Expérience d'un processus participatif autour d'un programme de recherche-action au Mali.

INTRODUCTION: Mali has implemented social protection initiatives in the context of universal health coverage, including the RAMED (medical assistance plan). PURPOSE OF THE RESEARCH: This article describes the participatory process involving researchers and national technical staff as part of an action-research program linked to this policy. RESULTS: The process allowed the interests of the target public, those living in poverty, to take priority over individual and institutional interests, without, however, allowing for their active participation. Despite this positive outcome, the recommendations were not taken on board. CONCLUSION: The main failure of this process was its political component, but there is still time to address this.

Financial issues in times of a COVID-19 pandemic in a tertiary hospital in Mali.

BACKGROUND: This study examines how the functioning of healthcare providers during the COVID-19 pandemic was affected by the government financing response, which was shaped by existing healthcare financing systems. METHODS: The study applied a single case study design at a tertiary hospital in Bamako during the 1st and 2nd waves of the COVID-19 pandemic. Data were gathered through 51 in-depth interviews with hospital staff, participatory observation, and reviewing media articles and hospital financial records. RESULTS: The study revealed the disruptions experienced by hospital managers, human resources for health and patients in Mali during the early stages of the pandemic. While the government aimed to support universal access to COVID-19-related services, efforts were undermined by issues associated with complex public financing management procedures. The hospital experienced long delays in transferring government funds. The hospital suffered a decrease in revenue during the early stages of the pandemic. Government budgets were not effectively used because of complex, non-agile procedures that could not adapt to the emergency. The challenges faced by the hospitals led to the delays in the staff payments of salaries and promised bonuses, which created potential for unfair treatment of patients. Excluding some COVID-19 related items from the government funded benefit package created a financial burden on people receiving services. The managerial challenges experienced in the study hospital during the first wave continued in the second wave. CONCLUSIONS: Pre-existent issues in healthcare financing and governance constrained the effective management of COVID-19-related services and created confusion at the front line of healthcare service delivery.

La résilience de l'hôpital du Mali face à la COVID-19 dans un contexte de pénuries.

AIM: The objective of this research is to report the strategies of resilience mobilized by the Hospital of Mali to face Coronavirus disease (COVID-19). METHOD: The data collected within the hospital covered the first months of the pandemic (April to July 2020). A total of 32 semi-structured interviews and 53 observation sessions were conducted. Data analyses were based on a conceptual framework and were conducted using a deductive approach. RESULTS: The results show that, due to the multiple effects of the COVID-19 such as the aggravation of staff penuries, the high workloads, the need to create dedicated infrastructures, the drastic decrease in revenue due to the drop in hospital's attendance, the hospital and its staff implemented multiple strategies (e.g., reduction or postponement of some expenses, requisition of facilities, recruitment of contractual staff and redeployment of some healthcare workers). Those strategies generally allowed to maintain patients access to care, although there were many restrictions for non-COVID-19 patients. The hospital was able to build absorptive resilience. CONCLUSION: This qualitative research provides a better understanding of hospitals' resilience processes to the COVID-19 pandemic in a hospital setting. Lessons learned from this study should help hospitals managers to design more appropriate and effective responses to future health crises.

Learning from public health and hospital resilience to the SARS-CoV-2 pandemic: protocol for a multiple case study (Brazil, Canada, China, France, Japan, and Mali).

BACKGROUND: All prevention efforts currently being implemented for COVID-19 are aimed at reducing the burden on strained health systems and human resources. There has been little research conducted to understand how SARS-CoV-2 has affected health care systems and professionals in terms of their work. Finding effective ways to share the knowledge and insight between countries, including lessons learned, is paramount to the international containment and management of the COVID-19 pandemic. The aim of this project is to compare the pandemic response to COVID-19 in Brazil, Canada, China, France, Japan, and Mali. This comparison will be used to identify strengths and weaknesses in the response, including challenges for health professionals and health systems. METHODS: We will use a multiple case study approach with multiple levels of nested analysis. We have chosen these countries as they represent different continents and different stages of the pandemic. We will focus on several major hospitals and two public health interventions (contact tracing and testing). It will employ a multidisciplinary research approach that will use qualitative data through observations, document analysis, and interviews, as well as quantitative data based on disease surveillance data and other publicly available data. Given that the methodological approaches of the project will be largely qualitative, the ethical risks are minimal. For the quantitative component, the data being used will be made publicly available. DISCUSSION: We will deliver lessons learned based on a rigorous process and on strong evidence to enable operational-level insight for national and international stakeholders.

Donor-funded project's sustainability assessment: a qualitative case study of a results-based financing pilot in Koulikoro region, Mali.

