GHR-CAPS seminar on the realist approach

The realist approach and its application in global health

Methodological seminar organized by Valéry Ridde and Emilie Robert

Thursday 29th of November 2012

PROGRAM

9 – 9.15 AM Welcome participants

9.15 – 9.30 Introduction of participants and speakers

9.30 – 11.00 Epistemology, theory and concepts of the realist approach

1. The realist approach, epistemological foundations and conceptual tools (Emilie Robert)

2. The concept of ‘mechanism’ from the realist approach: what are we talking about? (Eric Breton and Anthony Lacouture)

3. Discussion period

11.00 – 12.00 Practical examples of the use of the realist approach in global health

1. Free care in Africa: a realist review of the mechanisms involved in patients’ healthcare-seeking behaviours (Emilie Robert)

2. Uncovering the benefits of participatory research: implications of a realist review for health research and practice (Paula Bush)

3. Discussion period

12.00 – 1.00 PM Lunch The seminar will take place at Université du Québec à Montréal (UQAM):

Room N-7050, Pavillion N (8th floor) 1205, rue St Denis

Montréal For additional information, please contact:

• Emilie Robert: [email protected]

• Anne-Marie Turcotte-Tremblay (GHR-CAPS coordinator): [email protected]

Speakers:

• Eric Breton is a research professor and currently holds the "Health Promotion" Inpes Chair (National Institute for Prevention and Health Education) at the Ecole des Hautes Etudes in Public Health (EHESP) in France. He holds a Ph.D. in Public Health (Health Promotion) from the University of Montreal.

• Paula Bush is a Ph.D. candidate in the Department of kinesiology and physical education at McGill University. She holds a scholarship from Participatory Research at McGill (PRAM).

• Anthony Lacouture is a research engineer with the "Health Promotion" Inpes Chair at the EHESP in France. He holds a Masters of Public Health with a specialization in evaluation of actions and health systems (ISPED Bordeaux).

• Valery Ridde is an Associate Professor at the Department of Social and Preventive Medicine at University of Montreal and a researcher at the Research Centre of the Centre hospitalier de l'Universite de Montreal (CRCHUM).

• Emilie Robert is a Ph.D. candidate in Public Health at University of Montreal. She is a senior fellow of the GHR-CAPS program and holds a scholarship from the Fonds de recherche pour le Québec – Société et Culture.

Required readings: Astbury, B., & Leeuw, F. L. (2010). Unpacking Black Boxes: Mechanisms and Theory Building in

Evaluation. American Journal of Evaluation, 31(3), 363–381. doi:10.1177/1098214010371972

Marchal, B., Dedzo, M., & Kegels, G. (2010). A realist evaluation of the management of a well-performing regional hospital in Ghana. BMC health services research, 10, 24. doi:10.1186/1472-6963-10-24

Pawson, R., & Sridharan, S. (2010). Evidence-based Public Health: Effectiveness and efficiency. In A. Killoran & M. P. Kelly (Eds.), Evidence-based Public Health: Effectiveness and efficiency (pp. 43–62). Oxford: Oxford Scholarship Online. doi:10.1093/acprof:oso/9780199563623.003.04

Robert, E., Ridde, V., Marchal, B., & Fournier, P. (2012). Protocol: a realist review of user fee exemption policies for health services in Africa. BMJ open, 2(1), e000706. doi:10.1136/bmjopen-2011-000706

Additional readings: Evans, D., & Killoran, A. (2000). Tackling health inequalities through partnership working:

Learning from a realistic evaluation. Critical Public Health, 10(2), 125–140. doi:10.1080/09581590050075899

Jagosh, J., Macaulay, A. C., Pluye, P., Salsberg, J., Bush, P. L., Henderson, J., Sirett, E., et al. (2012). Uncovering the benefits of participatory research: implications of a realist review for health research and practice. The Milbank quarterly, 90(2), 311–46.

