An Exploration of the Unintended Consequences of Performance-Based Financing in 6 Primary Healthcare Facilities in Burkina Faso

International Journal of Health Policy and Management, Volume 11, No. 2, Year 2022

Interpretation

Background: Performance-based financing (PBF) is promoted to improve the quality and quantity of healthcare services in low-income countries. Despite the complexity of the intervention, little attention has been given to studying its unintended consequences. Our objective is to increase evidence on the unintended consequences of PBF in Burkina Faso. Methods: Using the diffusion of innovations theory, we conducted a multiple case study. The cases were 6 healthcare facilities in two districts. Between April 2015 and 2016, we collected data through 101 semi-structured interviews, discussions, observations, and documents. We conducted thematic analysis using a hybrid deductive-inductive approach. Secondary data was used to illustrate the evolution of reported services. We conducted a cross-case synthesis to identify the results arising independently from more than 1 case. Results: A desirable unintended consequence of PBF was that 3 facilities limited the sale of non-prescribed medication to encourage patients to consult. Undesirable unintended consequences were found in the majority of facilities including fixation on measures rather than on underlying objectives, the pursuit of narrow and less relevant performance indicators, gaming, and teaching trainees improper practices. Providers in all facilities deliberately manipulated medical registers and documents, such that the reported quantity and quality of care differed from what was actually delivered. While most participants indicated that PBF was more advantageous than previous practices, the long payment delays were a source of dissatisfaction and demotivation across all facilities. Dissatisfaction also emerged in relation to the distribution of subsidies and the non-attribution of quality points for services delivered by certain staff considered “unqualified” in guidelines. Results in many facilities revealed suboptimal planning, a perception of the intervention as “budgetivorous,” as well as tensions related to the principle of managerial autonomy. Conclusion: PBF led to numerous unintended consequences that could undermine the intervention’s effectiveness. The findings contribute to a more comprehensive picture of the consequences of implementing PBF. Policy-makers can use the results of this study to devise effective strategies before, during and after the implementation of the intervention to minimize undesirable unintended consequences and promote desirable ones. The study took place in 2 rural districts of Burkina Faso where improving the healthcare system’s performance remains a challenge. The low quality of healthcare is often characterised by the staff’s inhospitality, insufficient equipment/medication and lack of training. 27 In 2011, the government of Burkina Faso, with World Bank support, conducted a pre-pilot PBF test in 3 districts to address generalized quality deficiencies and improve healthcare system performance. 28 According to Steenland et al, 29 this intervention changed the previous financing system by defining a package of key health services to be targeted at contracted facilities, and issuing payments based on quantity and quality for these services. However, this pre-pilot PBF test did not include some recommended elements of PBF including an increase in health facility autonomy and the introduction of improved management tools. 29 Thus, in 2014, the intervention was modified to incorporate these elements and expanded to 12 more districts in order to conduct an experimental impact evaluation funded by the World Bank. The specific objectives of the intervention were to (1) increase the utilisation of healthcare services; (2) improve the quality of healthcare services; (3) improve the efficiency of the healthcare system; (4) ensure equity in access to healthcare services; (5) reinforce the motivation of personnel; (6) improve community participation; (7) reinforce the health information system; (8) consolidate public – private partnership; and (9) reinforce the governance of the healthcare system. Four intervention arms were implemented combining PBF modalities with different unit fees for service and equity measures (Supplementary file 1). The intervention model is available online. 30 Each month, a PBF auditor from the contractualisation and verification agency counted the number of reported healthcare services in registers to establish the subsidies. In total, 23 indicators were subsidized for the quantity of care at the primary care level. Every trimester, a team composed of district management team members (eg, doctor, midwife, nurse and pharmacist) assessed the facilities’ technical quality of care by sampling records from various medical registers and observing the facilities’ environment. Quality scores were reported in a 113-item grid (covering 28 domains) and were used to determine the bonuses to be paid (Supplementary file 2). Community verifications were also supposed to be conducted every trimester. Subsidies and bonuses were used to pay for facility expenditures and premiums to motivate staff. Providers were required to use an index tool every month to update the facilities’ revenues, plan expenditures, and determine the distribution of premiums. Each trimester, providers were also required to produce a performance improvement plan to set objectives and plan activities. We conducted a multiple case study with several embedded levels of analyses, using both qualitative and quantitative data. 31 Case studies are useful to investigate contemporary phenomenon in depth and within their real-life context when the boundaries between the phenomenon and context are not clear. 31 Evidence from multiple cases is considered more robust because it enables replication. 31 For this study, the cases were 6 primary healthcare facilities, called Centres de santé et de promotion sociale (CSPS) located in 2 districts. We selected 2 of the 12 districts involved in PBF in Burkina Faso. We selected these 2 districts because they (1) were located in diverse regions, (2) represented the normal context of the healthcare system, and (3) were relatively safe for data collectors. The first district has 21 primary healthcare facilities and 1 medical center with surgical satellite services. The second district has 56 primary healthcare facilities and 1 medical center with surgical satellite services and 1 regional hospital. Case selection for healthcare facilities followed a multistage screening procedure described elsewhere. 