Kingdon à Bamako : conceptualiser l’implantation d’une politique publique de santé en Afrique

Cet article est principalement d’ordre théorique. Il vise à voir comment une théorie issue de l’étude des politiques publiques associée à des concepts de l’anthropologie du développement permet de comprendre pourquoi l’implantation d’une politique de santé en Afrique de l’Ouest, l’initiative de Bamako, n’a pas produit les résultats escomptés (efficacité versus équité). L’application du prolongement de la théorie des courants de Kingdon proposée par Lemieux ainsi que l’étude du rôle des acteurs nous permettent de formuler cinq hypothèses de recherche qui rendent intelligible cette dérive. Nous tentons de montrer l’intérêt heuristique des propositions de Kingdon et de Lemieux, puis nous proposons un cadre d’analyse.In this mainly theoretical article, the author seeks to understand how a theory issued from the study of public policies associated with an anthropology of development lens helps to understand why the implementation of a health policy in West Africa, the Bamako Initiative, has not fulfilled its promises (effectiveness versus equity). The application of the extension of the agenda setting theory by Kingdon proposed by Lemieux (three streams approach), as well as the role of the actors, lead us towards five research hypothesis that explain the problem. The heuristic interest of Kingdon’s and Lemieux’s propositions are shown and an analytical framework is suggested

L’accès des indigents aux services de santé au Burkina Faso : un problème public ?

Au Burkina Faso, comme dans bien d’autres pays d’Afrique, les indigents demeurent exclus de l’accès aux services de santé, malgré la mise en oeuvre de politiques publiques qui s’étaient, entre autres objectifs, fixé celui d’améliorer leur sort. L’une des propositions d’explication à cette occultation de l’équité par les acteurs sociaux impliqués dans la mise en oeuvre de ces politiques est que la situation d’exclusion des indigents n’est pas comprise comme un problème public auquel une solution doit être trouvée. À l’aide d’une enquête de type socioanthropologique de terrain et d’un cadre d’analyse des politiques publiques, cet article vise à vérifier cette proposition au moyen de données empiriques recueillies lors d’une étude de cas au Burkina Faso. Ces données sont organisées en fonction des neuf composantes qui, conceptuellement, permettent de comprendre la manière dont une situation peut devenir un problème public.As in many other African countries, the indigent population in Burkina Faso has no access to health services, and this despite the institution of public policies that had, among other objectives, an improvement in the circumstances of the indigent. A proposed explanation for the lack of attention to equity by policy-makers and other actors involved in the implementation of these policies is that the situation of the indigent is not defined as a public problem in need of solution. This article seeks to confirm this explanation, using a socio-anthropological field inquiry and a public policy analytical framework. Empirical data were collected during fieldwork in Burkina Faso. The data are organised according to nine elements which provide a conceptual tool for understanding the manner in which such a situation could come to be defined as a public problem

Equity at all cost – and any price – for research funding in Canada?

This commentary is in response to the May 2018 announcement by the Canadian Institutes of Health Research (CIHR) of a new procedure to ensure fairer access to health research funding for participants. As such, all applicants to CIHR’s funding programs will now be required to complete a five-question questionnaire covering the dimensions of gender, age, Indigenous origin, visible minorities, and disability. On this basis, CIHR intends to gain a better understanding of the performance of its funding programs in terms of equity. In this commentary, we wish to question the theoretical and conceptual assumptions of a vision of equity framed principally in terms of diversity upstream from the research process as a founding principle of more equitable health research in Canada. We draw attention to the fact that diversity policies do not necessarily challenge inequity in research funding or in research projects. Having established the urgent need for action on equity to improve the health of populations, we recall the ethical responsibility of research and researchers to better take the various facets of equity in research into account. We recommend expanding efforts to understand and reflexively address both equity and diversity when considering the performance of population health research programsCe commentaire vient en réponse à l’annonce de mai 2018 des Instituts de recherche en santé du Canada (IRSC) d’une nouvelle procédure visant un accès plus équitable des participants au financement de la recherche en santé. À ce titre, les candidats aux programmes de financement des IRSC devront dorénavant compléter un questionnaire couvrant les cinq dimensions du genre, de l’âge, de l’origine autochtone, des minorités visibles et de l’incapacité. Sur cette base, les IRSC entendent se faire une meilleure idée du rendement de leurs programmes de financement en matière d'équité. Dans ce commentaire, nous interrogeons les postulats théoriques et conceptuels d’une vision de l’équité posée principalement sous l’angle de la diversité en amont de la recherche comme principe fondateur d’une recherche en santé plus équitable au Canada. Nous soulignons que les politiques de la diversité ne permettent pas nécessairement de s’attaquer aux inégalités dans le financement ou dans les projets de recherche. Après avoir rappelé le sens de l’équité en santé des populations et l’urgence d’agir, nous réaffirmons la responsabilité éthique de la recherche et des chercheurs à prendre en compte l’équité dans ses différents aspects et à redoubler d'efforts pour aborder de manière réflexive à la fois l'équité et la diversité dans les programmes de recherche en santé des populations

Abolishing User Fees in Africa

Valéry Ridde and Slim Haddad discuss a new trial in Ghana in which households were randomized into a pre-payment scheme allowing free primary care or to a control group who paid user fees for health care

