The co-production process of an assessment programme: Between clarifying identity and developing the quality of French-speaking Belgian community health centres.

BACKGROUND: The assessment of primary care organizations is considered to be essential for improving care. However, the assessments' acceptability to professionals poses a challenge. Developing assessment programmes in collaboration with the end-users is a strategy that is widely encouraged to make interventions better targeted. By doing so, it can help to prevent resistance and encourage adherence to the assessment. This process, however, is rarely reported. This paper aims to fill this gap by describing the process of the co-production of an assessment programme for community health centres (CHCs) affiliated to the Federation of Community Health Centres (FCHC) in French-speaking Belgium. METHODS: We conducted a documentary study on the co-production of the assessment programme before carrying out semi-structured interviews with the stakeholders involved in its development. RESULTS: CHCs in French-speaking Belgium are increasing in number and are becoming more diverse. For the FCHC, this growth and diversification pose challenges for the meaning of CHC (an identity challenge) and what beneficiaries can expect in terms of the quality of organizations declaring themselves CHC (a quality challenge). Faced with this double challenge, the FCHC decided to develop an assessment programme, initially called Label, using participatory action research. During the co-production process, this initial programme version was abandoned in favour of a new name "DEQuaP". This new name embodies new objectives and new design regarding the assessment programme. When studying the co-production process, we attributed these changes to two controversies. The first concerns how much and which type of variety is desired among CHCs part of the FCHC. The second concerns the organization of the FCHC in its capacity as a federation. It shed light on tensions between two professional segments that, in this paper, we called "political professionalism" and "pragmatic professionalism". CONCLUSIONS: These controversies show the importance of underlying challenges behind the development of an assessment programme for CHCs. This provided information about the evolution of the identity of multidisciplinary organizations in primary care. Issues raised in the development of this assessment programme also show the importance of considering assessment methods that reflect and embody the current realities of these organizations and the way of developing these assessment methods.

Is a bio-psychosocial approach model possible at the first level of health services in the Democratic Republic of Congo? An organizational analysis of six health centers in South Kivu.

BACKGROUND: The health system, in the Democratic Republic of Congo, is expected to move towards a more people-centered form of healthcare provision by implementing a biopsychosocial (BPS) approach. It's then important to examine how change is possible in providing healthcare at the first line of care. This study aims to analyze the organizational capacity of health centers to implement a BPS approach in the first line of care. METHODS: A mixed descriptive and analytical study was conducted from November 2017 to February 2018. Six health centers from four Health Zones (South Kivu, Democratic Republic of Congo) were selected for this study. An organizational analysis of six health centers based on 15 organizational capacities using the Context and Capabilities for Integrating Care (CCIC) as a theoretical framework was conducted. Data were collected through observation, document review, and individual interviews with key stakeholders. The annual utilization rate of curative services was analyzed using trends for the six health centers. The organizational analysis presented three categories (Basic Structures, People and values, and Key Processes). RESULT: This research describes three components in the organization of health services on a biopsychosocial model (Basic Structures, People and values, and Key processes). The current functioning of health centers in South Kivu shows strengths in the Basic Structures component. The health centers have physical characteristics and resources (financial, human) capable of operating health services. Weaknesses were noted in organizational governance through sharing of patient experience, valuing patient needs in Organizational/Network Culture, and Focus on Patient Centeredness & Engagement as well as partnering with other patient care channels. CONCLUSION: This study highlighted the predisposition of health centers to implement a BPS approach to their organizational capacities. The study highlights how national policies could regulate the organization of health services on the front line by relying more on the culture of teamwork in the care structures and focusing on the needs of the patients. Paying particular attention to the values of the agents and specific key processes could enable the implementation of the BPS approach at the health center level.

Community perceptions of a biopsychosocial model of integrated care in the health center: the case of 4 health districts in South Kivu, Democratic Republic of Congo.