32,33 Table 1 describes each primary healthcare facility included. Abbreviations: PBF, performance-based financing; IHW, itinerary health worker. a Data available online: http://www.fbrburkina.org/data. Participants included a wide range of stakeholders, including providers (ie, nurses, midwives, itinerary health worker), support staff (ie, drug manager, janitors, guards), patients (eg, seeking care for curative consultations or maternal and child health), and community representatives (eg, members of the facility management committee) (see Table 2). Participants were purposefully selected based on their ability to provide relevant information and their accessibility. In each facility, we selected all the providers, support staff and volunteers for semi-structured interviews. Then, following the snowball approach, some participants referred us to other people who could shed light on the intervention. 34 This strategy was used to identify potential participants who were knowledgeable about or had a particular experience with the intervention (eg, auditors and administrative staff at the district level). Overall, we conducted 101 semi-structured interviews. Abbreviations: COGES, facilities’ management committees; CHWs, community health workers; PADS, program to support health development. We adopted a broad, exploratory approach in order to capture all changes that were not initially targeted by program planners. Through observation, semi-structured interviews and informal discussions, we collected data on various dimensions of the healthcare system including service delivery, governance, human resources, medication, health information system and financial management. Data were collected during 3 sequential phases, with each informing methods for the next. In the pilot phase (April 2015), the first author conducted one week of fieldwork in 2 facilities in the same district (facilities A and B). These served as pilot case studies to validate the feasibility of the methods. In phase 1 (January–April 2016), the first author conducted 3 months of fieldwork, examining 4 facilities in another district with longer field visits and more participants, for greater depth (facilities 1–4). Each facility was visited for 2 weeks. The first week primarily served to conduct observation within the facilities and the second week served to conduct semi-structured interviews with participants. The first author lived in the facilities which enabled her to conduct observation as well as informal discussions around the clock. The first author also attended a 6-day annual national PBF review meeting for 2015. In phase 2 (May 2016), the second author conducted 20 days of fieldwork in those facilities and neighbouring ones, to deepen the assessment of community verifications. Of the 101 semi-structured interviews conducted, 11 were in the pilot phase; 76 in phase 1; and 14 in phase 2. Our semi-structured interview guides 35 built upon previous questionnaires used for research on diffusion of innovations 36,37 but were tailored to our objectives and participants (see Supplementary file 3). They enabled us to assess how factors related to the social system, characteristics of the members, and the nature and use of the intervention interacted to produce consequences over time. Interviews were recorded and local research assistants made verbatim transcriptions. In total, 258 observation sessions were recorded in research diaries. Observations sites included health facilities and villages. During observation, we collected a wide range of intervention documents (eg, quantity and quality verification reports, index tools) to fuel our analyses. We also used publicly available secondary quantitative data on service delivery (http://www.fbrburkina.org). These longitudinal data were collected monthly in each facility for PBF audits. Healthcare workers reported the quantity of healthcare services that were recorded in the medical registers. Then, PBF auditors verified the reported data by manually recounting the quantity of services. They entered the data into an electronic platform. We accessed and used data collected between 2014 and 2016 on the number of integrated household visits (IHVs) and the number of people who underwent voluntary HIV screening. We used several strategies to increase the trustworthiness of findings including (1) prolonged engagement on the field, (2) peer debriefing with members of the research team, (3) collection of audio recordings and photographs to test findings, (4) triangulation between sources of information and methods, and (5) member checks with stakeholders to confirm results. 38 The primary unit of analysis was each healthcare facility. We combined deductive and inductive thematic analysis. 39 We began by developing a template of themes based on our theoretical framework. Then, we carefully read the transcripts of the recorded semi-structured interviews and field notes to assign the raw data to the predefined themes. At the same time, we derived new themes that emerged from the data and were judged relevant to our research topic. Data were triangulated by comparing different information sources. 40 QDA Miner, a qualitative data analysis software, was used to code and retrieve text segments. We integrated the results from all data collection phases and used a cross-case synthesis to draw general conclusions. Following a replication logic for multiple case studies, we considered results arising independently from more than one case to be more powerful than those from a single case, and gave the former more importance in the results. 31 To avoid cherry-picking results within the rich material, we only present unintended consequences that emerged in multiple healthcare facilities. We organized a member check in Burkina Faso to confirm the researchers’ data interpretation, triangulate results, and validate conclusions. 41 Further member checks were conducted subsequently on specific elements. We selected verbatim quotations from participants and field notes to enable readers to access the raw data and assess the credibility of results. 38