Ridde, V., Robert, E., Guichard, A., Blaise, P., & Van Olmen, J. (2012). Théorie et pratique de l’approche Realist pour l'évaluation des programmes. In V. Ridde & C. Dagenais (Eds.), Approches et pratiques en évaluation de programmes: nouvelle édition revue et augmentée (pp. 255–275). Montréal: Les Presses de l’Université de Montréal.

The realist approach: epistemological foundations and conceptual tools

GHR-CAPS seminars

The realist approach and its application in global health (Montréal, November 2012)

Emilie Robert

© Robert E., 2012

Outline

1.  Grasping the complexity of social interventions

2.  Critical realism and generative causation

3.  A theory-driven approach

4.  Realistic evaluation and realist synthesis

2

© Robert E., 2012

Outline





3

© Robert E., 2012

1. Grasping the complexity of social interventions

What are we talking about?

4 Social phenomena,

interactions and interventions

© Robert E., 2012


Social phenomena are complex…

… So are social interventions.

5

SOCIETY

COMMUNITY

INSTITUTION

FAMILY

INDIVIDUAL

Socio-ecological model

•  They are theories. •  They are active. •  They consist of a series of processes that are thickly populated. •  They are non-linear and go into feedback loops. •  They are embedded into several layers of context and social systems. •  They are leaky and prone to be borrowed. •  They are open systems.

Adapted from Pawson et al. (2004)

© Robert E., 2012


The example of user fee exemption policies

6 Adapted from Ridde et al. (2012)

Interventions… User fee exemption policies… are theories. aim to improve access to health services while reducing the

financial burden of households.

are active. involve governments, NGOs, the population, health staff, etc.

consist of a series of processes that are thickly populated.

consist of formulating the policy, implementing the activities by different players, monitoring and evaluating etc.

are non-linear and go into feedback loops.

transform and adapt through the action and the influence of stakeholders.

are embedded into several layers of context and social systems.

are implemented in countries that have different populations living in different social realities and having distinct worldviews.

are leaky and prone to be borrowed.

are implemented in paralell with other health policies that influence them (and vice versa).

are open systems. are systems where actors learn from their past experience, which influence the way interventions are conceived, implemented and perceived.

© Robert E., 2012

Outline





7

© Robert E., 2012

2. Critical realism and generative causation

Critical realism in the philosophy of science

Positivism Postpositivism Constructivism

Ontology ‘Naive’ realism – Real but apprehendable reality

Critical realism – Real reality but only imperfectly apprehendable

Relativism – Local and specific constructed reality

Epistemology Objectivist Findings true

Objectivity as a ‘regulatory guardian’ Critical tradition Findings probably true

Transactional / subjectivist Created findings

Methodology Experimental / manipulative Verification of hypotheses Chiefly quantitative methods

‘Critical multiplism’ Inquiry in more natural settings, more situational information, soliciting more emic viewpoints Falsification of hypotheses Include qualitative methods

Hermeneutical / dialectical

8

Adapted from Guba & Lincoln (1994)

© Robert E., 2012


Generative causation

9

Context (C)

Outcome (O)

Mechanism (M)

Adapted from Pawson & Tilley (1997)

MECHANISM: element of the reasoning of the actor facing an intervention. A mechanism: (1)  is generally hidden, (2)  is sensitive to context variations (3)  produces outcomes.

from Robert et al. (2011), adapted from others

© Robert E., 2012


Logic of realist explanation

10

« The basic task of social inquiry is to explain interesting, puzzling, socially significant regularities. Explanation takes the form of positing some underlying mechanism which generates the regularity and thus consists of propositions about how the interplay between structure and agency has constituted the regularity. Within realist investigation there is also investigation of how the workings of such mechanisms are contingent and conditional, and thus only fired in particular local, historical or institutional contexts. » (p.71) (Pawson & Tilley, 1997)

What works? How? For whom? Under what circumstances? Why?

