Stakeholder perceptions and context of the implementation of performance-based financing in district hospitals in Mali

International Journal of Health Policy and Management, Volume 8, No. 10, Year 2019

Interpretation

Background: To improve the performance of the healthcare system, Mali’s government implemented a pilot project of performance-based financing (PBF) in the field of reproductive health. It was established in the Koulikoro region. This research analyses the process of implementing PBF at district hospital (DH) level, something which has rarely been done in Africa. Methods: This qualitative research is based on a multiple, explanatory, and contrasting case study with nested levels of analysis. It covered three of the 10 DHs in the Koulikoro region. We conducted 36 interviews: 12 per DH with council of circle’s members (2) and health personnel (10). We also conducted 24 non-participant observation sessions, 16 informal interviews, and performed a literature review. We performed data analysis using the Consolidated Framework for Implementation Research (CFIR). Results: Stakeholders perceived the PBF pilot project as a vertical intervention from outside that focused solely on reproductive health. Local actors were not involved in the design of the PBF model. Several difficulties regarding the quality of its design and implementation were highlighted: too short duration of the intervention (8 months), choice and insufficient number of indicators according to the priority of the donors, and impossibility of making changes to the model during its implementation. All health workers adhered to the principles of PBF intervention. Except for members of the district health management team (DHMT) involved in the implementation, respondents only had partial knowledge of the PBF intervention. The implementation of PBF appeared to be easier in District 3 Hospital compared to District 1 and District 2 because it benefited from a pre-pilot project and had good leadership. Conclusion: The PBF programme offered an opportunity to improve the quality of care provided to the population through the motivation of health personnel in Mali. However, several obstacles were observed during the implementation of the PBF pilot project in DHs. When designing and implementing PBF in DHs, it is necessary to consider factors that can influence the implementation of a complex intervention. The study took place in Mali, in the Koulikoro region. In this country, the health system pyramid has 3 levels (Figure S1, Supplementary file 1). Table S3 outlines socio-demographic and health characteristics of Mali and the Koulikoro region. Data collection and process analysis were carried out using the Consolidated Framework for Implementation Research (CFIR).25 According to this framework, 5 dimensions should be studied to understand the implementation of a health intervention (Figure): (i) Characteristics of PBF intervention, (ii) Outer Setting to DH, (iii) Inner Setting to DH, (iv) Characteristics of Individuals, and (v) Process (of PBF). Each of these dimensions includes several constructs. Thanks to a preliminary analysis of the CFIR conceptual framework by the research team, we were able to classify the selected constructs and their descriptions as well as the constructs not retained and their justification (see Table S4, Supplementary file 1). Conceptual Framework, Adapted From Damschroder et al.25 Abbreviation: PBF, performance-based financing. We adopted a qualitative approach, based on a set of explanatory and contrasting multiple case studies with nested levels of analysis26 corresponding to DHs and participants to the implementation of PBF. The conceptual framework outlined above (CFIR) guides our case studies. As per Yin’s 5 components of a case study, our study used: (1) a research question: how is PBF implemented in DHs?; (2) one main proposition in relation to the research question: the characteristics of the PBF intervention, the outer and inner setting of DHs, the characteristics of individuals, and the processes embedded in the intervention affect the implementation of PBF; (3) units of analysis (detailed in the paragraph below); (4) logic linking of the data to the propositions; and (5) the following criteria for interpreting the findings: CFIR’s 5 dimensions (ie, characteristics of the PBF intervention, outer setting of DH, inner setting of DH, characteristics of individuals, and PBF process) guiding data collection (eg, interview guides) and analytical approach. We chose 3 of the 10 DHs in the Koulikoro region. The characteristics of the 3 health districts and their DH are summarised in Table S5, Supplementary file 1. These figures take into account our resource constraints, but also feature an adequate representation of the diversity of contextual situations conducive to the analytical generalisation process specific to case.26 Our study is part of a wider research programme entitled: “Results-based financing for equitable access to maternal and child health care in Mali and Burkina Faso.” The cases were those identified for this research programme. Several districts were removed from the eligible cases because they did not represent the regular context of the health system that the intervention aims to improve (strong interventions by several NGOs), or are not accessible for security reasons. District 1 was selected for its urban character and the presence of a medical assistance scheme (Régime d’assistance médicale [RAMED]). In Mali, RAMED provides medical care for the poor and other vulnerable populations. District 2 was chosen for featuring an articulation of PBF with a community-based insurance was envisaged. This was intended to assess the extent to which PBF could serve as a basis for the accreditation process of health facilities, a process that predates the development of social protection systems (compulsory health insurance, community-based insurance, and RAMED). Finally, we selected District 3, a landlocked and agricultural area in which a community experiment to identify the poorest was also tested. Of the 3 districts selected, only District 3 experienced the PBF pilot phase. Purposeful sampling was used to select participants, so as to ensure external diversification. This selection makes it possible to contrast the different points of view of actors who occupy different positions within a group, in order to have an overall analysis that can be generalised.27 For each district, it was necessary to identify the different categories of actors involved in the implementation of PBF at the level of the 3 DHs. Different stakeholder profiles (Table 1) were selected to compare points of view.27 Participants were recruited based on their availability to answer interview questions. Abbreviations: PBF, performance-based financing; DH, district hospital. The research was conducted from December 2016 to January 2017. We stayed for 12 days in each of the 3 DHs. Actors’ perceptions and practices was the centre of the interview questions. Three semi-structured interview guides were prepared for the District Health Manager (Médecin chef de District [MCD]), staff (medical doctors, nurses, and other health workers and staff), and circle council members. The contents of the 3 guides have been adapted with the selected CFIR constructs. We conducted 36 semi-structured interviews. We also conducted 24 non-participant observation sessions as well as 16 informal interviews with 2 caretakers, 5 physicians, 1 pharmacist, 1 health information officer, 1 social development officer, 2 nurses, 2 interns, 1 midwife, 1 nurse woman, and 1 hygienist. Personal notes taken during non-participant observations and informal interviews were recorded in a journal. In the non-participant observation sessions, we focused on the following topics: (i) work environment (hygiene in hospital outbuildings, treatment rooms, waiting areas, washrooms, etc); (ii) technical tools in DHs (ie, availability and filling of clinical records, attendance books); and (iii) work performance (ie, quality of reception, quality of orientation, guard system). Data processing was done iteratively. All interviews and notes written were classified by site. Research assistants transcribed verbatim all the recordings. The transcribed data was reviewed and coded using a codebook derived from our theoretical framework.28 We coded the data using the QDA Miner Lite software. Based on these codes, we conducted data analysis using the CFIR. This method allowed for an analytical approach that followed a deductive-inductive logic, based on the CFIR dimensions, and allowed empirical themes to emerge that may be relevant to better understand the implementation of PBF in Mali. Our results are presented using the 5 dimensions of the CFIR framework, following a comprehensive and logical flow as recommended by a conceptor of the CFIR.25

