COVID-19 vaccination at a hospital in Paris: Spatial analyses and inverse equity hypothesis.

Background: Vaccination against SARS-CoV-2 has been deployed in France since January 2021. Without specific action for different population subgroups, the inverse equity hypothesis postulates that people in the most deprived neighbourhoods will be the last to benefit. The article aims to study whether the inverse care law has been verified in the context of vaccination against SARS-CoV-2 from a vaccination centre of a hospital in the Paris region. Methods: We performed a spatial analysis using primary data from the vaccination centre of the Avicenne Hospital in Bobigny from January 8th to September 30th, 2021. Primary data variables include the vaccinated person's date, age, and postal address. Secondary data calculates access times between residential neighbourhoods and the vaccination centre and social deprivation index. We performed flow analysis, k-means aggregation, and mapping. Results: 32,712 people were vaccinated at the study centre. Vaccination flow to the hospital shows that people living in the most disadvantaged areas were the last to be vaccinated. The number of people immunized according to the level of social deprivation then scales out with slightly more access to the vaccination centre for the most advantaged. The furthest have travelled more than 100 km, and more than 1h45 of transport time to get to this vaccination centre. Conclusion: The study confirms the inverse equity hypothesis and shows that vaccination preparedness strategies must consider equity issues. Public health interventions should be implemented according to proportionate universalism and use community health, health mediation, and outreach activities for more equity.

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.

Contextual factors for understanding the heterogeneity of outcomes of a policy of exemption from payment for care in Chad / Les facteurs contextuels pour comprendre l'hétérogénéité des résultats d'une politique d'exemption du paiement des soins au Tchad

Chad has one of the highest maternal and infant mortality rates in the world. Efforts to reduce these rates have led to the introduction of fee exemption and community involvement initiatives to further encourage the use of health services. Despite the introduction of these initiatives, inequalities in access to and use of health facilities persist. The aim of this study is to understand why and how the same action, implemented in a quasi-homogeneous way, produced contrasting results in different health centers. A multiple, contrasting case study was used to analyze the outcomes of pediatrics consultations and deliveries in four health centers in the Bénoye and Beinamar districts. Data were collected through individual interviews (n=26) and focus groups (n=22) with women beneficiaries, community health workers, and health care providers. The qualitative software QDA Miner was used to process the data. The study revealed that the organizational and managerial capacities of the providers and community actors would explain the heterogeneity of the results observed. Contextual factors such as the remoteness of services or the impassability and dangerousness of roads accentuated the disparities in the results observed. The results of this study show that human and contextual factors would explain the heterogeneity of the observed effects.

Le Tchad a l'un des taux de mortalité maternelle et infantile les plus élevés au monde. Les efforts visant à réduire ces taux ont conduit à la mise en place d'une politique d'exemption du paiement des soins, associée à l'implication des communautés pour encourager l'utilisation des services. Malgré l'introduction de cette initiative, des inégalités dans l'accès et l'utilisation des établissements de santé persistent. L'objectif de cette étude est de comprendre pourquoi et comment cette politique d'exemption, mise en œuvre de manière quasi homogène, a donné des résultats contrastés dans plusieurs centres de santé. Une étude de cas multiples contrastés a été utilisée pour analyser les résultats des consultations pédiatriques et des accouchements dans quatre centres de santé des districts de Bénoye et Beinamar. Les données ont été recueillies lors des entretiens individuels (n=26) et des groupes de discussion (n=22) auprès des femmes bénéficiaires, des agents de santé communautaire et des prestataires de soins. Le logiciel QDA Miner a été utilisé pour traiter les données. L'étude a révélé que les capacités organisationnelles et managériales des prestataires et des acteurs communautaires expliqueraient l'hétérogénéité des résultats observés. Des facteurs contextuels tels que l'éloignement des services ou l'impraticabilité et la dangerosité des routes ont accentué les disparités des résultats observés. Dans la mise en place des politiques de santé, il est important de tenir compte des facteurs humains et contextuels, car ils participent à l'explication de l'hétérogénéité des effets observés et renforcent la pertinence de ce type d'études.

External influences over Senegalese health financing policy: delaying universal health coverage?

