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Lara Gautier, Valéry Ridde 26 Sept 2015
Impact of donor-driven health
financing policies on
perceived quality of services
in Sub-Saharan Africa

A scoping review
Growing consensus for universal health coverage (UHC),
cf. SDG 3.8
UHC aims at reaching a balance between:
!  extending access to healthcare services
!  ensuring affordability for all
!  improving quality of care
! Focus has been on improving access & investing in
equipment (i.e. structural inputs) (Peabody, 2015)
!  Missing from these efforts is evidence on the quality of
care that patients actually receive when they enter a
clinic (Jishnu Das et al, 2012)
Background (1/4)
International community promoting a variety of
new policies in Sub-Saharan Africa:
! social health insurance
! user-fee exemption
! performance-based financing
! micro-insurance
! conditional cash transfer…
Background (2/4)
Scalable at
the national
level
!  “Studying healthcare quality from the patient’s perspective
provides valid and unique information about the quality of
care” (Fenny et al, 2014)
!  However, from North to South patients’ perceptions are
predominantly assessed by quantitative questionnaires
!  In addition, quality of care from the health workers’
perspective is too often assessed exclusively in clinical and
technical terms
!  This scoping review analyzes the literature on Sub-
Saharan patients’ and health providers’ perceptions of
quality following the implementation of donor-driven
UHC policies (social health insurance, user-fee
exemption, PBF)
Background (3/4)
!  Commonly, quality is measured through 2 main dimensions:
!  Structural factors
!  material resources (i.e., facilities, equipment, and money)
!  technical resources (i.e., evidence-based medicine)
!  human resources (i.e., number of personnel)
!  organizational structure (i.e., waiting times, hygiene…)
! category of “objectively measured quality”
!  Inter-personal factors ! patient-physician relationship
! category of “subjectively measured quality”
!  There are additional dimensions of quality:
!  Deployment of patients’ rights and empowerment
!  Friendly and welcoming services
! category of “subjectively measured quality”
Background (4/4)

Dimensions of quality
" 
" 
# 
What’s a scoping review?
Methods (1/2)
•  Systematic mixed studies review of the theoretical
and empirical literature (incl.: quantitative, qualitative,
and mixed methods)
Type of
literature review
•  English
•  FrenchLanguages
•  From January 2004 to December 2014Timespan
•  Medline/Pubmed, EBSCOhost and Web of
Science
Scientific
databases
Methods (2/2)
•  Sub-Saharan Africa, health financing, quality
of care, perception, satisfactionSearch strategy
•  Year of publication, language, Sub-Saharan
countries
•  Relevance (i.e., primary or secondary focus on
perceived quality of care)
Inclusion/
exclusion criteria
•  Coding and compilation of the data using a
data extraction form on Excel
Extraction
strategy
•  Based on Pluye & Hong’s methodology for conducting
systematic mixed studies review
•  All included studies have been synthesized qualitatively,
using themes emerging from the extracted data
Analytical design
Results
!
Records!after!duplicates!removed!
(n!=!1155)!
Records!identified!through!
databases!including!Pubmed,!
EBSCOhost,!Web!of!Science!
(n!=!1313)!!
PeerDreviewed!studies!included!
(n!=!25)!
Records!excluded!after!title!
screening!!(n!=!915)!
Records!excluded!because!of!lack!of!
specificity!to!theme!(n!=!190)!
Abstracts!assessed!for!eligibility!
(n!=!215)!
Records!screened!(n!=!1155)!
Identification+Screening+Eligibility+Included+
!  3 literature reviews, 22 original research papers
!  West Africa over-represented: 20/25 papers
!  Burkina Faso (9), Ghana (5), Nigeria (5), Senegal (4)
!  Eastern Africa: Rwanda (3), DR Congo (3), Burundi (2),
Uganda (1)
!  Southern Africa under-represented: South Africa (1)
Results
Policy N papers
Heath insurance 11
User-fee removal 9
PBF 4
All UHC policies 1
!  Only 7 articles out 25 papers mentioned using qualitative
tools (interviews, focus groups, observations) for data
collection (incl. 5 mixed-methods papers)
!  Predominantly quantitative literature
!  reflecting the scale-up of standardized questionnaires
!  Quality is measured “objectively” (i.e. with standardized &
quantified quality scores) in 12/25 papers
!  Quality is measured “subjectively” (i.e. reflecting patients’
and providers’ perceptions of quality) in 9/25 papers
!  In 4 papers, quality is measured in both ways
Results
!  The literature does not show evidence of satisfaction in
terms of quality of care after introducing UHC policies,
whether assessed by patients or health workers
!  Overall inconclusive results in 10/25 papers
!  Where results are clear, the implementation of these policies
has maintained original quality levels (7/25), or led to
worse quality levels (6/25) (e.g., higher workloads, poorer
communication between patients and physicians,…)
!  In only 2/25 papers the quality of services has increased
! in both cases, following the implementation of PBF
!  But their (quantitative) results were only measured with
standardized quality scores
Results
Results

