scholarly journals Applying the Realist Evaluation Approach to the Complex Process of Policy Implementation—The Case of the User Fee Exemption Policy for Cesarean Section in Benin

2021 ◽  
Vol 9 ◽  
Author(s):  
Jean-Paul Dossou ◽  
Sara Van Belle ◽  
Bruno Marchal
Keyword(s):  
Health Policy ◽  
Cesarean Section ◽  
Policy Implementation ◽  
National Health ◽  
Realist Evaluation ◽  
Systems Research ◽  
Fee Exemption ◽  
Exemption Policy ◽  
User Fee ◽  
Central Level

Realist evaluation is making inroads in the field of health policy and systems research to a large extent because of its good fit with complex issues. Until now, most realist studies focused on evaluating interventions or projects related to health care delivery, organization of health services, education, management, and leadership of health workers in high income countries. With this paper, we apply the realist approach to the study of national health policy implementation in a low resource country. We use the case of the user fee exemption policy for cesarean section in Benin, which we followed up from 2009 to 2018. We report on how realist evaluation can be applied for policy implementation research. We illustrate how we developed the initial programme theory—the starting point of any realist evaluation -, how we designed the study and data collection tools, and how we analyzed the data. For each step, we present current good practices, how we adapted them when needed, the challenges and the lessons learned. We report also on how the dynamic interactions between the central level (the national implementing agency) and the peripheral level (an implementing hospital) shaped the policy implementation. We found that at central level, availability of resources for a given policy is constantly challenged in the competitive national resource allocation arena. Key factors include the political power and the legitimacy of the group supporting the policy. These are influenced by the policy implementation structure, how the actual outputs of the implementation align with promises of the group supporting the policy and consequently how these outputs, the policy and its promoters are perceived by the community. We found that the service providers are key to the implementation, and that they are constrained or influenced by the dependability of the funding, their autonomy, their personal background, and the accountability arrangements. This study can inform the design and implementation of national health policies that involve interactions between central and operational level in other low-income countries.

scholarly journals Opening the ‘implementation black-box’ of the user fee exemption policy for caesarean section in Benin: a realist evaluation

2019 ◽  
Vol 35 (2) ◽  
pp. 153-166 ◽  
Author(s):  
Jean-Paul Dossou ◽  
Vincent De Brouwere ◽  
Sara Van Belle ◽  
Bruno Marchal
Keyword(s):  
Caesarean Section ◽  
Financial Incentives ◽  
Realist Evaluation ◽  
Health Coverage ◽  
Programme Theory ◽  
Financial Flows ◽  
Causal Pathways ◽  
Fee Exemption ◽  
Exemption Policy ◽  
User Fee

Abstract To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low- and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. We selected two hospitals with contrastive outcomes. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We identified two main causal pathways. First, in the state-owned hospital, which has a public-oriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor. We found that trust, perceived coercion, adherence to policy goals, perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes. Compliance with the policy depended on enforcement by hierarchical authority and bottom-up pressure. Persuasion depended on the alignment of the policy with personal and organizational values. Incentives may determine the adoption if they influence the local stakeholder’s revenue are trustworthy and perceived as fairly allocated. Failure to anticipate the differential responses of implementers will prevent the proper implementation of user fee exemption policies and similar universal health coverage reforms.

The Experience of Ghana in Implementing a User Fee Exemption Policy to Provide Free Delivery Care

2007 ◽  
Vol 15 (30) ◽  
pp. 61-71 ◽  
Author(s):  
Sophie Witter ◽  
Daniel Kojo Arhinful ◽  
Anthony Kusi ◽  
Sawudatu Zakariah-Akoto
Keyword(s):  
Delivery Care ◽  
Fee Exemption ◽  
Exemption Policy ◽  
User Fee

scholarly journals Removing user fees to improve access to caesarean delivery: a quasi-experimental evaluation in western Africa

2018 ◽  
Vol 3 (1) ◽  
pp. e000558 ◽  
Author(s):  
Marion Ravit ◽  
Martine Audibert ◽  
Valéry Ridde ◽  
Myriam de Loenzien ◽  
Clémence Schantz ◽  
...  
Keyword(s):  
Neonatal Mortality ◽  
Rural Areas ◽  
Caesarean Delivery ◽  
Positive Impact ◽  
Demographic And Health Surveys ◽  
Service Utilisation ◽  
Fee Exemption ◽  
Exemption Policy ◽  
User Fee ◽  
The Impact

