GHR-CAPS seminar on the realist approach

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These are the presentations given in the frame of a GHR-CAPS seminar on the realist approach and its application in global health. The seminar was held in Montréal (Canada) in November 2012. Information on the GHR-CAPS program can be found on the following link: http://www.pifrsm-ghrcaps.org/home.html

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GHR-CAPS seminar on the realist approach

  1. 1. The realist approach and its application in global health Methodological seminar organized by Valéry Ridde and Emilie Robert Thursday 29th of November 2012 PROGRAM9 – 9.15 AM Welcome participants9.15 – 9.30 Introduction of participants and speakers9.30 – 11.00 Epistemology, theory and concepts of the realist approach 1. The realist approach, epistemological foundations and conceptual tools (Emilie Robert) 2. The concept of ‘mechanism’ from the realist approach: what are we talking about? (Eric Breton and Anthony Lacouture) 3. Discussion period11.00 – 12.00 Practical examples of the use of the realist approach in global health 1. Free care in Africa: a realist review of the mechanisms involved in patients’ healthcare- seeking behaviours (Emilie Robert) 2. Uncovering the benefits of participatory research: implications of a realist review for health research and practice (Paula Bush) 3. Discussion period12.00 – 1.00 PM LunchThe seminar will take place at Université du Québec à Montréal (UQAM): Room N-7050, Pavillion N (8th floor) 1205, rue St Denis MontréalFor additional information, please contact: • Emilie Robert: emilie.robert.3@umontreal.ca • Anne-Marie Turcotte-Tremblay (GHR-CAPS coordinator): programmesantecap@gmail.com
  2. 2. Speakers: • Eric Breton is a research professor and currently holds the "Health Promotion" Inpes Chair (National Institute for Prevention and Health Education) at the Ecole des Hautes Etudes in Public Health (EHESP) in France. He holds a Ph.D. in Public Health (Health Promotion) from the University of Montreal. • Paula Bush is a Ph.D. candidate in the Department of kinesiology and physical education at McGill University. She holds a scholarship from Participatory Research at McGill (PRAM). • Anthony Lacouture is a research engineer with the "Health Promotion" Inpes Chair at the EHESP in France. He holds a Masters of Public Health with a specialization in evaluation of actions and health systems (ISPED Bordeaux). • Valery Ridde is an Associate Professor at the Department of Social and Preventive Medicine at University of Montreal and a researcher at the Research Centre of the Centre hospitalier de lUniversite de Montreal (CRCHUM). • Emilie Robert is a Ph.D. candidate in Public Health at University of Montreal. She is a senior fellow of the GHR-CAPS program and holds a scholarship from the Fonds de recherche pour le Québec – Société et Culture.Required readings:Astbury, B., & Leeuw, F. L. (2010). Unpacking Black Boxes: Mechanisms and Theory Building in Evaluation. American Journal of Evaluation, 31(3), 363–381. doi:10.1177/1098214010371972Marchal, B., Dedzo, M., & Kegels, G. (2010). A realist evaluation of the management of a well- performing regional hospital in Ghana. BMC health services research, 10, 24. doi:10.1186/1472-6963-10-24Pawson, R., & Sridharan, S. (2010). Evidence-based Public Health: Effectiveness and efficiency. In A. Killoran & M. P. Kelly (Eds.), Evidence-based Public Health: Effectiveness and efficiency (pp. 43–62). Oxford: Oxford Scholarship Online. doi:10.1093/acprof:oso/9780199563623.003.04Robert, E., Ridde, V., Marchal, B., & Fournier, P. (2012). Protocol: a realist review of user fee exemption policies for health services in Africa. BMJ open, 2(1), e000706. doi:10.1136/bmjopen-2011-000706Additional readings:Evans, D., & Killoran, A. (2000). Tackling health inequalities through partnership working: Learning from a realistic evaluation. Critical Public Health, 10(2), 125–140. doi:10.1080/09581590050075899Jagosh, J., Macaulay, A. C., Pluye, P., Salsberg, J., Bush, P. L., Henderson, J., Sirett, E., et al. (2012). Uncovering the benefits of participatory research: implications of a realist review for health research and practice. The Milbank quarterly, 90(2), 311–46.Ridde, V., Robert, E., Guichard, A., Blaise, P., & Van Olmen, J. (2012). Théorie et pratique de l’approche Realist pour lévaluation des programmes. In V. Ridde & C. Dagenais (Eds.), Approches et pratiques en évaluation de programmes: nouvelle édition revue et augmentée (pp. 255–275). Montréal: Les Presses de l’Université de Montréal.