Structrural factors
Health
insurance
User-fee removal PBF All
Increase
Burkina
Nigeria
Uganda Rwanda
Decrease
Burkina
Guinea
Senegal
Niger x2
Mali, Burkina
Maintained
Ghana
Burkina x2
Senegal
Uganda
Burkina x3
Burundi
DR Congo
Inconclusive
Ghana
Nigeria
Burkina, Ghana,
Mali, Niger, Nigeria,
Senegal
Burundi DR Congo,
Nigeria, Rwanda,
South Africa
!  Communication = the most important criteria for Nigerian
patients (Mohammed et al, 2013)
!  Yet investigated in only 11/25 papers, none of them assessing the
impact of PBF
Results

Patient-physician relationship or “inter-
personal care”
Health insurance User-fee removal
Increase
Ghana
BF
Decrease
BF x2
Nigeria
Senegal
Maintained
Ghana
Senegal
Uganda
BF
Inconclusive Ghana
!  “If we received good care, that is a friendly welcome,
good products and a fast recovery, I would be ready to
join […]. If that does not happen, then I am sorry but I am
not going to join” (Criel, 2006)
!  Patients clearly value the quality of welcoming in health
facilities for choosing to enrol to health insurance
!  Two articles also make references to this aspect (Fenny
et al, 2014; Robyn et al, 2013)
!  Unchanged situation following the implementation of health
insurance
Results

Friendly and welcoming services
Users have the right to medical information, make informed
choices and may refuse treatment
!  providers should involve patients in the decision-making process
(Mohammed et al, 2013)
!  Touré (2012) ! empowerment has diminished with
user-fee removal (Mali)
!  for patients & health workers, paying for services is
considered “the best guarantee of quality of services and
opening rights to users”
!  Mohammed et al (2013) ! patients enrolled in the
NHIS were less pleased with their involvement in
decision-making
Results

Empowerment
!  Interpretation of quality restricted to efficacy and
security of medical care:
!  Evaluating quality through standardized quality scores
on medicines supply, waiting times, etc.
!  Standardized and quantitative measurement of
subjective perceptions can be criticized:
1.  Eluding narrative discourses explaining the reasons for
quality changes
2.  How does such constraint to narration could reflect the
complexity of inter-personal relationships?
Discussion

A “biomedical” conception of quality?
The implementation at country level of global health policies
such as UHC is emblematic of extremely top-down
approaches
!  Global health policymaking is characterized by:
!  “paradoxical spaces of local sub-order, well-defined geographical
entities, such as cities/towns, and overall supra-territorial order, in
extremely distant places” (Suárez-Herrera, 2013)
!  Health policies aiming at UHC are formulated and
implemented within these paradoxical spaces
Discussion

