Tony Zitti

Cette thèse s’intéresse à la mise en œuvre du projet pilote de financement basé sur les résultats (FBR) dans les hôpitaux de district (HD) de la région de Koulikoro au Mali. Le FBR a pour but d'accroître la productivité et la qualité des prestations de soins de santé offerts aux populations, en payant les centres de santé sur la base de leur performance, mesurée par la quantité et la qualité des services prodigués. Au démarrage de cette thèse, aucune recherche sur le FBR dans les hôpitaux en Afrique de l’Ouest n’avait encore été entreprise. Nous avons adopté une démarche qualitative, reposant sur un devis d’études de cas multiples. Les cas sont des HD (N=3) de la région de Koulikoro. Nous avons collecté les données d’entretiens semi-directifs (N=128), d’entretiens informels (N=16), d’observations non participantes (N=24) et de documents institutionnels (N=12). Le cadre théorique utilisé est le Consolidated Framework for Implementation Research (CFIR) avec ses différentes taxonomies, dimensions et construits pour cerner les contours de la mise en œuvre d’une intervention complexe. Nous avons réalisé une analyse thématique et utilisé le logiciel QDA Miner Lite pour l’organisation des données. Pour diffuser nos résultats empiriques et influencer la prise de décisions, ils ont été présentés aux différentes parties prenantes de la recherche sous forme de note de politique et de présentation orale lors de plusieurs ateliers délibératifs. Le premier article analyse les perceptions, les rôles du contexte et des acteurs lors de la mise en œuvre du FBR dans les HD. Les résultats montrent que la grande majorité des agents de santé adhèrent à l'intervention du FBR. Toutefois, excepté les principaux acteurs impliqués dans la mise en œuvre, les répondants avaient une connaissance partielle de l’intervention. Les acteurs perçoivent le projet pilote du FBR comme une intervention verticale, venue de l’extérieur, et centrée sur la santé de la reproduction. Les acteurs locaux n’ont pas été impliqués dans la conception du modèle du FBR. Plusieurs difficultés quant à la qualité de son design et de sa mise en œuvre sont mises en lumière : une durée trop courte de l’intervention (huit mois), le choix et le nombre insuffisants des indicateurs selon la priorité des bailleurs de fonds (Banque mondiale), et l’impossibilité d’apporter des modifications au modèle pendant sa mise en œuvre. Le deuxième article analyse le processus de répartition des primes du FBR et de ses effets sur la motivation des agents de santé dans les HD. Les résultats montrent que les agents de santé sont plus motivés à exécuter leurs tâches quand des primes sont proposées. Selon eux, au-delà de la motivation financière, le FBR leur permet de mieux travailler. Toutefois, plusieurs problèmes de mise en œuvre (retard de décaissement des primes, manque de transparence lors de la distribution) ont entrainé un sentiment de frustration et de déception des agents de santé. Le montant des primes obtenues est jugé insuffisant et les agents estiment une inadéquation entre les efforts fournis et le montant de primes obtenues par le FBR. Le troisième article analyse le processus de vérification communautaire (VC) lors de la mise en œuvre du FBR. Il a été bien perçu et bien accueilli. Cependant, la grande majorité des enquêteurs déclare avoir eu des difficultés à repérer certains patients dans la communauté : orthographe incorrecte des noms, fiches illisibles, manque de coordonnées téléphoniques et informations incomplètes, cas d’homonymie. Tout ceci était dû à la mauvaise tenue des registres des patients dans les HD. Certains enquêteurs ont rempli de manière frauduleuse des fiches sans enquêter les usagers dans les communautés à cause de manque de temps. Aucun retour des résultats de la VC n’a été possible auprès des agents de santé.

Professionals and decision‐makers in regional or local administrations often face time and resource constraints that hinder evidence‐based decision‐making. This article examines the practices, obstacles, and needs relating to evidence use within the Regional Health Agency of Ile‐de‐France, a decentralized agency of the French Ministry of Health and Access to Care. We used a mixed‐methods action research approach, including an online questionnaire completed by 60 agents. In addition, we conducted 27 semi‐structured interviews with certain staff members. We also conducted an exploratory group interview with three documentalists. The results of the structural equation models show that agents' skills in accessing evidence, institutional support and being a project leader were correlated with evidence use in decision‐making 89% ( p = 0.009), 35% ( p < 0.001), and 48% ( p = 0.031) respectively. Respondents reported having skills in identifying and accessing experiential (84.1%, p = 0.007), contextual (84.8%, p = 0.002), and scientific (73.6%, p = 0.486) knowledge. In addition, 79.5% ( p = 0.274) of respondents stated they felt competent in assessing the reliability and relevance of evidence to inform their decision‐making. Although the quantitative results show that respondents generally declared moderate to moderately high levels of competence in accessing and assessing the quality and reliability of evidence, the qualitative analysis highlights partial discrepancies. Several agents mentioned lacking the necessary skills to access and evaluate evidence effectively. This discrepancy can be explained by several factors, including a subjective overestimation of respondents' ‘competence’ in the closed‐ended questionnaires, resulting in an overall positive self‐perception, as well as obstacles to identifying and accessing scientific knowledge (language barrier), difficulties in accessing paid scientific journals, lack of time on the part of agents, and work overload. These findings highlight a disconnect between agents' perceived competence and actual capabilities in accessing and evaluating evidence. It is therefore essential to go beyond simple self‐reported measurement by using mixed‐method approaches to understand better the complexity of the factors that influence the use of evidence in decision‐making in public health agencies. Building an evidence ecosystem in decentralized organizations could lead to better‐informed policies, reduced social inequality in health, and improved resource allocation.

