Factors supporting the primary care physicians’ performance in Benin: a multiple case study

Abstract

IntroductionIn Benin, as in many African countries, there is a gradual increase in physicians practising at the primary care level. A literature review showed that these primary care physicians (PCPs) have great potential for improving the quality of care. However, several conditions are necessary for this potential to be unlocked and for the PCPs to contribute effectively to strengthen their local health system. This study aims to understand the factors that underpin the performance of PCPs in Benin.MethodsWe conducted a multiple case study in which we analysed eight contrasting PCP practices spread across five health districts in Benin. The study used a combination of quantitative and qualitative methods. We collected quantitative data through direct observations of the services provided by the PCPs. A descriptive statistical analysis of these data helped to assign performance scores to each PCP’s practices (for the technical quality of services and communication with patients). For the qualitative data collection, we conducted 40 in-depth interviews and 16 focus group discussions with PCPs, other health workers, health authorities, local authorities and other community members. This qualitative data was subjected to thematic content analysis to identify the factors that might explain the observed performances. We then constructed a matrix presenting all the cases studied and the potential performance factors. Finally, we carried out a cross-case analysis to identify the most critical factors supporting the performance of PCPs in Benin.ResultsThe PCPs’ performance scores ranged from 14.7 to 19.3 (out of 20) for communication and from 68% to 88% (out of 100%) for technical quality of care. Out of 14 potential performance factors retained after the first phase of the qualitative analysis, cross-analysis revealed nine factors that appeared to be essential in supporting the performance of PCPs in Benin in both the public and private sectors. These were (i) the values supporting the PCPs’ practices, (ii) the PCPs’ preparation to practice at first-line, (iii) the support provided to the PCPs from the hierarchy, peers or professional associations, (iv) the leadership mandate given to the PCPs and the degree of autonomy allocated to exert it, (v) the modalities of the financing of the PCPs’ practices, (vi) the accountability mechanisms in place to support the PCPs’ practices, (vii) the PCPs’ relationship with the rest of the primary care team and their leadership style, (viii) the PCPs’ collaboration with community leaders and other public officials, and (ix) the context in which the PCP’s practices are embedded.ConclusionThis study has enabled the identification of a series of factors that could act as levers for improving the practice of PCPs in Benin.