From global policymakers to local
beneficiaries
!  Limited involvement of health workers in UHC policies
!  Poor involvement of populations in UHC policies
! lack of knowledge or understanding of policies that are
supposedly facilitating access to care
! weak utilization rates (health insurance)
!  The multiplicity and fragmentation of financing tools in
Sub-Saharan Africa might create more confusion in
national health landscapes for patients seeking quality of
health services (Nauleau et al, 2013)
Discussion
!  Future research in the area of health financing in
Sub-Saharan Africa could address two main
dimensions:
1.  Investigating the unintended consequences on
quality of care of health policies implemented in
Sub-Saharan contexts mainly through qualitative
research
2.  Further investigating the policymaking process
characterized by highly top-down health financing
policies
Conclusion
Acknowledgements

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Impact of donor-driven health financing policies on perceived quality of services in Sub-Saharan Africa: A scoping review

  • 1. Lara Gautier, Valéry Ridde 26 Sept 2015 Impact of donor-driven health financing policies on perceived quality of services in Sub-Saharan Africa
 A scoping review
  • 2. Growing consensus for universal health coverage (UHC), cf. SDG 3.8 UHC aims at reaching a balance between: !  extending access to healthcare services !  ensuring affordability for all !  improving quality of care ! Focus has been on improving access & investing in equipment (i.e. structural inputs) (Peabody, 2015) !  Missing from these efforts is evidence on the quality of care that patients actually receive when they enter a clinic (Jishnu Das et al, 2012) Background (1/4)
  • 3. International community promoting a variety of new policies in Sub-Saharan Africa: ! social health insurance ! user-fee exemption ! performance-based financing ! micro-insurance ! conditional cash transfer… Background (2/4) Scalable at the national level
  • 4. !  “Studying healthcare quality from the patient’s perspective provides valid and unique information about the quality of care” (Fenny et al, 2014) !  However, from North to South patients’ perceptions are predominantly assessed by quantitative questionnaires !  In addition, quality of care from the health workers’ perspective is too often assessed exclusively in clinical and technical terms !  This scoping review analyzes the literature on Sub- Saharan patients’ and health providers’ perceptions of quality following the implementation of donor-driven UHC policies (social health insurance, user-fee exemption, PBF) Background (3/4)
  • 5. !  Commonly, quality is measured through 2 main dimensions: !  Structural factors !  material resources (i.e., facilities, equipment, and money) !  technical resources (i.e., evidence-based medicine) !  human resources (i.e., number of personnel) !  organizational structure (i.e., waiting times, hygiene…) ! category of “objectively measured quality” !  Inter-personal factors ! patient-physician relationship ! category of “subjectively measured quality” !  There are additional dimensions of quality: !  Deployment of patients’ rights and empowerment !  Friendly and welcoming services ! category of “subjectively measured quality” Background (4/4)
 Dimensions of quality
  • 7. Methods (1/2) •  Systematic mixed studies review of the theoretical and empirical literature (incl.: quantitative, qualitative, and mixed methods) Type of literature review •  English •  FrenchLanguages •  From January 2004 to December 2014Timespan •  Medline/Pubmed, EBSCOhost and Web of Science Scientific databases
  • 8. Methods (2/2) •  Sub-Saharan Africa, health financing, quality of care, perception, satisfactionSearch strategy •  Year of publication, language, Sub-Saharan countries •  Relevance (i.e., primary or secondary focus on perceived quality of care) Inclusion/ exclusion criteria •  Coding and compilation of the data using a data extraction form on Excel Extraction strategy •  Based on Pluye & Hong’s methodology for conducting systematic mixed studies review •  All included studies have been synthesized qualitatively, using themes emerging from the extracted data Analytical design
  • 10. !  3 literature reviews, 22 original research papers !  West Africa over-represented: 20/25 papers !  Burkina Faso (9), Ghana (5), Nigeria (5), Senegal (4) !  Eastern Africa: Rwanda (3), DR Congo (3), Burundi (2), Uganda (1) !  Southern Africa under-represented: South Africa (1) Results Policy N papers Heath insurance 11 User-fee removal 9 PBF 4 All UHC policies 1
