack of national ownership led to the termination of PBF programmes in most districts in 2017. The termination of PBF in Benin represents a unique opportunity to analyse the ability of PBF to generate sustainable effects. This study aims to appraise the sustainability of PBF programmes through assessing the effects that were maintained after 9 months of termination.
Methods: Sustainability was examined from the perspective of health practitioners, using a qualitative approach. Semi-structured interviews were led with healthcare providers and managers (N=59) in two health districts during PBF implementation in 2017, and thematically analysed. This enabled to identify perceptions regarding PBFâs effect over providersâ competences and behaviour in their day-to-day work. These results were confronted with those from another round of semi-structured interviews led with some of the stakeholders already interviewed (N=38) and conducted 9 months after the programme stopped.
Results: Our results proved helpful to understand the dynamics of the transition period following PBF termination, the strategies implemented at the local level to guarantee sustainability of effects, and the effect of programme termination on healthcare providersâ performance and motivation. The PBF programmes aimed to motivate individuals in delivering health services. When implemented, they produced some positive effects on interpersonal communication and supervision, but also caused demotivation due to irregularity, low level and perceived unfair distribution of financial incentives. Our study shows that hardly no resource was dedicated to an exit strategy, so as to ensure continuing effects of PBF. Therefore, PBF termination was a major source of demotivation for healthcare practitioners, mainly attributable to the cessation of financial premiums that were already taken for granted, as well as to worsening in working conditions due to the withdrawals of PBF funding used for the recruitment of additional staff and the purchase of equipment for health facilities.
Discussion / Conclusion: This study enabled to shed light on the poor preparation and understand the dynamics of the transition period following PBF termination, and to appraise effects on health practitionersâ motivation. It shows that PBF effects were not sustained. Greater attention should be paid to sustainability issues in future PBF programmes.ARC Effi-Sant
The COVID-19 pandemic in francophone West Africa: from the first cases to responses in seven countries.
BACKGROUND: In early March 2020, the COVID-19 pandemic hit West Africa. In response, countries in the region quickly set up crisis management committees and implemented drastic measures to stem the spread of the SARS-CoV-2 virus. The objective of this article is to analyse the epidemiological evolution of COVID-19 in seven Francophone West African countries (Benin, Burkina Faso, CĂŽte d'Ivoire, Guinea, Mali, Niger, Senegal) as well as the public health measures decided upon during the first 7 months of the pandemic.
METHODS: Our method is based on quantitative and qualitative data from the pooling of information from a COVID-19 data platform and collected by a network of interdisciplinary collaborators present in the seven countries. Descriptive and spatial analyses of quantitative epidemiological data, as well as content analyses of qualitative data on public measures and management committees were performed.
RESULTS: Attack rates (October 2020) for COVID-19 have ranged from 20 per 100,000 inhabitants (Benin) to more than 94 per 100,000 inhabitants (Senegal). All these countries reacted quickly to the crisis, in some cases before the first reported infection, and implemented public measures in a relatively homogeneous manner. None of the countries implemented country-wide lockdowns, but some implemented partial or local containment measures. At the end of June 2020, countries began to lift certain restrictive measures, sometimes under pressure from the general population or from certain economic sectors.
CONCLUSION: Much research on COVID-19 remains to be conducted in West Africa to better understand the dynamics of the pandemic, and to further examine the state responses to ensure their appropriateness and adaptation to the national contexts.3. Good health and well-bein
Assessing implementation fidelity of a results-based financing intervention in Burkina Faso
Our study provides an overview of the implementation fidelity of a RBF program in Burkina Faso using the aspect of âadherenceâ to intervention design. We conducted a case study in three health districts and at different levels of the health system one year after the program was implemented. On the whole, the results show quite good adherence to intervention design without a significant difference between districts. However, the different levels of care demonstrated heterogeneous degrees of fidelity. Moreover, implementation fidelity varies according to the component being discussed. Overall, the implementation respected the program agenda, even if small delays are identified.ARC Effi-Sant
Initiatives de valorisation et dâintĂ©gration de la mĂ©decine traditionnelle dans le systĂšme de santĂ© public burkinabĂš. Etude de cas : la commune rurale de BaskourĂ©
La prĂ©occupation majeure de cette Ă©tude est dâexprimer la situation prĂ©valente au Burkina Faso en matiĂšre de pluralisme mĂ©dical en procĂ©dant Ă un Ă©tat des lieux du processus politique de revalorisation de la mĂ©decine traditionnelle et de sa collaboration avec la pratique biomĂ©dicale « moderne » .
