Tool and findings section to which it contributes | Level | Key themes | Approach | |
---|---|---|---|---|
1 | Observation grid in meetings (B-SCALA) Context and drivers | Actors at the national, regional and international level | The ways/direction and content of the discussion and presentation of the exemption policy Key concepts: hierarchy, power, evidence, etc. | Participant observation in policy and maternal health meetings |
Sample summary: Benin: 1 conference and 10 agency meetings | ||||
2 | Interview guide with national and regional actors Context and drivers; design and implementation | Actors at the national, regional and international level | Introduction of the policy Perceptions of how the policy was put in place and how it works Actual implementation of the policy compared to official documents Elements of the political context necessary to ensure the policy is implemented and is effective Exchange between national, regional and international actors policy on the policy | Structured discussion with key informants |
Number of informants interviewed in the following countries: Benin: 24; Morocco:12; Burkina Faso:23; International: 9 | ||||
3 | Policy document review Design and implementation | National | Review of published reports, analyses, press releases and other documents related to the policy at national level | Thematic analysis |
4 | Financial flows tracking (FFT) Financing of policies; facility finances | National, regional, district, and health facility level | Budgets & expenditure Distribution per region and health services 3. Payment Schedule (and the kits/equipments where necessary) Consistency with the recorded activities Consistency and adequacy of funds arriving at the health facilities | A structured collection and analysis of secondary data |
Sites: Benin: national level; 6 regions; 5 districts; 7 hospitals Burkina Faso: national level; 5 regions; 6 districts; 12 hospitals (1 CHU, 2 CHR, 4 CMA, 6 CSPS) Morocco: national level; 6 districts; 8 hospitals (2 CHU, 2 CHR, 4 CHP) Mali: national level; 4 regions; 8 hospitals | ||||
5 | Costing Financing of policies; facility finances | Health facilities | Unit cost of production of key maternal health services: normal deliveries, complicated deliveries, caesarean sections, antenatal care, postnatal care | Based on interviews and a extraction of information from sample of medical records |
Sample: Benin: 7 hospitals in 5 districts; 1050 cases Burkina Faso: 6 districts; 6 hospitals (4 CMA, 2 CHR); 443 cases Morocco: No Costing tool Mali:4 CHR; 4 HD; 2 CSREF; 2691 cases | ||||
6 | Exit interviews (EI) Household-level effects; quality of care | Women who had a delivery, their husband or relatives who accompanied them at the hospital | Costs for a given delivery inside and outside hospitals Expenditure as a percentage of household consumption Healthcare seeking behaviour Access to health facilities Perceptions of quality of care | Structured questionnaire |
Benin: 663 women in total interviewed; 294 with a caesarean; 294 women with a complicated delivery; 81 women with normal delivery Burkina Faso:1609 women in total; 818 with a caesarean; 462 with complications; 316 with a normal delivery Morocco: 973 women in total; 423 with complications; 442 with caesareans; 108 with normal deliveries Mali: 589 women in total; 30 complicated deliveries; 345 caesareans; 188 normal deliveries; 26 without assistance/home delivery | ||||
7 | Health worker survey (HWIS) Effects on human resources | Health workers | Health workers and their workload Working hours Sources of income Motivation at the workplace Changes in the above factors, associated with the policy Perceptions of the policy | Structured questionnaire (with some open questions) |
Sample: Benin: 190 health workers; Burkina Faso: 130 health workers; Morocco: 187 health workers; Mali: 176 health workers | ||||
8 | The Policy implementation assessment (POLIAS) Design and implementation | District Hospitals | The start of the implementation of the policy The service package covered by the policy The proportion of facilities offering the service package free of charge and on a permanent basis The actual geographical coverage | Structured discussion with key informants; Documentary review (for triangulation purposes); Routine data extraction |