AI Digest

Study Justification:

– Performance-based financing (PBF) is a widely promoted intervention to improve healthcare services in low-income countries.
– However, little attention has been given to studying the unintended consequences of PBF.
– This study aims to increase evidence on the unintended consequences of PBF in Burkina Faso.

Study Highlights:

– The study conducted a multiple case study in 6 primary healthcare facilities in Burkina Faso.
– Data was collected through interviews, discussions, observations, and documents.
– Desirable unintended consequences of PBF included limiting the sale of non-prescribed medication to encourage patients to consult.
– Undesirable unintended consequences included fixation on measures rather than underlying objectives, pursuit of narrow and less relevant performance indicators, gaming, and teaching trainees improper practices.
– Providers manipulated medical registers and documents to report different quantity and quality of care.
– Long payment delays and dissatisfaction with subsidy distribution were sources of dissatisfaction and demotivation.
– Suboptimal planning, perception of the intervention as “budgetivorous,” and tensions related to managerial autonomy were also identified.

Study Recommendations:

– Policy-makers can use the study results to devise effective strategies before, during, and after the implementation of PBF to minimize undesirable unintended consequences and promote desirable ones.

Key Role Players:

– Providers (nurses, midwives, itinerary health workers)
– Support staff (drug managers, janitors, guards)
– Patients
– Community representatives (members of facility management committees)
– Auditors and administrative staff at the district level

Cost Items for Planning Recommendations:

– Budget for training and capacity building of healthcare staff
– Budget for improving healthcare infrastructure and equipment
– Budget for monitoring and evaluation of PBF implementation
– Budget for community engagement and participation activities
– Budget for data collection and analysis
– Budget for communication and dissemination of study findings

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a multiple case study conducted in Burkina Faso, which involved data collection through interviews, discussions, observations, and documents. Thematic analysis was used to analyze the data. The study provides specific examples of both desirable and undesirable unintended consequences of performance-based financing (PBF) in healthcare facilities. The findings contribute to a more comprehensive understanding of the consequences of implementing PBF. However, the abstract does not provide information on the sample size or representativeness of the healthcare facilities included in the study. To improve the strength of the evidence, future studies could consider increasing the sample size and ensuring a more diverse representation of healthcare facilities across different regions. Additionally, the abstract does not mention any statistical analysis or quantitative data to support the findings. Including quantitative data and statistical analysis could further strengthen the evidence.

