Browsing by Person "Bertone, Maria Paola"

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A window of opportunity for reform in post-conflict settings? The case of Human Resources for Health policies in Sierra Leone, 2002-2012
(2014-07-23) Bertone, Maria Paola; Samai, Mohamed; Edem-Hotah, Joseph; Witter, Sophie
Background: It is recognized that decisions taken in the early recovery period may affect the development of health systems. Additionally, some suggest that the immediate post-conflict period may allow for the opening of a political 'window of opportunity' for reform. For these reasons, it is useful to reflect on the policy space that exists in this period, by what it is shaped, how decisions are made, and what are their long-term implications. Examining the policy trajectory and its determinants can be helpful to explore the specific features of the post-conflict policy-making environment. With this aim, the study looks at the development of policies on human resources for health (HRH) in Sierra Leone over the decade after the conflict (2002-2012). Methods. Multiple sources were used to collect qualitative data on the period between 2002 and 2012: a stakeholder mapping workshop, a document review and a series of key informant interviews. The analysis draws from political economy and policy analysis tools, focusing on the drivers of reform, the processes, the contextual features, and the actors and agendas. Findings. Our findings identify three stages of policy-making. At first characterized by political uncertainty, incremental policies and stop-gap measures, the context substantially changed in 2009. The launch of the Free Health Care Initiative provided to be an instrumental event and catalyst for health system, and HRH, reform. However, after the launch of the initiative, the pace of HRH decision-making again slowed down. Conclusions: Our study identifies the key drivers of HRH policy trajectory in Sierra Leone: (i) the political situation, at first uncertain and later on more defined; (ii) the availability of funding and the stances of agencies providing such funds; (iii) the sense of need for radical change - which is perhaps the only element related to the post-conflict setting. It also emerges that a 'windows of opportunity' for reform did not open in the immediate post-conflict, but rather 8 years later when the Free Health Care Initiative was announced, thus making it difficult to link it directly to the features of the post-conflict policy-making environment. 2014 Bertone et al.; licensee BioMed Central Ltd.
An exploration of the political economy dynamics shaping health worker incentives in three districts in Sierra Leone
(Elsevier, 2015) Bertone, Maria Paola; Witter, Sophie
The need for evidence-based practice calls for research focussing not only on the effectiveness of interventions and their translation into policies, but also on implementation processes and the factors influencing them, in particular for complex health system policies. In this paper, we use the lens of one of the health system's 'building blocks', human resources for health (HRH), to examine the implementation of official policies on HRH incentives and the emergence of informal practices in three districts of Sierra Leone. Our mixed-methods research draws mostly from 18 key informant interviews at district level. Data are organised using a political economy framework which focuses on the dynamic interactions between structure (context, historical legacies, institutions) and agency (actors, agendas, power relations) to show how these elements affect the HRH incentive practices in each district. It appears that the official policies are re-shaped both by implementation challenges and by informal practices emerging at local level as the result of the district-level dynamics and negotiations between District Health Management Teams (DHMTs) and nongovernmental organisations (NGOs). Emerging informal practices take the form of selective supervision, salary supplementations and per diems paid to health workers, and aim to ensure a better fit between the actors' agendas and the incentive package. Importantly, the negotiations which shape such practices are characterised by a substantial asymmetry of power between DHMTs and NGOs. In conclusion, our findings reveal the influence of NGOs on the HRH incentive package and highlight the need to empower DHMTs to limit the discrepancy between policies defined at central level and practices in the districts, and to reduce inequalities in health worker remuneration across districts. For Sierra Leone, these findings are now more relevant than ever as new players enter the stage at district level, as part of the Ebola response and post-Ebola reconstruction.
