Background
In May 2011, the World Health Assembly (WHA 64.9) reminded all countries of the need to avoid point-of-service user fees in order to achieve universal coverage. This was in keeping with resolutions of the African Union and United Nations agencies favouring point-of-service user fees exemptions for pregnant women and children under the age of five years [
1,
2]. However, at the same time, this World Health Assembly resolution stressed the importance of promoting a sharing of experience among countries on this matter. This article is aimed at contributing to that exchange.
Faced with the financial barrier created by user fees generalized across Africa in the 1990s [
3], more and more countries have chosen to implement user fees exemption policies. Most often these are aimed at certain services or categories of persons. Southern Africa was the first African region to embark on this initiative to find a solution to the population’s difficulties with financial access to services. Several surveys of the scientific literature on these recent policies have produced syntheses of the state of current knowledge [
4‐
6], and in so doing have echoed the cautionary advice put forward when these policies were first implemented [
7]. However, these surveys also show that in early 2009, when the project described in this article was conceived, scientific studies on these policies in West Africa were rare. At mid-July 2008, no scientific article on West Africa had yet been published [
4] and by the end of 2009, to our knowledge, only one article on an experience in Niger had been published [
8].
In fact, a series of cursory analyses done in 2009 of the implementation of these policies in several countries in the region clearly showed that the technicians putting these policies in place: i) often encountered the same operational challenges, sometimes made the same errors and did not borrow enough ideas from similar experiences; and ii) had experiences that, if put to use, would be helpful in producing pragmatic knowledge about these policies and drawing lessons from their implementation [
9].
Indeed, just as researchers produce scientific knowledge, the experience of street-level bureaucrats [
10] is a tacit source of knowledge that can be updated and put to use in a short time, without the long delays associated with producing scientific results [
11‐
13].
Thus, the objective of this article is to present a transversal analysis of the results of a knowledge aggregation process undertaken with street-level bureaucrats regarding user fees exemption policies in six West African countries (Benin, Burkina Faso, Mali, Niger, Togo and Senegal). This analysis was based on the results produced by each of the six teams working in the countries during a knowledge aggregation exercise published in a report [
14]. These case studies aimed to combine both tacit and scientific knowledge through a collaborative and participative process. Each team had performed a case study of one or more specific public policies, and we sought to understand whether, notwithstanding the heterogeneity of the studies, we could uncover any recurrent themes, points in common, as well as any innovations. Highlighting the elements that are convergent along with those that may be divergent is useful for drawing lessons on how policies were implemented in these six countries.
While all these policies were largely aimed at reducing the financial barrier to healthcare access in West Africa, they differed in terms of their contexts, the target publics and the services involved. In Table
1, some of the contextual indicators are compared.
Table 1
Some indicators from the six countries
Population (in thousands, 2008) | 8,662 | 15,234 | 12,706 | 14,704 | 12,211 | 6,459 |
Life expectancy at birth (years, 2008) | 57 | 51 | 49 | 52 | 59 | 59 |
Neonatal mortality rate (per 1,000 live births, 2008) | 33 | 36 | 52 | 34 | 34 | 33 |
< 5 years mortality rate (probability of death before the age of 5 years per 1,000 live births, 2008) | 121 | 169 | 194 | 167 | 108 | 98 |
Maternal mortality ratio (per 100,000 live births, 2005) | 840 | 700 | 970 | 1 800 | 980 | 510 |
Prenatal consultation rate (coverage by antenatal services (%): at least 1 visit in 2009) | 84 | 85 | 70 | 46 | 87 | 84 |
Rate of assisted deliveries (births assisted by qualified health personnel (%), 2008) | 78 | 54 | 49 | 18 | 52 | 62 |
Physician rate (per 10,000 inhabitants, 2009) | 0.63 | 0.60 | 0.83 | 0.2 | 0.61 | 0.54 |
State spending on health (as a % of total State spending, 2007) | 10.7 | 13.3 | 11.8 | 12.4 | 12.1 | 7.7 |
Total spending on health per capita in $ (PPA $ int., 2007) | 70 | 72 | 67 | 35 | 99 | 68 |
Public spending on health per inhabitant (PPA $ int., 2007) | 36 | 40 | 34 | 18 | 56 | 17 |
% GDP in health (total health spending as a % of gross domestic product, 2007) | 4.8 | 6.1 | 5.7 | 5.3 | 5.7 | 6.1 |
Methods
The methodological approach used for this inter-country knowledge aggregation process was one of multiple case studies with several embedded levels of analysis [
16].