  3. 3. © Robert E., 2012 GHR-CAPS seminars The realist approach and its application in global health (Montréal, November 2012) The realist approach: epistemological foundations and conceptual tools Emilie Robert
  4. 4. © Robert E., 2012 Outline 1.  Grasping the complexity of social interventions 2.  Critical realism and generative causation 3.  A theory-driven approach 4.  Realistic evaluation and realist synthesis 2
  5. 5. © Robert E., 2012 Outline 1.  Grasping the complexity of social interventions 2.  Critical realism and generative causation 3.  A theory-driven approach 4.  Realistic evaluation and realist synthesis 3
  6. 6. © Robert E., 2012 1. Grasping the complexity of social interventions What are we talking about? Social phenomena, interactions and interventions 4
  7. 7. © Robert E., 2012 1. Grasping the complexity of social interventions Social phenomena are … So are social complex… interventions. SOCIETY •  They are theories. •  They are active. COMMUNITY •  They consist of a series of processes that are thickly populated. INSTITUTION •  They are non-linear and go into feedback FAMILY loops. •  They are embedded into several layers of context and social systems. INDIVIDUAL •  They are leaky and prone to be borrowed. •  They are open systems. Socio-ecological model Adapted from Pawson et al. (2004) 5
  8. 8. © Robert E., 2012 1. Grasping the complexity of social interventions The example of user fee exemption policies Interventions… User fee exemption policies… are theories. aim to improve access to health services while reducing the financial burden of households. are active. involve governments, NGOs, the population, health staff, etc. consist of a series of processes consist of formulating the policy, implementing the activities by that are thickly populated. different players, monitoring and evaluating etc. are non-linear and go into transform and adapt through the action and the influence of feedback loops. stakeholders. are embedded into several layers are implemented in countries that have different populations living of context and social systems. in different social realities and having distinct worldviews. are leaky and prone to be are implemented in paralell with other health policies that borrowed. influence them (and vice versa). are open systems. are systems where actors learn from their past experience, which influence the way interventions are conceived, implemented and perceived. Adapted from Ridde et al. (2012) 6
  9. 9. © Robert E., 2012 Outline 1.  Grasping the complexity of social interventions 2.  Critical realism and generative causation 3.  A theory-driven approach 4.  Realistic evaluation and realist synthesis 7
  10. 10. © Robert E., 2012 2. Critical realism and generative causation Critical realism in the philosophy of science Positivism Postpositivism Constructivism Ontology ‘Naive’ realism – Critical realism – Relativism – Real but Real reality but only Local and specific apprehendable reality imperfectly apprehendable constructed reality Epistemology Objectivist Objectivity as a ‘regulatory Transactional / Findings true guardian’ subjectivist Critical tradition Created findings Findings probably true Methodology Experimental / ‘Critical multiplism’ Hermeneutical / manipulative Inquiry in more natural settings, dialectical Verification of more situational information, hypotheses soliciting more emic viewpoints Chiefly quantitative Falsification of hypotheses methods Include qualitative methods Adapted from Guba & Lincoln (1994) 8
  11. 11. © Robert E., 2012 2. Critical realism and generative causation Generative causation Context (C) MECHANISM: element of the reasoning Mechanism of the actor facing an intervention. (M) A mechanism: Outcome (1)  is generally hidden, (O) (2)  is sensitive to context variations (3)  produces outcomes. from Robert et al. (2011), adapted from others Adapted from Pawson & Tilley (1997) 9
  12. 12. © Robert E., 2012 2. Critical realism and generative causation Logic of realist explanation What works? How? For whom? Under what circumstances? Why? « The basic task of social inquiry is to explain interesting, puzzling, socially significant regularities. Explanation takes the form of positing some underlying mechanism which generates the regularity and thus consists of propositions about how the interplay between structure and agency has constituted the regularity. Within realist investigation there is also investigation of how the workings of such mechanisms are contingent and conditional, and thus only fired in particular local, historical or institutional contexts. » (p.71) (Pawson & Tilley, 1997) 10