Abstract

The study took place in 2 rural districts of Burkina Faso where improving the healthcare system’s performance remains a challenge. The low quality of healthcare is often characterised by the staff’s inhospitality, insufficient equipment/medication and lack of training. 27 In 2011, the government of Burkina Faso, with World Bank support, conducted a pre-pilot PBF test in 3 districts to address generalized quality deficiencies and improve healthcare system performance. 28 According to Steenland et al, 29 this intervention changed the previous financing system by defining a package of key health services to be targeted at contracted facilities, and issuing payments based on quantity and quality for these services. However, this pre-pilot PBF test did not include some recommended elements of PBF including an increase in health facility autonomy and the introduction of improved management tools. 29 Thus, in 2014, the intervention was modified to incorporate these elements and expanded to 12 more districts in order to conduct an experimental impact evaluation funded by the World Bank. The specific objectives of the intervention were to (1) increase the utilisation of healthcare services; (2) improve the quality of healthcare services; (3) improve the efficiency of the healthcare system; (4) ensure equity in access to healthcare services; (5) reinforce the motivation of personnel; (6) improve community participation; (7) reinforce the health information system; (8) consolidate public – private partnership; and (9) reinforce the governance of the healthcare system. Four intervention arms were implemented combining PBF modalities with different unit fees for service and equity measures (Supplementary file 1). The intervention model is available online. 30 Each month, a PBF auditor from the contractualisation and verification agency counted the number of reported healthcare services in registers to establish the subsidies. In total, 23 indicators were subsidized for the quantity of care at the primary care level. Every trimester, a team composed of district management team members (eg, doctor, midwife, nurse and pharmacist) assessed the facilities’ technical quality of care by sampling records from various medical registers and observing the facilities’ environment. Quality scores were reported in a 113-item grid (covering 28 domains) and were used to determine the bonuses to be paid (Supplementary file 2). Community verifications were also supposed to be conducted every trimester. Subsidies and bonuses were used to pay for facility expenditures and premiums to motivate staff. Providers were required to use an index tool every month to update the facilities’ revenues, plan expenditures, and determine the distribution of premiums. Each trimester, providers were also required to produce a performance improvement plan to set objectives and plan activities. We conducted a multiple case study with several embedded levels of analyses, using both qualitative and quantitative data. 31 Case studies are useful to investigate contemporary phenomenon in depth and within their real-life context when the boundaries between the phenomenon and context are not clear. 31 Evidence from multiple cases is considered more robust because it enables replication. 31 For this study, the cases were 6 primary healthcare facilities, called Centres de santé et de promotion sociale (CSPS) located in 2 districts. We selected 2 of the 12 districts involved in PBF in Burkina Faso. We selected these 2 districts because they (1) were located in diverse regions, (2) represented the normal context of the healthcare system, and (3) were relatively safe for data collectors. The first district has 21 primary healthcare facilities and 1 medical center with surgical satellite services. The second district has 56 primary healthcare facilities and 1 medical center with surgical satellite services and 1 regional hospital. Case selection for healthcare facilities followed a multistage screening procedure described elsewhere. 32,33 Table 1 describes each primary healthcare facility included. Abbreviations: PBF, performance-based financing; IHW, itinerary health worker. a Data available online: http://www.fbrburkina.org/data. Participants included a wide range of stakeholders, including providers (ie, nurses, midwives, itinerary health worker), support staff (ie, drug manager, janitors, guards), patients (eg, seeking care for curative consultations or maternal and child health), and community representatives (eg, members of the facility management committee) (see Table 2). Participants were purposefully selected based on their ability to provide relevant information and their accessibility. In each facility, we selected all the providers, support staff and volunteers for semi-structured interviews. Then, following the snowball approach, some participants referred us to other people who could shed light on the intervention. 34 This strategy was used to identify potential participants who were knowledgeable about or had a particular experience with the intervention (eg, auditors and administrative staff at the district level). Overall, we conducted 101 semi-structured interviews. Abbreviations: COGES, facilities’ management committees; CHWs, community health workers; PADS, program to support health development. We adopted a broad, exploratory approach in order to capture all changes that were not initially targeted by program planners. Through observation, semi-structured interviews and informal discussions, we collected data on various dimensions of the healthcare system including service delivery, governance, human resources, medication, health information system and financial management. Data were collected during 3 sequential phases, with each informing methods for the next. In the pilot phase (April 2015), the first author conducted one week of fieldwork in 2 facilities in the same district (facilities A and B). These served as pilot case studies to validate the feasibility of the methods. In phase 1 (January–April 2016), the first author conducted 3 months of fieldwork, examining 4 facilities in another district with longer field visits and more participants, for greater depth (facilities 1–4). Each facility was visited for 2 weeks. The first week primarily served to conduct observation within the facilities and the second week served to conduct semi-structured interviews with participants. The first author lived in the facilities which enabled her to conduct observation as well as informal discussions around the clock. The first author also attended a 6-day annual national PBF review meeting for 2015. In phase 2 (May 2016), the second author conducted 20 days of fieldwork in those facilities and neighbouring ones, to deepen the assessment of community verifications. Of the 101 semi-structured interviews conducted, 11 were in the pilot phase; 76 in phase 1; and 14 in phase 2. Our semi-structured interview guides 35 built upon previous questionnaires used for research on diffusion of innovations 36,37 but were tailored to our objectives and participants (see Supplementary file 3). They enabled us to assess how factors related to the social system, characteristics of the members, and the nature and use of the intervention interacted to produce consequences over time. Interviews were recorded and local research assistants made verbatim transcriptions. In total, 258 observation sessions were recorded in research diaries. Observations sites included health facilities and villages. During observation, we collected a wide range of intervention documents (eg, quantity and quality verification reports, index tools) to fuel our analyses. We also used publicly available secondary quantitative data on service delivery (http://www.fbrburkina.org). These longitudinal data were collected monthly in each facility for PBF audits. Healthcare workers reported the quantity of healthcare services that were recorded in the medical registers. Then, PBF auditors verified the reported data by manually recounting the quantity of services. They entered the data into an electronic platform. We accessed and used data collected between 2014 and 2016 on the number of integrated household visits (IHVs) and the number of people who underwent voluntary HIV screening. We used several strategies to increase the trustworthiness of findings including (1) prolonged engagement on the field, (2) peer debriefing with members of the research team, (3) collection of audio recordings and photographs to test findings, (4) triangulation between sources of information and methods, and (5) member checks with stakeholders to confirm results. 38 The primary unit of analysis was each healthcare facility. We combined deductive and inductive thematic analysis. 39 We began by developing a template of themes based on our theoretical framework. Then, we carefully read the transcripts of the recorded semi-structured interviews and field notes to assign the raw data to the predefined themes. At the same time, we derived new themes that emerged from the data and were judged relevant to our research topic. Data were triangulated by comparing different information sources. 40 QDA Miner, a qualitative data analysis software, was used to code and retrieve text segments. We integrated the results from all data collection phases and used a cross-case synthesis to draw general conclusions. Following a replication logic for multiple case studies, we considered results arising independently from more than one case to be more powerful than those from a single case, and gave the former more importance in the results. 31 To avoid cherry-picking results within the rich material, we only present unintended consequences that emerged in multiple healthcare facilities. We organized a member check in Burkina Faso to confirm the researchers’ data interpretation, triangulate results, and validate conclusions. 41 Further member checks were conducted subsequently on specific elements. We selected verbatim quotations from participants and field notes to enable readers to access the raw data and assess the credibility of results. 38

