The unintended consequences of a complex intervention combining performance-based financing with health equity measures in Burkina Faso

Contexte : La mauvaise qualité et la faible utilisation des services de santé contribuent aux taux élevés de morbidité et de mortalité dans plusieurs pays à faible et à moyen revenu. Face à cette situation, le gouvernement du Burkina Faso a testé une intervention novatrice qui combine le financement basé sur la performance (FBP) à des mesures d'équité en santé. Les formations sanitaires ont reçu des prix unitaires pour des services de santé fournis ainsi que des bonus conditionnels à la qualité des soins. Des comités communautaires ont sélectionné les indigents pour leur octroyer des exemptions de paiements des soins. Malgré le peu d’études sur le sujet, des acteurs en santé mondiale craignent que l’intervention puisse avoir des conséquences non intentionnelles importantes. Objectif : Cette thèse vise à accroître les connaissances scientifiques sur les conséquences non intentionnelles du FBP combiné à des mesures d'équité en santé dans un environnement à faible revenu. Méthodes : Nous avons développé un cadre conceptuel basé sur la théorie de la diffusion des innovations. Une étude de cas multiples a été réalisée avec neuf formations sanitaires au Burkina Faso. Cinq mois sur le terrain ont permis d’effectuer 104 entrevues semi-structurées, 266 séances d'observation et des conversations informelles avec un large éventail d'acteurs incluant les prestataires de soins, les patients et les vérificateurs. Les données qualitatives ont été codées avec QDA miner pour faciliter l’analyse thématique. Nous avons également utilisé des données quantitatives du système de gestion pour décrire l'évolution des services et trianguler les résultats. Résultats : La nature et la mise en œuvre de l'intervention ont interagi avec le système social et les caractéristiques de ses membres pour engendrer des conséquences non intentionnelles importantes, dont la plupart étaient indésirables. Les prestataires de soins ont démontré une fixation sur les mesures de rendement, ont falsifié les registres médicaux et ont enseigné de mauvaises pratiques aux stagiaires pour augmenter leurs subsides et bonus. Comme conséquence non intentionnelle désirable, certaines formations sanitaires ont limité la vente de médicaments sans prescriptions pour encourager les consultations. Les vérifications communautaires, durant lesquelles les patients sont retrouvés pour vérifier les services déclarés, ont entraîné la falsification des données de vérification, la perte de la confidentialité des patients et certaines craintes chez les patients, bien que certains étaient heureux de partager leurs opinions. Enfin, les prestataires de soins ont limité les services offerts gratuitement aux indigents, ce qui a déclenché des conflits. Discussion : Cette thèse contribue au développement des connaissances scientifiques sur la façon dont le FBP, combiné à des mesures d'équité, peut engendrer des conséquences non intentionnelles. Les résultats sont utiles pour affiner ce type d’intervention et éclairer une mise en œuvre efficace dans le secteur du financement de la santé. Plus largement, cette thèse démontre la faisabilité et la valeur ajoutée d'utiliser un cadre conceptuel pour étudier les conséquences non intentionnelles. Elle pourra guider les chercheurs à élargir leur angle d’analyse afin de rendre compte des conséquences intentionnelles et non intentionnelles des interventions complexes en santé.Background: Poor quality and low utilization of healthcare services contribute to high levels of morbidity and mortality in many low- and middle-income countries (LMICs). In response, the government of Burkina Faso tested an innovative intervention that combines performance-based financing (PBF) with health equity measures. Healthcare facilities received unit fees for targeted services and bonuses conditional upon the quality of care. To reduce inequities in access to care, community-based committees selected indigents, i.e., the poorest segment of the population, to offer them user fee exemptions. Facilities were also paid more for services delivered to indigents. Despite the potential of this type of intervention, many global health actors argue that it could lead to important unintended consequences that influence its overall impact. Yet, little attention has been given to studying the unintended consequences of this complex intervention. Objective: This thesis aims to increase the scientific knowledge on the unintended consequences of PBF combined with health equity measures in a low-income setting. Methods: We developed a conceptual framework based on the diffusion of innovations theory. Using a multiple case study design, we selected nine healthcare facilities in Burkina Faso. Over five months of fieldwork, we collected multiple sources of qualitative data including 104 semi-structured interviews, 266 recorded observation sessions, informal conversations and documentation. Participants included a wide range of stakeholders, such as providers, patients, and PBF verifiers. Data were coded using QDA miner to conduct a thematic analysis. We also used secondary data from the PBF routine management system to describe the evolution of services and triangulate results. Results: Interactions between the nature and implementation of the intervention, the nature of the social system, and its members’ characteristics led to important unintended consequences, most of which were undesirable. Providers were fixated on performance measures rather than on underlying objectives, falsified medical registers, and taught trainees improper practices to increase subsidies and bonuses. As a desirable unintended consequence, we found that some facilities limited the sale of non-prescribed medication to encourage patients to consult. Community verifications, in which patients are traced to verify the authenticity of reported services and patient satisfaction, also led to unintended consequences, such as the falsification of verification data, the loss of patient confidentiality, and fears among patients, although some were pleased to share their views. Lastly, health equity measures also triggered changes that were not intended by program planners. For example, providers limited the free services and medication delivered to indigents, which led to conflicts between parties. Discussion: This thesis contributes to the development of scientific knowledge on how PBF interventions, combined with equity measures, can trigger unintended consequences in a low-income setting. The results are useful to inform effective implementation and refine interventions, particularly in the health financing sector. More broadly, this thesis demonstrates the feasibility and added value of using a conceptual framework to study the unintended consequences of complex health interventions. This thesis can inspire and guide future researchers to broaden their analytical horizons to capture both intended and unintended consequences of health interventions