Senegal has long sought solutions to achieve universal health coverage (UHC). However, in a context dependent on international aid, the country faces multiple external pressures to choose policy instruments. In this commentary, we propose an analysis of this influence. The empirical material comes from our involvement in analysing health reforms for 20 years and from many interviews and observations. While studies have shown that community-based health insurance (CBHI) was not an appropriate solution for UHC, some international actors have influenced their continued application. Another global partner proposed an alternative (professional and departmental CBHI), which was counteracted and delayed. These issues of powers and influences of international and national consultants, established in a neo-liberal approach to health, have lost at least a decade from UHC in Senegal. The alternative now appears to be acquired and is scaling up at the country level, witnessing a change in the current policy paradigm.

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.

Assessing the acceptability of technological health innovations in sub-Saharan Africa: a scoping review and a best fit framework synthesis.

Acceptability is a key concept used to analyze the introduction of a health innovation in a specific setting. However, there seems to be a lack of clarity in this notion, both conceptually and practically. In low and middle-income countries, programs to support the diffusion of new technological tools are multiplying. They face challenges and difficulties that need to be understood with an in-depth analysis of the acceptability of these innovations. We performed a scoping review to explore the theories, methods and conceptual frameworks that have been used to measure and understand the acceptability of technological health innovations in sub-Saharan Africa. The review confirmed the lack of common definitions, conceptualizations and practical tools addressing the acceptability of health innovations. To synthesize and combine evidence, both theoretically and empirically, we then used the "best fit framework synthesis" method. Based on five conceptual and theoretical frameworks from scientific literature and evidence from 33 empirical studies, we built a conceptual framework in order to understand the acceptability of technological health innovations. This framework comprises 6 determinants (compatibility, social influence, personal emotions, perceived disadvantages, perceived advantages and perceived complexity) and two moderating factors (intervention and context). This knowledge synthesis work has also enabled us to propose a chronology of the different stages of acceptability.

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.

COVAX - Time to reconsider the strategy and its target.

COVAX, the international initiative supporting COVID-19 vaccination campaigns globally, is budgeted to be the costliest public health initiative in low- and middle-income countries, with over 16 billion US dollars already committed. While some claim that the target of vaccinating 70% of people worldwide is justified on equity grounds, we argue that this rationale is wrong for two reasons. First, mass COVID-19 vaccination campaigns do not meet standard public health requirements for clear expected benefit, based on costs, disease burden and intervention effectiveness. Second, it constitutes a diversion of resources from more cost-effective and impactful public health programmes, thus reducing health equity. We conclude that the COVAX initiative warrants urgent review.

How does explicit knowledge inform policy shaping? The case of Burkina Faso's national social protection policy.

In 2009, Burkina Faso embarked on a process leading to the development of a national social protection policy (politique nationale de protection sociale-PNPS) in 2012. The objective of this study was to analyze the circumstances under which explicit knowledge was used to inform the process of emergence and formulation PNPS. The term explicit knowledge excludes tacit and experiential knowledge, taking into account research data, grey literature, and monitoring data. Court and Young's conceptual framework was adapted by integrating concepts from political science, such as Kingdon's Multiple Streams framework. Discursive and documentary data were collected from 30 respondents from national and international institutions. Thematic analysis guided the data processing. Results showed that use of peer-reviewed academic research was not explicitly mentioned by respondents, in contrast to other types of knowledge, such as national statistical data, reports on government program evaluations, and reports on studies by international institutions and NGOs, also called technical and financial partners (TFPs). The emergence phase was more informed by grey literature and monitoring data. In this phase, national actors deepened and increased their knowledge (conceptual use) on the importance and challenges of social protection. The role of explicit knowledge in the formulation phase was nuanced. The actors' thinking was little guided by the question of whether the solutions had the capacity to solve the problem in the Burkina Faso context. Choices were based very little on analysis of strategies (effectiveness, equity, unintended effects) and their applicability (cost, acceptability, feasibility). This way of working was due in part to actors' limited knowledge on social protection and the lack of government guidance on strategic choices. Strategic use was clearly identified. It involved citing knowledge (reports on studies conducted by TFPs) to justify the utility and feasibility of a PNPS. Instrumental use consisted of drawing from workshop presentations and study reports when writing sections of the PNPS. The consideration of a recommendation based on explicit knowledge was influenced by perceived political gains, i.e., potential social and political consequences.

