Achieving impact
Through its evaluation processes and findings, the project is expected to impact on several main actors or levels: the scientific community working on complex health care evaluations, the global health and safe motherhood community, the women and their families in Africa and other poor settings, and finally the national stakeholders at policy and health service levels.
Dissemination
This project gives the highest priority to getting research into policy and practice (GRIPP).
It was designed on the basis of the hypothesis that national policy-makers, international agencies and health managers will use the results of a well-designed and implemented multi-disciplinary study in formulating policy and improving local practices provided (1) it addresses a high-priority problem; (2) they are involved in all phases of the project; (iii) they perceive researchers as experts contributing to the development of appropriate knowledge for current policies; and (4) the findings reach all relevant stakeholders.
We are confident on the high priority of our work area (point 1). We will engage with actors at national, regional and international levels in order to maximise the chances of meeting the conditions for points (2) and (4). The quality of work and engagement with local policy priorities will aim to ensure that (3) is also met.
Reports & Policy Briefs
The findings from the FEMHealth project have now been finalised. Below is a comprehensive list (with links) to the reports and policy briefs produced by the consortium.
- Overall Report
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For overall findings based on comparative analysis of the multi-disciplinary evaluations across four countries, please see below
- Country Reports
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For the detailed findings for specific countries, please see the reports below:
Benin
- Benin country report
- Assessment of three years of implementation of the free caesarean section policy in five health zones of Benin
- Evaluation de trois années de mise en oeuvre de la politique de gratuité de la césarienne dans cinq zones sanitaires du Bénin
Burkina Faso
- Burkina Faso country report
- Les résultats de l'enquête sur le personnel de santé, Burkina Faso, FEMHealth
- Effects of subsidising maternal and neonatal health care in Burkina Faso: “it's good but still not enough”!
- Effets de la subvention des soins de santé maternelle et néonatale au Burkina Faso : « c'est bon mais ce n'est pas encore arrivé »!
Morocco
- Methods
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For reports on the FEMHealth methodological findings, please see the reports below:
- Free care for deliveries and caesareans in West Africa and Morocco: research findings and lessons
- La gratuité des accouchements et des césariennes en Afrique de l'Ouest et au Maroc: résultats et leçons tirées de la recherche
- Assessing the implementation of health financing policies - a proposed approach and discussion of its application to an emergency obstetric care exemption policy in Benin
Specific methods reports and policy briefs can be found below:
- POEM guide
- POEM (Policy Effects Mapping tool) or how to assess the effects of a targeted policy on the local health system
- POEM (POlicy Effects Mapping tool) ou comment évaluer les effets d'une politique ciblée sur le système de santé local
- Reflections on complex evaluations
- Lessons learned from Realist Evaluations
- Why and how fee exemption policies are adopted by district-level health managers: Methodological lessons from a series of realist case studies in Benin, Burkina Faso and Morocco
- Pourquoi et comment les politiques d'exemption des paiements directs sont adoptées par les gestionnaires des districts sanitaires: Enseignements méthodologiques tirés d'une série d'études de cas réalistes au Bénin, au Burkina Faso et au Maroc
- Near miss tool and guide
- HEALTH CARE NEAR-MISS - Indicators to measure the performance of obstetric teams in poor resource settings
- HEALTH CARE NEAR-MISS - Indicateurs de mesure de la performance des équipes obstétricales dans les pays à ressources limitées
- Community of Practice
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For a report on the lessons learned for the early phases of setting up a Community of Practice, please see below:
- CoP report
- Managing knowledge for better health policies: the Financial Access to Health Services Community of Practice experience
- Gérer les connaissances pour de meilleures politiques de santé: l'expérience de la Communauté de Pratique Accès Financier aux Services de Santé
- CoP assessment framework 2012
- 'Maternal health fee exemptions - Policy Brief' Workshop 2011.
- Further information on the CoP and workshop reports from Bamako 2011 and Ouagadougou 2013 can be found here .
- Protocols
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The protocols developed during the FEMHealth programme can be found below:
Published Articles
- Publications
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'Trends in health facility deliveries and caesarean sections by wealth quintile in Morocco between 1987 and 2012' Jenny Cresswell, Bouchra Assarag, Fatima-Zahra Meski, Veronique Filippi and Carine Ronsmans. Tropical Medicine & International Health May 2015, 20(5) 607-616.
To examine trends in the utilisation of facility-based delivery care and caesareans in Morocco between 1987 and 2012, particularly among the poor, and to assess whether uptake increased at the time of introduction of policies or programmes aimed at improving access to intrapartum care.
Using data from nationally representative household surveys and routine statistics, our analysis focused on whether women delivered within a facility, and whether the delivery was by caesarean; analyses were stratified by relative wealth quintile and public/private sector where possible. A segmented Poisson regression model was used to assess whether trends changed at key events.