Assessing communities of practice in health policy: a conceptual framework as a first step towards empirical research
(2013-10) Bertone, Maria Paola; Meessen, Bruno; Clarysse, Guy; Hercot, David; Kelley, Allison; Kafando, Yamba; Lange, Isabelle; Pfaffmann, Jrme; Ridde, Valry; Sieleunou, Isidore; Witter, Sophie
Communities of Practice (CoPs) are groups of people that interact regularly to deepen their knowledge on a specific topic. Thanks to information and communication technologies, CoPs can involve experts distributed across countries and adopt a 'transnational' membership. This has allowed the strategy to be applied to domains of knowledge such as health policy with a global perspective. CoPs represent a potentially valuable tool for producing and sharing explicit knowledge, as well as tacit knowledge and implementation practices. They may also be effective in creating links among the different 'knowledge holders' contributing to health policy (e.g., researchers, policymakers, technical assistants, practitioners, etc.).CoPs in global health are growing in number and activities. As a result, there is an increasing need to document their progress and evaluate their effectiveness. This paper represents a first step towards such empirical research as it aims to provide a conceptual framework for the analysis and assessment of transnational CoPs in health policy.The framework is developed based on the findings of a literature review as well as on our experience, and reflects the specific features and challenges of transnational CoPs in health policy. It organizes the key elements of CoPs into a logical flow that links available resources and the capacity to mobilize them, with knowledge management activities and the expansion of knowledge, with changes in policy and practice and, ultimately, with an improvement in health outcomes. Additionally, the paper addresses the challenges in the operationalization and empirical application of the framework.
Assessing the role of non-state actors in health service delivery and health system resilience in Myanmar
(BioMed Central, 2024-10-24) Than, K.; Bertone, Maria Paola; La, T.; Witter, Sophie
Background: Due to the weaknesses of the public health system and its low reach, especially in border areas, provision of health services by non-state actors (NSAs) has historically played an important role in Myanmar. NSAs include local and international NGOs and civil society organisations (CSOs), but also Ethnic Health Organisations (EHOs) in the border areas, as well as the private (for profit) sector. This study aims to understand the changing role of NSAs in the shifting political environment of Myanmar between 2010 and 2022, and to explore their contribution to health system resilience. Methods: Our study includes three main components: a documentary review (n = 22), key informant interviews (KIIs) at central level (n = 14) and two township-level case studies (13 KIIs, 4 FGDs). Mostly qualitative data were collected in 2022 and synthesized, using a health system resilience framework to structure the analysis. Results: During the transition period (2010–2014) and the new political era (2015–2020), while the country gradually transitioned to a democratic system, the government increasingly recognized NSAs. Initially, engagement with NSAs remained focused on disease-specific activities and government oversight was limited, but later it expanded to health system strengthening, including the start of a “convergence” with ethnic health systems. Progress was relatively slow, but defined by a clear vision and plans. The military coup of February 2021 brought a halt to this progress. Collaboration between government and NSAs was interrupted, and NSAs restored previous practices and parallel systems. Initially, most health service provision stopped, but with time coping strategies emerged, which showed the capacity of NSAs to absorb the shocks (focusing on basic services; using informal communication channels; maintaining buffer stocks of supplies) and adapt (changing modes of delivery and supply chains, and adjusting HRH training). Conclusions: The study highlights the role of NSAs during crises, and provides insights on how the resilience capacities built over time by NSAs to provide services in adverse circumstances have informed the response to the latest crisis. While strategies of absorption and adaptation are noted in the study, we did not identify any transformation strategy – which might indicate the difficulty of NSAs to introduce radical changes when subjected to multiple shocks and a hostile political environment.