BACKGROUND: Biopsychosocial care is one of the approaches recommended in the health system by the WHO. Although efforts are being made on the provider side to implement it and integrate it into the health system, the community dynamic also remains to be taken into account for its support. The objective of this study is to understand the community's perceptions of the concept of integrated health care management according to the biopsychosocial approach (BPS) at the Health Center of a Health District and its evaluation in its implementation. METHODS: This cross-sectional study was done in six Health Areas belonging to four Health Districts in South Kivu, DRC. We conducted 15 semi-directive individual interviews with 9 respondents selected by convenience, including 6 members of the Development Committees of the Health Areas, with whom we conducted 12 interviews and 3 patients met in the health centers. The adapted Normalization MeAsure Development (NoMAD) tool, derived from the Theory of the Normalization Process of Complex Interventions, allowed us to collect data from November 2017 to February 2018, and then from November 2018 to February 2019. After data extraction and synthesis, we conducted a thematic analysis using the NoMAD tool to build a thematic framework. Six themes were grouped into three categories. RESULTS: Initially, community reports that the BPS approach of integrated care in the Health Centre is understood differently by providers; but then, through collective coordination and integrated leadership within the health care team, the approach becomes clearer. The community encouraged some practices identified as catalysts to help the approach, notably the development of financial autonomy and mutual support, to the detriment of those identified as barriers. According to the community, the BPS model has further strengthened the performance of health workers and should be expanded and sustained. CONCLUSIONS: The results of our study show the importance of community dynamics in the care of biopsychosocial situations by providers. The barriers and catalysts to the mechanism, both community-based and professional, identified in our study should be considered in the process of integrating the biopsychosocial model of person-centered health care.

Interprofessional collaboration between general practitioners and primary care nurses in Belgium: a participatory action research.

Given the sociodemographic challenges facing the Belgian primary care system, it is essential to strengthen interprofessional collaboration (IPC) between healthcare providers. Therefore, our aims for this study were to assess IPC between general practitioners (GPs) and nurses; identify target priorities for improving IPC; and facilitate the planning and implementation of the proposed improvement strategies. Based on diversity criteria, six groups of GPs and nurses were chosen for a participatory action research. Participants performed a SWOT analysis of their IPC to identify strengths and weaknesses of their collaboration practice configurations. Main factors limiting IPC were related to the type of financing system which impeded or facilitated multidisciplinary team meetings, a weak functional integration, and a lack of interprofessional education. Overall, communication and task delegation were co-identified as common priorities. Actions prioritized by each group were related to these two priorities and accounted for local, specific needs. Communication could be supported through improved tools and dedicating time for multidisciplinary team meetings. Task delegation was more challenging and raised questions related to nurses' training, legislation, and payment systems. IPC seems to be easier to achieve when healthcare professionals belong to the same organization and consider themselves a team.

Comparing the case-mix of frail older people at home and of those being admitted into residential care: a longitudinal study.

BACKGROUND: In order to optimize interventions and services in the community, it is important to identify the profile of persons who are able to stay at home and of those who are being admitted into residential care. Understanding their needs and their use of resources is essential. The main objective of the study is to identify persons who are likely to enter residential care based upon their needs and resource utilization, so that care providers can plan interventions effectively and optimize services and resources to meet the persons' needs. METHODS: This is a longitudinal quasi-experimental study. The data consists of primary data from the community setting collected every six months during the period of 2010-2016. Interventions had the goal of keeping older people longer at home. Participants were at least 65 years old and were living in the community. The interRAI Resource Utilization Group system (RUG-III) was used to calculate the case-mix indexes (CMI) of all participants. Comparisons were made between the case-mix of those who were still living at home and those who were admitted into residential care at follow-up. RESULTS: A total of 10,289 older persons participated in the study (81.2 ± 7.1 yrs., 69.1% female). From this population, 853 participants (8.3%) were admitted into residential care. The CMI of the persons receiving night care at home were the highest (1.6 at baseline and 1.7 at the entry point of residential care), followed by persons receiving occupational therapy (1.5 at baseline and 1.6 at the entry point of residential care) and persons enrolled in case management interventions with rehabilitation (1.4 at baseline and 1.6 at the entry point of residential care). The CMIs at follow-up were significantly higher than at baseline and the linear regression model showed that admission to residential care was a significant factor in the model. CONCLUSIONS: The study showed that the RUG-III system offers possibilities for identifying persons at risk of institutionalization. Interventions designed to avoid early nursing home admission can make use of the RUG-III system to optimize care planning and the allocation of services and resources. Based on the RUG-III case-mix, resources can be allocated to keep older persons at home longer, bearing in mind the complexity of care and the availability of services in the community.

Caring for a frail older person: the association between informal caregiver burden and being unsatisfied with support from family and friends.

