Que sait-on en 2011 des nouvelles politiques de gratuité des soins au Mali ?

Cette note fait le point de l’état actuel des connaissances sur la gratuité des soins au Mali. La gratuité des soins permet de prendre en compte des besoins jusque-là non couverts, elle est appréciée par les populations mais inquiète les ASACO, les conseils de cercle et les agents de santé. La gratuité ne peut réussir que si des mesures d’accompagnement sont planifiées, organisées, et évaluées; et si elle est, à terme, enchâssée dans un système de protection sociale

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

Low coverage but few inclusion errors in Burkina Faso: a community-based targeting approach to exempt the indigent from user fees

<p>Abstract</p> <p>Background</p> <p>User fees were generalized in Burkina Faso in the 1990 s. At the time of their implementation, it was envisioned that measures would be instituted to exempt the poor from paying these fees. However, in practice, the identification of indigents is ineffective, and so they do not have access to care. Thus, a community-based process for selecting indigents for user fees exemption was tested in a district. In each of the 124 villages in the catchment areas of ten health centres, village committees proposed lists of indigents that were then validated by the health centres' management committees. The objective of this study is to evaluate the effectiveness of this community-based selection.</p> <p>Methods</p> <p>An indigent-selection process is judged effective if it minimizes inclusion biases and exclusion biases. The study compares the levels of poverty and of vulnerability of indigents selected by the management committees (n = 184) with: 1) indigents selected in the villages but not retained by these committees (n = 48); ii) indigents selected by the health centre nurses (n = 82); and iii) a sample of the rural population (n = 5,900).</p> <p>Results</p> <p>The households in which the three groups of indigents lived appeared to be more vulnerable and poorer than the reference rural households. Indigents selected by the management committees and the nurses were very comparable in terms of levels of vulnerability, but the former were more vulnerable socially. The majority of indigents proposed by the village committees who lived in extremely poor households were retained by the management committees. Only 0.36% of the population living below the poverty threshold and less than 1% of the extremely poor population were selected.</p> <p>Conclusions</p> <p>The community-based process minimized inclusion biases, as the people selected were poorer and more vulnerable than the rest of the population. However, there were significant exclusion biases; the selection was very restrictive because the exemption had to be endogenously funded.</p

Equity and health policy in Africa: Using concept mapping in Moore (Burkina Faso)

<p>Abstract</p> <p>Background</p> <p>This methodological article is based on a health policy research project conducted in Burkina Faso (West Africa). Concept mapping (CM) was used as a research method to understand the local views of equity among stakeholders, who were concerned by the health policy under consideration. While this technique has been used in North America and elsewhere, to our knowledge it has not yet been applied in Africa in any vernacular language. Its application raises many issues and certain methodological limitations. Our objective in this article is to present its use in this particular context, and to share a number of methodological observations on the subject.</p> <p>Methods</p> <p>Two CMs were done among two different groups of local stakeholders following four steps: generating ideas, structuring the ideas, computing maps using multidimensional scaling and cluster analysis methods, and interpreting maps. Fifteen nurses were invited to take part in the study, all of whom had undergone training on health policies. Of these, nine nurses (60%) ultimately attended the two-day meeting, conducted in French. Of 45 members of village health committees who attended training on health policies, only eight were literate in the local language (Moore). Seven of these (88%) came to the meeting.</p> <p>Results</p> <p>The local perception of equity seems close to the egalitarian model. The actors are not ready to compromise social stability and peace for the benefit of the worst-off. The discussion on the methodological limitations of CM raises the limitations of asking a single question in Moore and the challenge of translating a concept as complex as equity. While the translation of equity into Moore undoubtedly oriented the discussions toward social relations, we believe that, in the context of this study, the open-ended question concerning social justice has a threefold relevance. At the same time, those limitations were transformed into strengths. We understand that it was essential to resort to the focus group approach to explore deeply a complex subject such as equity, which became, after the two CMs, one of the important topics of the research.</p> <p>Conclusion</p> <p>Using this technique in a new context was not the easiest thing to do. Nevertheless, contrary to what local organizers thought when we explained to them this "crazy" idea of applying the technique in Moore with peasants, we believe we have shown that it was feasible, even with persons not literate in French.</p

A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa)

<p>Abstract</p> <p>Background</p> <p>African policy-makers are increasingly considering abolishing user fees as a solution to improve access to health care systems. There is little evidence on this subject in West Africa, and particularly in countries that have organized their healthcare system on the basis of the Bamako Initiative. This article presents a process evaluation of an NGO intervention to abolish user fees in Niger for children under five years and pregnant women.</p> <p>Methods</p> <p>The intervention was launched in 2006 in two health districts and 43 health centres. The intervention consisted of abolishing user fees and improving the quality of services (drugs, ambulance, etc.). We carried out a process evaluation in April 2007 using qualitative and quantitative data. Three data collection methods were used: i) individual in-depth interviews (n = 85) and focus groups (n = 8); ii) participant observation in 12 health centres; and iii) self-administered structured questionnaires (n = 51 health staff).</p> <p>Results</p> <p>The population favoured abolition; health officials and local decision-makers were in favour, but they worried about its sustainability. Among health workers, opposition to providing free services was more widespread. The strengths of the process were: a top-down phase of information and raising community awareness; appropriate incentive measures; a good drug supply system; and the organization of a medical evacuation system. The major weaknesses of the process were: the perverse effects of incentive bonuses; the lack of community-based management committees' involvement in the management; the creation of a system running in parallel with the BI system; the lack of action to support the service offer; and the poor coordination of the availability of free services at different levels of the health pyramid. Some unintended outcomes are also documented.</p> <p>Conclusion</p> <p>The linkages between systems in which some patients pay (Bamako Initiative) and some do not should be carefully considered and organized in accordance with the local reality. For the poorest patients to really benefit, it is essential that, at the same time, the quality of services be improved and mechanisms be put in place to prevent abuses. Much remains to be done to generate knowledge on the processes for abolishing fees in West Africa.</p

Studying complex interventions : reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco

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