© Robert E., 2012


Mode of inquiry

11

Theory

Confirmation

Observation

Hypothesis

DEDUCTIVE REASONING

© Robert E., 2012

Observation

Pattern

Tentative hypothesis

Theory

INDUCTIVE REASONING


12

Mode of inquiry

RETRODUCTIVE REASONING (ABDUCTION)

© Robert E., 2012

Theory

Observation

Outline





13

© Robert E., 2012

3. A theory-driven approach

Program theory

14

© Robert E., 2012

« Set of hypotheses that explain how and why the intervention is expected to produce outcomes. » from Robert et al. (2011)

« The theory in question is the set of beliefs and assumptions that undergird program activities […] They are the hypotheses on which people, consciously or unconsciously, build their program plans and actions.» from Weiss (1997)

BASIC INTERVENTION THEORY

Identify and reach target population

Risk screening Health coaching

Signposting to services and

micro-interventions

Enhanced participant knowledge, confidence

and understanding

Improvements in lifestyle

Reduction in CHD risks

Reductions in health

inequalities

from Pawson & Sridharan (2009)

Building of the teams’ technical capacities

Utilization of HIS data

The legitimacy of the Obs. is established.

Better utilization of knowledge in decision-making on user fee exemption measures

The credibility of knowlege is ensured.

Process utilization

National dissemination workshop

Conduct of studies by the Observatory teams

Adaptation and dissemination of

knowledge

Support to the Observatory to produce

knowledge

Involvement of local stakeholders in

producing knowledge

Knowledge is accessible.

Supervision of the production of knowledge

Administrative and financial support during 12 months; UdeM / MoH / MSF-B / ECHO partnership ; human resources; equipments; consumables; infrastructures

EXPE

CTE

D

RES

ULT

S O

BJE

CTI

VE

Prioritizing needs for knowledge with

Observatory teams

PRO

CES

S

Implication of target users in identifying needs for

knowledge

Preparation of protocoles by the Observatory teams

Knowledge is useful to target users.

INPU

TS

Presentations at local meetings

© Robert, 2011

AC

TIVI

TIES

Participative process

Publication of policy briefs on new knowledge

Conduct of independant studies by UdeM

At the local level

At the national level

At the internat.

level

Workshop for the identification of needs for

knowledge

COMPLEX INTERVENTION THEORY © Robert E., 2012

16

Middle-range theory « Level of theoretical abstraction that provides an explanation of demi-regularities in the context – mechanism – outcome interactions of a set of interventions. » from Robert et al. (2011)

« theory that lies between the minor but necessary working hypotheses (...) and the all-inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities of social behavior, social organization and social change » from Merton (1968)

© Robert E., 2012

EXAMPLE – Human Resource Management

« Hospital managers of well-performing hospitals deploy organisation structures that allow decentralisation and self-managed teams and stimulate delegation of decision-making, good flows of information and transparency. Their HRM bundles combine employment security, adequate compensation and training. This results in strong organisational commitment and trust. Conditions include competent leaders with an explicit vision, relatively large decision-making spaces and adequate resources. »

from Marchal et al. (2010)


17

The elements of realist cumulation

C1 M1 O1

C4 M1 O2

C2 M1 O1 C3 M1 O1

C3 M1 O2

CA MB OC CD ME OF CG MH OI CJ MK OL

Empirical studies identifying C-M-O configurations

C1 M1 O1 C2 M2 O2 C3 M3 O3

Middle-range theories

C M O

Realist approach

DATA

THEORY Abstraction

Specification

Adapted from Pawson & Tilley (1997)

© Robert E., 2012


Outline





18

© Robert E., 2012

4. Realistic evaluation and realist synthesis

19

Pawson & Tilley (1997)

RR

Pawson (2006)

RE

© Robert E., 2012

Adapted from Pawson and Tilley (1997) and Pawson (2006).