Pour ce faire, il a Ă©tĂ© question de souligner les reprĂ©sentations mutuelles des acteurs issus de la mĂ©decine traditionnelle et ceux issus de la mĂ©decine « conventionnelle ». Ensuite, prĂȘter attention aux rapports entre les deux thĂ©rapeutiques grĂące aux pratiques et discours des praticiens nous a permis de mesurer qualitativement le degrĂ© dâacceptabilitĂ© et les reprĂ©sentations liĂ©es au processus dâintĂ©gration de la mĂ©decine traditionnelle dans le systĂšme de santĂ© publique burkinabĂš tel que recommandĂ© par lâOrganisation Mondiale de la SantĂ©
Analyse prĂ© Ă©valuative de la fidĂ©litĂ© de lâimplantation de la politique de financement basĂ© sur les rĂ©sultats au Burkina Faso
A lâaube des Objectifs du MillĂ©naire pour le DĂ©veloppement (OMD) dont lâatteinte semble malheureusement compromise, le Burkina Faso rend compte dâun certain engouement pour le financement basĂ© sur les rĂ©sultats (FBR), plĂ©biscitĂ© comme pouvant contribuer Ă lâamĂ©lioration de la performance des systĂšmes de santĂ© et ainsi, redresser dans un dernier Ă©lan les statistiques sanitaires du pays avant 2015. Le Burkina Faso lance dĂšs lors aujourdâhui lâĂ©largissement de sa phase-test du FBR en une phase pilote.
Notre modeste ambition dans le cadre de ce travail Ă©tait de rendre compte de la planification de la politique de FBR au Burkina Faso afin de mieux en comprendre les composantes et les effets attendus. Afin de dresser cet Ă©tat des lieux, nous avons procĂ©dĂ© Ă une analyse documentaire, Ă des entretiens et nous sommes pliĂ©s Ă lâobservation participante ; ce qui nous a permis de dĂ©crire les logiques dâintervention initiale (2011) et planifiĂ©e (2014) de lâintervention FBR. Nous avons ensuite comparĂ© ces deux logiques et avons ensuite dressĂ© la liste planifiĂ©e des activitĂ©s. Puis, nous avons portĂ© une apprĂ©ciation sur la pertinence du modĂšle FBR planifiĂ©.
Il ressort de notre Ă©tude que la logique de lâintervention FBR telle quâelle est actuellement planifiĂ©e (2014) diffĂšre de celle qui Ă©tait initialement prĂ©vue (2011). On note, entre autres, des changements terminologiques, une augmentation du nombre de districts sanitaires (DS) considĂ©rĂ©s par lâintervention, une idĂ©e de randomisation de ces DS selon une logique dâessai contrĂŽlĂ© randomisĂ© (ECR), une modification de la logique de paiement FBR aujourdâhui limitĂ© aux districts de traitement, lâapparition dâune prĂ©occupation dâĂ©quitĂ© accompagnĂ©e dâun seuil de 10% dâindigents exemptĂ©s pour les soins de santĂ© (malgrĂ© une sĂ©lection plafonnĂ©e Ă 20%), une complexification des processus de vĂ©rification de la performance et de paiement des primes de performance entrainant une importante charge de travail et des risques de mauvaises mesure de performance, et un manque dâintĂ©gration de lâintervention FBR dans le paysage sanitaire burkinabĂš. Si les conditionnalitĂ©s de la Banque Mondiale, les questions budgĂ©taires et le contact du terrain permettent dâexpliquer certain de ces changements, il nâen est pas de mĂȘme pour le reste des modifications qui ne trouvent, Ă ce jour, pas dâexplication.