The bumpy trajectory of performance-based financing for healthcare in Sierra Leone: agency, structure and frames shaping the policy process
(BioMed Central, 2018-10-20) Bertone, Maria Paola; Wurie, Haja; Samai, Mohamed; Witter, Sophie
Background - As performance-based financing (PBF) has been increasingly implemented in low-income countries, a growing literature has developed, assessing its effectiveness and, more recently, focussing on the political dynamics of PBF introduction and implementation. This study contributes to the latter body of literature by exploring decision-making processes on PBF in Sierra Leone during the 2010–2017 period. Sierra Leone presents an interesting case because of the ‘start-stop-start’ trajectory of PBF. Methods - The qualitative case study is based on a document review and 25 key informant interviews with national stakeholders and international actors. Documents and interviews were analysed based on a political economy framework focusing on actors and structure, but also making use of concepts drawn from interpretive policy analysis to look at frames. Results - Our analysis describes the process of negotiation and re-negotiation of PBF in Sierra Leone, highlighting the role of different players, both internal and external, their ideas, capacity and power relations, and the shifting narratives around PBF. It is shown that external actors driving the debate make use of ‘frames’, both actual (i.e., defining the timing and pace of the discussions, the funding available, etc.) and metaphorical (i.e., how PBF is interpreted, defined and understood) to fit in and influence the debate. This is facilitated by the lack of capacity and resources in the fragile setting. Other strategies, such as ‘venue shopping’ are employed, though they may add to fragmentation in the volatile context. Conclusions - The retrospective view of the study has an analytical advantage, but findings are also relevant to guide practice. Although power relations and rent-seeking issues are difficult to overcome in resource and capacity-constrained settings, more attention could be paid to other elements. In particular, adopting shared frames to ensure a common and inclusive understanding of technical concepts such as PBF may be useful to ensure the political sustainability of reforms. Also, the ‘actual frames’ which define negotiation and implementation should remain flexible, allowing for disrupting events (e.g., the Ebola epidemic in Sierra Leone) as well as for time to develop national capacity and ownership in order to ensure longer-term political support and better health system integration.
Context matters (but how and why?) A hypothesis-led literature review of performance based financing in fragile and conflict-affected health systems
(PLoS, 2018-04-03) Bertone, Maria Paola; Falisse, J-B; Russo, Giuliano; Witter, Sophie; ** Funder: Department for International Development; Grant num: ReBUILD; funder-id: http://dx.doi.org/10.13039/501100000278
Performance-based financing (PBF) schemes have been expanding rapidly across low and middle income countries in the past decade, with considerable external financing from multilateral, bilateral and global health initiatives. Many of these countries have been fragile and conflict-affected (FCAS), but while the influence of context is acknowledged to be important to the operation of PBF, there has been little examination of how it affects adoption and implementation of PBF. This article lays out initial hypotheses about how FCAS contexts may influence the adoption, adaption, implementation and health system effects of PBF. These are then interrogated through a review of available grey and published literature (140 documents in total, covering 23 PBF schemes). We find that PBF has been more common in FCAS contexts, which were also more commonly early adopters. Very little explanation of the rationale for its adoption, in particular in relation with the contextual features, is given in programme documents. However, there are a number of factors which could explain this, including the greater role of external actors and donors, a greater openness to institutional reform, and lower levels of trust within the public system and between government and donors, all of which favour more contractual approaches. These suggest that rather than emerging despite fragility, conditions of fragility may favour the rapid emergence of PBF. We also document few emerging adaptations of PBF to humanitarian settings and limited evidence of health system effects which may be contextually driven, but these require more in-depth analysis. Another area meriting more study is the political economy of PBF and its diffusion across contexts.
Evolution of policies on human resources for health: opportunities and constraints in four post-conflict and post-crisis settings
(BioMed Central, 2017-01-18) Witter, Sophie; Bertone, Maria Paola; Chirwa, Yotamu; Namakula, Justine; So, Sovannarith; Wurie, Haja R.
Background Few studies look at policy making in the health sector in the aftermath of a conflict or crisis and even fewer specifically focus on Human Resources for Health, which is a critical domain for health sector performance. The main objective of the article is to shed light on the patterns and drivers of post-conflict policy-making. In particular, we explore whether the post -conflict period offers increased chances for the opening of 'windows for opportunity' for change and reform and the potential to reset health systems. Methods This article uses a comparative policy analysis framework. It is based on qualitative data, collected using three main tools - stakeholder mapping, key informant interviews and document reviews - in Uganda, Sierra Leone, Cambodia and Zimbabwe. Results We found that HRH challenges were widely shared across the four cases in the post-conflict period but that the policy trajectories were different - driven by the nature of the conflicts but also the wider context. Our findings suggest that there is no formula for whether or when a 'window of opportunity' will arise which allows health systems to be reset. Problems are well understood in all four cases but core issues - such as adequate pay, effective distribution and HRH management - are to a greater or lesser degree unresolved. These problems are not confined to post-conflict settings, but underlying challenges to addressing them - including fiscal space, political consensus, willingness to pursue public objectives over private, and personal and institutional capacity to manage technical solutions - are liable to be even more acute in these settings. The role of the MoH emerged as weaker than expected, while the shift from donor dependence was clearly not linear and can take a considerable time. Conclusions Windows of opportunity for change and reform can occur but are by no means guaranteed by a crisis - rather they depend on a constellation of leadership, financing, and capacity. Recognition of urgency is certainly a facilitator but not sufficient alone. Post-conflict environments face particularly severe challenges to evidence-based policy making and policy implementation, which also constrain their ability to effectively use the windows which are presented.