  13. 13. © Robert E., 2012 2. Critical realism and generative causation Mode of inquiry DEDUCTIVE REASONING INDUCTIVE REASONING Theory Theory Tentative Hypothesis hypothesis Observation Pattern Confirmation Observation 11
  14. 14. © Robert E., 2012 2. Critical realism and generative causation Mode of inquiry RETRODUCTIVE REASONING (ABDUCTION) Theory Observation 12
  15. 15. © Robert E., 2012 Outline 1.  Grasping the complexity of social interventions 2.  Critical realism and generative causation 3.  A theory-driven approach 4.  Realistic evaluation and realist synthesis 13
  16. 16. © Robert E., 2012 3. A theory-driven approach Program theory « The theory in question is the set of « Set of hypotheses that explain how beliefs and assumptions that undergird and why the intervention is expected to program activities […] They are the produce outcomes. » hypotheses on which people, from Robert et al. (2011) consciously or unconsciously, build their program plans and actions.» from Weiss (1997) BASIC INTERVENTION THEORY Enhanced Signposting to participant Identify and Reductions in Health services and knowledge, Improvements Reduction in reach target Risk screening health coaching micro- confidence in lifestyle CHD risks population inequalities interventions and understanding from Pawson & Sridharan (2009) 14
  17. 17. © Robert E., 2012 INPUTS COMPLEX INTERVENTION THEORY Administrative and financial support during 12 months; UdeM / MoH / MSF-B / ECHO partnership ; human resources; equipments; consumables; infrastructures Participative process PROCESS Implication of target users in Involvement of local Support to the Adaptation and identifying needs for stakeholders in Observatory to produce dissemination of knowledge producing knowledge knowledge knowledge Preparation of protocoles Building of the teams’ Publication of policy briefs Workshop for the by the Observatory teams technical capacities on new knowledge identification of needs for ACTIVITIES knowledge Presentations at local Conduct of studies by the Supervision of the Observatory teams production of knowledge meetings Prioritizing needs for knowledge with Utilization of HIS data Conduct of independant National dissemination Observatory teams studies by UdeM workshopEXPECTED RESULTS Knowledge is useful to The legitimacy of the The credibility of Knowledge is Process target users. Obs. is established. knowlege is ensured. accessible. utilization Better utilization of knowledge in decision-making on user fee exemption measures OBJECTIVE At the At the local At the © Robert, 2011 internat. level national level level
  18. 18. © Robert E., 2012 3. A theory-driven approach Middle-range theory « theory that lies between the minor « Level of theoretical abstraction that but necessary working hypotheses provides an explanation of demi- (...) and the all-inclusive systematic regularities in the context – mechanism efforts to develop a unified theory that – outcome interactions of a set of will explain all the observed interventions. » uniformities of social behavior, social from Robert et al. (2011) organization and social change » from Merton (1968) EXAMPLE – Human Resource Management « Hospital managers of well-performing hospitals deploy organisation structures that allow decentralisation and self-managed teams and stimulate delegation of decision-making, good flows of information and transparency. Their HRM bundles combine employment security, adequate compensation and training. This results in strong organisational commitment and trust. Conditions include competent leaders with an explicit vision, relatively large decision-making spaces and adequate resources. » from Marchal et al. (2010) 16
  19. 19. © Robert E., 2012 3. A theory-driven approach The elements of realist cumulation THEORY Abstraction Realist approach C M O Middle-range theories C1 M1 O1 C2 M2 O2 C3 M3 O3 Empirical studies identifying C-M-O configurations C1 M1 O1 C2 M1 O1 C3 M1 O1 C4 M1 O2 C3 M1 O2 CA MB OC CD ME OF CG MH OI CJ MK OL Specification DATA 17 Adapted from Pawson & Tilley (1997)
  20. 20. © Robert E., 2012 Outline 1.  Grasping the complexity of social interventions 2.  Critical realism and generative causation 3.  A theory-driven approach 4.  Realistic evaluation and realist synthesis 18
  21. 21. © Robert E., 2012 4. Realistic evaluation and realist synthesis RE RR Pawson & Tilley (1997) Pawson (2006) 19
  22. 22. © Robert E., 2012 4. Realistic evaluation and realist synthesis 20 Adapted from Pawson and Tilley (1997) and Pawson (2006).