AI Digest

Study Justification:

– The study aims to analyze the implementation of performance-based financing (PBF) in district hospitals in Mali, which is a rare focus in Africa.
– By understanding the process of implementing PBF, the study seeks to improve the performance of the healthcare system in Mali and enhance the quality of care provided to the population.

Study Highlights:

– Stakeholders perceived the PBF pilot project as a vertical intervention from outside that focused solely on reproductive health.
– Difficulties regarding the quality of design and implementation of PBF were highlighted, including the short duration of the intervention, choice and insufficient number of indicators, and the inability to make changes during implementation.
– All health workers adhered to the principles of PBF, but respondents had only partial knowledge of the intervention.
– The implementation of PBF was easier in District 3 Hospital compared to District 1 and District 2 due to a pre-pilot project and good leadership.

Study Recommendations:

– When designing and implementing PBF in district hospitals, it is necessary to consider factors that can influence the implementation of a complex intervention.
– Local actors should be involved in the design of the PBF model to ensure its relevance and effectiveness.
– The duration of the intervention should be sufficient to allow for meaningful impact and adjustments to the model.
– The choice and number of indicators should align with the priorities of the donors and the healthcare system.
– Efforts should be made to improve knowledge and understanding of PBF among all stakeholders involved.

Key Role Players:

– Council of circle’s members
– Health personnel
– District health management team (DHMT)

Cost Items for Planning Recommendations:

– Stakeholder engagement and consultation
– Training and capacity building for health personnel
– Development and adaptation of PBF model
– Monitoring and evaluation of PBF implementation
– Communication and awareness campaigns
– Data collection and analysis

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative research study that utilized multiple case studies and interviews. The study provides detailed information about the implementation of performance-based financing (PBF) in district hospitals in Mali. The use of the Consolidated Framework for Implementation Research (CFIR) adds credibility to the study. However, the evidence could be strengthened by including quantitative data and a larger sample size. Additionally, the abstract could provide more information about the limitations of the study and suggestions for future research.

Abstract

The study took place in Mali, in the Koulikoro region. In this country, the health system pyramid has 3 levels (Figure S1, Supplementary file 1). Table S3 outlines socio-demographic and health characteristics of Mali and the Koulikoro region. Data collection and process analysis were carried out using the Consolidated Framework for Implementation Research (CFIR).25 According to this framework, 5 dimensions should be studied to understand the implementation of a health intervention (Figure): (i) Characteristics of PBF intervention, (ii) Outer Setting to DH, (iii) Inner Setting to DH, (iv) Characteristics of Individuals, and (v) Process (of PBF). Each of these dimensions includes several constructs. Thanks to a preliminary analysis of the CFIR conceptual framework by the research team, we were able to classify the selected constructs and their descriptions as well as the constructs not retained and their justification (see Table S4, Supplementary file 1). Conceptual Framework, Adapted From Damschroder et al.25 Abbreviation: PBF, performance-based financing. We adopted a qualitative approach, based on a set of explanatory and contrasting multiple case studies with nested levels of analysis26 corresponding to DHs and participants to the implementation of PBF. The conceptual framework outlined above (CFIR) guides our case studies. As per Yin’s 5 components of a case study, our study used: (1) a research question: how is PBF implemented in DHs?; (2) one main proposition in relation to the research question: the characteristics of the PBF intervention, the outer and inner setting of DHs, the characteristics of individuals, and the processes embedded in the intervention affect the implementation of PBF; (3) units of analysis (detailed in the paragraph below); (4) logic linking of the data to the propositions; and (5) the following criteria for interpreting the findings: CFIR’s 5 dimensions (ie, characteristics of the PBF intervention, outer setting of DH, inner setting of DH, characteristics of individuals, and PBF process) guiding data collection (eg, interview guides) and analytical approach. We chose 3 of the 10 DHs in the Koulikoro region. The characteristics of the 3 health districts and their DH are summarised in Table S5, Supplementary file 1. These figures take into account our resource constraints, but also feature an adequate representation of the diversity of contextual situations conducive to the analytical generalisation process specific to case.26 Our study is part of a wider research programme entitled: “Results-based financing for equitable access to maternal and child health care in Mali and Burkina Faso.” The cases were those identified for this research programme. Several districts were removed from the eligible cases because they did not represent the regular context of the health system that the intervention aims to improve (strong interventions by several NGOs), or are not accessible for security reasons. District 1 was selected for its urban character and the presence of a medical assistance scheme (Régime d’assistance médicale [RAMED]). In Mali, RAMED provides medical care for the poor and other vulnerable populations. District 2 was chosen for featuring an articulation of PBF with a community-based insurance was envisaged. This was intended to assess the extent to which PBF could serve as a basis for the accreditation process of health facilities, a process that predates the development of social protection systems (compulsory health insurance, community-based insurance, and RAMED). Finally, we selected District 3, a landlocked and agricultural area in which a community experiment to identify the poorest was also tested. Of the 3 districts selected, only District 3 experienced the PBF pilot phase. Purposeful sampling was used to select participants, so as to ensure external diversification. This selection makes it possible to contrast the different points of view of actors who occupy different positions within a group, in order to have an overall analysis that can be generalised.27 For each district, it was necessary to identify the different categories of actors involved in the implementation of PBF at the level of the 3 DHs. Different stakeholder profiles (Table 1) were selected to compare points of view.27 Participants were recruited based on their availability to answer interview questions. Abbreviations: PBF, performance-based financing; DH, district hospital. The research was conducted from December 2016 to January 2017. We stayed for 12 days in each of the 3 DHs. Actors’ perceptions and practices was the centre of the interview questions. Three semi-structured interview guides were prepared for the District Health Manager (Médecin chef de District [MCD]), staff (medical doctors, nurses, and other health workers and staff), and circle council members. The contents of the 3 guides have been adapted with the selected CFIR constructs. We conducted 36 semi-structured interviews. We also conducted 24 non-participant observation sessions as well as 16 informal interviews with 2 caretakers, 5 physicians, 1 pharmacist, 1 health information officer, 1 social development officer, 2 nurses, 2 interns, 1 midwife, 1 nurse woman, and 1 hygienist. Personal notes taken during non-participant observations and informal interviews were recorded in a journal. In the non-participant observation sessions, we focused on the following topics: (i) work environment (hygiene in hospital outbuildings, treatment rooms, waiting areas, washrooms, etc); (ii) technical tools in DHs (ie, availability and filling of clinical records, attendance books); and (iii) work performance (ie, quality of reception, quality of orientation, guard system). Data processing was done iteratively. All interviews and notes written were classified by site. Research assistants transcribed verbatim all the recordings. The transcribed data was reviewed and coded using a codebook derived from our theoretical framework.28 We coded the data using the QDA Miner Lite software. Based on these codes, we conducted data analysis using the CFIR. This method allowed for an analytical approach that followed a deductive-inductive logic, based on the CFIR dimensions, and allowed empirical themes to emerge that may be relevant to better understand the implementation of PBF in Mali. Our results are presented using the 5 dimensions of the CFIR framework, following a comprehensive and logical flow as recommended by a conceptor of the CFIR.25