IntroductionMali and Benin introduced a user fee exemption policy focused on caesarean sections in 2005 and 2009, respectively. The objective of this study is to assess the impact of this policy on service utilisation and neonatal outcomes. We focus specifically on whether the policy differentially impacts women by education level, zone of residence and wealth quintile of the household.MethodsWe use a difference-in-differences approach using two other western African countries with no fee exemption policies as the comparison group (Cameroon and Nigeria). Data were extracted from Demographic and Health Surveys over four periods between the early 1990s and the early 2000s. We assess the impact of the policy on three outcomes: caesarean delivery, facility-based delivery and neonatal mortality.ResultsWe analyse 99 800 childbirths. The free caesarean policy had a positive impact on caesarean section rates (adjusted OR=1.36 (95% CI 1.11 to 1.66; P≤0.01), particularly in non-educated women (adjusted OR=2.71; 95% CI 1.70 to 4.32; P≤0.001), those living in rural areas (adjusted OR=2.02; 95% CI 1.48 to 2.76; P≤0.001) and women in the middle-class wealth index (adjusted OR=3.88; 95% CI 1.77 to 4.72; P≤0.001). The policy contributes to the increase in the proportion of facility-based delivery (adjusted OR=1.68; 95% CI 1.48 to 1.89; P≤0.001) and may also contribute to the decrease of neonatal mortality (adjusted OR=0.70; 95% CI 0.58 to 0.85; P≤0.001).ConclusionThis study is the first to evaluate the impact of a user fee exemption policy focused on caesarean sections on maternal and child health outcomes with robust methods. It provides evidence that eliminating fees for caesareans benefits both women and neonates in sub-Saharan countries.

scholarly journals Women’s decision-making power in a context of free reproductive healthcare and family planning in rural Burkina Faso

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Camille Beaujoin ◽  
Alice Bila ◽  
Frank Bicaba ◽  
Véronique Plouffe ◽  
Abel Bicaba ◽  
...  
Keyword(s):  
Decision Making ◽  
Family Planning ◽  
Social Norms ◽  
Burkina Faso ◽  
Care Delivery ◽  
Childbearing Age ◽  
Fee Exemption ◽  
Exemption Policy ◽  
User Fee ◽  
Reproductive Healthcare

Abstract Background In 2016, the national user fee exemption policy for women and children under five was introduced in Burkina Faso. It covers most reproductive healthcare services for women including prenatal care, delivery, and postnatal care. In subsequent years, the policy was gradually extended to include family planning. While studies have shown that user fee abolition policies increase visits to health centers and improve access to reproductive healthcare and family planning, there are also indications that other barriers remain, notably women’s lack of decision-making power. The objective of the study is to investigate women’s decision-making power regarding access to reproductive health and family planning in a context of free healthcare in rural Burkina Faso. Methods A descriptive qualitative study was carried out in rural areas of the Cascades and Center-West regions. Qualitative data were collected using individual semi-structured interviews (n = 20 participants) and focus groups (n = 15 participants) with Burkinabe women of childbearing age, their husbands, and key informants in the community. Data was analyzed using thematic analysis. Results A conceptual framework describing women’s participation in the decision-making process was built from the analysis. Results show that the user fee exemption policy contributes to improving access to reproductive care and family planning by facilitating the negotiation processes between women and their families within households. However, social norms and gender inequalities still limit women’s decision-making power. Conclusion In light of these results, courses of action that go beyond the user fee exemption policy should be considered to improve women’s decision-making power in matters of health, particularly with regard to family planning. Interventions that involve men and community members may be necessary to challenge the social norms, which act as determinants of women’s health and empowerment.

scholarly journals Scaling-Up Performance-Based Financing in Burkina Faso: From PBF to User Fees Exemption Strategic Purchasing

2020 ◽  
Author(s):  
Mathieu Seppey ◽  
Valéry Ridde ◽  
Paul-André Somé
Keyword(s):  
Burkina Faso ◽  
Scale Up ◽  
Scaling Up ◽  
Healthcare Services ◽  
Decision Makers ◽  
Strategic Purchasing ◽  
Performance Based Financing ◽  
Fee Exemption ◽  
Exemption Policy ◽  
User Fee

Background: Numerous countries have undertaken performance-based financing (PBF) reforms to improve quality and quantity of healthcare services. However, only few reforms have successfully managed to achieve the different scale-up phases. In Burkina Faso, a pilot project was implemented, but was put on hold before being scaled. During the writing of this article, discussions to scale-up were still ongoing on a national strategic purchasing strategy within a government led user fee exemption policy. Methods: This study’s objective is to identify facilitators and barriers to scaling-up for that pilot, based on the World Health Organization’s (WHO’s) theoretical framework. Interviews were conducted in three health centres and in Ouagadougou to discuss the scale-up with different actors. The software QDA Miner© was used to help in the framework analysis. Results: The low involvement of some key stakeholders (mainly decision-makers) and the unstable context hindered ownership of the project, thus its priority on the political agenda. PBF reform therefore lost its momentum to the benefit of a user fee exemption policy. This latter program was seen to be more beneficial since it addressed access to healthcare services, in comparison to service quality, which was the PBF’s relative advantage. A scale-up of some PBF elements (eg, strategic purchasing tools) is however still in discussion in 2019, but would be integrated within the user fee exemption program. Increased costs during the PBF’s implementation gave the impression that the project was too costly and not scalable. The involvement of an important funding agency (World Bank, WB) also fed the impression of high costs, which demotivated the actors, especially decision-makers. Conclusion: Contextual factors remain central to the implementation of PBF, while their evaluation and mitigation have remained unclear. The participation of key actors in scaling-up operations and the use of social science as tools to better understand the context is therefore primordial.

Psychology and National Health Policy.

1981 ◽  
Vol 26 (2) ◽  
pp. 88-89
Author(s):  
Theodore H. Blau
Keyword(s):  
Health Policy ◽  
National Health ◽  
National Health Policy
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