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.

"It felt like building a plane while in flight": the consideration of social inequalities in the design and planning of a contact-tracing intervention for COVID-19 in Montreal, Quebec.

OBJECTIVE: In Canada and globally, the COVID-19 pandemic has increased social inequalities in health (SIH), furthering the vulnerability of certain groups and communities. Contact-tracing is a cornerstone intervention with COVID-19 prevention and control programs. The aim of this study was to describe whether and how SIH were considered during the design of the COVID-19 contact-tracing intervention in Montreal. METHODS: This study is part of the multi-country research program HoSPiCOVID, looking at the resilience of public health systems during the COVID-19 pandemic. A descriptive qualitative study was carried out in Montreal, based on a "bricolage" conceptual framework describing the consideration for SIH in intervention and policy design. Qualitative data were collected using semi-structured interviews with 16 public health practitioners, recruited using both purposive and snowball sampling. Data were analyzed thematically, both inductively and deductively. RESULTS: According to participants, SIH were not initially considered during the design of the contract-tracing intervention in Montreal. The participants were frustrated by the Minister of Health's initial resistance to integrating SIH into their public health response. However, adaptations were gradually made to better meet the needs of underserved populations. CONCLUSION: There is a need for a clear and common vision of SIH within the public health system. Decision-makers need to consider SIH prior to designing public health interventions in order for these not to further increase SIH in the future, especially in the face of a health crisis.

RéSUMé: OBJECTIF: Au Canada et dans le monde, la pandémie de COVID-19 a augmenté les inégalités sociales de santé (ISS), aggravant la vulnérabilité de certains groupes et communautés. Le suivi des contacts est une intervention fondamentale des programmes de prévention et de contrôle de la COVID-19. L'objectif de cette étude était de décrire si et comment les ISS ont été prises en compte lors de la conception de l'intervention de suivi des contacts pour la COVID-19 à Montréal. MéTHODES: Cette étude fait partie du programme de recherche multi-pays HoSPiCOVID, portant sur la résilience des systèmes de santé publique pendant la pandémie de COVID-19. Une étude qualitative descriptive a été menée à Montréal, sur la base d'un cadre conceptuel « bricolage ¼ décrivant la prise en compte des ISS dans la conception des interventions et des politiques. Des données qualitatives ont été recueillies au moyen d'entrevues semi-structurés avec 16 praticiens de la santé publique, recrutés par échantillonnage raisonné et en boule de neige. Les données ont été analysées de manière thématique, de façon inductive et déductive. RéSULTATS: Selon les participants, les ISS n'ont pas été initialement prises en compte lors de la conception de l'intervention de suivi des contacts à Montréal. Les professionnels de santé publique ont déploré le manque de volonté du Ministère de la Santé d'intégrer les ISS dans la réponse de santé publique. Toutefois, des adaptations ont été progressivement apportées pour mieux répondre aux besoins des populations vulnérables. CONCLUSION: Il est nécessaire d'avoir une vision claire et commune des ISS au sein du système de santé. Les décideurs doivent prendre en compte activement les ISS pour que celles-ci soient mieux conceptualisées, et que les interventions de santé publique n'aggravent pas les ISS, surtout en période de crise sanitaire.

Considering social inequalities in health in COVID-19 response: insights from a French case study.

The COVID-19 pandemic highlighted the impact of social inequalities in health (SIH). Various studies have shown significant inequalities in mortality and morbidity associated with COVID-19 and the influence of social determinants of health. The objective of this qualitative case study was to analyze the consideration of SIH in the design of two key COVID-19 prevention and control interventions in France: testing and contact tracing. Interviews were conducted with 36 key informants involved in the design of the intervention and/or the government response to the pandemic as well as relevant documents (n = 15) were reviewed. We applied data triangulation and a hybrid deductive and inductive analysis to analyze the data. Findings revealed the divergent understandings and perspectives about SIH, as well as the challenges associated with consideration for these at the beginning stages of the pandemic. Despite a shared concern for SIH between the participants, an epidemiological frame of reference dominated the design of the intervention. It resulted in a model in which consideration for SIH appeared as a complement, with a clinical goal of the intervention: breaking the chain of COVID-19 transmission. Although the COVID-19 health crisis highlighted the importance of SIH, it did not appear to be an opportunity to further their consideration in response efforts. This article provides original insights into consideration for SIH in the design of testing and contact-tracing interventions based upon a qualitative investigation.

