Contrat de performance avec une administration sanitaire provinciale : cas du Nord Kivu en République Démocratique du Congo.

Introduction : De nombreuses expériences de financement basé sur les performances sont documentées au niveau des hôpitaux et centres de santé, mais pas sur les administrations sanitaires. La présente étude décrit une expérience de contrat de performance au niveau de l’administration sanitaire provinciale du Nord Kivu, en RD Congo. Méthodes : Cette étude a recouru à la triangulation de trois méthodes : (i) une analyse documentaire, (ii) l’analyse des données d’interviews d’acteurs clés sur leur perception de la stratégie, (iii) l’analyse des données d’utilisation des services curatifs et préventifs dans la province. Résultats : Le contrat de performance a été négocié entre les cadres de l’administration sanitaire provinciale, l’administration centrale et les partenaires. Les trois parties prenantes se sont référées à huit fonctions jugées pertinentes pour l’administration sanitaire provinciale. Ces fonctions sont liées à la gouvernance provinciale du système sanitaire et à l’appui sociotechnique et logistique aux districts sanitaires (zones de santé). Les engagements négociés tous les trois mois ont varié en fonction du contexte et des besoins de soutien des zones de santé. Le niveau de réalisation des engagements et le score de fonctionnalité de l’administration sanitaire provinciale ont évolué respectivement de 75,3% à 87,3% et de 67% à 82%, entre 2007 et 2009. L’utilisation des services curatifs et préventifs au niveau de la province s’est également améliorée : l’utilisation des services curatifs est passée de 0,40 NC/habitant à 0,65 NC/habitant entre 2007 et 2009. En revanche peu d’améliorations de la qualité des soins ont été observées. Cette stratégie a été perçue par les acteurs impliqués comme s’étant bien intégrée à d’autres stratégies au niveau provincial et ayant renforcé leur mise en oeuvre, notamment le financement basé sur les performances au niveau des centres de santé et hôpitaux. Conclusion : Le contrat de performance peut s’avérer utile au niveau d’une administration sanitaire provinciale d’un pays à faible revenu pourvu qu’il soit mis en oeuvre dans une perspective globale. Cette perspective impose de prendre en compte certains défis notamment une articulation avec les fonctions pertinentes de l’administration sanitaire provinciale et une flexibilité

The African Political Business Cycle: Varieties of Experience

We seek to understand both the incidence and the impact of the African political business cycle in the light of a literature which has argued that, with major extensions of democracy since the 1990s, the cycle has both become more intense and has made African political systems more fragile. With the help of country-case studies, we argue, first, that the African political business cycle is not homogeneous, and occurs relatively infrequently in so-called ‘dominant-party systems’ where a pre-election stimulus confers little political advantage. Secondly, we show that, in those countries where a political cycle does occur, it does not necessarily cause institutional damage. Whether it does or not depends not so much on whether there is an electoral cycle as on whether this cycle calms or exacerbates fears of an unjust allocation of resources. In other words, the composition of the pre-election stimulus, in terms of its allocation between different categories of voter, is as important as its size

Using a community-based definition of poverty for targeting poor households for premium subsidies in the context of a community health insurance in Burkina Faso

