University of Edinburgh, Centre of African Studies, Chrystal Macmillan Building, 15a George Square, Edinburgh, EH8 9LD, United Kingdom.
Institut National de Santé Publique, Avenue de L'Hopital, 3, B.P. 6807, Bujumbura, Burundi.
Soc Sci Med. 2020 Nov;265:113331. doi: 10.1016/j.socscimed.2020.113331. Epub 2020 Aug 28.
Health Facility Committees (HFCs) made of elected community members are often presented as key for improving the delivery of services in primary health-care facilities. They are expected to help Health Facility (HF) staff make decisions that best serve the interests of the population. More recently, Performance-Based Financing (PBF) advocates have also put the HFC at the core of health reform, expecting it to hold HF staff into account for the HF performances and development. In Burundi, a country where PBF is implemented nationwide, a randomised control trial was implemented in 251 health facilities where the HFC had been largely inactive in recent years. A random sample of 168 H FCs was trained on their roles and rights, with a subset also given information about the performance of their HF (using PBF indicators) and the PBF approach in general. The interventions, taking place in 2011-2013, made the HFCs better organised but largely failed to generate any effect on HF management and service delivery. Nested qualitative analysis reveals important tensions between nurses and HFC members that often prevent further change at the HF. In the HFs that received both the training and information interventions, this tension appeared exacerbated: the turnover of chief nurses was significantly higher as the HFCs exerted pressure to remove them. This situation was more likely to happen if the HFC had already received training before the interventions, thereby suggesting that repeated training empowers committees. Overall, the results provide rare rigorous evidence on HFCs, suggesting that more attention needs to be paid to the socio-economic and cultural contexts in which they operate. They also invite to caution when discussing the role of HFCs as a possible watchdog in PBF schemes.
健康设施委员会（HFC）由选举产生的社区成员组成，通常被认为是改善基层卫生保健设施服务提供的关键。他们被期望帮助卫生设施（HF）工作人员做出最符合民众利益的决策。最近，基于绩效的融资（PBF）倡导者也将 HFC 置于卫生改革的核心，期望它能够让 HF 工作人员对 HF 的表现和发展负责。在布隆迪，一个在全国范围内实施 PBF 的国家，在 251 个近年来 HFC 基本不活跃的卫生设施中实施了一项随机对照试验。对 168 个 HFC 进行了随机抽样培训，让他们了解自己的角色和权利，其中一部分还提供了有关 HF 绩效（使用 PBF 指标）和 PBF 方法的信息。这些干预措施于 2011 年至 2013 年进行，使 HFC 组织得更好，但基本上没有对 HF 管理和服务提供产生任何影响。嵌套的定性分析揭示了护士和 HFC 成员之间的重要紧张关系，这常常阻止 HF 进一步变革。在接受培训和信息干预的 HF 中，这种紧张局势似乎更加加剧：首席护士的离职率明显更高，因为 HFC 对他们施加压力要求他们离职。如果 HFC 在干预之前已经接受过培训，这种情况就更有可能发生，这表明反复培训赋予了委员会权力。总的来说，这些结果为 HFC 提供了罕见的严格证据，表明需要更加关注它们运作的社会经济和文化背景。它们还提醒人们在讨论 HFC 作为 PBF 计划中可能的监督者的角色时要谨慎。