The COVID-19 pandemic has highlighted the importance of social inequalities in health (SIH) and the disproportionate burden of the pandemic and its consequences related to socioeconomic status, ethnicity and race, among other determinants of health. Public health interventions are likely to increase SIH when they are not considered in the design phase. Through a qualitative case study, we analyzed the design of one of the first local initiative providing testing and contact tracing offer to the general population in the Île-de-France region (Paris region, France) in response to the COVID-19 pandemic. This article discusses the uncertainty and challenges associated with consideration for SIH in the intervention design. It explores the diverse understandings of SIH among the actors and the complexities of cross-sectoral partnerships addressing SIH in times of health crisis. Despite a consensual concern for this issue among the respondents, an epidemiological frame of reference dominated the intervention design. It resulted in a model in which consideration for SIH appeared as a complement, with a clinical goal of the intervention: breaking the chain of COVID-19 transmission.

Effect of cost-reduction interventions on facility-based deliveries in Burkina Faso: a controlled interrupted time-series study with multiple non-equivalent dependent variables.

BACKGROUND: Evaluating health intervention effectiveness in low-income countries involves many methodological challenges to be addressed. The objective of this study was to estimate the sustained effects of two interventions to improve financial access to facility-based deliveries. METHODS: In an innovative controlled interrupted time-series study with primary data, we used four non-equivalent dependent variables (antenatal care) as control outcomes to estimate the effects of a national subsidy for deliveries (January 2007-December 2013) and a local 'free delivery' intervention (June 2007-December 2010) on facility-based deliveries. The statistical analysis used spline linear regressions with random intercepts and slopes. RESULTS: The analysis involved 20 877 observations for the national subsidy and 8842 for the 'free delivery' intervention. The two interventions did not have immediate effects. However, both were associated with positive trend changes varying from 0.21 to 0.52 deliveries per month during the first 12 months and from 0.78 to 2.39 deliveries per month during the first 6 months. The absolute effects, evaluated 84 and 42 months after introduction, ranged from 2.64 (95% CI 0.51 to 4.77) to 10.78 (95% CI 8.52 to 13.03) and from 9.57 (95% CI 5.97 to 13.18) to 14.47 (95% CI 10.47 to 18.47) deliveries per month for the national subsidy and the 'free delivery' intervention, respectively, depending on the type of antenatal care used as a control outcome. CONCLUSION: The results suggest that both interventions were associated with sustained non-linear increases in facility-based deliveries. The use of multiple control groups strengthens the credibility of the results, making them useful for policy makers seeking solutions for universal health coverage.

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.

The resilience of two departmental health insurance units during the COVID-19 pandemic in Senegal.

BACKGROUND: In its pursuit of solutions for universal health coverage (UHC), Senegal has set up two departmental health insurance units (UDAMs) since 2014. Few studies on the resilience of health systems in Africa have examined health insurance organisations. This article aims to understand how these two UDAMs have been resilient during the COVID-19 pandemic and the restrictive measures imposed by the State to maintain services to their members and reimbursements to healthcare providers. METHODS: This study was a multicase study with multiple levels of analysis using a conceptual framework of resilience and analysis of organisational configurations. Empirical data are derived from document analysis, observations for 6 months and 17 qualitative in-depth interviews. RESULTS: The results identified three main configurations concerning (1) safety and hygiene, (2) organisation and planning and (3) communication for sustainable payment. The UDAM faced the pandemic with resilience processes to absorb the shock and maintain service to their members. The UDAM learnt positive lessons from crisis management, such as remote work or the ability to support members in their care in hospitals away from their headquarters. They have innovated (transformative resilience) with the organisation of electronic payment and the use of social networks to raise funds and communicate with members. Strengthening their effectiveness after the shock of the departure of the donors in 2017 contributed to the adaptation and even transformation from the pandemic shock of 2020 and 2021. The study shows that leadership, team dynamics and adaptation to contexts are drivers of resilience processes. CONCLUSION: Both UDAMs adapted to the shocks of the pandemic and government measures to maintain the services of their members and their organisational routine. This resilience confirms that UDAMs are one of the possible solutions for UHC in the Sahel.