Purpose: This article compares the processes of community verification (CV) and user satisfaction surveys during the implementation of performance-based financing (PBF) in Mali and Burkina Faso.Design/methodology/approach: The authors adopted a qualitative approach based on a multiple-case study design. Data were collected from August 10 to 25, 2017, in Mali, and from January to May 2016 in Burkina Faso. In Mali, 191 semi-structured interviews were conducted with investigators (people who collect information from health centre users in the communities, using survey tools), users, users' relatives, and health workers in three of the 10 health districts in the Koulikoro region. In Burkina Faso, 241 non-participatory observation sessions were recorded in a research diary, and 92 semi-structured interviews and informal discussions were conducted with investigators, community verifiers, users, PBF support staff at the national level, and administrative staff in one of the 15 health districts involved in PBF. The data were analysed inductively.Findings: In both Mali and Burkina Faso, the delayed availability of survey forms led to a delay in starting the surveys. In Mali, to get off to a quick start, some investigators went to health centres to conduct the sampling with their supervisors. In both countries, investigators reported difficulties in finding certain users in the community due to incorrect spelling of names, lack of telephone details, incomplete information on the forms, common or similar sounding names within the community, and user mobility. There was little interference from health workers during user selection and surveys in both countries. In both countries, many surveys were conducted in the presence of the user's family (husband, father-in-law, brother, uncle, etc.) and the person accompanying the investigator. Also in both countries, some investigators filled in forms without investigating. They justified this data fabrication by the inadequate time available for the survey and the difficulty or impossibility of finding certain users. In both countries, the results were not communicated to health centre staff or users in either country.Research limitations/implications: CV and user satisfaction surveys are important components of PBF implementation. However, their implementation and evaluation remain complex. The instruments for CV and user satisfaction surveys for PBF need to be adapted and simplified to the local context. Emphasis should be placed on data analysis and the use of CV results.Originality/value: There are similarities and differences in the CV process and user satisfaction surveys in Mali and Burkina Faso. In Mali, the data from the user satisfaction survey was not analyzed, while in Burkina Faso, the analysis did not allow for feedback. The local non-governmental organisations (NGOs) that carried out the CV were pre-financed for 50% of the amount in Mali. In Burkina Faso, community-based organisations (CBOs) were not pre-financed. The lack of financing negatively impacted the conduction of the surveys. In Mali, fraudulent completion of survey forms by interviewers was more common in urban than in rural areas. In Burkina Faso, the frauds concerned consultations for children under five years of age. In Burkina Faso, the survey form was not adapted to collect data on the level of satisfaction of the indigent.Key messages: There were similarities and differences in the community verification (CV) processes in Mali and Burkina Faso. In both Mali and Burkina Faso, tracing users within their community was difficult for several reasons, including incorrect or incomplete information on forms, common or similar names, and user mobility. In both countries, there was no feedback on the results of the CV process to health centre staff or users. Survey forms were falsified by investigators in both countries. In Mali, falsification was more common in urban than in rural areas. In Burkina Faso, falsification was more often observed for consultations for children under five years of age.

Context: User satisfaction in health facilities is increasingly taken into account to improve the quality of care. In Mali, performance-based financing (PBF) aims to improve the quality of care by increasing the motivation, responsibility, and accountability of health workers. Community verification (CV) is one of the main functions of the PBF. CV makes it possible to monitor the effectiveness of the services reported by the health facilities and to conduct satisfaction surveys of the users who have received care. This paper aims to analyze the CV process during the implementation of the PBF in the Koulikoro region of Mali.Methods: We adopted a qualitative approach based on a multiple case study design corresponding to the district hospitals (DH) and stakeholder groups. We conducted thirty-nine semi-structured interviews with investigators, patients, and health workers in three of the ten DHs in the Koulikoro region. We designed three interview guides and inductively analyzed our data.Results: The CV process was well perceived and welcomed. However, the vast majority of interviewers reported difficulties locating some patients in the community for several reasons: incorrect spelling of names, illegible cards, lack of telephone contact information and incomplete information on the cards, and cases of homonymity. All of this was due to poor record-keeping at the health facilities. Some investigators fraudulently filled out forms without investigating users in the communities. They justified this by the lack of time available to them to conduct the CV. No feedback on the results of the CV was possible from the health workers.Conclusion: The CV is an essential component of PBF implementation. The validity, reliability, and efficiency of the measurement instruments must be considered in user-satisfaction surveys. In addition, emphasis should be placed on data analysis and the use of CV results.

