Presentation by Matthew Hunt (McGill University). Global Health Workshop: Methods For Implementation Science in Global Health. http://www.equitesante.org/implementation-science-methods-in-global-health/

1. Bringing an ethics lens to the
evaluation of a project on user fee
exemptions in Burkina Faso
METHODS FOR IMPLEMENTATION SCIENCE
IN GLOBAL HEALTH
April, 20th. 2017
McGill University
Workshop co-organised by REALISME Chair and McGill of Global Health Programs
Matthew Hunt, PT, PhD

2. Context
• User fee exemptions for the most vulnerable (les indigents)
identified in national policy, but not implemented
• Participatory development, roll out and evaluation of a
project incorporating 1) community selection of the
indigents, and 2) endogenous funding for user fee
exemptions from the marginal profit of village dispensaries
Protocol
development,
Site selection
Community
consultation &
stakeholder training
Village Selection Committee (VSC)
creates list of indigents
Village chief reviews list
Management Committee (MC) for the
Local Health Centre validates list
Indigents receive
plasticized card to
enable them to access
health services
Costs subsidized by
marginal profits of
local health
dispensaries

3. Objectives of the study
Investigate how ethical considerations arise in
this action-research from the perspectives of
different stakeholders
* Operational definition: ethical considerations encompass
features of the project in which values that were important to
respondents were experienced as being realized or thwarted.
(adapted from Hunt & Carnevale, 2011)

4. Method
An Interpretive Description (Thorne,
2008) study informed by the
hermeneutic approach of moral
experience (Hunt & Carnevale, 2011)
39 semi structured interviews -
purposive sampling
Inductive analysis using constant
comparative techniques
5
Decision-
makers6 Health
Professionals
5 Researchers6
Members of
Village Selection
Committees
(VSCs)
Members
Manageme
nt
Committe
es (MCs)
13 Indigents
5

5. Results
• Tensions around participatory approaches: instrumental
or intrinsic value, invite participation but also preserve
methodological integrity
• Addressing a single dimension of vulnerability: “If I’d
had to pay when I got sick last year, I would have died. I
didn’t have enough to eat, never mind to get medical
care.” (indigent)
• Risks of “labelling”, stigma when targeting vulnerability
• Facilitator of community values: “the community had
compassion for them; it was just the people didn’t have
the means to help them” (member of MC)
• Efforts to promote fairness/ avoid deflection of the
intervention
• Power relations in the development of partnerships: “It’s
bound to create dominance, because when we talk about
a ‘leader’, that’s the person with the money, that creates
dominance…” (research team member)
The distinctive ethical
terrain of an action-
research project:
Selected elements:

6. Lessons learned for
implementation
science in global
health
Strengths
• Draws attention to how the implementation
of an intervention implicates, supports or
undermines values for diverse stakeholders
• Provides a lens to look across various
components of an intervention – can dial in
the focus at different levels (micro, meso,
macro)
Limits
• Challenging to elicit discussion of values and
moral experience!
• What sort of critical distance is needed for
this analysis?
• Design considerations: timing, integration

7. To go further
• Gogognon Patrick, Matthew Hunt, Valéry Ridde. (2012). Les enjeux éthiques
d’une recherche-action sur une sélection communautaire des indigents au
Burkina Faso. Éthique et Santé. 9(4): 148-155.
• Hunt, Matthew and Franco A. Carnevale. (2011). Moral Experience: A framework
for bioethics research. Journal of Medical Ethics. 37: 658-662.
• Hunt, Matthew, Patrick Gogognon, Valéry Ridde (2014). Ethical considerations
related to participation and partnership: An investigation of stakeholders’
perceptions of an action-research project on user fee removal for the poorest in
Burkina Faso. BMC Medical Ethics. 15:13; DOI: 10.1186/1472-6939-15-13.
• Kleinman, Arthur. What really matters: living a moral life amidst uncertainty and
danger. Oxford University Press, 2006.
• Thorne, Sally. (2008). Interpretive Description. Left Coast Press: Walnut Grove CA

8. Let’s discuss together!
Meet the experts
Thank you for your attention