20

4. Realistic evaluation and realist synthesis

© Robert E., 2012

Emilie Robert is a Ph.D. student in public health at Montreal University and is a fellow of the Global Health Research Strengthening Program, funded by the Canadian Institutes of Health Research and the Population Health Research Network of Quebec.

Contact: [email protected]

21

Marchal, B., Dedzo, M., & Kegels, G. (2010). A realist evaluation of the management of a well-performing regional hospital in Ghana. BMC health services research, 10, 24. doi:10.1186/1472-6963-10-24

Merton, R.K. (1968). On sociological theories of the middle range. In R.K. Merton (Ed.), Social Theory and Social Structures (pp. 39-72). New York: Free Press.

Pawson, R. (2004). Evidence-based Policy: A Realist Perspective. London: SAGE Publications.

Pawson, R., Greenhalgh, T., Harvey, G. & Walshe, K. (2004). Realist synthesis: an introduction. ERSC Research Methods Programme, University of Manchester.

Pawson, R., & Tilley, N. (1997). Realistic Evaluation. London: SAGE Publications.

Pawson, R., & Sridharan, S. (2009). Evidence-based Public Health: Effectiveness and efficiency. In A. Killoran & M. P. Kelly (Eds.), Evidence-based Public Health: Effectiveness and efficiency (pp. 43–62). Oxford: Oxford Scholarship Online. doi:10.1093/acprof:oso/9780199563623.003.04

Ridde, V., Robert, E., Guichard, A., Blaise, P., & Van Olmen, J. (2012). Théorie et pratique de l’approche Realist pour l'évaluation des programmes. In V. Ridde & C. Dagenais (Eds.), Approches et pratiques en évaluation de programmes: nouvelle édition revue et augmentée (pp. 255–275). Montréal: Les Presses de l’Université de Montréal.

Robert, E., Ridde, V., Marchal, B., & Fournier, P. (2012). Protocol: a realist review of user fee exemption policies for health services in Africa. BMJ open, 2(1), e000706. doi:10.1136/bmjopen-2011-000706

Weiss, K. (1997). How Can Theory-Based Evaluation Make Greater Headway? Evaluation Review, 21, 501.

22

Bibliography

1 To view this presentation on Prezi, please consult the following link: http://prezi.com/6fgvsoch6kf1/the-‐concept-‐of-‐mechanism-‐from-‐the-‐realist-‐approach-‐what-‐are-‐we-‐talking-‐about/

http://prezi.com/6fgvsoch6kf1/the-concept-of-mechanism-from-the-realist-approach-what-are-we-talking-about/



























Uncovering the Benefits of Participatory Research: Implications of a Realist Review for Health Research and Practice

© 2012 PRAM

Project Partnership:

Academic Co-Applicants and Trainees: !  Ann C. Macaulay, Pierre Pluye, Jon Salsberg, Justin Jagosh, Jim Henderson,

Robbyn Seller, Erin Sirett, Paula L. Bush, Geoff Wong, Trish Greenhalgh, Margaret Cargo, Carol P. Herbert, Lawrence W. Green.

Knowledge-User Co-Applicants: !  Sarena Seifer, Susan Law, David Clements, Marielle Gascon-Barré, David L.

Mowat, Sylvie Stachenko, Sylvie Desjardins, Ilde Lepore.

Acknowledgements: This review and post-doctoral fellows Drs. Jagosh and Seller, were supported by a Canadian

Institutes of Health Research KT-Synthesis Grant (# KRS-91805), funding from Participatory Research at McGill (PRAM), and the Department of Family Medicine, McGill University.

We also thank David Parry BA (Hons) for his comments on the grant proposal.

Presentation Outline

!  Working definition of participatory research;

!  Middle range theory

!  Findings (Demi-regularities 1-7)

!  So what?

PR

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Research Education

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Middle Range Theory: Challenge # 2

Partnership synergy theory (Lasker, Weiss, & Miller, 2001)

!  Combining the perspectives, resources, and skills of a group of people to “create something new and valuable together—a whole that is greater than the sum of its individual parts.”