Exploring implementation practices in results-based financing: The case of the verification in Benin
(Springer Nature, 2017-03-14) Antony, Matthieu; Bertone, Maria Paola; Barthes, Olivier
Background Results-based financing (RBF) has been introduced in many countries across Africa and a growing literature is building around the assessment of their impact. These studies are usually quantitative and often silent on the paths and processes through which results are achieved and on the wider health system effects of RBF. To address this gap, our study aims at exploring the implementation of an RBF pilot in Benin, focusing on the verification of results.
Health financing in fragile and conflict-affected settings: What do we know, seven years on?
(Elsevier, 2019-04-19) Bertone, Maria Paola; Jowett, Matthew; Dale, Elina; Witter, Sophie
Over the last few years, there has been growing attention to health systems research in fragile and conflict-affected setting (FCAS) from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the on-going gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.
Health financing in fragile and conflict-affected situations: A review of the evidence
(World Health Organization, 2020-04-01) Witter, Sophie; Bertone, Maria Paola; Dale, Elina; Jowett, Matthew
WHO has well-developed guidance for health financing policy, which supports progress towards universal health coverage (UHC) and overall health system goals. Central to this is the importance of public finances, and the role of government in using those finances in the best way, to strengthen their health system to maximize progress towards UHC. Fragile and conflict affected settings (FCAS) present a growing challenge for countries trying to make progress towards UHC and improve health. This paper examines the core features of FCAS, including deficits in capacity, legitimacy, and security, and considers their implications for efforts to build resilient health systems. Health financing interventions pursued in FCAS in response to both the challenges and opportunities arising from the different deficits are summarized using the WHO health financing functional approach as the organizing framework. Data analysis shows that FCAS countries have significantly higher out of pocket expenditures, greater external dependency and health-related impoverishment, as well as lower mean government expenditure on health. There are substantial challenges for health financing in FCAS settings but considerable ingenuity has also been shown in addressing them, often driven by external stakeholders. Certain approaches, such as performance-based contracting and funding emerged in FCAS settings out of the need to innovate but leave a longer legacy which is given close consideration. This paper forms provides the background to and informs a second paper which revises and adapts WHO’s health financing guidance in the context of FCAS.
Health financing policy & implementation in fragile & conflict-affected settings: A synthesis of evidence and policy recommendations
(World Health Organization, 2020-04-02) Jowett, Matthew; Dale, Elina; Griekspoor, Andre; Kabaniha, Grace; Mataria, Awad; Bertone, Maria Paola; Witter, Sophie
This paper provides tailored guidance for policy makers tasked with developing and implementing health financing policy in fragile and conflict affected situations, as well as those who advise such policy. The document takes the perspective of public policy given its central importance for the long-term development of health systems, and as such is highly relevant to the humanitarian development nexus agenda, which aims to ensure connectivity between humanitarian and development efforts, an issue highlighted during the World Humanitarian Summit 2016. The intention is to not to prescribe specific processes or health financing arrangement, but to guide policy makes to develop and implement policies in a way which increases resilience in the health system in both the short, medium and long-term. The recommendations are based on a review of evidence from a wide range of fragile and conflict-affected settings, as well as an extensive process of consultation with stakeholders. The overarching recommendations are: safeguarding the financing of critical health system functions, include population-based interventions such as disease surveillance, ensuring safe medication, water and sanitation systems, and other common goods for health. ensuring policy is consistent with a set of principles which underpin health financing in support of UHC, to avoid the development of multiple uncoordinated and incoherent schemes or sub-systems which undermines resilience in health systems. Use cash and voucher assistance (CVA) to protect human welfare to meet both health and non-health needs, but as a complement to supply-side support for the delivery of essential health services.