  • 11. !  Only 7 articles out 25 papers mentioned using qualitative tools (interviews, focus groups, observations) for data collection (incl. 5 mixed-methods papers) !  Predominantly quantitative literature !  reflecting the scale-up of standardized questionnaires !  Quality is measured “objectively” (i.e. with standardized & quantified quality scores) in 12/25 papers !  Quality is measured “subjectively” (i.e. reflecting patients’ and providers’ perceptions of quality) in 9/25 papers !  In 4 papers, quality is measured in both ways Results
  • 12. !  The literature does not show evidence of satisfaction in terms of quality of care after introducing UHC policies, whether assessed by patients or health workers !  Overall inconclusive results in 10/25 papers !  Where results are clear, the implementation of these policies has maintained original quality levels (7/25), or led to worse quality levels (6/25) (e.g., higher workloads, poorer communication between patients and physicians,…) !  In only 2/25 papers the quality of services has increased ! in both cases, following the implementation of PBF !  But their (quantitative) results were only measured with standardized quality scores Results
  • 13. Results
 Structrural factors Health insurance User-fee removal PBF All Increase Burkina Nigeria Uganda Rwanda Decrease Burkina Guinea Senegal Niger x2 Mali, Burkina Maintained Ghana Burkina x2 Senegal Uganda Burkina x3 Burundi DR Congo Inconclusive Ghana Nigeria Burkina, Ghana, Mali, Niger, Nigeria, Senegal Burundi DR Congo, Nigeria, Rwanda, South Africa
  • 14. !  Communication = the most important criteria for Nigerian patients (Mohammed et al, 2013) !  Yet investigated in only 11/25 papers, none of them assessing the impact of PBF Results
 Patient-physician relationship or “inter- personal care” Health insurance User-fee removal Increase Ghana BF Decrease BF x2 Nigeria Senegal Maintained Ghana Senegal Uganda BF Inconclusive Ghana
  • 15. !  “If we received good care, that is a friendly welcome, good products and a fast recovery, I would be ready to join […]. If that does not happen, then I am sorry but I am not going to join” (Criel, 2006) !  Patients clearly value the quality of welcoming in health facilities for choosing to enrol to health insurance !  Two articles also make references to this aspect (Fenny et al, 2014; Robyn et al, 2013) !  Unchanged situation following the implementation of health insurance Results
 Friendly and welcoming services
  • 16. Users have the right to medical information, make informed choices and may refuse treatment !  providers should involve patients in the decision-making process (Mohammed et al, 2013) !  Touré (2012) ! empowerment has diminished with user-fee removal (Mali) !  for patients & health workers, paying for services is considered “the best guarantee of quality of services and opening rights to users” !  Mohammed et al (2013) ! patients enrolled in the NHIS were less pleased with their involvement in decision-making Results
 Empowerment
  • 17. !  Interpretation of quality restricted to efficacy and security of medical care: !  Evaluating quality through standardized quality scores on medicines supply, waiting times, etc. !  Standardized and quantitative measurement of subjective perceptions can be criticized: 1.  Eluding narrative discourses explaining the reasons for quality changes 2.  How does such constraint to narration could reflect the complexity of inter-personal relationships? Discussion
 A “biomedical” conception of quality?
  • 18. The implementation at country level of global health policies such as UHC is emblematic of extremely top-down approaches !  Global health policymaking is characterized by: !  “paradoxical spaces of local sub-order, well-defined geographical entities, such as cities/towns, and overall supra-territorial order, in extremely distant places” (Suárez-Herrera, 2013) !  Health policies aiming at UHC are formulated and implemented within these paradoxical spaces Discussion
 From global policymakers to local beneficiaries
  • 19. !  Limited involvement of health workers in UHC policies !  Poor involvement of populations in UHC policies ! lack of knowledge or understanding of policies that are supposedly facilitating access to care ! weak utilization rates (health insurance) !  The multiplicity and fragmentation of financing tools in Sub-Saharan Africa might create more confusion in national health landscapes for patients seeking quality of health services (Nauleau et al, 2013) Discussion
  • 20. !  Future research in the area of health financing in Sub-Saharan Africa could address two main dimensions: 1.  Investigating the unintended consequences on quality of care of health policies implemented in Sub-Saharan contexts mainly through qualitative research 2.  Further investigating the policymaking process characterized by highly top-down health financing policies Conclusion