BACKGROUND/OBJECTIVE: although informal caregivers (ICG) find caring for a relative mainly satisfying, it can be difficult at times and it can lead to a state of subjective burden characterised by -among others- fatigue and stress. The objective of this study is to analyse the relationship between perceived social support and subjective burden in providing informal care to frail older people. METHODS: a descriptive cross-sectional study was conducted using data from a large nationwide longitudinal effectiveness study. Pearson correlations were calculated between the variables for support and burden. Logistic regression models were applied to determine the association between being unsatisfied with support and burden, taking into account multiple confounding variables. RESULTS: of the 13,229 frail older people included in this study, 85.9% (N = 11,363) had at least one informal caregiver. Almost 60% of the primary informal caregivers manifested subjective burden, measured with the 12-item Zarit-Burden-Interview (ZBI-12). The percentage of informal caregivers that were unsatisfied with support from family and friends was on average 11.5%. Logistic regression analysis showed that being unsatisfied with support is associated with burden (OR1.85; 95%CI1.53-2.23). These results were consistent for the three groups of impairment level of the frail older persons analysed. CONCLUSIONS: the association between perceived social support and subjective caregiver burden was explored in the context of caring for frail older people. ICGs who were unsatisfied with support were more likely to experience burden. Our findings underline the importance of perceived social support in relation to caregiver burden reduction. Therefore efforts to improve perceived social support are worth evaluating.

A new look at population health through the lenses of cognitive, functional and social disability clustering in eastern DR Congo: a community-based cross-sectional study.

BACKGROUND: The importance of viewing health from a broader perspective than the mere presence or absence of disease is critical at primary healthcare level. However, there is scanty evidence-based stratification of population health using other criteria than morbidity-related indicators in developing countries. We propose a novel stratification of population health based on cognitive, functional and social disability and its covariates at primary healthcare level in DR Congo. METHOD: We conducted a community-based cross-sectional study in adults with diabetes or hypertension, mother-infant pairs with child malnutrition, their informal caregivers and randomly selected neighbours in rural and sub-urban health zones in South-Kivu Province, DR Congo. We used the WHO Disability Assessment Schedule 2.0 (WHODAS) to measure functional, cognitive and social disability. The study outcome was health status clustering derived from a principal component analysis with hierarchical clustering around the WHODAS domains scores. We calculated adjusted odds ratios (AOR) using mixed-effects ordinal logistic regression. RESULTS: Of the 1609 respondents, 1266 had WHODAS data and an average age of 48.3 (SD: 18.7) years. Three hierarchical clusters were identified: 9.2% of the respondents were in cluster 3 of high dependency, 21.1% in cluster 2 of moderate dependency and 69.7% in cluster 1 of minor dependency. Associated factors with higher disability clustering were being a patient compared to being a neighbour (AOR: 3.44; 95% CI: 1.93-6.15), residency in rural Walungu health zone compared to semi-urban Bagira health zone (4.67; 2.07-10.58), female (2.1; 1.25-2.94), older (1.05; 1.04-1.07), poorest (2.60; 1.22-5.56), having had an acute illness 30 days prior to the interview (2.11; 1.24-3.58), and presenting with either diabetes or hypertension (2.73; 1.64-4.53) or both (6.37; 2.67-15.17). Factors associated with lower disability clustering were being informally employed (0.36; 0.17-0.78) or a petty trader/farmer (0.44; 0.22-0.85). CONCLUSION: Health clustering derived from WHODAS domains has the potential to suitably classify individuals based on the level of health needs and dependency. It may be a powerful lever for targeting appropriate healthcare service provision and setting priorities based on vulnerability rather than solely presence of disease.

Evaluation of bottom-up interventions targeting community-dwelling frail older people in Belgium: methodological challenges and lessons for future comparative effectiveness studies.

BACKGROUND: Optimizing the organization of care for community-dwelling frail older people is an important issue in many Western countries. In Belgium, a series of complex, innovative, bottom-up interventions was recently designed and implemented to help frail older people live at home longer. As the effectiveness of these interventions may vary between different population groups according to their long-term care needs, they must be evaluated by comparison with a control group that has similar needs. METHODS: The goal was to identify target groups for these interventions and to establish control groups with similar needs and to explore, per group, the extent to which the utilization of long-term care is matched to needs. We merged two databases: a clinical prospective database and the routine administrative database for healthcare reimbursements. Through Principal Component Analysis followed by Clustering, the intervention group was first stratified into disability profiles. Per profile, comparable control groups for clinical variables were established, based on propensity scores. Using chi-squared tests and logistic regression analysis, long-term care utilization at baseline was then compared per profile and group studied. RESULTS: Stratification highlighted five disability profiles: people with low-level limitations; people with limitations in instrumental activities of daily life and low-level of cognitive impairment; people with functional limitations; people with functional and cognitive impairments; and people with functional, cognitive, and behavioral problems. These profiles made it possible to identify long-term care needs. For instance, at baseline, those who needed more assistance with hygiene tasks also received more personal nursing care (P < 0.05). However, there were some important discrepancies between the need for long-term care and its utilization: while 21% of patients who were totally dependent for hygiene tasks received no personal nursing care, personal nursing care was received by 33% of patients who could perform hygiene tasks. CONCLUSIONS: The disability profiles provide information on long-term care needs but not on the extent to which those needs are met. To assess the effectiveness of interventions, controls at baseline should have similar disability profiles and comparable long-term care utilization. To allow for large comparative effectiveness studies, these dimensions should ideally be available in routine databases.