  23. 23. Emilie Robert is a Ph.D. student in public health at Montreal University and is a fellowof the Global Health Research Strengthening Program, funded by the CanadianInstitutes of Health Research and the Population Health Research Network of Quebec.Contact: emilie.robert.3@umontreal.ca 21
  24. 24. BibliographyMarchal, B., Dedzo, M., & Kegels, G. (2010). A realist evaluation of the management of a well-performingregional hospital in Ghana. BMC health services research, 10, 24. doi:10.1186/1472-6963-10-24Merton, R.K. (1968). On sociological theories of the middle range. In R.K. Merton (Ed.), Social Theory andSocial Structures (pp. 39-72). New York: Free Press.Pawson, R. (2004). Evidence-based Policy: A Realist Perspective. London: SAGE Publications.Pawson, R., Greenhalgh, T., Harvey, G. & Walshe, K. (2004). Realist synthesis: an introduction. ERSCResearch Methods Programme, University of Manchester.Pawson, R., & Tilley, N. (1997). Realistic Evaluation. London: SAGE Publications.Pawson, R., & Sridharan, S. (2009). Evidence-based Public Health: Effectiveness and efficiency. In A.Killoran & M. P. Kelly (Eds.), Evidence-based Public Health: Effectiveness and efficiency (pp. 43–62).Oxford: Oxford Scholarship Online. doi:10.1093/acprof:oso/9780199563623.003.04Ridde, V., Robert, E., Guichard, A., Blaise, P., & Van Olmen, J. (2012). Théorie et pratique de l’approcheRealist pour lévaluation des programmes. In V. Ridde & C. Dagenais (Eds.), Approches et pratiques enévaluation de programmes: nouvelle édition revue et augmentée (pp. 255–275). Montréal: Les Presses del’Université de Montréal.Robert, E., Ridde, V., Marchal, B., & Fournier, P. (2012). Protocol: a realist review of user fee exemptionpolicies for health services in Africa. BMJ open, 2(1), e000706. doi:10.1136/bmjopen-2011-000706Weiss, K. (1997). How Can Theory-Based Evaluation Make Greater Headway? Evaluation Review, 21, 501. 22
  25. 25. To  view  this  presentation  on  Prezi,  please  consult  the  following  link:   1  http://prezi.com/6fgvsoch6kf1/the-­‐concept-­‐of-­‐mechanism-­‐from-­‐the-­‐realist-­‐approach-­‐what-­‐are-­‐we-­‐talking-­‐about/  
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  46. 46. Uncovering the Benefits ofParticipatory Research:Implications of a Realist Review forHealth Research and Practice © 2012 PRAM
  47. 47. Project Partnership:Academic Co-Applicants and Trainees:!  Ann C. Macaulay, Pierre Pluye, Jon Salsberg, Justin Jagosh, Jim Henderson, Robbyn Seller, Erin Sirett, Paula L. Bush, Geoff Wong, Trish Greenhalgh, Margaret Cargo, Carol P. Herbert, Lawrence W. Green.Knowledge-User Co-Applicants:!  Sarena Seifer, Susan Law, David Clements, Marielle Gascon-Barré, David L. Mowat, Sylvie Stachenko, Sylvie Desjardins, Ilde Lepore.Acknowledgements: This review and post-doctoral fellows Drs. Jagosh and Seller, were supported by a Canadian Institutes of Health Research KT-Synthesis Grant (# KRS-91805), funding from Participatory Research at McGill (PRAM), and the Department of Family Medicine, McGill University. We also thank David Parry BA (Hons) for his comments on the grant proposal.
  48. 48. Presentation Outline!  Working definition of participatory research;!  Middle range theory!  Findings (Demi-regularities 1-7)!  So what?
  49. 49. !"#$%&%(#)$&*&+#$,)-%.//#)*"0%!"#$%&(%)*+&,-.)/#0+1)%2+%2&+*344(53/(%)3,+36+%23$&+(7&*%&8+5#+%2&+)$$.&+5&),9+ PR$%.8)&80+63/+%2&+:./:3$&+36+&8.*(%)3,+(,8+%(;),9+(*%)3,+ Research Education3/+&7&*%),9+$3*)(4+*2(,9&<=+(Green et al 1995) Action
  50. 50. !"#$%&%(#)$&*&+#$,)-%.//#)*"0% "2(/&8+8&*)$)3,+ (;),9+ ?,%&/:/&%(%)3,+ B)$$&),(%)3,+CA>&$&(/*2+63*.$+ 36+@,8),9$A 3/+ /&$.4%$+ ):4&&,%(%)3,+
  51. 51. .//#)*"%12/$&,34%5"#66/37/%89%D2(%+5&,&@%$+(,8A3/+*3,$%/(),%$+&&/9&+6/3+%2&+*344(53/(%)E&+.,8&/%(;),9+36+2&(4%2F/&4(%&8+/&$&(/*2+5#+/&$&(/*2&/$+(,8+%23$&+(7&*%&8+5#+%2&+)$$.&$+.,8&/+$%.8#+(,8A3/+%23$&+123+13.48+(::4#+/&$&(/*2+/&$.4%$G+
  52. 52. Middle Range Theory: Challenge # 2Partnership synergy theory (Lasker, Weiss, & Miller, 2001)!  Combining the perspectives, resources, and skills of a group of people to “create something new and valuable together— a whole that is greater than the sum of its individual parts.”!  Applied to participatory health interventions, the theory holds that multiple stakeholder collaboration creates or enhances research outcomes beyond what could be achieved by a single person or organization working under similar conditions
  53. 53. Demi-regularity 1PR generates culturally and logistically appropriate research characteristics related to:!  Shaping the scope and direction of research The coalition members acknowledged widespread!  Developing program and research protocols problems associated with community-based research,!  Implementing program and research protocols particularly research conducted in communities of color!  Interpreting and disseminating research findings by predominantly white researchers (context). They demonstrated sensitivity (mechanism) to this history of mistreatment and, through mutual respect (mechanism), used their collective expertise to identify a locally relevant research agenda (outcome).