Synthèse de couches ultra-minces de siliciures sur silicium cristallin et endommagé étudiée par microscopie et profilométrie en profondeur

Les siliciures métalliques constituent un élément crucial des contacts électriques des transistors que l'on retrouve au coeur des circuits intégrés modernes. À mesure qu'on réduit les dimensions de ces derniers apparaissent de graves problèmes de formation, liés par exemple à la limitation des processus par la faible densité de sites de germination. L'objectif de ce projet est d'étudier les mécanismes de synthèse de siliciures métalliques à très petite échelle, en particulier le NiSi, et de déterminer l’effet de l’endommagement du Si par implantation ionique sur la séquence de phase. Nous avons déterminé la séquence de formation des différentes phases du système Ni-Si d’échantillons possédant une couche de Si amorphe sur lesquels étaient déposés 10 nm de Ni. Celle-ci a été obtenue à partir de mesures de diffraction des rayons X résolue en temps et, pour des échantillons trempés à des températures critiques du processus, l’identité des phases et la composition et la microstructure ont été déterminées par mesures de figures de pôle, spectrométrie par rétrodiffusion Rutherford et microscopie électronique en transmission (TEM). Nous avons constaté que pour environ la moitié des échantillons, une réaction survenait spontanément avant le début du recuit thermique, le produit de la réaction étant du Ni2Si hexagonal, une phase instable à température de la pièce, mélangée à du NiSi. Dans de tels échantillons, la température de formation du NiSi, la phase d’intérêt pour la microélectronique, était significativement abaissée.Currently metal silicide constitutes a crucial component in the formation of electrical contacts for transistors that forms the heart of modern day integrated circuits. As we reduce the dimensions of the latter, we are faced with serious problems of formation, related for example to the process limitation due to the weak density of germination sites. The objective of this project is to study at small scale the synthesis mechanisms of metal silicide, in particular NiSi, and to determine the effect of Si implantation damage on the phase sequence. We have determined the different phase sequences of the Ni-Si system for samples composed of a 10 nm Ni surface layer deposited on a-Si. These were obtained by time resolved x-ray diffraction (TR-XRD) measurements. As for samples quenched at critical temperatures we identified the different phases, their composition and their microstructure were determined by pole figures, Rutherford back scattering (RBS) spectrometry and transmission electron microscopy (TEM). We noted that for approximately half the samples, a spontaneous reaction happened before annealing. The result of the reaction was hexagonal Ni2Si, a phase unstable at room temperature, mixed with NiSi. In theses samples, the temperature of formation for the phase of interest, the NiSi, was lower