Materials

Innovations

Based on the provided information, it appears that the study focused on the unintended consequences of performance-based financing (PBF) in improving maternal health in Burkina Faso. The study identified both desirable and undesirable unintended consequences of PBF. Some of the innovations that could potentially improve access to maternal health based on the study findings include:

1. Limiting the sale of non-prescribed medication: Three facilities in the study limited the sale of non-prescribed medication to encourage patients to consult with healthcare providers. This innovation can help ensure that pregnant women receive appropriate medical advice and care, improving maternal health outcomes.

2. Improving performance indicators: The study found that some facilities pursued narrow and less relevant performance indicators. An innovation could be to develop and implement a comprehensive set of performance indicators specifically tailored to maternal health, ensuring that healthcare providers are incentivized to deliver high-quality maternal care.

3. Strengthening healthcare provider training: The study revealed that providers in all facilities manipulated medical registers and documents, leading to discrepancies between reported and actual care delivered. An innovation could be to invest in training programs for healthcare providers, focusing on ethical practices, accurate documentation, and quality care delivery.

4. Addressing payment delays: The study highlighted that long payment delays were a source of dissatisfaction and demotivation among healthcare providers. An innovation could be to streamline the payment process, ensuring that healthcare providers receive timely compensation for their services, which can help improve access to maternal health services.

5. Ensuring equitable distribution of subsidies: Dissatisfaction emerged regarding the distribution of subsidies and the non-attribution of quality points for services delivered by certain staff considered “unqualified” in guidelines. An innovation could be to develop transparent and fair criteria for the distribution of subsidies, ensuring that all healthcare providers involved in maternal health receive appropriate recognition and support.

