University of Montreal Public Health Research Institute, 7101 Avenue du Parc, Room 3060, Montreal, QC, H3N 1X9, Canada.
School of Public Health, University of Montreal, 7101 Avenue du Parc, Montreal, QC, H3N 1X9, Canada.
Int J Equity Health. 2018 Sep 24;17(1):109. doi: 10.1186/s12939-018-0780-6.
User fees and poor quality of care contribute to low use of healthcare services in Burkina Faso. The government implemented an innovative intervention that combines equity measures with performance-based financing (PBF). These health equity measures included a community-based selection of indigents to receive user fee exemptions and paying healthcare centres higher purchase prices for services provided to indigents. Research suggests complex interventions can trigger changes not targeted by program planners. To date, however, there is a knowledge gap regarding the unintended consequences that can emerge from combining PBF with health equity measures. Our objective is to document unintended consequences of the equity measures in this complex intervention.
We developed a conceptual framework using the diffusion of innovations theory. For the design, we conducted a multiple case study. The cases were four healthcare facilities in one district. We collected data through 93 semi-structured interviews, informal discussions, observation, as well as intervention documents. We conducted thematic analysis using a hybrid deductive-inductive approach. We also used secondary data to describe the monthly evolution of services provided to indigent and non-indigent patients before and after indigent cards were distributed. Time series graphs were used to validate some results.
Local actors, including members of indigent selection committees and healthcare workers, re-invented elements of the PBF equity measures over which they had control to increase their relative advantage or to adapt to implementation challenges and context. Some individuals who did not meet the local conceptualization of indigents were selected to the detriment of others who did. Healthcare providers believed that distributing free medications led to financial difficulties and drug shortages, especially given the low purchase prices and long payment delays. Healthcare workers adopted measures to limit free services delivered to indigents, which led to conflicts between indigents and providers. Ultimately, selected indigents received uncertain and unequal coverage.
The severity of unintended consequences undermined the effectiveness and equity of the intervention. If the intervention is prolonged and expanded, decision-makers and implementers will have to address these unintended consequences to reduce inequities in accessing care.
在布基纳法索，用户付费和医疗服务质量差导致医疗服务利用率低。政府实施了一项创新性干预措施，将公平措施与基于绩效的融资（PBF）相结合。这些卫生公平措施包括以社区为基础选择穷人，使其获得豁免用户付费的权利，并为向穷人提供服务的医疗中心支付更高的购买价格。研究表明，复杂的干预措施可能会引发计划制定者未针对的变化。然而，迄今为止，对于将 PBF 与卫生公平措施相结合可能产生的意外后果，人们知之甚少。我们的目标是记录这一复杂干预措施中公平措施带来的意外后果。
我们使用创新扩散理论制定了一个概念框架。在设计方面，我们进行了一项多案例研究。案例为一个区的四个医疗机构。我们通过 93 次半结构化访谈、非正式讨论、观察以及干预文件收集数据。我们使用混合演绎-归纳方法进行主题分析。我们还使用辅助数据描述在分发贫困卡前后，向贫困和非贫困患者提供服务的每月变化情况。时间序列图用于验证部分结果。
当地行为者，包括贫困选择委员会成员和医疗保健工作者，对他们控制范围内的 PBF 公平措施的要素进行了重新发明，以增加其相对优势，或适应实施挑战和背景。一些不符合当地贫困概念的人被选中，而其他符合条件的人则被排除在外。医疗保健提供者认为，免费发放药物导致了财务困难和药物短缺，特别是考虑到低购买价格和长期付款延迟。医疗保健工作者采取措施限制向贫困者提供免费服务，这导致了贫困者和提供者之间的冲突。最终，选定的贫困者获得的覆盖范围不确定且不平等。
意外后果的严重程度削弱了干预措施的有效性和公平性。如果干预措施延长和扩大，决策者和实施者将不得不解决这些意外后果，以减少获得护理的不平等。
