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: emilie.robert.3@umontreal.ca
• Anne-Marie Turcotte-Tremblay (GHR-CAPS coordinator):
programmesantecap@gmail.com

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.

© Robert E., 2012

GHR-CAPS seminars
The realist approach and its application in global
health (Montréal, November 2012)

The realist approach: epistemological
foundations and conceptual tools

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

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Outline





3

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1. Grasping the complexity of social
interventions

What are we talking about?

Social phenomena,
interactions and interventions 4

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interventions
Social phenomena are … So are social
complex… interventions.

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

Socio-ecological model Adapted from Pawson et al. (2004)

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interventions

The example of user fee exemption policies
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 consist of formulating the policy, implementing the activities by
that are thickly populated. different players, monitoring and evaluating etc.
are non-linear and go into transform and adapt through the action and the influence of
feedback loops. stakeholders.
are embedded into several layers are implemented in countries that have different populations living
of context and social systems. in different social realities and having distinct worldviews.
are leaky and prone to be are implemented in paralell with other health policies that
borrowed. 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.
Adapted from Ridde et al. (2012) 6

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Outline





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2. Critical realism and generative
causation

Critical realism in the philosophy of science
Positivism Postpositivism Constructivism

Ontology ‘Naive’ realism – Critical realism – Relativism –
Real but Real reality but only Local and specific
apprehendable reality imperfectly apprehendable constructed reality

Epistemology Objectivist Objectivity as a ‘regulatory Transactional /
Findings true guardian’ subjectivist
Critical tradition Created findings
Findings probably true

Methodology Experimental / ‘Critical multiplism’ Hermeneutical /
manipulative Inquiry in more natural settings, dialectical
Verification of more situational information,
hypotheses soliciting more emic viewpoints
Chiefly quantitative Falsification of hypotheses
methods Include qualitative methods

Adapted from Guba & Lincoln (1994)

8

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causation

Generative causation

Context (C)
MECHANISM: element of the reasoning
Mechanism of the actor facing an intervention.
(M)
A mechanism:
Outcome (1)  is generally hidden,
(O) (2)  is sensitive to context variations
(3)  produces outcomes.
from Robert et al. (2011), adapted from others
Adapted from Pawson & Tilley (1997)

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causation

Logic of realist explanation
What works? How? For whom? Under what
circumstances? Why?

« 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)
10

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causation

Mode of inquiry
DEDUCTIVE REASONING INDUCTIVE REASONING

Theory Theory

Tentative
Hypothesis
hypothesis

Observation Pattern

Confirmation Observation
11

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causation

Mode of inquiry
RETRODUCTIVE REASONING
(ABDUCTION)

Theory

Observation

12

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Outline





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3. A theory-driven approach

Program theory
« The theory in question is the set of « Set of hypotheses that explain how
beliefs and assumptions that undergird and why the intervention is expected to
program activities […] They are the produce outcomes. »
hypotheses on which people, from Robert et al. (2011)

consciously or unconsciously, build their
program plans and actions.»
from Weiss (1997)

BASIC INTERVENTION THEORY
Enhanced
Signposting to participant
Identify and Reductions in
Health services and knowledge, Improvements Reduction in
reach target Risk screening health
coaching micro- confidence in lifestyle CHD risks
population inequalities
interventions and
understanding

from Pawson & Sridharan (2009)
14

© Robert E., 2012
INPUTS
COMPLEX INTERVENTION THEORY
Administrative and financial support during 12 months; UdeM / MoH / MSF-B / ECHO partnership ; human
resources; equipments; consumables; infrastructures

Participative process
PROCESS

Implication of target users in Involvement of local Support to the Adaptation and
identifying needs for stakeholders in Observatory to produce dissemination of
knowledge producing knowledge knowledge knowledge

Preparation of protocoles Building of the teams’ Publication of policy briefs
Workshop for the
by the Observatory teams technical capacities on new knowledge
identification of needs for
ACTIVITIES

knowledge Presentations at local
Conduct of studies by the Supervision of the
Observatory teams production of knowledge meetings
Prioritizing needs for
knowledge with Utilization of HIS data Conduct of independant National dissemination
Observatory teams studies by UdeM workshop
EXPECTED
RESULTS

Knowledge is useful to The legitimacy of the The credibility of Knowledge is Process
target users. Obs. is established. knowlege is ensured. accessible. utilization

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

At the
At the local At the © Robert, 2011
internat.
level national level
level

© Robert E., 2012


Middle-range theory
« theory that lies between the minor « Level of theoretical abstraction that
but necessary working hypotheses provides an explanation of demi-
(...) and the all-inclusive systematic regularities in the context – mechanism
efforts to develop a unified theory that – outcome interactions of a set of
will explain all the observed interventions. »
uniformities of social behavior, social from Robert et al. (2011)

organization and social change »
from Merton (1968)

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) 16

© Robert E., 2012


The elements of realist cumulation
THEORY Abstraction
Realist approach

C M O

Middle-range theories

C1 M1 O1 C2 M2 O2 C3 M3 O3

Empirical studies identifying C-M-O configurations
C1 M1 O1 C2 M1 O1 C3 M1 O1

C4 M1 O2 C3 M1 O2

CA MB OC CD ME OF CG MH OI CJ MK OL
Specification
DATA
17
Adapted from Pawson & Tilley (1997)

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Outline





18

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4. Realistic evaluation and realist
synthesis

RE RR

Pawson & Tilley (1997) Pawson (2006)

19

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4. Realistic evaluation and realist
synthesis

20

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

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: emilie.robert.3@umontreal.ca

21

Bibliography
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

To view this presentation on Prezi, please consult the following link: 1
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?

