Bart Criel

Le profil des membres et des non membres des mutuelles de santé au Rwanda: le cas du district sanitaire de Kabutare

Le Rwanda a retenu la mise en place des mutuelles de santé dans ses priorités. Des expériences pilotes ont été lancées dans trois districts du pays. Quatre ans durant (1999–2003), le taux dadhésion de la population à ces systèmes est resté relativement faible (15,6%). Une étude transversale de 1 042 ménages dans le district sanitaire de Kabutare nous a permis de comparer les caractéristiques socio‐économiques et démographiques, les antécédents médicaux, chirurgicaux et gynéco‐obstétriques des membres et des non membres de la mutuelle développée dans le district. Il ressort de l’étude que les membres et les non membres sont comparables en termes de sexe, ètat civil, statut professionnel et antécédents de maladie. Les ménages de grande taille (>5 personnes) et ceux ayant un revenu relativement plus élevé (>230

Performance-based financing: the same is different

EU/an) adhèrent plus. Les membres de la mutuelle utilisent plus les services de santé que les non membres, dépensent moins pour leurs soins de santé et se fidélisent à la mutuelle au fil des années. L’étude plaide en faveur de la poursuite de ces systèmes de mutualisation du risque maladie, tout en rèfléchissant à la mise en place de mécanismes qui permettront aux pauvres dadhérer.

The complex challenge of providing patient-centred perinatal healthcare in rural Uganda: A qualitative enquiry

Although it is increasingly acknowledged within the Performance-Based Financing (PBF) research community that PBF is more than just payments based on outputs verified for quality, this narrow definition of PBF is still very present in many studies and evaluations. This leads to missed opportunities, misunderstandings and an unhelpful debate. Therefore, we reinforce the claim that PBF should be viewed as a reform package focused on targeted services with many different aspects that go beyond the health worker level. Failing to acknowledge the importance of the different elements of PBF negatively influences the task of practitioners, researchers and policymakers alike. After making the case for this wider definition, we propose three research pathways (describing, understanding and framing PBF) and give a short and tentative starting point for future research, leaving the floor open for more in-depth discussions. From these three vantage points it appears that when it comes to PBF the same is different. Notwithstanding the increased complexity due to the use of the wider definition, progress on these three different research pathways will strongly improve our knowledge, lead to better adapted PBF programs and create a more nuanced debate on PBF.

Combining Theory-Driven Evaluation and Causal Loop Diagramming for Opening the ‘Black Box’ of an Intervention in the Health Sector: A Case of Performance-Based Financing in Western Uganda

RATIONALEnIncreasing research and reflections on quality of healthcare across the perinatal period slowly propels the global community to lobby for improved standards of quality perinatal healthcare, especially in low- and middle-income countries.nnnOBJECTIVEnThe purpose of this qualitative study was to obtain a deeper understanding of how interpersonal dimensions of the quality of care relate to real-life experiences of perinatal care, in a resource-constrained local health system.nnnMETHODSnIn total, 41 in-depth interviews and five focus group discussions (Nu202f=u202f34) were conducted with perinatal women and local health system health professionals living and working in rural Uganda. Data analysis used an emergent and partially inductive, thematic framework based on the grounded theory approach.nnnRESULTSnThe results indicated that interpersonal aspects of quality of perinatal care and service delivery are largely lacking in this low-resource setting. Thematic analysis showed three interrelated process aspects of quality of perinatal care: negative reported patient-provider interactions, the perceptions shaping patient-provider interactions, and emergent consequences arising out of these processes of care. Further reflections expose the central, yet often-unheeded, role of perinatal womens agency in their own health seeking behaviours and overall well-being, as well as that of underlying practical norms surrounding health worker attitudes and behaviours.nnnCONCLUSIONnThese findings highlight the complexity of patient-centred perinatal healthcare provision in rural Uganda and point to the relevance of linking the interpersonal dimensions of quality of care to the larger systemic and structural dimensions of perinatal healthcare.

An in-depth investigation of the causes of persistent low membership of community-based health insurance: a case study of the mutual health organisation of Dar Naïm, Mauritania

Increased attention on “complexity” in health systems evaluation has resulted in many different methodological responses. Theory-driven evaluations and systems thinking are two such responses that aim for better understanding of the mechanisms underlying given outcomes. Here, we studied the implementation of a performance-based financing intervention by the Belgian Technical Cooperation in Western Uganda to illustrate a methodological strategy of combining these two approaches. We utilized a systems dynamics tool called causal loop diagramming (CLD) to generate hypotheses feeding into a theory-driven evaluation. Semi-structured interviews were conducted with 30 health workers from two districts (Kasese and Kyenjojo) and with 16 key informants. After CLD, we identified three relevant hypotheses: “success to the successful”, “growth and underinvestment”, and “supervision conundrum”. The first hypothesis leads to increasing improvements in performance, as better performance leads to more incentives, which in turn leads to better performance. The latter two hypotheses point to potential bottlenecks. Thus, the proposed methodological strategy was a useful tool for identifying hypotheses that can inform a theory-driven evaluation. The hypotheses are represented in a comprehensible way while highlighting the underlying assumptions, and are more easily falsifiable than hypotheses identified without using CLD.