!  Applied to participatory health interventions, the theory holds that multiple stakeholder collaboration creates or enhances research outcomes beyond what could be achieved by a single person or organization working under similar conditions

Demi-regularity 1

PR generates culturally and logistically appropriate research characteristics related to:

!  Shaping the scope and direction of research

!  Developing program and research protocols

!  Implementing program and research protocols

!  Interpreting and disseminating research findings

The coalition members acknowledged widespread problems associated with community-based research, particularly research conducted in communities of color by predominantly white researchers (context). They demonstrated sensitivity (mechanism) to this history of mistreatment and, through mutual respect (mechanism), used their collective expertise to identify a locally relevant research agenda (outcome).

Demi-regularity 2

PR generates capacity to recruit: !  community members to the advisory board !  community members for implementation !  community members as recipients of programs

Despite the difficult experiences at the end of life (C), residents at the facility felt safe (M) participating, with the assurance of the endorsement from the nursing staff, which generated very high enrollment (O).

Demi-regularity 3

PR generates the capacity of: !  the community partners !  the academic partners

The partnership offered formal and informal opportunities for training (C) that community health workers recognized and valued (M), which resulted in a sense of empowerment (O) and a search for additional training and employment positions (O).

The partnership provided opportunities and experiences for academic partners to learn how to collaborate (C), which they valued (M), resulting in their developing new and informed perspectives on community knowledge and leadership (O).

Demi-regularity 4

PR generates disagreements between the co-governing stakeholders during decision-making processes, resulting in:

!  positive outcomes for subsequent programming

!  negative outcomes for subsequent programming

Stakeholders had no prior history together and lacked established trust in the group (C). Academic researchers were also unaware of community interests (C). By recognizing the value of coming to consensus on a research focus (M), the researchers were able to create a change in direction and a new agenda to focus on health promotion/disease prevention efforts in the community (O). New trust was built among coalition members from the consensus-building process (O).

Demi-regularity 5

PR synergy accumulates in cases of repeated successful outcomes in partnering, thus increasing the quality of outputs and outcomes over time

C1-M1-O1 C2-M2-O2 C3-M3-O3

To overcome barriers to conducting a community RCT, a decision was made at the outset to hire only African-Americans familiar with the community as project staff (C1). Because of their prior history in the community, the project staff were glad to assist community members beyond the scope of the study (M1). This led to the staff’s greater investment in the project (O1-C2) which led to community members’ trust in the project (M2), resulting in closer interactions between the staff and the community (O2-C3); leading to a greater sense of trust and safety (M3), and thus some participants revealed their desire to now enroll in the project (O3). This led to new methods of recruitment being developed and higher than expected enrollment (O3-C4). This added to the project stakeholders’ desire to overcome attrition obstacles (M4). As a result, a new capacity to retain participants and prevent attrition in a complex clinical trial was created in a mobile population by addressing problems as they arose and through the project stakeholders’ increasing sense of motivation, trust, and co-ownership of the project (O4).

Demi-regularity 6

Partnership synergy accumulates capacity to sustain project goals beyond funded time frames and during gaps in external funding

The involvement of trained lay health workers and church groups who implemented the weight-loss intervention gained leadership and expertise on weight-loss issues affecting their community (C). They felt inspired (M) to continue working for this cause after the project ended, resulting in strengthened ties with one another and other church organizations (O).

Demi-regularity 7

PR generates systemic changes and new unanticipated projects and activity

From the success of the project (C), coalition members were motivated to advocate system changes for cancer prevention in the Vietnamese community (M), which had a lasting effect beyond immediate intervention (O).

Project TEAL was very successful in acquiring high-quality, credible scientific data (C). The coalition members wanted to capitalize on this success (M) to work with other groups on lead poisoning prevention (O) and to plan a book and documentary on their experiences (O).