A critique of the Uganda district league table using a normative health system performance assessment framework.

BACKGROUND: In 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality. METHODS: A normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis. RESULTS: Stakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range. CONCLUSIONS: The critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks. Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.

Cost-effectiveness of screening for active cases of tuberculosis in Flanders, Belgium.

OBJECTIVE: To assess the cost-effectiveness of the tuberculosis screening activities currently funded by the Flemish government in Flanders, Belgium. METHODS: After estimating the expenses for 2013-2014 of each of nine screening components - which include high-risk groups, contacts and people who are seeking tuberculosis consultation at a centre for respiratory health care - and the associated costs per active case of tuberculosis identified between 2007 and 2014, we compared the cost-effectiveness of each component. The applied perspective was that of the Flemish government. FINDINGS: The three most cost-effective activities appeared to be the follow-up of asylum seekers who were found to have abnormal X-rays in initial screening at the Immigration Office, systematic screening in prisons and contact investigation. The mean costs of these activities were 5564 (95% uncertainty interval, UI: 3791-8160), 11 603 (95% UI: 9010-14 909) and 13 941 (95% UI: 10 723-18 201) euros (€) per detected active case, respectively. The periodic or supplementary initial screening of asylum seekers and the screening of new immigrants from high-incidence countries - which had corresponding costs of €51 813 (95% UI: 34 855-76 847), €126 236 (95% UI: 41 984-347 822) and €418 359 (95% UI: 74 975-1 686 588) - appeared much less cost-effective. Between 2007 and 2014, no active tuberculosis cases were detected during screening in the juvenile detention centres. CONCLUSION: In Flanders, tuberculosis screening in juvenile detention centres and among new immigrants and the periodic or supplementary initial screening of asylum seekers appear to be relatively expensive ways of detecting people with active tuberculosis.

Integrating acute malnutrition interventions into national health systems: lessons from Niger.

BACKGROUND: Since 2007, integrated care of acute malnutrition has been promoted in Niger, a country affected by high burden of disease. This policy change aimed at strengthening capacity and ownership to manage the condition. Integration was neither defined nor planned but assumed to have been achieved. This paper studied the level and progress of integration of acute malnutrition interventions into key health system functions. METHODS: The qualitative study method involved literature searches on acute malnutrition interventions for children under 5 in low-income countries to develop a matrix of integration. Integration indicators defined three levels of integration of acute malnutrition interventions into health system functions-full, partial or none. Indicators of health services and health status were added to describe health system improvements. Data from qualitative and quantitative studies conducted in Niger between 2007 and 2013 were used to measure the indicators for the years under study. RESULTS: Results showed a mosaic of integration levels across key health system functions. Four indicators showed full integration, 22 showed partial integration and three showed no integration. Two-thirds of system functions showed progress in assimilating acute malnutrition interventions, while six persistently stagnated over time. There was variation within and across health system domains, with governance and health information functions scoring highest and financing lowest. Steady improvements were noted in geographic coverage, access and under-5 mortality risk. CONCLUSIONS: This study provided useful information to inform policy makers and guide strategic planning to improve integration of acute malnutrition interventions in Niger. The proposed method of assessing the extent of integration and monitoring progress may be adapted and used in Niger and other low-income countries that are integrating or intending to integrate acute malnutrition interventions.

Do informal caregivers for elderly in the community use support measures? A qualitative study in five European countries.