Background: Performance-Based Financing (PBF), an innovative health financing initiative, was recently implemented in Mali. PBF aims to improve quality of care by motivating health workers. The purpose of this research was to identify and understand how health workers’ expectations related to their experiences of the first cycle of payment of PBF subsidies, and how this experience affected their motivation and sentiments towards the intervention. We pose the research question, “how does the process of PBF subsidies impact the motivation of health workers in Mali?”Methods: We adopted a qualitative approach using multiple case studies. We chose three district hospitals (DH 1, 2 and 3) in three health districts (district 1, 2 and 3) among the ten in the Koulikoro region. Our cases correspond to the three DHs. We followed the principle of data source triangulation; we used 53 semi-directive interviews conducted with health workers (to follow the principle of saturuation), field notes, and documents relating to the distribution grids of subsidies for each DH. We analyzed data in a mixed deductive and inductive manner.Results: The results show that the PBF subsidies led to health workers feeling more motivated to perform their tasks overall. Beyond financial motivation, this was primarily due to PBF allowing them to work more efficiently. However, respondents perceived a discrepancy between the efforts made and the subsidies received. The fact that their expectations were not met led to a sense of frustration and disappointment. Similarly, the way in which the subsidies were distributed and the lack of transparency in the distribution process led to feelings of unfairness among the vast majority of respondents. The results show that frustrations can build up in the early days of the intervention.Conclusion: The PBF implementation in Mali left health workers frustrated. The short overall implementation period did not allow actors to adjust their initial expectations and motivational responses, neither positive nor negative. This underlines how short-term interventions might not just lack impact, but instil negative sentiments likely to carry on into the future.

Introduction: Numerous sub-Saharan African countries have experimented with performance-based financing (PBF) with the goal of improving health system performance. To date, few articles have examined the implementation of this type of complex intervention in Francophone West Africa. This qualitative research aims to understand the process of implementing a PBF pilot project in Mali's Koulikoro region.Method: We conducted a contrasted multiple case study of performance in 12 community health centres in three districts. We collected 161 semi-structured interviews, 69 informal interviews and 96 non-participant observation sessions. Data collection and analysis were guided by the Consolidated Framework for Implementation Research adapted to the research topic and local context.Results: Our analysis revealed that the internal context of the PBF implementation played a key role in the process. High-performing centres exercised leadership and commitment more strongly than low-performing ones. These two characteristics were associated with taking initiatives to promote PBF implementation and strengthening team spirit. Information regarding the intervention was best appropriated by qualified health professionals. However, the limited duration of the implementation did not allow for the emergence of networks or champions. The enthusiasm initially generated by PBF quickly dissipated, mainly due to delays in the implementation schedule and the payment modalities.Conclusion: PBF is a complex intervention in which many actors intervene in diverse contexts. The initial level of performance and the internal and external contexts of primary healthcare facilities influence the implementation of PBF. Future work in this area would benefit from an interdisciplinary approach combining public health and anthropology to better understand such an intervention. The deductive–inductive approach must be the stepping-stone of such a methodological approach.

Background: To improve the performance of the healthcare system, Mali’s government implemented a pilot project of performance-based financing (PBF) in the field of reproductive health. It was established in the Koulikoro region. This research analyses the process of implementing PBF at district hospital (DH) level, something which has rarely been done in Africa. Methods: This qualitative research is based on a multiple, explanatory, and contrasting case study with nested levels of analysis. It covered three of the 10 DHs in the Koulikoro region. We conducted 36 interviews: 12 per DH with council of circle’s members (2) and health personnel (10). We also conducted 24 non-participant observation sessions, 16 informal interviews, and performed a literature review. We performed data analysis using the Consolidated Framework for Implementation Research (CFIR). Results: Stakeholders perceived the PBF pilot project as a vertical intervention from outside that focused solely on reproductive health. Local actors were not involved in the design of the PBF model. Several difficulties regarding the quality of its design and implementation were highlighted: too short duration of the intervention (8 months), choice and insufficient number of indicators according to the priority of the donors, and impossibility of making changes to the model during its implementation. All health workers adhered to the principles of PBF intervention. Except for members of the district health management team (DHMT) involved in the implementation, respondents only had partial knowledge of the PBF intervention. The implementation of PBF appeared to be easier in District 3 Hospital compared to District 1 and District 2 because it benefited from a pre-pilot project and had good leadership. Conclusion: The PBF programme offered an opportunity to improve the quality of care provided to the population through the motivation of health personnel in Mali. However, several obstacles were observed during the implementation of the PBF pilot project in DHs. When designing and implementing PBF in DHs, it is necessary to consider factors that can influence the implementation of a complex intervention