Materials

https://efashare.b-cdn.net/materials/15b303c3e7cbb02e350821563a4537535f332ee57723607560f1e2c12c89d3b8/ijhpm-8-583-s001.pdf

Innovations

Based on the provided information, it is not clear what specific innovations were used or recommended to improve access to maternal health. The study focused on analyzing the implementation of performance-based financing (PBF) in district hospitals in Mali. The findings highlighted difficulties in the design and implementation of the PBF pilot project, as well as the need to consider various factors that can influence the implementation of a complex intervention.

To improve access to maternal health, some potential innovations that could be considered include:

1. Mobile health (mHealth) solutions: Utilizing mobile phones and other digital technologies to provide maternal health information, reminders for prenatal care appointments, and access to telemedicine consultations.

2. Community health worker programs: Training and deploying community health workers to provide maternal health education, antenatal care, and postnatal care services in remote or underserved areas.

3. Telemedicine services: Establishing telemedicine networks to connect healthcare providers in rural areas with specialists in urban centers, enabling remote consultations and diagnosis for pregnant women.

4. Transportation solutions: Implementing innovative transportation systems or partnerships to ensure that pregnant women have access to timely and safe transportation to healthcare facilities for prenatal care, delivery, and emergency obstetric care.

5. Maternal health vouchers: Introducing voucher programs that provide pregnant women with financial assistance to cover the costs of maternal health services, including antenatal care, delivery, and postnatal care.

6. Task-shifting and task-sharing: Expanding the roles and responsibilities of healthcare workers, such as nurses and midwives, to provide comprehensive maternal health services, including emergency obstetric care, in areas with a shortage of doctors.

7. Community engagement and empowerment: Implementing community-based interventions that involve and empower local communities in decision-making processes related to maternal health, such as establishing community health committees or women’s groups.