The cases were made up of certain user fees exemption policies implemented in six countries. Case selection was instrumental to the process, in that it was based on feasibility and on the utility that country team members could draw from the results they would produce [
17]. Table
2 summarizes the content of these policies, for which details are available elsewhere [
14].
Table 2
Synthesis of the content of the policies studied
Services exempted (year of initiation)
| Caesareans (2009) | All types of deliveries (2006/2007) | Caesareans (2005) and antimalaria treatments (2007) | Caesareans (2005) and consultations for children under 5 years (2006) | Consultations for persons over the age of 60 years (2006) | ARV treatment for PLHIV (2008) |
Source of financing
| State | State | State (with partners for malaria inputs) | State and partners | State | State and partners |
Reimbursement method
| Fixed-rate reimbursement by the act | Fixed-rate reimbursement by the act (plus actual expenses) | Provision of inputs (and fixed-rate reimbursement of acts for caesareans) | Fixed-rate reimbursement | Drug vouchers and budget allocation | Provision of inputs |
Governance
| Independent national agency | Cell of the Ministry of Health’s Department of Health and Family | Steering committees | Free healthcare services steering committee of the Ministry of Health | Steering committee | National Anti-AIDS Program |
The teams carried out a framework analysis process [
19] using a common framework to describe the context of the public policies studied and their content, as well their formulation, implementation and effects, thereby following the classic divisions of the study of public policies [
12].
Each team used multiple sources of data to be able to triangulate the information. The persons in charge of country case studies received training sessions in methodology and were closely followed. Table
3 summarizes the methods used in each country. It should also be noted that, since the methodological approach adopted meant that the case studies were produced by people involved in the policies’ implementation, all the case studies thus benefited from data coming from the actors’ experiences, that is, participant observations used largely in internal team meetings (in each country) and regional groups (in Ouagadougou).
Table 3
Synthesis of the data sources used in each country
Documentation
| 9 reports 7 decrees, memorandums, 2 theses | 12 reports 1 memorandum 1 newspaper article 1 scientific article | 15 reports 1 master’s thesis 3 laws, decrees and letters | 12 reports 1 law 1 scientific article | 17 reports 4 decrees or circulars 5 newspaper articles 1 thesis 1 scientific article | 26 reports 5 decrees, laws and procedures |
Questionnaire
| - | - | - | - | 30 persons | - |
Individual and group discussions
| 15 | - | - | 10 | 33 | 25 |
Country team workshops
| 2 | 2 | 3 | 2 | 2 | 4 |
In Benin, the team consisted of a health sociologist, a public hospital manager and the director of an NGO supporting mutual health organizations. They conducted 15 individual interviews with managers in the Ministry of Health involved in these policies, did an in-depth documentary analysis, and held two team meetings.
In Burkina Faso, the team consisted of three Ministry of Health representatives from central departments and one district, two physicians, and a health attaché from an NGO supporting user fees exemption policies. This team carried out an in-depth documentary analysis and held two team meetings.
The Mali team consisted of five people from central departments of the Ministry of Health responsible for exemption policies and the medical coordinator of an NGO supporting these policies. The team carried out a large documentary study and conducted three workshops open to other people in the Ministry to obtain additional data.
In Niger, the team consisted of four people from departments of the Ministry of Health and three members of NGOs involved in supporting the implementation of user fees exemption policies. The team held two working sessions, conducted an in-depth documentary analysis, and conducted 10 qualitative interviews with members of the cell coordinating the policy, representatives of two NGOs, and persons from the Ministry of Health’s planning department.
In Senegal, the team consisted mainly of three people: a geriatrician in charge of a health facility, a consultant researcher in social policy, and a researcher in political science. The team used a self-administered questionnaire completed by 10 managers and five directors of healthcare facilities, as well as by 15 elderly persons. These respondents were randomly selected from health facilities in the Dakar region that were directly involved in implementing the free healthcare policy for elderly persons (i.e., Sesame plan). The team also organized three discussion groups, each with eight elderly persons, all of whom were randomly selected from among the patients of Dakar’s only geriatric centre. In addition, 25 qualitative interviews were carried out with five Sesame plan managers from the central level, two agents of the national health financing cell, 10 physician managers, and eight members of the health committees of the 10 health facilities that received the questionnaires. These interviews and discussions with a total of 49 people, conducted in French and in the national language, were recorded. Finally, a documentary analysis was also carried out.