Health system resilience during COVID-19 understanding SRH service adaptation in North Kivu
(BMC, 2022-06-06) Ho, Lara S.; Bertone, Maria Paola; Mansour, Wesam; Masaka, Cyprien; Kakesa, Jessica
Background: There is often collateral damage to health systems during epidemics, afecting women and girls the most, with reduced access to non-outbreak related services, particularly in humanitarian settings. This rapid case study examines sexual and reproductive health (SRH) services in the Democratic Republic of the Congo when the COVID-19 hit, towards the end of an Ebola Virus Disease (EVD) outbreak, and in a context of protracted insecurity. Methods: This study draws on quantitative analysis of routine data from four health zones, a document review of policies and protocols, and 13 key-informant interviews with staf from the Ministry of Public Health, United Nations agencies, international and national non-governmental organizations, and civil society organizations. Results: Utilization of SRH services decreased initially but recovered by August 2020. Signifcant fuctuations remained across areas, due to the end of free care once Ebola funding ceased, insecurity, number of COVID-19 cases, and funding levels. The response to COVID-19 was top-down, focused on infection and prevention control measures, with a lack of funding, technical expertise and overall momentum that characterized the EVD response. Communities and civil society did not play an active role for the planning of the COVID-19 response. While health zone and facility staf showed resilience, developing adaptations to maintain SRH provision, these adaptations were short-lived and inconsistent without external support and funding. Conclusion: The EVD outbreak was an opportunity for health system strengthening that was not sustained during COVID-19. This had consequences for access to SRH services, with limited-resources available and deprioritization of SRH.
How can we strengthen partnership and coordination for health system emergency preparedness and response? Findings from a synthesis of experience across countries facing shocks.
(2022-11-29) Gooding, Kate; Bertone, Maria Paola; Loffreda, Giulia; Witter, Sophie
Discussions of health system resilience and emergency management often highlight the importance of coordination and partnership across government and with other stakeholders. However, both coordination and partnership have been identified as areas requiring further research. This paper identifies characteristics and enablers of effective coordination for emergency preparedness and response, drawing on experience from different countries with a range of shocks, including floods, drought, and COVID-19. The paper synthesises evidence from a set of reports related to research, evaluation and technical assistance projects, bringing together evidence from 11 countries in sub-Saharan Africa and South Asia. Methods for the original reports included primary data collection through interviews, focus groups and workshop discussions, analysis of secondary data, and document review. Reports were synthesised using a coding framework, and quality of evidence was considered for reliability of the findings. The reports highlighted the role played by coordination and partnership in preparedness and response, and identified four key areas that characterise and enable effective coordination. First, coordination needs to be inclusive, bringing together different government sectors and levels, and stakeholders such as development agencies, universities, the private sector, local leaders and civil society, with equitable gender representation. Second, structural aspects of coordination bodies are important, including availability of coordination structures and regular meeting fora; clear roles, mandates and sufficient authority; the value of building on existing coordination mechanisms; and ongoing functioning of coordination bodies, before and after crises. Third, organisations responsible for coordination require sufficient capacity, including staff, funding, communication infrastructure and other resources, and learning from previous emergencies. Fourth, effective coordination is supported by high-level political leadership and incentives for collaboration. Country experience also highlighted interactions between these components, and with the wider health system and governance architecture, pointing to the need to consider coordination as part of a complex adaptive system. COVID-19 and other shocks have highlighted the importance of effective coordination and partnership across government and with other stakeholders. Using country experience, the paper identifies a set of recommendations to strengthen coordination for health system resilience and emergency management. [Abstract copyright: © 2022. The Author(s).]
