Did the design and planning of testing and contact tracing interventions for COVID-19 consider social inequalities in health? A multiple case study from Brazil, Canada, France & Mali.

The COVID-19 pandemic has led to an unprecedented global crisis. It has exposed and exacerbated weaknesses in public health systems worldwide, particularly with regards to reaching the most vulnerable populations, disproportionately impacted by the pandemic. The objective of our study was to examine whether and how social inequalities in health (SIH) were considered in the design and planning of public health responses to COVID-19 in jurisdictions of Brazil, Canada, France, and Mali. This article reports on a qualitative multiple case study of testing and contact tracing interventions in regions with high COVID-19 incidence in each country, namely: Manaus (Brazil), Montréal (Canada), Île-de-France (France), and Bamako (Mali). We conducted interviews with 108 key informants involved in these interventions in the four jurisdictions, focusing on the first and second waves of the pandemic. We analyzed our data thematically using a theoretical bricolage framework. Our analysis suggests that the lack of a common understanding of SIH among all actors involved and the sense of urgency brought by the pandemic eclipsed the prioritization of SIH in the initial responses. The pandemic increased intersectoral collaboration, but decision-making power was often unequal between Ministries of Health and other actors in each jurisdiction. Various adaptations to COVID-19 interventions were implemented to reach certain population groups, therefore improving the accessibility, availability, and acceptability of testing and contact tracing. Our study contributes to identifying lessons learned from the current pandemic, namely that the ways in which SIH are understood shape how interventions are planned; that having clear guidelines on how to integrate SIH into public health interventions could lead to more inclusive pandemic responses; that for intersectoral collaboration to be fruitful, there needs to be sufficient resources and equitable decision-making power between partners; and that interventions must be flexible to respond to emerging needs while considering long-standing structural inequalities.

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.

Exploring how social inequalities in health have influenced the design of Mali's SARS-CoV-2 testing policy: a qualitative study.

In the fight against infectious diseases, social inequalities in health (SIH) are generally forgotten. Mali, already weakened by security and political unrest, has not been spared by the COVID-19 pandemic. Although the country was unprepared, the authorities were quick to implement public health measures, including a SARS-CoV-2 testing programme. This study aimed to understand if and how social inequalities in health were addressed in the design and planning for the national COVID-19 testing policy in Mali. A qualitative survey was conducted between March and April 2021 in Bamako, the capital of Mali. A total of 26 interviews were conducted with key government actors and national and international partners. A document review of national reports and policy documents complemented this data collection. The results demonstrated that the concept of SIH was unclear to the participants and was not a priority. The authorities focused on a symptom-based testing strategy that was publicly available. Participants also mentioned some efforts to reduce inequalities across geographical territories. The reflection and consideration of SIH within COVID-19 interventions was difficult given the governance approach to response efforts. The urgency of the situation, the perceptions of COVID-19 and the country's pre-existing fragility were factors limiting this reflection. Over time, little action has been taken to adapt to the specific needs of certain groups in the Malian population. This study (re)highlights the need to consider SIH in the planning stages of a public health intervention, to adapt its implementation and to limit the negative impact on SIH.

Does the gap between health workers' expectations and the realities of implementing a performance-based financing project in Mali create frustration?

BACKGROUND: Performance-Based Financing (PBF), an innovative health financing initiative, was recently implemented in Mali. PBF aims to improve quality of care by motivating health workers. The purpose of this research was to identify and understand how health workers' expectations related to their experiences of the first cycle of payment of PBF subsidies, and how this experience affected their motivation and sentiments towards the intervention. We pose the research question, "how does the process of PBF subsidies impact the motivation of health workers in Mali?" METHODS: We adopted a qualitative approach using multiple case studies. We chose three district hospitals (DH 1, 2 and 3) in three health districts (district 1, 2 and 3) among the ten in the Koulikoro region. Our cases correspond to the three DHs. We followed the principle of data source triangulation; we used 53 semi-directive interviews conducted with health workers (to follow the principle of saturuation), field notes, and documents relating to the distribution grids of subsidies for each DH. We analyzed data in a mixed deductive and inductive manner. RESULTS: The results show that the PBF subsidies led to health workers feeling more motivated to perform their tasks overall. Beyond financial motivation, this was primarily due to PBF allowing them to work more efficiently. However, respondents perceived a discrepancy between the efforts made and the subsidies received. The fact that their expectations were not met led to a sense of frustration and disappointment. Similarly, the way in which the subsidies were distributed and the lack of transparency in the distribution process led to feelings of unfairness among the vast majority of respondents. The results show that frustrations can build up in the early days of the intervention. CONCLUSION: The PBF implementation in Mali left health workers frustrated. The short overall implementation period did not allow actors to adjust their initial expectations and motivational responses, neither positive nor negative. This underlines how short-term interventions might not just lack impact, but instil negative sentiments likely to carry on into the future.