Stigmatisation de la maladie mentale par les étudiants en médecine en Guinée, Conakry

BackgroundPersistent low membership is observed in many community-based health insurance (CBHI) schemes in Africa. Causes for low membership have been identified and solutions suggested, but this did not result in increased membership. In this case study of the mutual health organisation of Dar Naïm in Mauritania we explore the underlying drivers that may explain why membership continued to stagnate although several plans for change had been designed.MethodsWe used a systems approach focussed on processes, underlying dynamics and complex interactions that produce the outcomes, to delve into 10xa0years of data collected between 2003 and 2012. We used qualitative research methods to analyse the data and interpret patterns.ResultsDirect causes of stagnation and possible solutions had been identified in the early years of operations, but most of the possible solutions were not implemented. A combination of reasons explains why consecutive action plans were not put into practice, showing the complexity of implementation and the considerable management capacity required, as well as the challenges of integrating a novel organisational structure into exiting social structures.ConclusionsFor any CBHI project aiming at high membership, skilled professional management seems essential, with capacity to question and adapt routine procedures and interpret interactions within the wider society. Countries that include community-based health insurance in their strategic plan towards universal coverage will have to pay more attention to management capacity and the minutiae of implementation.

Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi

Introductionu2008: La stigmatisation de la maladie mentale constitue un obstacle majeur au developpement de soins de qualite, particulierement lorsqu’elle emane des professionnels eux-memes. L’objectif de cette recherche etait d’apprehender les eventuelles attitudes de stigmatisation parmi les etudiants de premiere et derniere annee en medecine a l’Universite de Conakry (Guinee), a partir d’une description de leurs representations de la maladie mentale, des malades mentaux et de la psychiatrie.Methodesu2008: Des focus groups ont permis de faire emerger les perceptions et attitudes des etudiants face a la maladie mentale, leurs modeles explicatifs et opinions sur les therapeutiques traditionnelles et modernes, ainsi que leur interet a integrer la psychiatrie dans leur pratique future.Resultatsu2008: Beaucoup regrettent la discrimination dont font l’objet les malades mentaux dans la societe guineenne, mais partagent neanmoins avec la population generale des attitudes de stigmatisation. Le stereotype dominant est la grande folie, meme si les etudiants de derniere annee citent des troubles mentaux plus diversifies. Il y a une forte adhesion aux modeles explicatifs profanes integrant les forces occultes ainsi qu’au recours aux soins traditionnels pour les traiter, y compris parmi les etudiants de derniere annee de medecine.Discussionu2008: Aucun etudiant ne choisirait la psychiatrie comme specialite, meme si certains se montrent interesses a l’integrer dans leur pratique. Notre etude suggere cependant aussi que les attitudes de stigmatisation des etudiants ne sont pas figees. Des dispositifs pedagogiques specifiques peuvent faire evoluer les attitudes et creer des espaces de tolerance et de compassion.

The Social Nature of Perceived Illness Representations of Perinatal Depression in Rural Uganda

Background The high burden of chronic communicable diseases such as HIV/AIDS, and an escalating rise of non-communicable diseases (NCDs) in Malawi and other sub-Saharan African countries, calls for a shift in how health care services are designed and delivered. Patient-centred care and patient self-management are critical elements in chronic care, and are advocated as universal strategies. In sub-Saharan Africa, there is need for more evidence around the practice of patient self-management, and how to best support patients with chronic conditions in the African context. Our study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource-constrained setting in Malawi. Methods This is primarily a qualitative study, involving patients with different chronic conditions from one rural district in Malawi. Data are drawn from semi-structured questions of a survey with 129 patients (from the third of four-part data collection series), 14 in-depth interviews, and four focus-group discussions with patients (n = 31 respondents). A framework approach was used for qualitative analysis, and descriptive statistical analysis was performed on survey data. Results Patients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and external factors. Factors included: 1) ability to acquire appropriate disease knowledge; 2) poverty level; 3) the presence of support from family caregivers and community-based support initiatives; 4) the nature of one’s social relations; and 5) the ability to deal with stressors and stigma. NCD and HIV comorbid patients were more disadvantaged in their access to care, as they experienced frequent drug stock-outs and incurred additional costs when referred. These barriers contributed to delayed care, poorer treatment adherence, and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of (multiple) care challenges. Conclusion Our findings complement other research on self-management experiences in chronically ill patients with its analysis on factors and barriers that influence patient self-management capacity in a resource-constrained setting. We recommend expanding current peer-patient and support group initiatives to patients with NCDs, and further investments in the decentralisation of integrated health services to primary care level in Malawi.

A critique of the Uganda district league table using a normative health system performance assessment framework

While the global health community advocates for greater integration of mental health into maternal health agendas, a more robust understanding of perinatal mental health, and its role in providing integrated maternal health care and service delivery, is required. The present study uses the Illness Representation Model, a theoretical cognitive framework for understanding illness conceptualisations, to qualitatively explore multiple stakeholder perspectives on perinatal depression in rural Uganda. A total of 70 in-depth interviews and 9 focus group discussions were conducted with various local health system stakeholders, followed by an emergent thematic analysis using NVivo 11. Local communities perceived perinatal depression as being both the fault of women, and not. It was perceived as having socio-economic and cultural causal factors, in particular, as being partner-related. In these communities, perinatal depression was thought to be a common occurrence, and its negative consequences for women, infants and the community at large were recognised. Coping and help-seeking behaviours prescribed by the participants were also primarily socio-cultural in nature. Placing the dynamics and mechanisms of these local conceptualisations of perinatal depression alongside existing gaps in social and health care systems highlights both the need of, and the opportunities for, growth and prioritisation of integrated perinatal biomedical, mental, and social health programs in resource-constrained settings.

Effects of demand-side incentives in improving the utilisation of delivery services in Oyam District in northern Uganda: a quasi-experimental study

BackgroundIn 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality.MethodsA normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis.ResultsStakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range.ConclusionsThe critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks.Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.