Ethical Considerations of Dissemination and Restitution of Findings in Global Health Research

Étude de cas / Case studyThis case study discusses ethical obligations regarding the extent and scope of knowledge dissemination and restitution strategies in the context of global health research.Cette étude de cas porte sur les obligations éthiques concernant l’étendue et la portée des stratégies de dissémination et de restitution des connaissances dans un contexte de recherche en santé mondiale

"La première fois que j’ai joué..." : l’expérience d’adolescents considérés comme ayant des difficultés avec les jeux de hasard et d’argent

Notre étude vise à décrire les premières expériences de jeux de hasard et d’argent (JHA) d’adolescents ayant développé des habitudes problématiques sur ce plan concernant :a) la nature des activités de JHA, b) la signification des premières expériences au regard des bénéfices et des aspects attrayants des JHA, et c) la progression vers des comportements problématiques. Le devis de recherche qualitatif s’appuie sur des analyses secondaires de données issues d’entrevues semi-structurées réalisées auprès de 31 adolescents présentant des habitudes problématiques de JHA et en traitement pour leur consommation de substances psychoactives (SPA). L’analyse des propos des adolescents révèle que les bénéfices associés aux premières expériences de JHA et à leur exacerbation sont de nature matérielle, émotive et sociale. Les résultats sont analysés à la lumière du contexte social dans lequel les adolescents évoluent : popularité de certains jeux, importance de la performance, la richesse et de la recherche de plaisir.This study describes the initial gambling experiences of teenagers who have developed problem gambling habits with regard to: a) the nature of the gambling activities, b) the significance of the first experience in terms of the benefits and attractive aspects of gambling, and c) the progression toward the development of problematic behaviours. The research design draws on secondary analysis of data from semi-structured interviews carried out with 31 adolescents with problem gambling behaviours in treatment for the consumption of psychoactive substances (PS). An analysis of the teenagers' responses reveals the existence of material, emotive and social benefits associated with their first gambling experience and the exacerbation of their behaviours. The results were analysed in light of the teenagers' social context: popularity of certain games, importance of performance, wealth and the pursuit of pleasure

Valeur des collégiens et réussite scolaire filles et garçons au collège : des univers parallèles ? : étude sur la problématique des genres et la réussite scolaire en milieu collégial /

"Recherche subventionnée par le ministère de l'Éducation, du Loisir et du Sport dans le cadre du Programme d'aide à la recherche sur l'enseignement et l'apprentissage (PAREA)"Titre de l'écran-titre (visionné le 20 sept. 2010)Également disponible en version papier.Bibliogr

Prenatal Maternal Stress Predicts Childhood Asthma in Girls: Project Ice Storm

Little is known about how prenatal maternal stress (PNMS) influences risks of asthma in humans. In this small study, we sought to determine whether disaster-related PNMS would predict asthma risk in children. In June 1998, we assessed severity of objective hardship and subjective distress in women pregnant during the January 1998 Quebec Ice Storm. Lifetime asthma symptoms, diagnoses, and corticosteroid utilization were assessed when the children were 12 years old (N = 68). No effects of objective hardship or timing of the exposure were found. However, we found that, in girls only, higher levels of prenatal maternal subjective distress predicted greater lifetime risk of wheezing (OR = 1.11; 90% CI = 1.01–1.23), doctor-diagnosed asthma (OR = 1.09; 90% CI = 1.00–1.19), and lifetime utilization of corticosteroids (OR = 1.12; 90% CI = 1.01–1.25). Other perinatal and current maternal life events were also associated with asthma outcomes. Findings suggest that stress during pregnancy opens a window for fetal programming of immune functioning. A sex-based approach may be useful to examine how prenatal and postnatal environments combine to program the immune system. This small study needs to be replicated with a larger, more representative sample

Prevalence of shedding and antibody to Coxiella burnetii in post-partum dairy cows and its association with reproductive tract diseases and performance : a pilot study