BACKGROUND: Results-based financing (RBF) is emerging as a new alternative to finance health systems in many African countries. In Mali, a pilot project was conducted to improve demand and supply of health services through financing performance in targeted services. No study has explored the sustainability process of such a project in Africa. This study's objectives were to understand the project's sustainability process and to assess its level of sustainability. METHODS: Sustainability was examined through its different determinants, phases, levels and contexts. These were explored using qualitative interviews to discern, via critical events, stakeholders' ideas regarding the project's sustainability. Data collection sites were chosen with the participation of different stakeholders, based on a variety of criteria (rural/urban settings, level of participation, RBF participants still present, etc.). Forty-nine stakeholders were then interviewed in six community health centres and two referral health centres (from 11/12/15 to 08/03/16), including health practitioners, administrators, and those involved in implementing and conceptualizing the program (government and NGOs). A theme analysis was done with the software © QDA Miner according to the study's conceptual framework. RESULTS: The results of this project show a weak level of sustainability due to many factors. While some gains could be sustained (ex.: investments in long-term resources, high compatibility of values and codes, adapted design to the implementations contexts, etc.) other intended benefits could not (ex.: end of investments, lack of shared cultural artefacts around RBF, loss of different tasks and procedures, need of more ownership of the project by the local stakeholders). A lack of sustainability planning was observed, and few critical events were associated to phases of sustainability. CONCLUSIONS: While this RBF project aimed at increasing health agents' motivation through different mechanisms (supervision, investments, incentives, etc.), these results raise questions on what types of motivation could be more stable and what could be the place of local stakeholders in the project; all this with the aim of more sustained and efficient results.

User fee exemption policies in Mali: sustainability jeopardized by the malfunctioning of the health system.

In Mali, where rates of attendance at healthcare facilities remain far below what is needed, three user fee exemption policies were instituted to promote access to care. These related to HIV/AIDS treatment, as of 2004, caesarean sections, since 2005, and treatment of malaria in children under five and pregnant women, since 2007. Our qualitative study compared these three policies, looking at their implementation provisions, functioning and outcomes. In each healthcare facility, we analysed documentation and carried out three months of on-site observations. We also conducted a total of 254 formal and informal interviews with health personnel and patients.

Improving healthcare accessibility for pregnant women and children in the context of health system strengthening initiatives and terrorist attacks in Central Mali: a controlled interrupted time series analysis.

INTRODUCTION: The Health and Social Development Program of the Mopti Region (PADSS2) project, launched in Mali's Mopti region, targeted Universal Health Coverage (UHC). The project addressed demand-side barriers by offering an additional subsidy to household contributions, complementing existing State support (component 1). Component 2 focused on supply-side improvements, enhancing quality and coverage. Component 3 strengthened central and decentralised capacity for planning, supervision and UHC reflection, integrating gender mainstreaming. The study assessed the impact of the project on maternal and child healthcare use and explored how rising terrorist activities might affect these health outcomes. METHODS: The impact of the intervention on assisted births, prenatal care and curative consultations for children under 5 was analysed from January 2016 to December 2021. This was done using an interrupted time series analysis, incorporating a comparison group and spline regression. RESULTS: C1 increased assisted deliveries by 0.39% (95% CI 0.20 to 0.58] and C2 by 1.52% (95% CI 1.36 to 1.68). C1-enhanced first and fourth antenatal visits by 1.37% (95% CI 1.28 to 1.47) and 2.07% (95% CI 1.86 to 2.28), respectively, while C2 decreased them by 0.53% and 1.16% (95% CI -1.34 to -0.99). For child visits under 5, C1 and C2 showed increases of 0.32% (95% CI 0.20 to 0.43) and 1.36% (95% CI 1.27 to 1.46), respectively. In areas with terrorist attacks, child visits decreased significantly by 24.69% to 39.86% compared with unexposed areas. CONCLUSION: The intervention had a limited impact on maternal and child health, falling short of expectations for a health system initiative. Understanding the varied effects of terrorism on healthcare is key to devising strategies that protect the most vulnerable in the system.

Minimal resilience and insurgent conflict: qualitative analysis of the resilience process in six primary health centres in central Mali.

BACKGROUND: In the context of universal health coverage in the Sahel, the study focuses on primary health centres and the difficulties of their implementation in the context of insurgency conflicts in central Mali. METHODS: This is qualitative research through a multiple case study. We selected six health centres according to a reasoned choice to bring together contrasting situations. We conducted 96 semistructured interviews and consulted secondary quantitative data on attendance. By focusing on community health centres, the conceptual approach focuses on the process of resilience that unfolds in a dual context of chronic health system dysfunctions and armed conflict. RESULTS: The resilience strategies deployed by health professionals were relatively basic and uncoordinated. In the end, it was the individuals who showed absorption. However, their room for manoeuvre was limited. In the most isolated health centres, resilience was based on subordinate, poorly trained staff, often from the locality. Degraded working conditions and fear caused a form of resignation among health workers. CONCLUSION: The strategies and resources used showed a form of minimal resilience. This form is unfolding in a context marked by two structuring features. On the one hand, the Malian health system was relatively dysfunctional before the crisis, and on the other hand, the type of conflict was relatively low intensity that allowed health centres to remain open.

Innovations in mutuality: challenges and learnings for the Universal Health Insurance Plan in Mali.

