Evaluating the Process and Extent of Institutionalization: A Case Study of a Rapid Response Unit for Health Policy in Burkina Faso.

BACKGROUND: Good decision-making requires gathering and using sufficient information. Several knowledge translation platforms have been introduced in Burkina Faso to support evidence-informed decision-making. One of these is the rapid response service for health. This platform aims to provide quick access for policy-makers in Burkina Faso to highquality research evidence about health systems. The purpose of this study is to describe the process and extent of the institutionalization of the rapid response service. METHODS: A qualitative case study design was used, drawing on interviews with policy-makers, together with documentary analysis. Previously used institutionalization frameworks were combined to guide the analysis. RESULTS: Burkina Faso's rapid response service has largely reached the consolidation phase of the institutionalization process but not yet the final phase of maturity. The impetus for the project came from designated project leaders, who convinced policy-makers of the importance of the rapid response service, and obtained resources to run a pilot. During the expansion stage, additional policy-makers at national and sub-national levels began to use the service. Unit staff also tried to improve the way it was delivered, based on lessons learned during the pilot stage. The service has, however, stagnated at the consolidation stage, and not moved into the final phase of maturity. CONCLUSION: The institutionalization process for the rapid response service in Burkina Faso has been fluid rather than linear, with some areas developing faster than others. The service has reached the consolidation stage, but now requires additional efforts to reach maturity.

The factors affecting the institutionalisation of two policy units in Burkina Faso's health system: a case study.

BACKGROUND: This paper is one of three linked studies that attempts to understand the process of institutionalisation of policy units within Burkina Faso's health system. It examines the relationships between the existence of an institutional framework, data production capacity and other resource availability in the institutionalisation of policy units in health systems. It therefore contributes to our understanding of the dynamics linking the key drivers and indicators of institutionalisation. Additionally, it examines how factors within the managerial setting, including workplace environment, and budgetary and human resource availability, may influence the institutionalisation process. METHODS: The study used an explanatory qualitative case study approach, examining two policy units in Burkina Faso's Ministry of Health, the first of which had been institutionalised successfully and the other less so. Data were collected from key policymakers, including 13 connected with the first policy unit and 10 with the second, plus two funders. We also conducted a documentary analysis of the National Program for Health Development, two mid-term strategic plans, 230 action plans, eight Ministry of Health state budgets, eight Ministry of Health annual statistics reports, 16 policy unit budgets and published literature. RESULTS: The framework within which the government gave the policy unit its mandate and policy focus had the strongest effect on the institutionalisation process. Institutionalisation depended on political will, in both the host government and any donors, and the priority given to the policy unit's focus. It was also affected by the leadership of the policy unit managers. These factors were influenced by human resource capacity, and our findings suggest that, for successful institutionalisation in Burkina Faso's health system, policy units need to be given sufficient human resources to achieve their objectives. CONCLUSION: Policy units' institutionalisation in Burkina Faso's health system depend on the leadership of the unit managers to implement relevant activities, mobilise funding, and recruit and maintain enough human resources, as well as the mandate given by the government.

Analysis of the policymaking process in Burkina Faso's health sector: case studies of the creation of two health system support units.

BACKGROUND: Burkina Faso has made a number of health system policy decisions to improve performance on health indicators and strengthen responsiveness to health-related challenges. These included the creation of a General Directorate of Health Information and Statistics (DGISS) and a technical unit to coordinate performance-based financing (CT-FBR). We analysed the policymaking processes associated with the establishment of these units, and documented the factors that influenced this process. METHOD: We used a multiple-case study design based on Kingdon's agenda-setting model to investigate the DGISS and CT-FBR policymaking processes. Data were collected from interviews with key informants (n = 28), published literature, policy documents (including two strategic and 230 action plans), and 55 legal/regulatory texts. Interviews were analysed using thematic qualitative analysis. Data from the documentary analysis were triangulated with the qualitative interview data. RESULTS: Key factors influencing the policymaking processes associated with the two units involved the 'problem' (problem identification), 'policy' (formation of policy proposals), and 'politics' (political climate/change) streams, which came together in a way that resulted in proposals being placed on the decision agenda. A number of problems with Burkina Faso's health information and financing systems were identified. Policy proposals for the DGISS and CT-FBR units were developed in response to these problems, emerging from several sources including development partners. Changes in political and public service administrations (specifically the 2008 appointment of a new Minister of Health and the establishment of a new budget allocation system), with corresponding changes in the actors and interests involved, appeared key in elevating the proposals to the decision agenda. CONCLUSIONS: Efforts to improve performance on health indicators and strengthen responsiveness to health-related challenges need focus on the need for a compelling problem, a viable policy, and conducive politics in order to make it to the decision agenda.

Strategies de viabilisation de l'assurance maladie universelle au Burkina Faso

Cette note de politique a été élaborée par l?équipe pays du projet « Soutenir l?utilisation des bases factuelles issues de la recherche (SURE) dans les politiques de santé en Afrique ¼. Elle porte sur les stratégies de viabilisation de l?assurance maladie universelle au Burkina Faso. Les financements de la santé au Burkina Faso viennent principalement de trois sources : le budget de l?Etat, la contribution directe des populations et l?aide internationale. Contrairement à la plupart des autres régions du monde, le recours aux diverses modalités d?assurance pour mobiliser des fonds et se protéger contre les effets appauvrissant de la mauvaise santé n?est pas très répandu au Burkina Faso. Pour accroitre et étendre la couverture maladie aux populations, des systèmes alternatifs fondés sur la mutualité ont été développés mais la faiblesse des revenus des populations n?a pas permis un passage à l?échelle de cette stratégie. Il en résulte que plus de 90% de la population est exposée au risque maladie, faute d?une couverture maladie adéquate. Une meilleure mobilisation des ressources internes à travers l?assurance maladie est essentielle parce que les pays à faible revenu comme le Burkina Faso ont nettement besoin de recettes supplémentaires. Les conditions requises pour réduire la pauvreté, améliorer les infrastructures et partant accélérer la croissance sont de grands défis à relever. La banque mondiale estime que ces pays devront relever de quatre points leur ratio impôts / PIB s?ils veulent atteindre les OMDs (Nations Unies ,2005). Dans le domaine de la couverture maladie, l?expérience montre que des progrès significatifs peuvent être accomplis s?il existe une forte volonté politique et une approche pragmatique fondée sur l?apport des capacités locales (extension par le haut et extension par le bas). Des déceptions sont survenues à la suite de certaines expériences (comme l?adoption rapide de prélèvements obligatoires sur les salaires avec en exemple la défunte caisse maladie au Burkina Faso en 1985) et des stratégies d?extension adoptées par certains pays (recours à des solutions informatiques perfectionnées pour l?enrôlement des populations par exemple). Cependant, quelques pays ont pu nettement améliorer leurs taux de couverture dans des délais assez brefs. Il ressort d?une analyse comparative des performances des différents pays, que dans beaucoup de pays d?Afrique, le taux de couverture pourrait augmenter de 10 à 40% en quatre ans. Aussi, une forte volonté politique constante au plus haut niveau des Etats apparait comme un facteur de succès.