Background: One of the biggest challenges in subsidizing premiums of poor households for community health insurance is the identification and selection of these households. Generally, poverty assessments in developing countries are based on monetary terms. The household is regarded as poor if its income or consumption is lower than a predefined poverty cut-off. These measures fail to recognize the multi-dimensional character of poverty, ignoring community members? perception and understanding of poverty, leaving them voiceless and powerless in the identification process. Realizing this, the steering committee of Nouna's health insurance devised a method to involve community members to better define `perceived? poverty, using this as a key element for the poor selection. The community-identified poor were then used to effectively target premium subsidies for the insurance scheme. Methods: The study was conducted in the Nouna's Health District located in northwest Burkina Faso. Participants in each village were selected to take part in focus-group discussions (FGD) organized in 41 villages and 7 sectors of Nouna's town to discuss criteria and perceptions of poverty. The discussions were audio recorded, transcribed and analyzed in French using the software NVivo 9. Results: From the FGD on poverty and the subjective definitions and perceptions of the community members, we found that poverty was mainly seen as scarcity of basic needs, vulnerability, deprivation of capacities, powerlessness, voicelessness, indecent living conditions, and absence of social capital and community networks for support in times of need. Criteria and poverty groups as described by community members can be used to identify poor who can then be targeted for subsidies. Conclusion: Policies targeting the poorest require the establishment of effective selection strategies. These policies are well-conditioned by proper identification of the poor people. Community perceptions and criteria of poverty are grounded in reality, to better appreciate the issue. It is crucial to take these perceptions into account in undertaking community development actions which target the poor. For most community-based health insurance schemes with limited financial resources, using a community-based definition of poverty in the targeting of the poorest might be a less costly alternative

From Poverty to Disaster and Back: a Review of the Literature

Poor people are disproportionally affected by natural hazards and disasters. This paper provides a review of the multiple factors that explain why this is the case. It explores the role of exposure (often, but not always, poor people are more likely to be affected by hazards), vulnerability (when they are affected, poor people tend to lose a larger fraction of their wealth), and socio-economic resilience (poor people have a lower ability to cope with and recover from disaster impacts). Finally, the paper highlights the vicious circle between poverty and disaster losses: poverty is a major driver of people’s vulnerability to natural disasters, which in turn increase poverty in a measurable and significant way. The main policy implication is that poverty reduction can be considered as disaster risk management, and disaster risk management can be considered as poverty reduction

The political economy of progressive fiscal contracts in Africa and Latin America

Motivation How can poorer developing countries escape from the vicious circle in which, because the state is fragile, those countries cannot raise sufficient public revenue to be able to finance development, leading to the persistence of poverty and state fragility? We explore a new approach to this problem, which we call progressive fiscal contracts, in which government earmarks the proceeds of particular taxes to be spent on forms of expenditure which will have widespread benefits for lower income groups, such as health, education and social protection. Taxpayers are thus offered a contractual relationship with government (better‐targeted delivery of public services in return for tax payments) in place of a coercive one (simply being ordered to pay taxes, with nothing being offered in exchange). We seek to examine whether this kind of contractual approach offers a way forward for developing countries. Purpose Across five countries (Bolivia, Ecuador, Venezuela, Ghana and Zambia) between 2000 and 2015, we seek to find out whether tax yields have improved following the introduction of progressive fiscal contracts, whether conflict and poverty have declined, and whether there have been countervailing costs in terms of reduced efficiency. We also examine the experience of two countries (Brazil and Chile) where there is no formal ear‐marking but government has encouraged the public to think of particular taxes as being associated with particular forms of expenditure. Approach and methods We assess the impact of changes in tax yields, welfare indicators and conflict indicators by means of panel‐data regressions, tabular comparisons and, in Bolivia, qualitative interviews. Changes in efficiency are assessed through examination of changes in tax structure. Findings Across all of the countries surveyed, the introduction of progressive fiscal contracts has been associated with a reduction in headcount poverty between 2000 and 2015, and in Bolivia our qualitative evidence suggests that the relationship can be seen as a causal one. In three cases out of five (Ghana, Bolivia and Ecuador) tax yields have increased, and in two (Ecuador and Bolivia) there was a significant reduction in political violence. In the Latin American cases examined, but not the African ones, there was a shift from royalty‐based taxation to income‐based taxation of natural resources, suggesting the likelihood of an improvement in efficiency over the period in those countries only. In these cases, the stereotypical view that progressive fiscal contracts improve equity at the expense of efficiency is contradicted. Policy implications (or conclusions) ‘Progressive fiscal contracts’, which originated as a device for making tax payments more palatable by offering social benefits in return, show promise as an innovative strategy for boosting tax ratios, reducing political violence and reducing poverty, which deserves further exploration