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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
The coalition members acknowledged widespread
!  Developing program and research protocols
problems associated with community-based research,
!  Implementing program and research protocols
particularly research conducted in communities of color
!  Interpreting and disseminating research findings
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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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

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

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

© Robert, Ridde, 2012

GHR-CAPS seminars
The realist approach and its application in global
health (Montréal, November 2012)

Gratuité des soins de santé en Afrique

Emilie Robert
Valéry Ridde

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)


2. Objectif de recherche et méthode

!  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 ?
!  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


3. Résultats
!  Reconstruire la théorie de l’intervention
CONTEXTE
Contexte politique / social / economique
Contexte du système de santé / formation sanitaire
Contexte du ménage et individuel

1) Identification 2) Planification 3) Observance 4) Propension 5) Santé
du problème de la politique du personnel des usagers à améliorée
• Problème: • Gouvernance de santé recourir aux • Réduction des
accès financier • Le personnel soins inégalités
• Circuit du
aux soins de adhère au • Les usagers d’accès aux
médicament
santé moderne principe de n’ont pas soins
limités. • Financement
l’exemption. besoin • Réduction des
• Information
• Solution: • Le personnel d’arbitrer avec dépenses de
identifier les • Soutien RH d’autres
met en œuvre santé
populations • Coordination les lignes dépenses. catastrophiques
cibles et abolir • Suivi / directrices de • Ils n’ont pas • Amélioration de
les paiements évaluation la politique. besoin de la santé des
directs. • Supervision • Le personnel recourir à populations
exempte la l’auto-
population médication.
cible des • Ils ont recours
paiements aux soins de
directs. santé moderne
selon leurs
besoins.

IDENTIFICATION ACTIVITES PROCESSUS DE MISE RESULTAT EFFET A LONG
DU PROBLEME INITIALES EN ŒUVRE ATTENDU TERME


3. Résultats
!  Chercher et évaluer la littérature
Database Networks Snowballing ISI Web of Science
n = 934 n = 46 n = 146 n = 15

N = 1 141
Excluded based on titles
n = 464

Inclusion and exclusion
N = 677
Excluded based on abstracts

criteria
n = 391
N = 286
Documents that could not be found Excluded based on content
n = 31 n = 189
N = 66

Quality
Excluded from the analysis
N=?
N = ???

3. Résultats

!  Identification du problème… et de la solution

Mise en œuvre des paiements
ins directs pour les soins de santé Dépe
s so nses
e c ts de infor
m
indir elles
de so
C oûts ins

Accroissement de la barrière
financière à l’accès aux soins

Augmentation des
Auto-médication/ inégalités d’accès
centres privés Augmentation aux soins
des dépenses de
santé
Régression des Plus faible utilisation
‘Medical poverty indicateurs de des services de
trap’ fréquentation santé
Détérioration de
l’état de santé
Augmentation des
Exclusion
délais de recours
sociale
aux soins

Conséquences aux niveaux Conséquences aux niveaux
individuel et du ménage communautaire et national


3. Résultats

!  Planification de la politique et mise en oeuvre (exemples)
Fonctions du Pressions exercés sur le système de santé
système de santé

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

Problèmes de disponibilité des médicaments
Médicaments et
Médicaments insuffisants et kits qui ne répondent pas aux besoins
vaccins Délais et sous-distribution des consommables
Financement imprévisible, insuffisant et discontinu
Financement Réintroduction des paiements pour les services et les médicaments
Délais de remboursement
Planification et communication déficientes; mauvaise compréhension des
PEP
Gouvernance 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
"It was reported that registration fees were too
Inquiétudes / insatisfaction low, were often insufficient to meet the running
liées aux termes de la costs of the facility, and that budgetary
politique allocations from the government were
inadequate" (Chuma, 2009)
Adhésion à / Insatisfaction liées aux "... increased workloads were seen to have
satisfaction retombées professionnelles had direct negative effects at a personal level
et/ou personnelles for the majority of nurses" (Walker, 2004)
des PEP
"They do not reject the policy or its goals so
much as expressing concern about the direct
Insatisfaction liée à la mise
impacts they perceive it to have had on them
en œuvre and the processes through which it has been
implemented." (Nimpagaritse, 2011)

Ajustement des prix des "... policy modiﬁcation was by fully exempting
Stratégies some children from all fees while others
services
d’adaptation 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…
CONTEXTE (au niveau du système de santé)

Theory of street-level
Health providers’ coping

bureaucracy
Weak health system
strategies

MECHANISMES
Exemption policy
implementation gap

Uncertainty Distrust

Determinants of healthcare
Persistence of fees for Deterioration of the
supposedly free patient-provider

seeking behaviours
healthcare relationship
Limited propensity
to engage with
free healthcare

Experience with Persistence of other barriers
health system to accessing healthcare

EFFETS
CONTEXTE (au niveau du ménage) Limited decrease in catastrophic health expenditures
Limited decrease in inequalities in access to modern care
Limited improvement in population health


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: emilie.robert.3@umontreal.ca

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

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