Implementing performance-based financing in peripheral health centres in Mali: what can we learn from it?

INTRODUCTION: Numerous sub-Saharan African countries have experimented with performance-based financing (PBF) with the goal of improving health system performance. To date, few articles have examined the implementation of this type of complex intervention in Francophone West Africa. This qualitative research aims to understand the process of implementing a PBF pilot project in Mali's Koulikoro region. METHOD: We conducted a contrasted multiple case study of performance in 12 community health centres in three districts. We collected 161 semi-structured interviews, 69 informal interviews and 96 non-participant observation sessions. Data collection and analysis were guided by the Consolidated Framework for Implementation Research adapted to the research topic and local context. RESULTS: Our analysis revealed that the internal context of the PBF implementation played a key role in the process. High-performing centres exercised leadership and commitment more strongly than low-performing ones. These two characteristics were associated with taking initiatives to promote PBF implementation and strengthening team spirit. Information regarding the intervention was best appropriated by qualified health professionals. However, the limited duration of the implementation did not allow for the emergence of networks or champions. The enthusiasm initially generated by PBF quickly dissipated, mainly due to delays in the implementation schedule and the payment modalities. CONCLUSION: PBF is a complex intervention in which many actors intervene in diverse contexts. The initial level of performance and the internal and external contexts of primary healthcare facilities influence the implementation of PBF. Future work in this area would benefit from an interdisciplinary approach combining public health and anthropology to better understand such an intervention. The deductive-inductive approach must be the stepping-stone of such a methodological approach.

Stakeholder Perceptions and Context of the Implementation of Performance-Based Financing in District Hospitals in Mali.

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.

From Amsterdam to Bamako: a qualitative case study on diffusion entrepreneurs' contribution to performance-based financing propagation in Mali.

For the past 15 years, several donors have promoted performance-based financing (PBF) in Africa for improving health services provision. European and African experts known as 'diffusion entrepreneurs' (DEs) assist with PBF pilot testing. In Mali, after participating in a first pilot PBF in 2012-13, the Ministry of Health and Public Hygiene included PBF in its national strategic plan. It piloted this strategy again in 2016-17. We investigated the interactions between foreign experts and domestic actors towards PBF diffusion in Mali from 2009 to 2018. Drawing on the framework on DEs (Gautier et al., 2018), we examine the characteristics of DEs acting at the global, continental and (sub)national levels; and their contribution to policy framing, emulation, experimentation and learning, across locations of PBF implementation. Using an interpretive approach, this longitudinal qualitative case study analyses data from observations (N = 5), interviews (N = 33) and policy documentation (N = 19). DEs framed PBF as the logical continuation of decentralization, contracting policies and existing policies. Policy emulation started with foreign DEs inspiring domestic actors' interest, and succeeded thanks to longstanding relationships and work together. Learning was initiated by European DEs through training sessions and study tours outside Mali, and by African DEs transferring their passion and tacit knowledge to PBF implementers. However, the short-time frame and numerous implementation gaps of the PBF pilot project led to incomplete policy learning. Despite the many pitfalls of the region-wide pilot project, policy actors in Mali decided to pursue this policy in Mali. Future research should further investigate the making of successful African DEs by foreign DEs advocating for a given policy.

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.