In Togo, the team was made up of five managers of the national HIV program and two members of patients’ associations. The team carried out an in-depth documentary analysis, conducted 25 individual interviews of healthcare providers, persons living with HIV, and members of the Ministry of Health, and organized four team meetings, one of which was largely open to outside guests with useful information to document the policy.
To do the transversal analysis that synthesizes the knowledge produced by the countries, we focused our analytical approach on highlighting, on one hand, the policies’ main intervention components (the technical aspects of implementation), and on the other, the attitudes and reactions of the actors involved in these components. These implementation components and actor’s attitudes were identified by means of two exploratory workshops carried out with decision-makers in Burkina Faso and in Mali in June 2010 and a review of the available grey literature on exemption policies implemented in these six countries [
18]. These two sources allowed us to uncover the existence of:
• Five main implementation components: management (S1), communication (S2), monitoring / evaluation / coordination (S3), community involvement (S4), and patient management and referral (S5);
• Five main actor’s attitudes : health workers’ motivation and satisfaction (A1), the provider–patient relationship (A2), patients’ satisfaction (A3), patients’ perceptions on health and on financial access to healthcare (A4), and health workers’ coping strategies (A5).
We thus synthesized the data produced by each country to highlight, first, the core elements from the perspective of this analytical framework [
19], then the commonalities and some particular features. These latter features were specifically highlighted when they were innovative in relation to current policy processes implemented in West Africa [
4,
9]. Therefore, this transversal analysis was conducted based on three data sources.
The first source consisted of ongoing discussions and interactions between the authors of this article and the country team members regarding their specific case study. These discussions took place at three regional workshops between October 2010 and May 2011 that brought together all the authors of the country case studies, first to launch their studies, then to present progress reports. To prepare for the second and third workshops, the teams sent the case study document they were producing to the project team for systematic analysis. Then, at the general meetings, the case study authors presented their work verbally. The discussions and working groups that followed helped the country teams to continue working on their documents. The present transversal analysis also takes into account the content of these discussions.
The second source was the final versions of the case study documents, which are available elsewhere, see [
14]. Taking into account the preliminary versions that each team produced, the country case studies were all read in their entirety several times, an essential process for thoroughly comprehending and analyzing their content.
The third source of data came out of the transversal analysis of the multiple case studies. In effect, at the final project workshop (May 2011), members of the country teams held several working group meetings in order to begin working on the transversal analysis by groups of three countries. A presentation of these three-country transversal analyses in a plenary session allowed us to pursue the analytical discussion further. In addition, the authors of this article presented to everyone in attendance their own preliminary transversal analysis based on the results of five countries. All of these discussions were captured using systematic note-taking and audio-recordings for subsequent analysis by the authors of the present article.
Except for Senegal, there was no need for ethical authorization since this was a process of self-reflection undertaken by people involved in the policies being studied. Their involvement was authorized by their respective institutions, essentially the ministries of health of their countries and the participating NGOs. The people interviewed were guaranteed anonymity upon providing informed consent to participation. In Senegal the Director of the gerontological public health facility in Dakar provided the ethical authorization to implement the study and to interview the patients.
Competing interests
The authors of this article initiated the knowledge aggregation project on public policies in the six countries. They supported those responsible for writing the case studies in each country in order to ensure the rigour of their approaches.
Authors’ contributions
VR and LQ were in charge of the multiple case study designs with the assistance of YK. VR, LQ and YK were in charge of the training and coaching of six country teams in the national case study process (including field visits in the countries). ER did the literature review, developed the analytical framework and assisted VR and LQ in the whole process. VR conducted the transversal data analysis based on the report freely accessible in French at:
http://www.vesa-tc.umontreal.ca/pdf/2012/livre_CAPI.pdf. All authors contributed to the interpretation of the results. VR wrote the manuscript with contributions from all authors. All authors had full access to all of the country case studies and take responsibility for the integrity of the data and the accuracy of the data analysis. All author read and approved the final manuscript.