BACKGROUND: Informal caregivers are essential figures for maintaining frail elderly at home. Providing informal care can affect the informal caregivers' physical and psychological health and labour market participation capabilities. They need support to prevent caregiver burden. A variety of existing support measures can help the caregiver care for the elderly at home, but with some limitations. The objective of this review was to explore the experiences of informal caregivers caring for elderly in the community with the use of supportive policy measures in Belgium and compare these to the experiences in other European countries. METHODS: An empirical qualitative case study research was conducted in five European countries (Belgium, The Netherlands, Luxembourg, France and Germany). Semi-structured interviews were conducted with informal caregivers and their dependent elderly. Interview data from the different cases were analysed. In particular data from Belgium was compared to data from the cases abroad. RESULTS: Formal services (e.g. home care) were reported to have the largest impact on allowing the caregiver to care for the dependent elderly at home. One of the key issues in Belgium is the lack of timely access to reliable information about formal and informal services in order to proactively support the informal caregiver. Compared to the other countries, informal caregivers in Belgium expressed more difficulties in accessing support measures and navigating through the health system. In the other countries information seemed to be given more timely when home care was provided via care packages. CONCLUSION: To support the informal caregiver, who is the key person to support the frail elderly, fragmentation of information regarding supportive policy measures is an important issue of concern.

[Potentially inappropriate medication use in elderly care in Burkina Faso]. / Utilisation des médicaments potentiellement inappropriés dans les soins gériatriques au Burkina Faso.

These results suggest approaches to encourage the development of care provider skills, standardized practices and rational prescription to help improve medication use in the elderly..

A comprehensive grid to evaluate case management's expected effectiveness for community-dwelling frail older people: results from a multiple, embedded case study.

BACKGROUND: Case management is a type of intervention expected to improve the quality of care and therefore the quality of life of frail, community-dwelling older people while delaying institutionalisation in nursing homes. However, the heterogeneity, multidimensionality and complexity of these interventions make their evaluation by the means of classical approaches inadequate. Our objective was twofold: (i) to propose a tool allowing for the identification of the key components that explain the success of case management for this population and (ii) to propose a typology based on the results of this tool. METHODS: The process started with a multiple embedded case study design in order to identify the key components of case management. Based on the results of this first step, data were collected among 22 case management interventions, in order to evaluate their expected effectiveness. Finally, multiple correspondence analyses was conducted to propose a typology of case management. The overall approach was informed by Wagner's Chronic Care Model and the theory of complexity. RESULTS: The study identified a total of 23 interacting key components. Based on the clustering of response patterns of the 22 case management projects included in our study, three types of case management programmes were evidenced, situated on a continuum from a more "socially-oriented" type towards a more "clinically-oriented" type of case management. The type of feedback provided to the general practitioner about both the global geriatric assessment and the result of the intervention turned out to be the most discriminant component between the types. CONCLUSION: The study design allowed to produce a tool that can be used to distinguish between different types of case management interventions and further evaluate their effect on frail older people in terms of the delaying institutionalisation, functional and cognitive status, quality of life and societal costs.

Obstetric Fistula "Disease" and Ensuing Care: Patients' Views in West-Africa.

We explored obstetric fistula patients' real-life experience of care in modern Health System. Our aim was to analyze how these women's views impacted their care uptake and coping. We conducted 67 in-depth interviews with 35 fistula patients or former patients in 5 fistula repair centers within referral hospitals in Mali and Niger. Perceptions of obstetric fistula influenced the care experience and vice versa. Obstetric fistula was viewed as a severe chronic disease due to length of care process, limitation of surgery and persisting physical and moral suffering. We highlight the opportunity to build on patients' views on obstetric fistula trauma and care in order to implement an effective holistic care process.

[Change management: An analysis of actors; perceptions about technical assistance in the Democratic Republic of Congo]. / Accompagnement du changement : une analyse de représentations d’acteurs sur l’assistance technique en République Démocratique du Congo.

INTRODUCTION: Technical assistance (TA) is a common component of health system strengthening interventions. This type of intervention is too often designed and evaluated according to a logic that fails to take into account social complexity. Actors' perceptions are one element of this complexity. This article presents a study conducted in the Democratic Republic of Congo designed to identify perceptions concerning two types of technical support providers for health system strengthening: long-term technical assistants (agents of development agencies) and provincial technical advisors (agents of the Ministry of Health). METHODS: Interviews were conducted with an innovative tool inspired by the principles of systems thinking. Interviewees were actors involved in a TA intervention in the province of Bandundu. Their expectations regarding TA providers were identified in terms of personal characteristics (knowledge, know-how and interpersonal skills), roles, and styles of interaction for capacity building ("interventionist/ prescriptive axes"). RESULTS AND DISCUSSION: Interviewees emphasized the importance of mutual learning and the quality of interactions, which depends on TA provider's interpersonal skills and mutual willingness. Perceptions of TA provider's characteristics tend to be similar, but several differences were observed concerning the expectations about the roles of TAs, and the style that should be adopted for capacity building. Ignoring these differences in expectations may be a threat to the effectiveness of TA.