How do we design and evaluate health system strengthening? Collaborative development of a set of health system process goals
(2022-12-28) Bertone, Maria Paola; Palmer, Natasha; Kruja, Krista; Witter, Sophie; HSSEC Working Group 1
Strong health systems are widely recognized as a key requirement for improving health outcomes and also for ensuring that health systems are equitable, resilient and responsive to population needs. However, the related term Health Systems Strengthening (HSS) remains unclear and contested, and this creates challenges for how HSS can be monitored and evaluated. A previous review argued for the need to rethink evaluation methods for HSS to examine systemic effects of HSS investments. In line with that recommendation, this article describes the work of the HSS Evaluation Collaborative (HSSEC) in the development of a framework and tool to guide HSS monitoring, evaluation and learning by national and global actors. It was developed based on a rapid review of the literature and iterative expert consultation, with the aim of going beyond a focus on the building blocks of health systems and on health system outputs or health outcomes to think about the features that constitute a strong health system. As a result, we developed a list of 22 health system process goals which represent desirable attributes for health systems. The health system process goals (or rather, progress towards them) are influenced by positive and negative, intended and unintended effects of HSS interventions. Finally, we illustrate how the health system process goals can be operationalised for prospective and retrospective HSS monitoring, evaluation and learning, and how they also have the potential to be used for opening a space for participatory, inclusive policy dialogue about HSS.
(How) does RBF strengthen strategic purchasing of health care? Comparing the experience of Uganda, Zimbabwe and the Democratic Republic of the Congo
(BioMed Central, 2019-01-31) Witter, Sophie; Bertone, Maria Paola; Namakula, Justine; Chandiwana, Pamela; Chirwa, Yotamu; Ssennyonjo, Aloysius; Ssengooba, Freddie
Background - Results-Based Financing (RBF) has proliferated in health sectors of low and middle income countries, especially fragile and conflict-affected ones, and has been presented as a way of reforming and strengthening strategic purchasing. However, few studies have empirically examined how RBF impacts on health care purchasing in these settings. This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings: Uganda, Zimbabwe and the Democratic Republic of Congo (DRC) over the past decade.
Implementation of PM-JAY in India: a qualitative study exploring the role of competency, organizational and leadership drivers shaping early roll-out of publicly funded health insurance in three Indian states
(BMC, 2023-06-27) Srivastava, Swati; Bertone, Maria Paola; Basu, Sharmishtha; De Allegri, Manuela; Brenner, Stephan
Background The Pradhan Mantri Jan Arogya Yojana (PM-JAY), a publicly funded health insurance scheme, was launched in India in September 2018 to provide financial access to health services for poor Indians. PM-JAY design enables state-level program adaptations to facilitate implementation in a decentralized health implementation space. This study examines the competency, organizational, and leadership approaches affecting PM-JAY implementation in three contextually different Indian states. Methods We used a framework on implementation drivers (competency, organizational, and leadership) to understand factors facilitating or hampering implementation experiences in three PM-JAY models: third-party administrator in Uttar Pradesh, insurance in Chhattisgarh, and hybrid in Tamil Nadu. We adopted a qualitative exploratory approach and conducted 92 interviews with national, state, district, and hospital stakeholders involved in program design and implementation in Delhi, three state capitals, and two anonymized districts in each state, between February and April 2019. We used a deductive approach to content analysis and interpreted coded material to identify linkages between organizational features, drivers, and contextual elements affecting implementation. Results and conclusion PM-JAY guideline flexibilities enabled implementation in very different states through state-adapted implementation models. These models utilized contextually relevant adaptations for staff and facility competencies and organizational and facilitative administration, which had considerable scope for improvement in terms of recruitment, competency development, programmatic implementation support, and rationalizing the joint needs of the program and implementers. Adaptations also created structural barriers in staff interactions and challenged implicit power asymmetries and organizational culture, indicating a need for aligning staff hierarchies and incentive structures. At the same time, specific adaptations such as decentralizing staff selection and task shifting (all models); sharing of claims processing between the insurer and state agency (insurance and hybrid model); and using stringent empanelment, accreditation, monitoring, and benchmarking criteria for performance assessment, and reserving secondary care benefit packages for public hospitals (both in the hybrid model) contributed to successful implementation. Contextual elements such as institutional memory of previous schemes and underlying state capacities influenced all aspects of implementation, including leadership styles and autonomy. These variations make comparisons across models difficult, yet highlight constraints and opportunities for cross-learning and optimizing implementation to achieve universal health coverage in decentralized contexts.