Effect of the free healthcare policy on socioeconomic inequalities in care seeking for fever in children under five years in Burkina Faso: a population-based surveys analysis.

BACKGROUND: In 2016, Burkina Faso implemented a free healthcare policy as an initiative to remove user fees for women and under-5 children to improve access to healthcare. Socioeconomic inequalities create disparities in the use of health services which can be reduced by removing user fees. This study aimed to assess the effect of the free healthcare policy (FHCP) on the reduction of socioeconomic inequalities in the use of health services in Burkina Faso. METHODS: Data were obtained from three nationally representative population based surveys of 2958, 2617, and 1220 under-5 children with febrile illness in 2010, 2014, and 2017-18 respectively. Concentration curves were constructed for the periods before and after policy implementation to assess socioeconomic inequalities in healthcare seeking. In addition, Erreyger's corrected concentration indices were computed to determine the magnitude of these inequalities. RESULTS: Prior to the implementation of the FHCP, inequalities in healthcare seeking for febrile illnesses in under-5 children favoured wealthier households [Erreyger's concentration index = 0.196 (SE = 0.039, p = 0.039) and 0.178 (SE = 0.039, p < 0.001) in 2010 and 2014, respectively]. These inequalities decreased after policy implementation in 2017-18 [Concentration Index (CI) = 0.091, SE = 0.041; p = 0.026]. Furthermore, existing pro-rich disparities in healthcare seeking between regions before the implementation of the FHCP diminished after its implementation, with five regions having a high CI in 2010 (0.093-0.208), four regions in 2014, and no region in 2017 with such high CI. In 2017-18, pro-rich inequalities were observed in ten regions (CI:0.007-0.091),whereas in three regions (Plateau Central, Centre, and Cascades), the CI was negative indicating that healthcare seeking was in favour of poorest households. CONCLUSION: This study demonstrated that socioeconomic inequalities for under-5 children with febrile illness seeking healthcare in Burkina Faso reduced considerably following the implementation of the free healthcare policy. To reinforce the reduction of these disparities, policymakers should maintain the policy and focus on tackling geographical, cultural, and social barriers, especially in regions where healthcare seeking still favours rich households.

Is empowerment in sexual health measurable? A scoping review of definitions and measurement indicators.

The concept of empowerment in sexual health is widely used in health promotion. This scoping review aims to identify how it is defined and measured. PubMed, Sage Journals, PsycInfo and the Web of Science are data sources. The inclusion criteria for studies were as follows: (1) an analysis of empowerment in sexual health, (2) quantitative evaluation and (3) publication in a peer-reviewed journal in French or English since January 1996. Data were extracted using a summary table of the definitions and indicators of empowerment in sexual health. Of the 2181 articles found, 29 met the inclusion criteria. Only 4 studies on 29 clearly defined empowerment in sexual health. Five dimensions emerged from the indicators used in the 29 studies in relation to sexual empowerment (social participation, participation in decision making, power to act, sexual health knowledge and gender norms), with two types of indicators: indicators unspecific to sexual health, which can be viewed as empowerment basic skills, and indicators specific to sexual health. Most studies concerned women and focused on individual empowerment, with a lack of measure of collective and structural levels of empowerment. Despite great heterogeneity in the definitions and indicators used, a set of core indicators emerged: participation in decision making, sexual negotiation power and sexual communication skills, knowledge and use of contraceptive methods, and HIV and sexually transmitted infections risk perception. This set could be systematically used in each study based on sexual empowerment concept, completed by supplementary indicators considering the specific context.