Benin: 5 districts and 7 hospitals; Burkina Faso: 6 districts and 6 hospitals; Mali: 8 districts and 8 hospitals; Morocco: 6 districts and 6 hospitals | ||||
9 | Policy Effects Mapping study (POEM) Effects on health systems | District Health management team Management team at the hospital Health workers | Governance Provision of care Human Resources Financial resources Drugs and equipment Health Information System Patients & the community | Interviews with key informants Documentary review Routine data extraction Check-list/observation |
Benin: 85 interviews in 4 districts hospital, 2 private hospital,1 departmental hospital, 10 health centres Burkina Faso: 57 interviews in 4 districts hospitals and 2 regional hospital and 12 health centres Mali: 84 interviews in 4 regional hospitals, 4 district hospital and 16 health centres. Morocco: 110 interviews in 5 districts hospital, 2 regional hospitals, 2 university hospital, 12 health centres | ||||
10 | Realist case studies Factors behind differential implementation | Districts hospitals | Actual implementation of the policy compared to official documents Perceptions of managers on the challenges posed by the new policy Mechanisms that explain the ownership and the implementation of policy at the operational level. Contextual elements necessary for the policy to be effective | Interviews with key informants Documentary review Routine data extraction Using data from other tools for triangulation. |
2 districts/country (excluding Mali); Benin: interviews from POEM; Burkina : interviews from POEM + 16 extra interviews to complete the analysis; Morocco: interviews from POEM | ||||
11 | Quantitative instrument on near-miss, caesarean sections and the quality of care Impact on quality of care | Women and newborns | The outcome of hospitalisation The demographic characteristics The reproductive history The causes of complications The near-miss definitions for women and newborns The indications for caesarean section Delays in receiving care Quality of care for caesarean section Quality of care for all women | Medical records and records of admitted women in the maternity ward (normal deliveries, near-miss, caesarean sections) |
Benin: 3361 deliveries; Burkina Faso: 1752 deliveries; Morocco: 3134 deliveries; Mali: 6386 deliveries | ||||
12 | Quantitative analysis of secondary data Impact on utilisation; inequities of access | National | Utilisation of facility delivery care Trends in caesarean section rates Equity of access | Segmented regression analysis of data from routine annual statistics and nationally-representative household survey data The model was specified as: Y t = β 0 + β 1 *time + β 2 *policy + β 3 *postslope + ε t Where Y t is the outcome variable (either facility delivery or caesarean delivery) at time t; time is a continuous variable; policy is a dummy variable indicating whether or not the policy has been implemented at time t; and postslope is coded 0 up to the last point before the introduction of the policy and coded sequentially from 1 thereafter Based on recommendations by [22] |
Benin: Demographic and Health Survey data for 1993–2011 (n = 36,375) Burkina Faso: routine data published by the Ministry of Health for 1992, 1998 2000–2010; Demographic and Health Survey data for 1988–2010 (n = 36,836) Mali: Demographic and Health Survey data for 1993–2013 (n = 43,952) Morocco: routine data published by the Ministry of Health for 1997–2011; Demographic and Health Survey data for 1987–1992, 1998–2011 (n = 16,679) Missing data points in Figs. 2, 3, 4, 5, 6 and 7 are due to lack of coverage due to gaps between DHS. | ||||
13 | Observation guide in health facilities Impact on quality of care; other household-level effects | Health facilities | Quality of care for all women Quality of care for caesarean sections Delays in receiving care Communication between staff, patients and their carers Resources (human, materials, etc.) Costs and payments for services | Participant observations in hospitals |
Benin : 4 weeks’ observation in 2 hospitals; Morocco :3 weeks’ observation in 2 sites | ||||
14 | Interview guide with women Impact on quality of care; other household-level effects | Health facilities/community (women) | Perceptions of quality of care Perceptions of costs related to hospital delivery Awareness of free care | Structured discussion with women after they return home |
Benin: 44 caesareans; 9 Near Miss; 9 “normal” deliveries; Morocco: 30 Near Miss |