Le financement basé sur les résultats au Bénin et au Sénégal : Un levier pérenne de changement de pratiques des agents de santé ?

Le financement basé sur les résultats (ou FBR) est depuis près de vingt ans largement implanté dans les pays à revenu faible et intermédiaire avec l’objectif de motiver les personnels de santé à augmenter la quantité et améliorer la qualité des soins prodigués. Néanmoins, l’approche de FBR souffre toujours d’un manque de données probantes (et cohérentes) quant à ses effets, et d’une insuffisante compréhension des facteurs motivationnels qui en expliquent la présence ou l’absence. Cette recherche doctorale entend contribuer à combler ce manquement. Elle vise à explorer le potentiel de changement de pratiques des agents de santé impliqués dans le FBR au Bénin et au Sénégal, et à mettre au jour les multiples facteurs explicatifs sous-jacents à l’œuvre dans la réalisation de ces changements. L’originalité de notre recherche est multiple. Elle combine deux pays d’étude, analyse plusieurs programmes de FBR, avec un accent original sur la question de la pérennité des effets du FBR au Bénin. Elle se base également sur l’articulation de méthodes de recherche qualitative (recherches documentaires, observations participantes, entretiens semi-directifs) et quantitative (analyses statistiques). Elle mobilise, enfin, un cadre d’analyse original et dynamique – le I-Change model. Il ressort de notre étude de terrain que le FBR permet, selon les agents de santé interrogés, de changer certaines de leurs pratiques, même si les modifications décrites ne sont pas systématiques. En ce qui concerne le Sénégal, ces changements ne s’accompagnent pas d’une amélioration systématique des indicateurs de santé, même lorsque le FBR est combiné à un appui à la demande au travers d’un mécanisme de transfert monétaire conditionnel. Notre étude démontre que le potentiel du FBR à influer sur les pratiques des agents de santé ne s’explique pas uniquement par l’incitant financier, qui constitue pourtant un élément central dans la stratégie de diffusion des approches de financement de type results-based. En effet, de nombreux leviers de changement de pratiques des agents de santé – matériels comme immatériels – ont été identifiés, alors que d’autres n’ont pas été activés, ou du moins pas toujours entièrement. La seconde enquête de terrain au Bénin, respectivement 9 et 12 mois après l’arrêt des programmes FBR, a montré une tendance générale au « relâchement » progressif du « sérieux », de la « rigueur » professionnelle, de même qu’une désactivation de certains leviers de changement de pratiques du FBR. Les programmes de FBR béninois n’ont pas eu d’effets pérennes. Par ailleurs, nos études de terrain ont montré que le contexte d’implantation des programmes FBR joue un rôle crucial – pouvant être facilitateur ou entravant – dans l’atteinte et le maintien de ses résultats. Ensemble, ces constats remettent en cause l’idée que le FBR peut constituer une approche efficace pour répondre aux dysfonctionnements des systèmes de santé. Ils appellent plutôt une mise en œuvre coordonnée des programmes de FBR avec les différentes réformes engagées ou à engager au sein des systèmes de santé nationaux (portant notamment sur la rémunération des ressources humaines pour la santé et le financement du plateau technique). Une mise en œuvre qui devrait s’inscrire dans une réflexion de fond sur les défis relatifs tant à l’offre et qu’à 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 workers’ 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 workers’ practices cannot be only explained by the financial incentive, which is central in results-based approaches dissemination strategy. Indeed, many levers for changing health workers’ 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 “relaxation” of “seriousness”, of professional “rigor”, 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 – 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 d’Actions de Recherche Concertées (ARC) « Effi-Santé » « 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 “the continuation of benefits from a development intervention after major development assistance has been completed”, 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 PBF’s effect over providers’ 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 providers’ 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 practitioners’ 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, Côte 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

Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches

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 “adherence” 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 d’intégration de la médecine traditionnelle dans le système de santé public burkinabè. Etude de cas : la commune rurale de Baskouré

La préoccupation majeure de cette étude est d’exprimer la situation prévalente au Burkina Faso en matière de pluralisme médical en procédant à un état des lieux du processus politique de revalorisation de la médecine traditionnelle et de sa collaboration avec la pratique biomédicale « moderne » . Pour ce faire, il a été question de souligner les représentations mutuelles des acteurs issus de la médecine traditionnelle et ceux issus de la médecine « conventionnelle ». Ensuite, prêter attention aux rapports entre les deux thérapeutiques grâce aux pratiques et discours des praticiens nous a permis de mesurer qualitativement le degré d’acceptabilité et les représentations liées au processus d’intégration de la médecine traditionnelle dans le système de santé publique burkinabè tel que recommandé par l’Organisation Mondiale de la Santé

Analyse pré évaluative de la fidélité de l’implantation de la politique de financement basé sur les résultats au Burkina Faso

A l’aube des Objectifs du Millénaire pour le Développement (OMD) dont l’atteinte semble malheureusement compromise, le Burkina Faso rend compte d’un certain engouement pour le financement basé sur les résultats (FBR), plébiscité comme pouvant contribuer à l’amélioration de la performance des systèmes de santé et ainsi, redresser dans un dernier élan les statistiques sanitaires du pays avant 2015. Le Burkina Faso lance dès lors aujourd’hui l’élargissement de sa phase-test du FBR en une phase pilote. Notre modeste ambition dans le cadre de ce travail était 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 état des lieux, nous avons procédé à une analyse documentaire, à des entretiens et nous sommes pliés à l’observation participante ; ce qui nous a permis de décrire les logiques d’intervention initiale (2011) et planifiée (2014) de l’intervention FBR. Nous avons ensuite comparé ces deux logiques et avons ensuite dressé la liste planifiée des activités. Puis, nous avons porté une appréciation sur la pertinence du modèle FBR planifié. Il ressort de notre étude que la logique de l’intervention FBR telle qu’elle est actuellement planifiée (2014) diffère de celle qui était initialement prévue (2011). On note, entre autres, des changements terminologiques, une augmentation du nombre de districts sanitaires (DS) considérés par l’intervention, une idée de randomisation de ces DS selon une logique d’essai contrôlé randomisé (ECR), une modification de la logique de paiement FBR aujourd’hui limité aux districts de traitement, l’apparition d’une préoccupation d’équité accompagnée d’un seuil de 10% d’indigents exemptés pour les soins de santé (malgré une sélection plafonnée à 20%), une complexification des processus de vérification 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 d’intégration de l’intervention FBR dans le paysage sanitaire burkinabè. Si les conditionnalités de la Banque Mondiale, les questions budgétaires et le contact du terrain permettent d’expliquer certain de ces changements, il n’en est pas de même pour le reste des modifications qui ne trouvent, à ce jour, pas d’explication. Plus fondamentalement, le modèle du FBR burkinabè souffre dans son design actuel de nombreuses apories : iniquité inter- et intra-formations sanitaires, rationnement déséquilibré des indigents (20% d’indigents sélectionnés pour, au maximum, 10% d’indigents exemptés pour les soins de santé), consommation de temps et d’énergie importante et manque de cohérence de la politique au regard des réformes sanitaires précédentes. Autant d’éléments sur lesquels les décideurs doivent aujourd’hui se pencher en vue de la mise en œuvre de la phase pilote de l’intervention au Burkina Faso sinon quoi, le FBR pourrait bien ne pas répondre aux espérances qu’on lui assigne et voir sa viabilité institutionnelle mise en péril

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 intervention’s foundations. Our study provides an overview of the implementation fidelity of a RBF program in Burkina Faso using one aspect of fidelity: “adherence” 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

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