  54. 54. Demi-regularity 2PR generates capacity to recruit:!  community members to the advisory board!  community members for implementation!  community members as recipients of programs Despite the difficult experiences at the end of life (C), residents at the facility felt safe (M) participating, with the assurance of the endorsement from the nursing staff, which generated very high enrollment (O).
  55. 55. Demi-regularity 3PR generates the capacity of:!  the community partners!  the academic partners The partnership offered formal and informal opportunities for training (C) that community health workers recognized and valued (M), which resulted in a sense of empowerment (O) and a search for additional training and employment positions (O). The partnership provided opportunities and experiences for academic partners to learn how to collaborate (C), which they valued (M), resulting in their developing new and informed perspectives on community knowledge and leadership (O).
  56. 56. Demi-regularity 4PR generates disagreements between the co-governingstakeholders during decision-making processes, resulting in:!  positive outcomes for subsequent programming!  negative outcomes for subsequent programmingStakeholders had no prior history together and lacked established trustin the group (C). Academic researchers were also unaware ofcommunity interests (C). By recognizing the value of coming toconsensus on a research focus (M), the researchers were able tocreate a change in direction and a new agenda to focus on healthpromotion/disease prevention efforts in the community (O). New trustwas built among coalition members from the consensus-buildingprocess (O).
  57. 57. Demi-regularity 5PR synergy accumulates in cases of repeated successfuloutcomes in partnering, thus increasing the quality ofoutputs and outcomes over timeC1-M1-O1 C2-M2-O2 C3-M3-O3
  58. 58. To overcome barriers to conducting a community RCT, a decision wasmade at the outset to hire only African-Americans familiar with thecommunity as project staff (C1).Because of their prior history in the community, the project staff wereglad to assist community members beyond the scope of the study (M1).This led to the staff’s greater investment in the project (O1-C2) which ledto community members’ trust in the project (M2), resulting in closerinteractions between the staff and the community (O2-C3); leading to agreater sense of trust and safety (M3), and thus some participantsrevealed their desire to now enroll in the project (O3). This led to newmethods of recruitment being developed and higher than expectedenrollment (O3-C4).This added to the project stakeholders’ desire to overcome attritionobstacles (M4).As a result, a new capacity to retain participants and prevent attrition ina complex clinical trial was created in a mobile population by addressingproblems as they arose and through the project stakeholders’ increasingsense of motivation, trust, and co-ownership of the project (O4).
  59. 59. Demi-regularity 6Partnership synergy accumulates capacity to sustainproject goals beyond funded time frames and during gapsin external fundingThe involvement of trained lay health workers and churchgroups who implemented the weight-loss intervention gainedleadership and expertise on weight-loss issues affecting theircommunity (C).They felt inspired (M) to continue working for this cause afterthe project ended, resulting in strengthened ties with oneanother and other church organizations (O).
