Browsing by Person "Marchal, Bruno"

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Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco
(BioMed Central, 2016-08-02) Witter, Sophie; Boukhalfa, C.; Cresswell, Jenny A.; Daou, Z.; Filippi, Veronique; Ganaba, Rasman; Goufodji, Sourou B.; Lange, Isabelle; Marchal, Bruno; Richard, Fabienne
Background: Across the Africa region and beyond, the last decade has seen many countries introducing policies aimed at reducing financial barriers to obstetric care. This article provides evidence of the cost and effects of national policies focussed on improving financial access to caesarean and facility deliveries in Benin, Burkina Faso, Mali and Morocco. Methods: The study uses a comparative case study design with mixed methods, including realist evaluation components. This article presents results across 14 different data collection tools, used in 4-6 research sites in each of the four study countries over 2011-13. The methods included: document review; interviews with key informants; analysis of secondary data; structured extraction from medical files; cross-sectional surveys of patients and staff; interviews with patients and observation of care processes. Results: The article finds that the policies have contributed to continued increases in skilled birth attendance and caesarean sections and a narrowing of inequalities in all four countries, but these trends were already occurring so a shift cannot be attributed solely to the policies. It finds a significant reduction in financial burdens on households after the policy, suggesting that the financial protection objectives may have been met, at least in the short term, although none achieved total exemption of targeted costs. Policies are domestically financed and are potentially sustainable and efficient, and were relatively thoroughly implemented. Further, we find no evidence of negative effects on technical quality of care, or of unintended negative effects on untargeted services. Conclusions: We conclude that the policies were effective in meeting financial protection goals and probably health and equity goals, at sustainable cost, but that a range of measures could increase their effectiveness and equity. These include broadening the exempted package (especially for those countries which focused on caesarean sections alone), better calibrated payments, clearer information on policies, better stewardship of the local health system to deal with underlying systemic weaknesses, more robust implementation of exemptions for indigents, and paying more attention to quality of care, especially for newborns.
How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia
(2021-06-29) Marchal, Bruno; Abejirinde, Ibukun-Oluwa Omolade; Sulaberidze, Lela; Chikovani, Ivdity; Uchaneishvili, Maia; Shengelia, Natia; Diaconu, Karin; Vassall, Anna; Zoidze, Akaki; Giralt, Ariadna Nebot; Witter, Sophie
This paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt. Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders' assumptions on challenges and possible solutions for better TB control. Two participatory workshops were conducted with key actors, interspersed by reflection meetings within the research team and discussions with policymakers. Using concept mapping and causal mapping techniques, and drawing causal loop diagrams, we visualised how actors understood TB service provision challenges and the potential means by which a results-based financing (RBF) policy could address these. The study was conducted in Tbilisi, Georgia. A total of 64 key actors from the Ministry of Labour, Health and Social Affairs, staff of the Global Fund to Fight AIDS, TB and Malaria Georgia Project, the National Centre for Disease Control and Public Health, the National TB programme, TB service providers and members of the research team were involved in the workshops. Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organisational incentives, retraining service providers, clear redistribution of roles to support an integrated care model, and refinement of monitoring tools. Health system elements, such as effective referral systems and health information systems were highlighted as necessary for service improvement. Developing policies that address complex issues requires methods that facilitate linkages between multiple stakeholders and between theory and practice. Such participatory approaches can be informed by realist evaluation principles and visually facilitated by causal loop diagrams. This approach allowed us leverage stakeholders' knowledge and expertise on TB service delivery and RBF to codesign a new policy. [Abstract copyright: © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.]