Integrating healthcare financing for refugees into national health systems: findings from a rapid review of the literature
(Elsevier, 2025-10-16) Bertone, Maria Paola; Palmer, Natasha; Witter, Sophie
As the number of refugees increases and displacement becomes protracted, providing equitable healthcare in sustainable ways is increasingly challenging. The Global Compact for Refugees calls for greater inclusion of refugees in national health systems. However, evidence is limited on the most suitable approaches to achieve integration, including from a health financing perspective. This study reviewed normative and empirical literatures on health financing for refugees, reflecting on existing arrangements, and their level of integration with national health systems. A total of 52 documents were reviewed following a purposeful search of grey and published literature. Data were analysed according to core health financing sub-functions as defined by the WHO, specifically reflecting on pathways and approaches to integration for each. The analysis found that challenges remains in relation to funding for refugee healthcare, and areas of focus concern fair burden-sharing and engagement of development funders. Fund pooling proves to be a potential entry point for integration to reduce fragmentation in health financing through use of existing mechanisms (budgets or social health insurance schemes), despite challenges highlighted in the empirical literature. Fewer documents look at purchasing and benefit packages, and they highlight the importance of tailoring those to the specific needs of refugees. In relation to equity and efficiency, integration is often assumed to lead to improvements, but evidence is limited and issues related to the underlying weaknesses of the national health system might hamper the benefits of integration. Overall, the review findings support the development of hypotheses as to how best support health financing integration processes, and highlight areas for further research.
Investigating the remuneration of health workers in the DR Congo: Implications for the health workforce and the health system in a fragile setting
(Oxford University Press, 2016-01-11) Bertone, Maria Paola; Lurton, Gregoire; Mutombo, Paulin Beya
The financial remuneration of health workers (HWs) is a key concern to address human resources for health challenges. In low-income settings, the exploration of the sources of income available to HWs, their determinants and the livelihoods strategies that those remunerations entail are essential to gain a better understanding of the motivation of the workers and the effects on their performance and on service provision. This is even more relevant in a setting such as the DR Congo, characterized by the inability of the state to provide public services via a well-supported and financed public workforce. Based on a quantitative survey of 1771 HWs in four provinces of the DR Congo, this article looks at the level and the relative importance of each revenue. It finds that Congolese HWs earn their living from a variety of sources and enact different strategies for their financial survival. The main income is represented by the share of user fees for those employed in facilities, and per diems and top-ups from external agencies for those in Health Zone Management Teams (in both cases, with the exception of doctors), while governmental allowances are less relevant. The determinants at individual and facility level of the total income are also modelled, revealing that the distribution of most revenues systematically favours those working in already favourable conditions (urban facilities, administrative positions and positions of authority within facilities). This may impact negatively on the motivation and performance of HWs and on their distribution patters. Finally, our analysis highlights that, as health financing and health workforce reforms modify the livelihood opportunities of HWs, their design and implementation go beyond technical aspects and are unavoidably political. A better consideration of these issues is necessary to propose contextually grounded and politically savvy approaches to reform in the DR Congo.
Le défi de la fidélisation des personnels de santé dans les zones rurales: analyse des stratégies mises en œuvre dans sept pays d’Afrique francophone = The challenge of health workforce retention in rural areas: an analysis of the strategies implemented in seven countries of francophone Africa.