BACKGROUND: Many Sahel countries in Africa are looking for solutions for universal health coverage (UHC). Mali is in the process of adopting the Universal Health Insurance Plan, which allows for the mutualisation of existing schemes. Its operationalisation requires numerous adjustments to the current mutualist proposal and innovations in the system. The study focuses on innovations experienced in mutuality and their conditions of scale for UHC in Mali. METHODS: This is qualitative research by multiple case studies. It is based on the collection of data by interviews (n=136), at a national and local level, on the analysis of documents (n=42) and a long field observation (7 months). The analytical framework concerns the dissemination and maintenance of health innovations (Greenhalgh et al, 2004). RESULT: The analysis of this innovation shows an interest in the technical and institutional viability that determines its performance and scale-up. The procrastination and scepticism displayed at the highest level of the state and the international level, the reluctance, both financial and ideological, to renew the old mutualist proposal, penalise this Malian experiment. CONCLUSION: This innovation is a decisive step in ensuring the health coverage of Mali's agricultural and informal sectors. The reform will need to be amplified and supported in the future to expect the scale-up of a cheaper, technically and institutionally more efficient system. Without a political intention to mobilise national resources and accept a fundamental paradigm shift in health financing, the search for the financial viability of mutuality may, again, be at the expense of the performance.

Evolution of assisted deliveries at primary healthcare centres in an unstable security context in Mali.

INTRODUCTION: In Mali, healthcare systems are severely affected by conflict. However, several studies suggest a lack of knowledge about its impact on maternal healthcare. Frequent and repeated attacks increase insecurity, limit access to maternal care, and thus represent a barrier to accessing care. The objective of this study is to understand how assisted deliveries are being reorganised at the health centre level, and how they are adapting to the security crisis. METHOD: This is a mixed sequential and explanatory study. The quantitative approaches combine a spatial scan analysis of assisted deliveries by health centres, an analysis of health centre performance using an ascending hierarchical classification, and a spatial analysis of violent events in two health districts in central Mali: Mopti and Bandiagara. The qualitative phase analyses semidirective and targeted interviews with managers (n=22) of primary healthcare centres (CsCOM) and two agents of international institutions. RESULTS: The study reveals an important territorial heterogeneity of assisted deliveries. The primary health centres with high rates of assisted deliveries have mainly high-performance levels. This high level of use can be explained by the movement of the population to areas less exposed to attacks. The centres with low rates of assisted deliveries are those where qualified health workers refused to practice, where populations had few financial resources, and where they limited their travel to reduce their exposure to insecurity. CONCLUSION: This study confirms that combining methodological approaches is essential to explain significant use in the local context. The analysis of the number of assisted deliveries in conflict zones must consider the number of procedures, the nearby security context, the number of internally displaced persons and the presence of camps in which humanitarian organisations offer programmes.

Responses to Hospital Restrictions on Family Visits during the COVID-19 Epidemic in Mali and France.

Few studies have focused on the presence of families in the hospital in the context of an epidemic. The present study aims to contribute to filling this gap by answering the following question: How did professionals, patients and their families cope with more or less drastic restrictions to family visits and presence during the COVID-19 pandemic in a French and a Malian hospital during the COVID-19 pandemic? Data were collected during the first two waves of the pandemic through 111 semi-structured interviews (France = 55, Mali = 56). Most of the interviews were conducted with staff (n = 103), but also with families in the case of Mali (n = 8). The investigators also conducted 150 days of field observations, 44 in France and 106 in Mali. Thematic analysis was applied using an inductive approach. Interviews were content analyzed to identify passages in the interviews that were relevant to these different themes. The study highlighted the difficulty for the medical-clinical system to provide appropriate responses to the many emotional needs of patients in a pandemic context. Families in France benefited from a support service to reduce stress, while in Mali, no initiative was taken in this sense. In both countries, families often used the telephone as an alternative means of communicating with relatives. The results showed that in the two contexts, the presence and involvement of the families contributed to a better response to the patients' psycho-affective demands and thus promoted resilience in this field.

The emergence of the national medical assistance scheme for the poorest in Mali.

Universal health coverage is high up the international agenda. The majority of the West Africa's countries are seeking to define the content of their compulsory, contribution-based medical insurance system. However, very few countries apart from Mali have decided to develop a national policy for poorest population that is not based on contributions. This qualitative research examines the historical process that has permitted the emergence of this public policy. The research shows that the process has been very long, chaotic and suspended for long periods. One of the biggest challenges has been that of intersectoriality and the social construction of the poorest to be targeted by this public policy, as institutional tensions have evolved in accordance with the political issues linked to social protection. Eventually, the medical assistance scheme for the poorest saw the light of day in 2011, funded entirely by the government. Its emergence would appear to be attributable not so much to any new concern for the poorest in society but rather to a desire to give the social protection policy engaged in a guarantee of universality. This policy nonetheless remains an innovation within French-speaking West Africa.

Performance-based financing in low-income and middle-income countries: isn't it time for a rethink?

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.