[Negotiation of a heath policy controversy: application of an indirect dialogue approach to performance-based financing in sub-Saharan Africa]. / Arbitrage d’une controverse de politique de santé : application d’une démarche délibérative au Financement basé sur la Performance en Afrique subsaharienne.

OBJECTIVES: This article assesses the controversy around performance-based financing (PBF) and its contribution to the reform of health systems. It aims to reduce tensions between the different camps by restructuring the debate. METHODS: Our approach was to organize an indirect dialogue between critics and supporters of PBF, based on the framework developed by Norman Daniels. This analytical framework is non-partisan and uses clear and objective criteria. The interviews were carried out in two rounds (first the critics, then the supporters) and were then analyzed. Parts of answers were regrouped according to the most common sectoral themes while also highlighting major areas of disagreement. RESULTS: The interviews revealed some areas of convergence around PBF; the strategy is considered to be a complementary strategy to other strategies; such as those which aim to improving financial access to health care. The analysis also revealed disagreements based on misunderstandings of claims often ascribed to PBF, or lack of sufficient evidence, or asymmetrical information between experts. CONCLUSIONS: Several questions polarize PBF discussions. However, better structuring of convergent and divergent areas and arguments should facilitate a synthesis, at least to some extent. Experts need to adopt an objective approach with universally accepted criteria, for the benefit of all.

[The debate concerning performance-based financing in Africa South of the Sahara: analysis of the nature]. / Le débat autour du financement basé sur la performance en Afrique subsaharienne: analyse de la nature des tensions.

OBJECTIVES: Performance-based financing (PBF) is a strategy designed to link thefunding of health services to predetermined results. Payment by an independent strategic purchaser is subject to verification of effective achievement of health outcomes in terms ofquantity and quality. This article investigates the complex tensions observed in relation to performance based financing (PBF) and identifies some reasons for disagreement on this approach. METHODS: This study was essentially qualitative. Interviews were conducted with a panel of experts on PBF mobilizing their ability to reflect on the various arguments and positions concerning this financing mechanism. To enhance our analyses, we proposed a framework based on the main reasonsfor scientific or political controversies and factors involved in their emergence. Analysis of the information collected therefore consisted of combining experts verbatim reports with corresponding factors of controversies of our framework. Graphic representations of the differences were also established. RESULTS: Tensions concerning PBF are based on facts (experts' interpretation ofPBF), principles and values (around each expert's conceptual framework), balances of power between experts but also inappropriate behavior in the discussion process. Viewpoints remain isolated, each individual experience and an overview are lacking, which can interfere with decision-making and maintain the Health system reform crisis. Potential solutions to reduce these tensions are proposed. CONCLUSIONS: Our study shows that experts have difficulties agreeing on a theoretical priority approach to PBE. A good understanding of the nature of the tensions and an improvement in the quality of dialogue will promote a real dynamic of change and the proposal of an agenda of PBF actions.

[Does the National HIV /AIDS Control programme provide support for district hospitals in Cameroon?]. / Le programme national de lutte contre le VIH/sida renforce-t-il les hôpitaux de district au Cameroun?

The aim of this study was to investigate the effects of the national HIV/AIDS control programme on district hospitals in Cameroon. A multiple case study was conducted in two district hospitals- one public and one faith-based. Data were collected by document review, semi-structured interviews and observation of managerial processes and health care delivery. Programme interventions result in a series of positive and negative effects on the functioning of district hospitals and local health systems. High input and support of staff skills were observed for antiretroviral therapy and the management of opportunistic infections. However, the impact of the programme on the stewardship function is problematic. The low implication of district management teams in the implementation of HIV /AIDS activities reduces their structural capacity to run the local health systems. Programme and health system managers failed to take advantage of opportunities to develop synergies between the HIV/AIDS programme and local health systems. The HIV/AIDS programme weakens the systemic and structural capacity of local health systems. Managers of both programmes and general health systems should analyse and adapt their interventions in order to effective' strengthen health systems. One of the research questions is to understand why health system stakeholders do not seize opportunities to develop synergies between programmes and the general system and to strengthen health systems.