Uptake of facility-based deliveries and caesareans in Morocco has risen considerably over the past two decades, particularly among the poor. The rate of increase in facility deliveries was much faster in the poorest quintile (annual increase RR: 1.09; 95% CI: 1.07-1.11) than the richest quintile (annual increase RR: 1.01; 95% CI: 1.02-1.02). A similar pattern was observed for caesareans (annual increase among poorest RR: 1.13; 95% CI: 1.07-1.19 vs. annual increase among richest RR: 1.08; 95% CI: 1.06-1.10). We found no significant acceleration in trend coinciding with any of the events investigated.
Morocco's success in improving uptake of facility deliveries and caesareans is likely to be the result of the synergistic effects of comprehensive demand and supply-side strategies, including a major investment in human resources and free delivery care. Equity still needs to be improved; however, the overall trend is positive.
'Studying complex interventions: reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco' Bruno Marchal, Sara Van Belle, Vincent De Brouwere, and Sophie Witter. BMC Health Services Research 2013, 13:469.
The importance of complexity in health care policy-making and interventions, as well as research and evaluation is now widely acknowledged, but conceptual confusion reigns and few applications of complexity concepts in research design have been published. Taking user fee exemption policies as an entry point, we explore the methodological consequences of 'complexity' for health policy research and evaluation. We first discuss the difference between simple, complicated and complex and introduce key concepts of complex adaptive systems theory. We then apply these to fee exemption policies.
'Communities of practice: the missing link for knowledge management on implementation issues in low-income countries?' Bruno Meessen, Seni Kouanda, Laurent Musango, Fabienne Richard, Valery Ridde, and Agnes Soucat. Tropical Medicine and International Health vol. 16, no. 8, pp. 1007-1014. August 2011.
The implementation of policies remains a huge challenge in many low-income countries. Several factors play a role in this, but improper management of existing knowledge is no doubt a major issue. In this article, we argue that new platforms should be created that gather all stakeholders who hold pieces of relevant knowledge for successful policies. To build our case, we capitalize on our experience in our domain of practice, health care financing in sub-Saharan Africa. We recently adopted a community of practice strategy in the region. More in general, we consider these platforms as the way forward for knowledge management of implementation issues.
'Fee Exemption for Maternal Care in Sub-Saharan Africa: A Review of 11 Countries and Lessons for the Region' Fabienne Richard, Matthieu Antony, Sophie Witter, Allison Kelley, Isidore Sieleunou, Yamba Kafando, and Bruno Meessen. Global Health Governance, Vol 6, No. 2 (Summer 2013)
Several countries have recently introduced maternal health care fee exemptions as a quick win approach to reach MDG 5 goals. It has also been argued that these policies were relevant first steps towards universal health coverage (UHC). The scope and contents of the benefits package covered by these policies vary widely. First evaluations raised questions about efficiency and equity. This article offers a more comprehensive view of these maternal health fee exemptions in Africa. We document the contents and the financing of 11 of these policies. Our analysis highlights (1) the importance of balancing different risks when a service is the target of the policy - C-sections address some of the main catastrophic costs, but do not necessarily address the main health risks to women, and (2) the necessity of embedding such exemptions in a national framework to avoid further health financing fragmentation and to reach UHC.
'Assessing communities of practice in health policy: a conceptual framework as a first step towards empirical research' . Maria Paola Bertone, Bruno Meessen, Guy Clarysse, David Hercot, Allison Kelley, Yamba Kafando, Isabelle Lange,Jérôme Pfaffmann, Valéry Ridde, Isidore Sieleunou and Sophie Witter. Health Research Policy and Systems, 2013, 11:39
Communities of Practice (CoPs) are groups of people that interact regularly to deepen their knowledge on a specific topic. Thanks to information and communication technologies, CoPs can involve experts distributed across countries and adopt a 'transnational' membership. This has allowed the strategy to be applied to domains ofknowledge such as health policy with a global perspective. CoPs represent a potentially valuable tool for producing and sharing explicit knowledge, as well as tacit knowledge and implementation practices. They may also be effective in creating links among the different 'knowledge holders' contributing to health policy (e.g., researchers,policymakers, technical assistants, practitioners, etc.). CoPs in global health are growing in number and activities. As a result, there is an increasing need to document their progress and evaluate their effectiveness. This paper represents a first step towards such empirical research as it aims to provide a conceptual framework for the analysis and assessment of transnational CoPs in health policy. The framework is developed based on the findings of a literature review as well as on our experience, and reflects the specific features and challenges of transnational CoPs in health policy. It organizes the key elements of CoPs into a logical flow that links available resources and the capacity to mobilize them, with knowledge management activities and the expansion of knowledge, with changes in policy and practice and, ultimately, with an improvement in health outcomes. Additionally, the paper addresses the challenges in the operationalization and empirical application of the framework.
Witter, S. and Cunden, N. (2012) Une introduction à l'évaluation économique des programmes in Ridde, V. and Dagenais, C. eds Approches et pratiques en évaluation de programme. Montreal, CA : Montreal University Press.