In the context of an open and responsive partnership that encouraged community members to contribute to the program’s design (C), elders in the community felt safe and supported (M) in forming an elders’ council (O), which led to better cultural education of service staff (O), and self-empowerment of the elders (O)

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PR stakeholders’ recognizing and valuing the collective knowledge, resources, relationships, and capacity through the alignment of purpose, values, and goals.

Once established, such an alignment becomes a feature of the research context in which partnerships operate.+

So what?

! Our findings confirm what had been previously noted regarding improved research quality and capacity building in PR. (Demi regularities 1-3)

! We uncovered new benefits (Demi regularities 4-7)

!  productive conflict and negotiation; !  long-term synergy building (the positive outcome of

one stage leads to a better context for the next); !  ability to mitigate funding gaps, invoke sustainability,

and extend programs; !  create new unanticipated projects and activity.

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Protocol:

J Jagosh, P Pluye, AC Macaulay, J Salsberg, J Henderson, E Sirett, PL Bush, R Seller, G Wong, T Greenhalgh, M Cargo, CP Herbert, SD Seifer, LW Green. Assessing the Outcomes of Participatory Research: Protocol for Identifying, Selecting and Appraising the Literature for Realist Review. Implementation Science, 6(24). 2011

Commentary:

AC Macaulay, J Jagosh, R Seller, J Henderson, M Cargo, T Greenhalgh, G Wong, J Salsberg, LW Green, C Herbert, P Pluye. Benefits of Participatory Research: A Rationale For a Realist Review. Global Health Promotion. 18(2) : 45-48. June. 2011

Findings:

Jagosh J, Macaulay AC, Pluye P, Salsberg J, Bush PL, Henderson J, Sirett E, Wong G, Cargo M, Herbert CP, Seifer SD, Green LW, Greenhalgh T. Uncovering the Benefits of Participatory Research: Implications of a Realist Review for Health Research and Practice. Milbank Quarterly, 90(2) (in press for June 2012). 2012

Gratuité des soins de santé en Afrique

Emilie Robert Valéry Ridde

GHR-CAPS seminars

The realist approach and its application in global health (Montréal, November 2012)

© Robert, Ridde, 2012

Sommaire

1. Pertinence de l’étude

2. Objectif de recherche et méthode

3. Résultats

4. Leçons pour l’approche réaliste

© Robert & Ridde, 2012

1. Pertinence de l’étude

!  Les pays d’Afrique abolissent les paiements directs dans le secteur de la santé pour améliorer l’accès aux soins. "  ‘an official reduction in direct payments for health care, which is targeted

by group, area or service’ (Witter, 2009)

"  Plus de 15 pays africains concernés (Robert & Samb, in press)

"  Un corpus de données scientifiques hétérogène (Ridde & Morestin, 2010)

!  Les revues systématiques traditionnelles n’ont donné qu’un aperçu limité. "  Centré sur l’efficacité des interventions "  Exclusion des études utilisant des méthodes considérées ‘moins robustes’ "  ‘Most studies included in this review suffered from serious methodological

weaknesses’ (Lagarde & Palmer, 2011)


Sommaire



3. Résultats



!  Ouvrir la ‘boîte noire’ des politiques d’exemption (PEP): "  Comment les PEP influencent-elles les comportements de

recours aux soins des patients? Pourquoi ? Dans quelles circonstances ?

2. Objectif de recherche et méthode

!  Buts: "  Réconcilier: Comprendre pourquoi des interventions similaires

produisent des effets différents ; comprendre quels éléments contextuels entrent en jeu.

"  Juxtaposer: Préciser comment les mécanismes similaires sont déclenchés dans des contextes similaires.

!  Les types de PEP:

"  Enfants de < 5 ans, femmes enceintes ou allaitantes, personnes âgées

"  Soins de santé primaire ou de base pour toute la population


Sommaire



3. Résultats



1) Identification du problème • Problème: accès financier aux soins de santé moderne limités.