These are just a few examples of potential innovations that can be explored to improve access to maternal health. It is important to consider the specific context, resources, and needs of the target population when selecting and implementing these innovations.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health would be to address the obstacles and difficulties observed during the implementation of the performance-based financing (PBF) pilot project in district hospitals (DHs) in Mali. Some of the key findings from the study include:

1. Lack of involvement of local actors in the design of the PBF model: To improve access to maternal health, it is important to engage and involve local stakeholders, including healthcare providers, community leaders, and women themselves, in the design and implementation of interventions. This will ensure that the interventions are tailored to the specific needs and context of the community.

2. Short duration of the intervention: The study highlighted that the 8-month duration of the PBF pilot project was too short to fully assess its impact and make necessary adjustments. It is recommended to extend the duration of interventions to allow for a more comprehensive evaluation and adjustment of the program.

3. Insufficient number and choice of indicators: The study found that the PBF model had a limited number of indicators, which may not have adequately captured the full range of maternal health outcomes. It is important to include a comprehensive set of indicators that cover various aspects of maternal health, including access to antenatal care, skilled birth attendance, postnatal care, and family planning services.

4. Limited knowledge of the PBF intervention: The study revealed that apart from the district health management team involved in the implementation, other stakeholders had only partial knowledge of the PBF intervention. It is crucial to ensure that all relevant stakeholders, including healthcare providers, community leaders, and women, are well-informed about the intervention and its objectives to facilitate its successful implementation.

5. Leadership and pre-pilot project: The study found that District 3 Hospital had an easier implementation of the PBF intervention compared to District 1 and District 2 due to its pre-pilot project and good leadership. It is important to provide adequate support and resources to DHs to strengthen their leadership capacity and facilitate the implementation of innovative interventions.

Based on these findings, the recommendation to improve access to maternal health would be to involve local stakeholders in the design and implementation of interventions, extend the duration of interventions, include a comprehensive set of indicators, ensure adequate knowledge and awareness of the intervention among stakeholders, and provide support and resources to DHs for effective implementation.

AI Innovations Methodology

Based on the provided description, the study focuses on the implementation of performance-based financing (PBF) in district hospitals in Mali to improve access to maternal health. To simulate the impact of recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Identify key recommendations: Review the findings of the study and identify the key recommendations for improving access to maternal health. These recommendations could include changes to the PBF intervention, involvement of local actors, addressing design and implementation difficulties, and enhancing knowledge and understanding of the intervention.

2. Define indicators: Determine the indicators that will be used to measure the impact of the recommendations on improving access to maternal health. These indicators could include maternal mortality rates, antenatal care coverage, skilled birth attendance, and access to emergency obstetric care.

3. Collect baseline data: Gather baseline data on the selected indicators before implementing the recommendations. This data will serve as a reference point for comparison and evaluation of the impact.

4. Simulate the impact: Use a simulation model to estimate the potential impact of the recommendations on the selected indicators. The model should take into account the specific context of the district hospitals in Mali and consider factors such as population size, healthcare infrastructure, and available resources.

5. Analyze the results: Evaluate the simulated impact of the recommendations on improving access to maternal health. Compare the projected outcomes with the baseline data to assess the potential effectiveness of the recommendations.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and feedback from stakeholders. Validate the model by comparing the simulated outcomes with real-world data, if available.

7. Communicate findings and recommendations: Present the findings of the simulation analysis, including the projected impact of the recommendations on improving access to maternal health. Provide clear and concise recommendations based on the simulation results to guide decision-making and policy development.

It is important to note that the methodology described above is a general framework and may need to be adapted and customized based on the specific context and available data in Mali. Additionally, involving relevant stakeholders, such as healthcare providers, policymakers, and community members, throughout the simulation process can help ensure the accuracy and relevance of the findings and recommendations.

Author

Dima Health

Statistics:

Citations: 10

Identifiers:

DOI: 10.15171/ijhpm.2019.45

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Burkina Faso, Mali, Multi-Countries

Study Design:

Case Study, Cross Sectional Study, Ethnographic Study, Exploratory Study, Grounded Theory, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Quantitative, Systematic Review