  60. 60. Demi-regularity 7 PR generates systemic changes and new unanticipated projects and activityFrom the success of the project (C), coalition members were motivatedto advocate system changes for cancer prevention in the Vietnamesecommunity (M), which had a lasting effect beyond immediateintervention (O).Project TEAL was very successful in acquiring high-quality, crediblescientific data (C). The coalition members wanted to capitalize on thissuccess (M) to work with other groups on lead poisoning prevention (O)and to plan a book and documentary on their experiences (O).In the context of an open and responsive partnership that encouragedcommunity members to contribute to the program’s design (C), eldersin the community felt safe and supported (M) in forming an elders’council (O), which led to better cultural education of service staff (O),and self-empowerment of the elders (O)
  61. 61. :#&3%;/*"#3&;%,<%+#)$&*&+#$&,3% PR stakeholders’ recognizing and valuing the collective knowledge, resources, relationships, and capacity through the alignment of purpose, values, and goals. Once established, such an alignment becomes a feature of the research context in which partnerships operate.+
  62. 62. So what?!  Our findings confirm what had been previously noted regarding improved research quality and capacity building in PR. (Demi regularities 1-3)!  We uncovered new benefits (Demi regularities 4-7) !  productive conflict and negotiation; !  long-term synergy building (the positive outcome of one stage leads to a better context for the next); !  ability to mitigate funding gaps, invoke sustainability, and extend programs; !  create new unanticipated projects and activity.
  63. 63. =><&%/$%#?#3$#7/%@/%6#%..%!  H3./+-.&44&$+%#:&$+8&+-.&$%)3,$+8&+/&*2&/*2&+:&.%+4(+>>+ I%/&+.%)4)$J&G+!  K.L&$%F*&+-.L.,+J*(,)$&G+!  K.&+6()%F3,+$)+3,+,L(+:($+.,+M>N+(.+8J5.%+8&+4(+>>G+!  H3./+.,&+I&+-.&$%)3,+8&+/&*2&/*2&0+&,+-.3)+8)7O/&,%+ 4&$+/J$.4%(%$+8L.,+>>+8L.,+(.%/&+%#:&+8&+/&E.&G+
  64. 64. Findings:Jagosh J, Macaulay AC, Pluye P, Salsberg J, Bush PL, Henderson J, Sirett E, WongG, Cargo M, Herbert CP, Seifer SD, Green LW, Greenhalgh T. Uncovering theBenefits of Participatory Research: Implications of a Realist Review for HealthResearch and Practice. Milbank Quarterly, 90(2) (in press for June 2012). 2012Commentary:AC Macaulay, J Jagosh, R Seller, J Henderson, M Cargo, T Greenhalgh, G Wong, JSalsberg, LW Green, C Herbert, P Pluye. Benefits of Participatory Research: ARationale For a Realist Review. Global Health Promotion. 18(2) : 45-48. June. 2011Protocol:J Jagosh, P Pluye, AC Macaulay, J Salsberg, J Henderson, E Sirett, PL Bush, R Seller,G Wong, T Greenhalgh, M Cargo, CP Herbert, SD Seifer, LW Green. Assessing theOutcomes of Participatory Research: Protocol for Identifying, Selecting and Appraisingthe Literature for Realist Review. Implementation Science, 6(24). 2011
  65. 65. © Robert, Ridde, 2012 GHR-CAPS seminars The realist approach and its application in global health (Montréal, November 2012) Gratuité des soins de santé en Afrique Emilie Robert Valéry Ridde
  66. 66. Sommaire1.  Pertinence de l’étude2.  Objectif de recherche et méthode3.  Résultats4.  Leçons pour l’approche réaliste © Robert & Ridde, 2012
  67. 67. Sommaire1.  Pertinence de l’étude2.  Objectif de recherche et méthode3.  Résultats4.  Leçons pour l’approche réaliste © Robert & Ridde, 2012
  68. 68. 1. Pertinence de l’étude!  Les pays d’Afrique abolissent les paiements directs dans le secteur de la santé pour améliorer l’accès aux soins. "  ‘an official reduction in direct payments for health care, which is targeted by group, area or service’ (Witter, 2009) "  Plus de 15 pays africains concernés (Robert & Samb, in press) "  Un corpus de données scientifiques hétérogène (Ridde & Morestin, 2010)!  Les revues systématiques traditionnelles n’ont donné qu’un aperçu limité. "  Centré sur l’efficacité des interventions "  Exclusion des études utilisant des méthodes considérées ‘moins robustes’ "  ‘Most studies included in this review suffered from serious methodological weaknesses’ (Lagarde & Palmer, 2011) © Robert & Ridde, 2012
  69. 69. Sommaire1.  Pertinence de l’étude2.  Objectif de recherche et méthode3.  Résultats4.  Leçons pour l’approche réaliste © Robert & Ridde, 2012