• Solution: identifier les populations cibles et abolir les paiements directs.

2) Planification de la politique • Gouvernance • Circuit du médicament • Financement • Information • Soutien RH • Coordination • Suivi / évaluation • Supervision

3) Observance du personnel de santé • Le personnel adhère au principe de l’exemption.

• Le personnel met en œuvre les lignes directrices de la politique.

• Le personnel exempte la population cible des paiements directs.

4) Propension des usagers à recourir aux soins • Les usagers n’ont pas besoin d’arbitrer avec d’autres dépenses.

• Ils n’ont pas besoin de recourir à l’auto-médication.

• Ils ont recours aux soins de santé moderne selon leurs besoins.

5) Santé améliorée • Réduction des inégalités d’accès aux soins

• Réduction des dépenses de santé catastrophiques

• Amélioration de la santé des populations

EFFET A LONG TERME

RESULTAT ATTENDU

PROCESSUS DE MISE EN ŒUVRE

ACTIVITES INITIALES

IDENTIFICATION DU PROBLEME

CONTEXTE Contexte politique / social / economique

Contexte du système de santé / formation sanitaire Contexte du ménage et individuel

3. Résultats

!  Reconstruire la théorie de l’intervention


Database n = 934

Networks n = 46

Snowballing n = 146

N = 1 141

N = 677

N = 286

Excluded based on titles n = 464

Excluded based on abstracts n = 391

N = 66

Excluded based on content n = 189

Documents that could not be found n = 31

Excluded from the analysis N=?

ISI Web of Science n = 15

N = ???

Inclusion and exclusion criteria

Quality

3. Résultats

!  Chercher et évaluer la littérature


Mise en œuvre des paiements directs pour les soins de santé

Accroissement de la barrière financière à l’accès aux soins

Coûts indirects des soins Dépenses informelles de soins

Augmentation des délais de recours

aux soins

Conséquences aux niveaux communautaire et national

Augmentation des inégalités d’accès

aux soins

Plus faible utilisation des services de

santé

Régression des indicateurs de fréquentation

3. Résultats

!  Identification du problème… et de la solution

Conséquences aux niveaux individuel et du ménage

Augmentation des dépenses de

santé

‘Medical poverty trap’

Exclusion sociale

Auto-médication/ centres privés

Détérioration de l’état de santé


3. Résultats

!  Planification de la politique et mise en oeuvre (exemples) Fonctions du

système de santé Pressions exercés sur le système de santé

Information sanitaire

Manque d’information sur le nombre et le type de services fournis dans les formations sanitaires et sur le montant des remboursements

Médicaments et vaccins

Problèmes de disponibilité des médicaments Médicaments insuffisants et kits qui ne répondent pas aux besoins Délais et sous-distribution des consommables

Financement Financement imprévisible, insuffisant et discontinu Réintroduction des paiements pour les services et les médicaments Délais de remboursement

Gouvernance

Planification et communication déficientes; mauvaise compréhension des PEP Supervision inadéquate Complexité des procédures de financement

Ridde, Robert et al, 2012

Ces éléments (C) contribuent à influencer les attitudes du personnel de santé et de la population.


3. Résultats

!  Observance du personnel de santé (exemples) Comportements et attitudes Exemples de données empiriques

Adhésion à / satisfaction des PEP

Inquiétudes / insatisfaction liées aux termes de la politique

"It was reported that registration fees were too low, were often insufficient to meet the running costs of the facility, and that budgetary allocations from the government were inadequate" (Chuma, 2009)

Insatisfaction liées aux retombées professionnelles et/ou personnelles

"... increased workloads were seen to have had direct negative effects at a personal level for the majority of nurses" (Walker, 2004)

Insatisfaction liée à la mise en œuvre

"They do not reject the policy or its goals so much as expressing concern about the direct impacts they perceive it to have had on them and the processes through which it has been implemented." (Nimpagaritse, 2011)

Stratégies d’adaptation

Ajustement des prix des services

"... policy modification was by fully exempting some children from all fees while others received a partial or no exemption." (Agyepong, 2010)

Ces éléments (C) contribuent à influencer les comportements et attitudes de la population.