From the Formulation of a National Policy to the Compilation of Social Protection Actions: A Case of ‘Non-design’ in Burkina Faso

To improve the social protection of its population, Burkina Faso adopted a national policy in 2012. This paper analyses the process whereby this policy was formulated, looking at the issue from the standpoint of ‘policy design’ (Howlett and Mukherjee, 2014). Conducted in accordance with an inductive qualitative approach, the collection and analysis of the data show that this process of formulation has led neither to reflecting on the problem to be solved nor to identifying the specific needs of the beneficiaries. Nor has it led to evaluating the potential outcomes of the proposed solutions in order to choose the most appropriate ones. The authors are thus led to an empirical observation of ‘non-design’. This policy boils down to a document whose all-encompassing content brings together every conceivable action of social protection, without any arbitration. Three factors have contributed to this non-formulation: (1) the lack of clear government direction to guide discussions; (2) a weakness of support and of political will, resulting in a low degree of involvement in the process on the part of high-level decision makers; and (3) conceptual and technical misunderstandings on the part of national stakeholders in social protection—so much so that they have simply relied on the advice of international bodies. The government announced its intention of playing a leading role in the process of formulating this policy, but this was a purely rhetorical declaration. The study shows that leadership and political will have been lacking, particularly when it has come to channelling the respective interests of the stakeholders and managing the contradictions that hinder the formulation of a coherent policy adapted to the needs of the population

Challenges of scaling up and of knowledge transfer in an action research project in Burkina Faso to exempt the worst-off from health care user fees

<p>Abstract</p> <p>Background</p> <p>Systems to exempt the indigent from user fees have been put in place to prevent the worst-off from being excluded from health care services for lack of funds. Yet the implementation of these mechanisms is as rare as the operational research on this topic. This article analyzes an action research project aimed at finding an appropriate solution to make health care accessible to the indigent in a rural district of Burkina Faso.</p> <p>Research</p> <p>This action research project was initiated in 2007 to study the feasibility and effectiveness of a community-based, participative and financially sustainable process for exempting the indigent from user fees. A interdisciplinary team of researchers from Burkina Faso and Canada was mobilized to document this action research project.</p> <p>Results and knowledge sharing</p> <p>The action process was very well received. Indigent selection was effective and strengthened local solidarity, but coverage was reduced by the lack of local financial resources. Furthermore, the indigent have many other needs that cannot be addressed by exemption from user fees. Several knowledge transfer strategies were implemented to share research findings with residents and with local and national decision-makers.</p> <p>Partnership achievements and difficulties</p> <p>Using a mixed and interdisciplinary research approach was critical to grasping the complexity of this community-based process. The adoption of the process and the partnership with local decision-makers were very effective. Therefore, at the instigation of an NGO, four other districts in Burkina Faso and Niger reproduced this experiment. However, national decision-makers showed no interest in this action and still seem unconcerned about finding solutions that promote access to health care for the indigent.</p> <p>Lessons learned</p> <p>The lessons learned with regard to knowledge transfer and partnerships between researchers and associated decision-makers are: i) involve potential users of the research results from the research planning stage; ii) establish an ongoing partnership between researchers and users; iii) ensure that users can participate in certain research activities; iv) use a variety of strategies to disseminate results; and v) involve users in dissemination activities.</p

The concept of mechanism from a realist approach: a scoping review to facilitate its operationalization in public health program evaluation

International audienceBackground: Public health interventions are complex by nature, and their evaluation requires unpacking their intervention logic and their interactions with open social systems. By focusing on the interrelationships between context, mechanism, and outcome, Pawson and Tilley's realist approach appears a promising innovation for public health-related evaluation works. However, and as expected of any methodological innovation, this approach is being constructed gradually by answering the multiple challenges to its operationalization that fall in its path. One of these challenges, users of this approach agree on, is the necessity of clarifying its key concept of mechanism.Method: We first collected the definitions of mechanism from published works of Pawson and colleagues. Secondly, a scoping review was conducted to identify the ones quoted by users of the realist approach for evaluating public health interventions (1997–2012). We then appraised the clarity and precision of this concept against the three dimensions defined by Daigneault and Jacobs " term, sense and referent. "Results: Of the 2344 documents identified in the scoping review, 49 documents were included. Term: Users of the realist approach use adjectives qualifying the term mechanism that were not specifically endorsed by Pawson and colleagues. Sense: None of the attributes stated by Pawson and colleagues has been listed in all of the documents analyzed, and some contributions clarified its attributes. Referent: The concept of mechanism within a realist approach can be ascribed to theory-based evaluation, complex social interventions, and critical realism.Conclusion: This review led us to reconsider the concept of mechanism within the realist approach by confronting the theoretical stance of its proponents to the practical one of its users. This resulted in a clearer, more precise definition of the concept of mechanism which may in turn trigger further improvements in the way the realist approach is applied in evaluative practice in public health and potentially beyond. A mechanism is hidden but real, is an element of reasoning and reactions of agents in regard to the resources available in a given context to bring about changes through the implementation of an intervention, and evolves within an open space-time and social system of relationships