  70. 70. 2. Objectif de recherche et méthode!  Ouvrir la ‘boîte noire’ des politiques d’exemption (PEP): "  Comment les PEP influencent-elles les comportements de recours aux soins des patients? Pourquoi ? Dans quelles circonstances ?!  Buts: "  Réconcilier: Comprendre pourquoi des interventions similaires produisent des effets différents ; comprendre quels éléments contextuels entrent en jeu. "  Juxtaposer: Préciser comment les mécanismes similaires sont déclenchés dans des contextes similaires.!  Les types de PEP: "  Enfants de < 5 ans, femmes enceintes ou allaitantes, personnes âgées "  Soins de santé primaire ou de base pour toute la population © Robert & Ridde, 2012
  71. 71. Sommaire1.  Pertinence de l’étude2.  Objectif de recherche et méthode3.  Résultats4.  Leçons pour l’approche réaliste © Robert & Ridde, 2012
  72. 72. 3. Résultats!  Reconstruire la théorie de l’intervention CONTEXTE Contexte politique / social / economique Contexte du système de santé / formation sanitaire Contexte du ménage et individuel 1) Identification 2) Planification 3) Observance 4) Propension 5) Santé du problème de la politique du personnel des usagers à améliorée • Problème: • Gouvernance de santé recourir aux • Réduction des accès financier • Le personnel soins inégalités • Circuit du aux soins de adhère au • Les usagers d’accès aux médicament santé moderne principe de n’ont pas soins limités. • Financement l’exemption. besoin • Réduction des • Information • Solution: • Le personnel d’arbitrer avec dépenses de identifier les • Soutien RH d’autres met en œuvre santé populations • Coordination les lignes dépenses. catastrophiques cibles et abolir • Suivi / directrices de • Ils n’ont pas • Amélioration de les paiements évaluation la politique. besoin de la santé des directs. • Supervision • Le personnel recourir à populations exempte la l’auto- population médication. cible des • Ils ont recours paiements aux soins de directs. santé moderne selon leurs besoins. IDENTIFICATION ACTIVITES PROCESSUS DE MISE RESULTAT EFFET A LONG DU PROBLEME INITIALES EN ŒUVRE ATTENDU TERME © Robert & Ridde, 2012
  73. 73. 3. Résultats!  Chercher et évaluer la littérature Database Networks Snowballing ISI Web of Science n = 934 n = 46 n = 146 n = 15 N = 1 141 Excluded based on titles n = 464 Inclusion and exclusion N = 677 Excluded based on abstracts criteria n = 391 N = 286Documents that could not be found Excluded based on content n = 31 n = 189 N = 66 Quality Excluded from the analysis N=? N = ??? © Robert & Ridde, 2012
  74. 74. 3. Résultats!  Identification du problème… et de la solution Mise en œuvre des paiements ins directs pour les soins de santé Dépe s so nses e c ts de infor m indir elles de soC oûts ins Accroissement de la barrière financière à l’accès aux soins Augmentation des Auto-médication/ inégalités d’accès centres privés Augmentation aux soins des dépenses de santé Régression des Plus faible utilisation ‘Medical poverty indicateurs de des services de trap’ fréquentation santé Détérioration de l’état de santé Augmentation des Exclusion délais de recours sociale aux soins Conséquences aux niveaux Conséquences aux niveaux individuel et du ménage communautaire et national © Robert & Ridde, 2012
  75. 75. 3. Résultats!  Planification de la politique et mise en oeuvre (exemples) Fonctions du Pressions exercés sur le système de santésystème de santéInformation Manque d’information sur le nombre et le type de services fournis dans lessanitaire formations sanitaires et sur le montant des remboursements Problèmes de disponibilité des médicamentsMédicaments et Médicaments insuffisants et kits qui ne répondent pas aux besoinsvaccins Délais et sous-distribution des consommables Financement imprévisible, insuffisant et discontinuFinancement Réintroduction des paiements pour les services et les médicaments Délais de remboursement Planification et communication déficientes; mauvaise compréhension des PEPGouvernance Supervision inadéquate Complexité des procédures de financement Ridde, Robert et al, 2012 Ces éléments (C) contribuent à influencer les attitudes du personnel de santé et de la population. © Robert & Ridde, 2012
  76. 76. 3. Résultats!  Observance du personnel de santé (exemples) Comportements et attitudes Exemples de données empiriques "It was reported that registration fees were too Inquiétudes / insatisfaction low, were often insufficient to meet the running liées aux termes de la costs of the facility, and that budgetary politique allocations from the government were inadequate" (Chuma, 2009)Adhésion à / Insatisfaction liées aux "... increased workloads were seen to havesatisfaction retombées professionnelles had direct negative effects at a personal level et/ou personnelles for the majority of nurses" (Walker, 2004)des PEP "They do not reject the policy or its goals so much as expressing concern about the direct Insatisfaction liée à la mise impacts they perceive it to have had on them en œuvre and the processes through which it has been implemented." (Nimpagaritse, 2011) Ajustement des prix des "... policy modification was by fully exemptingStratégies some children from all fees while others servicesd’adaptation received a partial or no exemption." (Agyepong, 2010) Ces éléments (C) contribuent à influencer les comportements et attitudes de la population. © Robert & Ridde, 2012