3. Résultats

!  Propension des usagers à recourir aux soins

La combinaison de ces éléments entre en jeu dans la décision des usagers de recourir aux soins.


3. Résultats

!  Identifier les configurations C-M-E

DEMI-REG 1

Les délais et l’imprédictibilité dans le financement de la politique au niveau des formations sanitaires (remboursement ou distribution des intrants) (C) encourage le personnel de santé à adjuster le prix des services de santé (strategie d’adaptation -M). En conséquence, les usagers ne bénéficie pas systématiquement de la gratuité des soins(O).

"After the introduction of the exemptions, funds did not suffice to buy all the drugs needed and the management team at Muramvya Hospital decided that children under 5 simply could not be offered free care at the hospital outpatient clinic. […] Therefore, these financial issues did not allow for the provision of drugs for free to ambulatory patients under 5, although this was included in the announced reform. " (Nimpagaritse, 2011)


3. Résultats


DEMI-REG 2

L’ajustement du prix des services de santé par le personnel (C) entraîne les usagers à se protéger des coûts potentiels liés au recours aux soins (M) et limite ainsi leur opportunité à bénéficier des services de santé(O).

"Inconsistent patterns of public service uptake and partial protection from direct costs were, finally, also influenced by specific health service weaknesses including drug […] exemption implementation failures at hospitals" (Goudge, 2009)


3. Résultats


DEMI-REG 3

L’augmentation de l’utilisation des services de santé par les patients associé aux défaillances de mise en œuvre (C) entraîne un détérioration de l’enthousiasme initial du personnel de santé pour les PEP (M), ce qui contribue notamment à la détérioration de leur relation avec les usagers (O).

" The increase in patient load and reduced drug supply made nurses’ relationships with their patients very difficult ." (Walker, 2004)


3. Résultats !  Une tentative de théorisation…

EFFETS Limited decrease in catastrophic health expenditures

Limited decrease in inequalities in access to modern care Limited improvement in population health

Persistence of fees for supposedly free

healthcare

Distrust Uncertainty

Limited propensity to engage with free healthcare

MECHANISMES Exemption policy

implementation gap

Weak health system Health providers’ coping strategies

CONTEXTE (au niveau du système de santé)

CONTEXTE (au niveau du ménage)

Experience with health system

Persistence of other barriers to accessing healthcare

Deterioration of the patient-provider

relationship

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Sommaire



3. Résultats



4. Leçons de l’approche réaliste

!  Dans la mesure où elles sont combinées à d’autres mesures ciblant d’autres barrières à l’accès aux soins, les PEP ont un potentiel fort de produire les effets attendus.

!  Les défaillances de mise en œuvre compromettent la propension des usagers à recourir aux soins de santé moderne du fait de l’incertitude et de la défiance.

!  La théorie du ‘street-level bureaucracy’ et les déterminants du recours aux soins fournissent les pièces manquantes pour comprendre comment les PEP fonctionnent.


Emilie Robert is a Ph.D. student in public health at Montreal University and is a fellow of the Global Health Research Strengthening Program, funded by the Canadian Institutes of Health Research and the Population Health Research Network of Quebec.

Contact: [email protected]

Valéry Ridde is a associate professor at Montreal University and a researcher at the Research Center of Montreal University Hospital Center (CRCHUM).

Acknowledgments to the research team: •  Abel Bicaba, RESAO •  Pierre Fournier, CRCHUM •  Guy Kegels, ITM Antwerp •  Bruno Marchal, ITM Antwerp

GHR-CAPS seminar on the realist approach

Documents

Transcript of GHR-CAPS seminar on the realist approach