Empowerment is at the heart of health promotion. The concept of empowerment in sexual health has been increasingly used in the field of health promotion, but there is a lack of a consensual definition and great heterogeneity in the indicators used to assess that concept and measure it, according to targeted populations and cultural contexts. In this scoping review on how empowerment in sexual health is defined and measured, five dimensions emerged: social participation, participation in decision making, power to act, sexual health knowledge and gender norms. Through these dimensions, two types of indicators were collected: indicators unspecific to sexual health, which can be viewed as empowerment basic skills, and indicators specific to sexual health. Despite great heterogeneity in the definitions and indicators used, a set of core indicators emerged: participation in decision making, sexual negotiation power and sexual communication skills, knowledge and use of contraceptive methods, and HIV and sexually transmitted infections risk perception. For future research, this set could be systematically used in each study based on sexual empowerment concept, and should be completed by supplementary indicators considering the specific context.

Universal health coverage and the poor: to what extent are health financing policies making a difference? Evidence from a benefit incidence analysis in Zambia.

BACKGROUND: Zambia has invested in several healthcare financing reforms aimed at achieving universal access to health services. Several evaluations have investigated the effects of these reforms on the utilization of health services. However, only one study has assessed the distributional incidence of health spending across different socioeconomic groups, but without differentiating between public and overall health spending and between curative and maternal health services. Our study aims to fill this gap by undertaking a quasi-longitudinal benefit incidence analysis of public and overall health spending between 2006 and 2014. METHODS: We conducted a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies at three time points. We combined data from household surveys and National Health Accounts. RESULTS: Results showed that public (concentration index of - 0.003; SE 0.027 in 2006 and - 0.207; SE 0.011 in 2014) and overall (0.050; SE 0.033 in 2006 and - 0.169; SE 0.011 in 2014) health spending on curative services tended to benefit the poorer segments of the population while public (0.241; SE 0.018 in 2007 and 0.120; SE 0.007 in 2014) and overall health spending (0.051; SE 0.022 in 2007 and 0.116; SE 0.007 in 2014) on institutional delivery tended to benefit the least-poor. Higher inequalities were observed at higher care levels for both curative and institutional delivery services. CONCLUSION: Our findings suggest that the implementation of UHC policies in Zambia led to a reduction in socioeconomic inequality in health spending, particularly at health centres and for curative care. Further action is needed to address existing barriers for the poor to benefit from health spending on curative services and at higher levels of care.

Contributing to collaborative health governance in Africa: a realist evaluation of the Universal Health Coverage Partnership.

BACKGROUND: Policy dialogue, a collaborative governance mechanism, has raised interest among international stakeholders. They see it as a means to strengthen health systems governance and to participate in the development of health policies that support universal health coverage. In this context, WHO has set up the Universal Health Coverage Partnership. This Partnership aims to support health ministries in establishing inclusive, participatory, and evidence-informed policy dialogue. The general purpose of our study is to understand how and in what contexts the Partnership may support policy dialogue and with what outcomes. More specifically, our study aims to answer two questions: 1) How and in what contexts may the Partnership initiate and nurture policy dialogue? 2) How do collaboration dynamics unfold within policy dialogue supported by the Partnership?  METHODS: We conducted a multiple-case study realist evaluation based on Emerson's integrative framework for collaborative governance to investigate the role of the Partnership in policy dialogue on three policy issues in six sub-Saharan African countries: health financing (Burkina Faso and Democratic Republic of Congo), health planning (Cabo Verde, Niger, and Togo), and aid coordination for health (Liberia). We interviewed 121 key informants, analyzed policy documents, and observed policy dialogue events. RESULTS: The Partnership may facilitate the initiation of policy dialogue when: 1) stakeholders feel uncertain about health sector issues and acknowledge their interdependence in responding to such issues, and 2) policy dialogue coincides with their needs and interests. In this context, policy dialogue enables stakeholders to build a shared understanding of issues and of the need for action and encourages collective leadership. However, ministries' weak ownership of policy dialogue and stakeholders' lack of confidence in their capacity for joint action hinder their engagement and curb the institutionalization of policy dialogue. CONCLUSIONS: Development aid actors wishing to support policy dialogue must do so over the long term so that collaborative governance becomes routine and a culture of collaboration has time to grow. Public administrations should develop collaborative governance mechanisms that are transparent and intelligible in order to facilitate stakeholder engagement.