  77. 77. 3. Résultats!  Propension des usagers à recourir aux soins La combinaison de ces éléments entre en jeu dans la décision des usagers de recourir aux soins. © Robert & Ridde, 2012
  78. 78. 3. Résultats!  Identifier les configurations C-M-E DEMI-REG 1Les délais et l’imprédictibilité dans le financement de la politique auniveau des formations sanitaires (remboursement ou distribution desintrants) (C) encourage le personnel de santé à adjuster le prix desservices de santé (strategie d’adaptation -M). En conséquence, lesusagers ne bénéficie pas systématiquement de la gratuité des soins(O)."After the introduction of the exemptions, funds did not suffice to buy all the drugs needed and the management team at Muramvya Hospital decided that children under 5 simply could not be offered free care at the hospital outpatient clinic. […] Therefore, these financial issues did not allow for the provision of drugs for free to ambulatory patients under 5, although this was included in the announced reform. " (Nimpagaritse, 2011) © Robert & Ridde, 2012
  79. 79. 3. Résultats!  Identifier les configurations C-M-E DEMI-REG 2L’ajustement du prix des services de santé par le personnel (C)entraîne les usagers à se protéger des coûts potentiels liés au recoursaux soins (M) et limite ainsi leur opportunité à bénéficier des servicesde santé(O)."Inconsistent patterns of public service uptake and partial protection from direct costs were, finally, also influenced by specific health service weaknesses including drug […] exemption implementation failures at hospitals" (Goudge, 2009) © Robert & Ridde, 2012
  80. 80. 3. Résultats!  Identifier les configurations C-M-E DEMI-REG 3L’augmentation de l’utilisation des services de santé par les patientsassocié aux défaillances de mise en œuvre (C) entraîne undétérioration de l’enthousiasme initial du personnel de santé pour lesPEP (M), ce qui contribue notamment à la détérioration de leur relationavec les usagers (O)." The increase in patient load and reduced drug supply made nurses’ relationships with their patients very difficult ." (Walker, 2004) © Robert & Ridde, 2012
  81. 81. 3. Résultats!  Une tentative de théorisation… CONTEXTE (au niveau du système de santé) Theory of street-level Health providers’ coping bureaucracy Weak health system strategies MECHANISMES Exemption policy implementation gap Uncertainty Distrust Determinants of healthcare Persistence of fees for Deterioration of the supposedly free patient-provider seeking behaviours healthcare relationship Limited propensity to engage with free healthcare Experience with Persistence of other barriers health system to accessing healthcare EFFETS CONTEXTE (au niveau du ménage) Limited decrease in catastrophic health expenditures Limited decrease in inequalities in access to modern care Limited improvement in population health © Robert & Ridde, 2012
  82. 82. Sommaire1.  Pertinence de l’étude2.  Objectif de recherche et méthode3.  Résultats4.  Leçons pour l’approche réaliste © Robert & Ridde, 2012
  83. 83. 4. Leçons de l’approche réaliste!  Dans la mesure où elles sont combinées à d’autres mesures ciblant d’autres barrières à l’accès aux soins, les PEP ont un potentiel fort de produire les effets attendus.!  Les défaillances de mise en œuvre compromettent la propension des usagers à recourir aux soins de santé moderne du fait de l’incertitude et de la défiance.!  La théorie du ‘street-level bureaucracy’ et les déterminants du recours aux soins fournissent les pièces manquantes pour comprendre comment les PEP fonctionnent. © Robert & Ridde, 2012
  84. 84. Emilie Robert is a Ph.D. student in public health at Montreal University and is a fellowof the Global Health Research Strengthening Program, funded by the CanadianInstitutes of Health Research and the Population Health Research Network of Quebec.Contact: emilie.robert.3@umontreal.caValéry Ridde is a associate professor at Montreal University and a researcher at theResearch Center of Montreal University Hospital Center (CRCHUM).Acknowledgments to the research team: •  Abel Bicaba, RESAO •  Pierre Fournier, CRCHUM •  Guy Kegels, ITM Antwerp •  Bruno Marchal, ITM Antwerp

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