(2017-09-25) Bertone, Maria Paola
Objectifs: De nombreux pays font face à des défis en termes de nombre, de composition, de compétences et de distribution des ressources humaines pour la santé. Cet article décrit les interventions de fidélisation adoptées au cours de la dernière décennie dans sept pays d’Afrique francophone et les compare aux recommandations de l’OMS, en évaluant l’étendue de l’adoption des politiques reflétant ces recommandations. Méthodes: L’étude se base sur la comparaison d’études de cas, et a été articulée en deux phases. Premièrement, sept pays d’études ont été consultés pour faire une cartographie et une analyse préliminaire des interventions. Deuxièmement, une synthèse analytique a été préparée en comparant systématiquement les études de cas. Résultats: Les résultats indiquent que les politiques de fidélisation des ressources humaines envisagent rarement un « éventail » des interventions et que certaines des recommandations de l’OMS sont moins souvent adoptées que d’autres. L’analyse montre aussi l’existence d’efforts pour développer des stratégies (informelles) locales, alors que l’élaboration des politiques officielles demeure souvent un exercice standardisé, sans une véritable réflexion spécifique au contexte. En outre, il y a peu d’information sur la mise en œuvre et sur l’efficacité des politiques en place. Discussion et conclusion: L’étude souligne l’importance de la disponibilité des données, ainsi que des outils de suivi et d’évaluation, de même que de la création d’un environnement politique favorable à l’élaboration de stratégies réalistes et fondées sur l’identification des besoins. En effet, les « bonnes pratiques » sont souvent le résultat d’adaptations locales, plutôt que de l’adoption de lignes directrices standardisées. Pour être efficaces, les recommandations internationales doivent être complétées par des connaissances construites et appropriées localement. Objectives: Many countries face challenges in terms of number, skill mix, quality and distribution of the health workforce. This paper provides an overview of interventions focusing on retention adopted over the last decade in seven countries of francophone Africa. We assessed these interventions with respect to WHO guidelines and evaluated the extent of application of these recommended policies. Methods: This study was conducted according to a comparative multiple case-study design and comprised two phases. First, seven country reports were consulted to provide a mapping and preliminary analysis of the interventions. Secondly, an analytic synthesis was prepared by systematically and deliberately comparing and contrasting country cases in order to draw higher-level conclusions. Results: This comparative analysis indicated that some WHO guidelines are introduced less often than others and HRH retention policies are rarely envisaged within coherent 'bundles' of interventions. This analysis identifies the efforts to develop local (informal) strategies tailored to the context, while official policy-making often remains a standardized exercise, which does not take context-specific features into account. Moreover, little information is available on the implementation and effectiveness of existing policies. Discussion and conclusions: The study stresses the importance of two key issues for the design of effective policies: the availability of sound data, as well as monitoring and evaluation structures, and the creation of a supportive and coherent political environment, focused on country-driven, realistic policy-making based on contextual problem identification and actual needs. This paper also suggests that good practices are often the result of local adaptations, rather than the close adoption of standardized guidelines. Therefore, in order to be effective, international guidelines must be complemented by locally acquired and fully appropriated knowledge.
Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone
(BioMed Central, 2016-07-19) Bertone, Maria Paola; Lagarde, M.; Witter, Sophie
motivation and performance. However, the literature so far tends to look at PBF payments in isolation, without reference to the overall remuneration of health workers. Taking the case of Sierra Leone, where PBF was introduced in 2011, this study investigates the absolute and relative contribution of PBF to health workers' income and explores their views on PBF bonuses, in comparison to and interaction with other incomes. Methods: The study is based on a mixed-methods research consisting in a survey and an 8-week longitudinal logbook collecting data on the incomes of primary health workers (n = 266) and 39 in-depth interviews with a subsample of the same workers, carried out in three districts of Sierra Leone (Bo, Kenema and Moyamba). Results: Our results show that in this setting PBF contributes about 10 % of the total income of health workers. Despite this relatively low contribution, their views on the bonuses are positive, especially compared to the negative views on salary. We find that this is because PBF is seen as a complement, with less sense of entitlement compared to the official salary. Moreover, PBF has a specific role within the income utilization strategies enacted by health workers, as it provides extra money which can be used for emergencies or reinvested in income generating activities. However, implementation issues with the PBF scheme, such as delays in payment and difficulties in access, cause a series of problems that limit the motivational effects of the incentives. Overall, staff still favor salary increases over increases in PBF. Conclusions: The study confirms that the remuneration of health workers is complex and interrelated so that the different financial incentives cannot be examined independently from one. It also shows that the implementation of PBF schemes has an impact on the way it does or does not motivate health workers, and must be thoroughly researched in order to assess the impact of PBF.