Primary Health Care in the 21st century: Primary care providers and people’s empowerment
(Wiley, 2010-02-09) Van Olmen, Josefien; Criel, Bart; Devadasan, Narayanan; Pariyo, George; De Vos, Pol; Van Damme, Wim; Van Dormael, Monique; Marchal, Bruno; Kegels, Guy
International health debates often confront enduring values with new realities. The events and publications surrounding the 30th anniversary of Alma Ata, the Primary Health Care (PHC) focus of the 2008 World Health Report and the report(s) of the Commission on Social Determinants of Health illustrate the durability of PHC values such as equity, self-determination, participation, trans-sectoral collaboration and the right to health (Gilson et al. 2007; Chan 2008; Lawn et al. 2008; Reich et al. 2008; Walley et al. 2008; World Health Organisation 2008; Hanson et al. 2009). Taking into account recent transitions that are changing the relationship between primary care providers and their patients, we examine the role providers can play in enhancing people’s individual and collective empowerment, an important but rather neglected component of PHC (Walley et al. 2008).
'Rowing against the current': The policy process and effects of removing user fees for caesarean sections in Benin
(BMJ, 2018-02-02) Dossou, Jean-Paul; Cresswell, Jenny A.; Makoutode, Patrick; De Brouwere, Vincent; Witter, Sophie; Filippi, Veronique; Kanhonou, Lydie G.; Goufodji, Sourou B.; Lange, Isabelle; Lawin, Lionel; Affo, Fabien; Marchal, Bruno
Background In 2009, the Benin government introduced a user fee exemption policy for caesarean sections. We analyse this policy with regard to how the existing ideas and institutions related to user fees influenced key steps of the policy cycle and draw lessons that could inform the policy dialogue for universal health coverage in the West African region. Methods Following the policy stages model, we analyse the agenda setting, policy formulation and legitimation phase, and assess the implementation fidelity and policy results. We adopted an embedded case study design, using quantitative and qualitative data collected with 13 tools at the national level and in seven hospitals implementing the policy. Results We found that the initial political goal of the policy was not to reduce maternal mortality but to eliminate the detention in hospitals of mothers and newborns who cannot pay the user fees by exempting a comprehensive package of maternal health services. We found that the policy development process suffered from inadequate uptake of evidence and that the policy content and process were not completely in harmony with political and public health goals. The initial policy intention clashed with the neoliberal orientation of the political system, the fee recovery principles institutionalised since the Bamako Initiative and the prevailing ideas in favour of user fees. The policymakers did not take these entrenched factors into account. The resulting tension contributed to a benefit package covering only caesarean sections and to the variable implementation and effectiveness of the policy. Conclusion The influence of organisational culture in the decision-making processes in the health sector is often ignored but must be considered in the design and implementation of any policy aimed at achieving universal health coverage in West African countries.
Studying complex interventions: reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco
(BioMed Central, 2013-11-08) Marchal, Bruno; Van Belle, Sara; De Brouwere, Vincent; Witter, Sophie
Background The importance of complexity in health care policy-making and interventions, as well as research and evaluation is now widely acknowledged, but conceptual confusion reigns and few applications of complexity concepts in research design have been published. Taking user fee exemption policies as an entry point, we explore the methodological consequences of 'complexity' for health policy research and evaluation. We first discuss the difference between simple, complicated and complex and introduce key concepts of complex adaptive systems theory. We then apply these to fee exemption policies. Design We describe how the FEMHealth research project attempts to address the challenges of complexity in its evaluation of fee exemption policies for maternal care. We present how the development of a programme theory for fee exemption policies was used to structure the overall design. This allowed for structured discussions on the hypotheses held by theresearchers and helped to structure, integrate and monitor the sub-studies. We then show how the choice of data collection methods and tools for each sub-study was informed by the overall design. Discussion Applying key concepts from complexity theory proved useful in broadening our view on fee exemption policies and in developing the overall research design. However, we encountered a number of challenges, including maintaining adaptiveness of the design during the evaluation, and ensuring cohesion in the disciplinary diversity of the research teams. Whether the programme theory can fulfil its claimed potential to help making sense of the findings is yet to be tested. Experience from other studies allows for some moderate optimism. However, the biggest challenge complexity throws at health system researchers may be to deal with the unknown unknowns and the consequence that complex issues can only be understood in retrospect. From a complexity theory point of view, only plausible explanations can be developed, not predictive theories. Yet here, theory-driven approaches may help.