6. Enhancing planning and resource allocation: The study revealed suboptimal planning and tensions related to the principle of managerial autonomy. An innovation could be to implement effective planning and resource allocation strategies specifically targeted at improving maternal health, ensuring that resources are allocated efficiently and effectively to address the unique needs of pregnant women.

These innovations, if implemented, have the potential to improve access to maternal health by addressing the unintended consequences identified in the study and promoting desirable outcomes.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the study is to address the unintended consequences of performance-based financing (PBF) in healthcare facilities. The study found that while PBF had some desirable unintended consequences, such as limiting the sale of non-prescribed medication to encourage patients to consult, it also had several undesirable unintended consequences. These included fixation on measures rather than underlying objectives, pursuit of narrow and less relevant performance indicators, gaming, teaching trainees improper practices, manipulation of medical registers and documents, long payment delays, dissatisfaction with the distribution of subsidies, and tensions related to managerial autonomy.

To improve access to maternal health, it is recommended to develop innovative strategies that address these unintended consequences. This could involve:

1. Strengthening the monitoring and evaluation system: Implement a robust monitoring and evaluation system to ensure that performance indicators are aligned with the underlying objectives of improving maternal health. This can help prevent fixation on measures and narrow performance indicators.

2. Enhancing transparency and accountability: Implement measures to ensure transparency and accountability in the reporting of healthcare services. This can include regular audits and verification of reported data to prevent manipulation of medical registers and documents.

3. Streamlining payment processes: Address the issue of long payment delays by streamlining the payment processes. This can involve implementing automated payment systems or exploring alternative payment methods to ensure timely payment to healthcare facilities.

4. Ensuring equitable distribution of subsidies: Review the distribution of subsidies to ensure that they are allocated equitably among healthcare facilities. This can help address dissatisfaction with the distribution of subsidies and promote fairness in resource allocation.

5. Promoting professional development and training: Provide ongoing professional development and training opportunities for healthcare providers to ensure that they are equipped with the necessary skills and knowledge to deliver quality maternal health services. This can help prevent the teaching of improper practices and improve the quality of care.

By addressing these unintended consequences, the innovation can help improve the effectiveness of performance-based financing in improving access to maternal health.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Strengthen healthcare facility autonomy: Increase the decision-making power and autonomy of healthcare facilities, allowing them to tailor their services to the specific needs of the community.

2. Improve management tools: Introduce improved management tools to help healthcare facilities effectively plan and manage their resources, ensuring efficient service delivery.

3. Address payment delays: Minimize long payment delays to healthcare facilities, as these can lead to dissatisfaction and demotivation among healthcare providers.

4. Enhance distribution of subsidies: Ensure equitable distribution of subsidies to healthcare facilities, taking into account the quality and quantity of services provided.

5. Promote community participation: Encourage active involvement of the community in decision-making processes related to maternal health, fostering a sense of ownership and accountability.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators that reflect access to maternal health, such as the number of antenatal care visits, percentage of births attended by skilled health personnel, and maternal mortality rate.

2. Collect baseline data: Gather data on the identified indicators before implementing the recommendations. This will serve as a baseline for comparison.

3. Implement recommendations: Introduce the recommended innovations and interventions in selected healthcare facilities or districts.

4. Monitor and evaluate: Continuously monitor and evaluate the implementation of the recommendations, collecting data on the identified indicators. This can be done through surveys, interviews, observations, and analysis of existing data.

5. Analyze data: Analyze the collected data to assess the impact of the recommendations on the identified indicators. Compare the post-implementation data with the baseline data to determine any changes or improvements.

6. Draw conclusions: Based on the analysis of the data, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. Identify any challenges or unintended consequences that may have arisen.

7. Refine and adjust: Use the findings from the evaluation to refine and adjust the recommendations as needed. This iterative process will help optimize the impact of the interventions.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of innovations and interventions on improving access to maternal health. This information can then be used to inform decision-making and guide the implementation of effective strategies.

Authors & Co-Authors

Statistics:

Citations: 7

Authors: 3

Identifiers:

DOI: 10.34172/ijhpm.2020.83

Research Areas:

Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Burkina Faso

Study Design:

Case Study, Cohort Study, Exploratory Study, Grounded Theory, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Quantitative