Learning for Universal Health Coverage

Meessen, Bruno; Akhnif, El Houcine; Kiendrébéogo, Joël Arthur; Alaoui, Abdelali Belghiti; Bello, Kéfilath; Bhattacharyya, Sanghita; Dini, Hannah Sarah; Dkhimi, Fahdi; Dossou, Jean‐Paul; Kelley, Allison; Keugoung, Basile; Millimouno, Tamba Mina; Zambruni, Jérôme Pfaffmann; Rouve, Maxime; Sieleunou, Isidore; Heteren, Godelieve van

doi:10.1136/bmjgh-2019-002059

Cited by 13 publications

(16 citation statements)

References 26 publications

(31 reference statements)

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“…This can happen by making explicit the assumptions of policy makers and implementers and testing them prospectively ( 54 ). The refined theories which result from such studies can inform the subsequent stages of the policy process and strengthen the learning system necessary for stronger and more resilient health systems ( 55 ).…”

Section: Discussionmentioning

confidence: 99%

Applying the Realist Evaluation Approach to the Complex Process of Policy Implementation—The Case of the User Fee Exemption Policy for Cesarean Section in Benin

Dossou

Belle

Marchal

2021

Front. Public Health

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Realist evaluation is making inroads in the field of health policy and systems research to a large extent because of its good fit with complex issues. Until now, most realist studies focused on evaluating interventions or projects related to health care delivery, organization of health services, education, management, and leadership of health workers in high income countries. With this paper, we apply the realist approach to the study of national health policy implementation in a low resource country. We use the case of the user fee exemption policy for cesarean section in Benin, which we followed up from 2009 to 2018. We report on how realist evaluation can be applied for policy implementation research. We illustrate how we developed the initial programme theory—the starting point of any realist evaluation -, how we designed the study and data collection tools, and how we analyzed the data. For each step, we present current good practices, how we adapted them when needed, the challenges and the lessons learned. We report also on how the dynamic interactions between the central level (the national implementing agency) and the peripheral level (an implementing hospital) shaped the policy implementation. We found that at central level, availability of resources for a given policy is constantly challenged in the competitive national resource allocation arena. Key factors include the political power and the legitimacy of the group supporting the policy. These are influenced by the policy implementation structure, how the actual outputs of the implementation align with promises of the group supporting the policy and consequently how these outputs, the policy and its promoters are perceived by the community. We found that the service providers are key to the implementation, and that they are constrained or influenced by the dependability of the funding, their autonomy, their personal background, and the accountability arrangements. This study can inform the design and implementation of national health policies that involve interactions between central and operational level in other low-income countries.

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Section: Discussionmentioning

confidence: 99%

Applying the Realist Evaluation Approach to the Complex Process of Policy Implementation—The Case of the User Fee Exemption Policy for Cesarean Section in Benin

Dossou

Belle

Marchal

2021

Front. Public Health

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“…16 21-24 Even experimental trials that successfully demonstrate impact locally using robust evaluation methods generally fail to scale because the data and information loops necessary to continuously inform scale-up are not integrated with policy. [25][26][27][28] We accordingly lack evidence from data that are representative at the population level and sufficiently comprehensive to capture the cross-cutting benefits of HSS and UHC initiatives, while simultaneously being granular enough to inform policy and implementation. In this sense, adding adaptive evaluation designs that use robust data collection and analytics (eg, observational and quasi-experimental) in parallel to HSS interventions being implemented across the developing world can generate rigorous evidence while informing the implementation process via dynamic information loops and iterative learning.…”

Section: Bmj Global Healthmentioning

confidence: 99%

District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018

et al. 2020

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IntroductionDespite renewed commitment to universal health coverage and health system strengthening (HSS) to improve access to primary care, there is insufficient evidence to guide their design and implementation. To address this, we conducted an impact evaluation of an ongoing HSS initiative in rural Madagascar, combining data from a longitudinal cohort and primary health centres.MethodsWe carried out a district representative household survey at the start of the HSS intervention in 2014 in over 1500 households in Ifanadiana district, and conducted follow-up surveys at 2 and 4 years. At each time point, we estimated maternal, newborn and child health coverage; economic and geographical inequalities in coverage; and child mortality rates; both in the HSS intervention and control catchments. We used logistic regression models to evaluate changes associated with exposure to the HSS intervention. We also estimated changes in health centre per capita utilisation during 2013 to 2018.ResultsChild mortality rates decreased faster in the HSS than in the control catchment. We observed significant improvements in care seeking for children under 5 years of age (OR 1.23; 95% CI 1.05 to 1.44) and individuals of all ages (OR 1.37, 95% CI 1.19 to 1.58), but no significant differences in maternal care coverage. Economic inequalities in most coverage indicators were reduced, while geographical inequalities worsened in nearly half of the indicators.ConclusionThe results demonstrate improvements in care seeking and economic inequalities linked to the early stages of a HSS intervention in rural Madagascar. Additional improvements in this context of persistent geographical inequalities will require a stronger focus on community health.

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“…In any case, there are probably missed opportunitiescountries do not leverage the large array of learning situations that have great potential to spur their progress toward UHC. Today, too few ministries or technical departments are purposely investing in their own systemic learning capacities [10][11][12].…”

Section: The Way Forwardmentioning

confidence: 99%

“…For instance, a policy that has succeeded in one place may fail in another [8] or the results of a policy designed and implemented in a country may be quite the opposite of what was expected [9]. Therein, it has been argued that the ability to continually learn and adapt is essentiallearning should then be at the heart of UHC-related policy processes [10][11][12]. Indeed, there is growing interest among global health actors towards 'learning for UHC'.…”

Section: Introductionmentioning

confidence: 99%

Policy learning and Universal Health Coverage in low- and middle-income countries

Kiendrébéogo

Allegri

Meessen³

2020

Health Res Policy Sys

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Learning is increasingly seen as an essential component to spur progress towards universal health coverage (UHC) in low-and middle-income countries (LMICs). However, learning remains an elusive concept, with different understandings and uses that vary from one person or organisation to another. Specifically, it appears that 'learning for UHC' is dominated by the teacher modenotably scientists and experts as 'teachers' conveying to local decision/policy-makers as 'learners' what to do. This article shows that, to meet countries' needs, it is important to acknowledge that UHC learning situations are not restricted to the most visible epistemic learning approach practiced today. This article draws on an analytical framework proposed by Dunlop and Radaelli, whereby they identified four learning modes that can emerge according to the specific characteristics of the policy process: epistemic learning, learning in the shadow of hierarchy, learning through bargaining and reflexive learning. These learning modes look relevant to help widen the learning prospects that LMICs need to advance their UHC agenda. Actually, they open up new perspectives in a research field that, until now, has appeared scattered and relatively blurry.

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Learning for Universal Health Coverage

Cited by 13 publications

References 26 publications

Applying the Realist Evaluation Approach to the Complex Process of Policy Implementation—The Case of the User Fee Exemption Policy for Cesarean Section in Benin

Applying the Realist Evaluation Approach to the Complex Process of Policy Implementation—The Case of the User Fee Exemption Policy for Cesarean Section in Benin

District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018

Policy learning and Universal Health Coverage in low- and middle-income countries

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