The bacterium Coxiella burnetii has been associated with reproduction disorders in dairy cattle. A cross-sectional study was conducted in Québec, Canada, to estimate the prevalence of C. burnetii in dairy cows from C. burnetii RT-PCR-positive and/or ELISA-positive herds. As a secondary objective, the associations between C. burnetii-positivity and three reproductive outcomes (purulent vaginal discharge, cytological endometritis, and success at first service) were assessed. A total of 202 post-parturient dairy cows from nine herds were sampled at 35 ± 7 days in milk. Vaginal mucus and composite milk were collected from each cow and screened for the presence of C. burnetii by real-time PCR (RT-PCR) and ELISA, respectively. Purulent vaginal discharge and cytological endometritis were evaluated using a Metricheck device and a modified cytobrush, respectively. The first insemination postpartum was done following an ovulation synchronization protocol around 70 days in milk, and success at first service was recorded. Multilevel logistic regressions adjusted for parity were used to model purulent vaginal discharge, cytological endometritis and success at first service according to C. burnetii cow status. All 202 RT-PCR-assayed vaginal samples were C. burnetii-negative. A positive result for anti-C. burnetii antibodies detection in composite milk was obtained in 25/202 samples and a doubtful result in 4/202 samples. After adjustment for sampling weights, the 202 ELISA-assayed composite milk samples gave an estimated overall prevalence of C. burnetii positive cows of 12.9 % (CI = 6.1–19.6 %) and of doubtful cows of 1.4 % (CI = 0.0–3.3 %). The proportion of ELISA-positive cows was lower in first parity (0%) compared to second (17.1 %) or third parity cows (20.0 %). The associations between ELISA positivity and reproductive outcomes were not statistically significant, perhaps due to the limited sample size, but could be used as pilot estimate for large-scale studies investigating the impact of C. burnetii infection on reproduction disorders in dairy cattle

Epidemiological study of Coxiella burnetii in dairy cattle and small ruminants in Québec, Canada

The bacterium Coxiella burnetii (C. burnetii) can infect a wide range of animals, most notably ruminants where it causes mainly asymptomatic infections and, when clinical, it is associated with reproductive disorders such as abortion. It is also the etiological agent of Q fever in humans, a zoonosis of increasingly important public health concern. A cross-sectional study was performed to estimate the apparent prevalence and spatial distribution of C. burnetii positivity in dairy cattle and small ruminant herds of two regions of Québec, Canada, and identify potential risk factors associated with positivity at animal and herd levels. In dairy cattle herds, individual fecal samples and repeated bulk tank milk samples (BTM) were collected. In small ruminant herds, serum and feces were sampled in individual animals. ELISA analyses were performed on serum and BTM samples. Real-time quantitative PCR (qPCR) was done on fecal and BTM samples. An animal was considered C. burnetii-positive when at least one sample was revealed positive by ELISA and/or qPCR, while a herd was considered C. burnetii-positive when at least one animal inside that herd was revealed positive. None of the 155 cows had a qPCR-positive fecal sample, whereas 37.2 % (95 % CI = 25.3–49.1) of the 341 sheep and 49.2 % (95 % CI = 25.6–72.7) of the 75 goats were C. burnetii-positive. The apparent prevalence of C. burnetii-positive herds was 47.3 % (95 % CI = 35.6–59.3) in dairy cattle herds (n = 74), 69.6 % (95 % CI = 47.1–86.8) in sheep flocks (n = 23) and 66.7 % (95 % CI = 22.3–95.7) in goat herds (n = 6). No spatial cluster of positive herds was detected. At the individual level, the only significant association with positivity in multivariable regressions was higher parity number in small ruminants. At the herd level, the use of calving group pen, the distance to the closest positive bovine herd, and small ruminant herd density in a 5 km radius were associated with dairy cattle herd positivity, whereas small ruminant herds with more than 100 animals and with a dog on the farm had greater odds of C. burnetii positivity. Our study shows that the infection is frequent on dairy cattle and small ruminant herds from the two studied regions and that some farm and animal characteristics might influence the transmission dynamics of the C. burnetii infection