Plus fondamentalement, le modĂšle du FBR burkinabĂš souffre dans son design actuel de nombreuses apories : iniquitĂ© inter- et intra-formations sanitaires, rationnement dĂ©sĂ©quilibrĂ© des indigents (20% dâindigents sĂ©lectionnĂ©s pour, au maximum, 10% dâindigents exemptĂ©s pour les soins de santĂ©), consommation de temps et dâĂ©nergie importante et manque de cohĂ©rence de la politique au regard des rĂ©formes sanitaires prĂ©cĂ©dentes. Autant dâĂ©lĂ©ments sur lesquels les dĂ©cideurs doivent aujourdâhui se pencher en vue de la mise en Ćuvre de la phase pilote de lâintervention au Burkina Faso sinon quoi, le FBR pourrait bien ne pas rĂ©pondre aux espĂ©rances quâon lui assigne et voir sa viabilitĂ© institutionnelle mise en pĂ©ril
Assessing implementation fidelity of a results-based financing intervention in Burkina Faso
Implementation fidelity assessment represents a significant piece in the program evaluation puzzle although it is often overlooked. This is particularly the case of results-based financing (RBF) studies where the major part of the attention is taken up by impact studies. However, bending to the exercise of assessing fidelity implementation is essential to go beyond the demonstration of program effectiveness and to better understand the interventionâs foundations. Our study provides an overview of the implementation fidelity of a RBF program in Burkina Faso using one aspect of fidelity: âadherenceâ to intervention design and its components (content, coverage, temporality). We conducted a case study in three health districts and at different levels of the health system one year after the program was implemented. On the whole, the results show quite good adherence to intervention design without a significant difference between districts. However, the different levels of care demonstrated heterogeneous degrees of fidelity: the community health centres level seems to have encountered particular implementation issues. Moreover, implementation fidelity varies according to the component being discussed: if the programming component (including training and material allocations activities) was relatively faithful to the intervention design, our study shows weak fidelity in three aspects: action research, performance verification and grant payments. This leads to the fact that, at this stage of the program implementation, the financial incentives considered to be at the core of the RBF logic do not reach health staff. Overall, the implementation globally respected the program agenda, even if small delays are sometimes identified.ARC Effi-Sant
Distribution and Number of Intracardiac Ganglion Cells in the Rat
info:eu-repo/semantics/publishe
What can behavioural change analysis bring to the comprehensive understanding of performance-based financing sustainability? Exploration through the application of the I-change model on the case of Benin: Exploration through the application of the I-change model on the case of Benin
Introduction: Performance-based financing (PBF) is promoted as a way to improve health workersâ performance. However, despite a growing interest in the issue of motivation and the use of several motivational theories to appraise it, little is still known about PBF internal mechanisms leading to behavioural change, even less on their sustainability. The recent termination of donor-funded PBF programmes in Benin represents a unique opportunity to analyse which motivational mechanisms are sustained when incentives cease.Aim: This study aims to refine the understanding of PBF by using the I-change model1 and to explore how PBF affects health workers behavioural change in Benin during implementation and after termination. Methods: Our study rests on a qualitative design. We conducted semi-structured interviews with healthcare providers and managers from health centres (N=6) and hospitals (N=2) in two health districts supported by different donors), first during PBF implementation in 2017 and secondly, with some of the stakeholders previously interviewed (N=40), 6 and 9 months after the programmes stopped. Interviews were analysed thematically. Results: PBF produced positive effects on some health workersâ behaviours, like interpersonal communication and reporting, that are sustained after PBF termination. During implementation, the prospect of extra gain contributed to the motivation of health workers to adopt these behaviours, however that effect was reduced due to low level and perceived unfair distribution of financial incentives, and reversed with their cessation. Beyond financial incentives, other mechanisms also play an important role in health workers behaviours adoption, which persisted after PBF termination, notably awareness of inner duty, social pressure, and demonstration of the usefulness of some practices. However, some systemic constraints, design and implementation issues, and the absence of an exit strategy reduced their motivational effect. Conclusion: Our behavioural change analysis using the I-change model helps refine the understanding of PBF and sheds light on its effects on health workersâ behaviours that go beyond the effects of financial incentives, but can be reduced by systemic constraints, design, implementation and exit strategy issues. Reference:1. De Vries H. Dijkstra M. Kuhlman P. Self-efficacy: the third factor besides attitude and subjective norm as a predictor of behavioral intentions. Health Education Research 1988; 3; 273â282.info:eu-repo/semantics/nonPublishe