Table 1 Summary of FEMHealth research tools

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

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

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

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

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

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)

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

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

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.

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)

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]

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

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