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Breast cancer affects nearly 60,000 new women in France each year, with a net 5-year survival of 87%. However, for a breast cancer detected at an early stage, the 5-year survival is 99%. In an attempt to detect breast cancer in women at an early stage, France has set up a national screening program organized for women aged 50 to 74 and at "medium" risk. In 2017, French citizens and professionals have expressed their wish that the organized screening becomes more and more personalized according to risk factors. In the first part of this thesis, we developed TEMAS (Text-mining Algorithm- assisted Search), a new literature search method using text-mining and classification methods. We then created a web application allowing people to implement TEMAS without the need for special knowledge. In the second part of this thesis, given the risk factors identified with TEMAS, we developed a questionnaire. This questionnaire was completed by 3,077 women included in the organized screening in the Hérault department, France, in order to estimate their individual risk of breast cancer for a 12-year follow-up, based on a score. This score was constructed using a Cox model and the Breslow estimator. Then, within the population currently considered at "medium" risk, this score enabled to delineate two risk thresholds, on the one hand of lower risk, and on the other hand of higher risk. Then, according to the level of risk within the three groups of graduated risk, we proposed a new strategy that personalized the organized screening.; Le cancer du sein de la femme concerne près de 60.000 nouveaux cas par an, avec une survie nette à 5 ans de 87%. Cependant, si le cancer du sein est dépisté à un stade précoce, la survie à 5 ans est de 99%. Pour tenter de dépister le cancer du sein chez les femmes à un stade précoce, la France a mis en œuvre un programme national de dépistage organisé pour les femmes âgées de 50 à 74 ans et à risque "moyen". En 2017, les citoyennes et les professionnels ont exprimé leur souhait que le dépistage organisé devienne de plus en plus personnalisé selon les facteurs de risque. Dans la première partie de cette thèse nous avons développé TEMAS (Text-mining Algorithm- assisted Search), une nouvelle méthode de recherche de la littérature utilisant des méthodes de text-mining et de classification. Nous avons ensuite créé une application web permettant de mettre en œuvre TEMAS sans nécessité de connaissances particulières. Dans la deuxième partie de cette thèse nous avons développé un questionnaire à partir des facteurs de risque de cancer du sein identifiés grâce à TEMAS. Nous avons posé ce questionnaire à 3077 femmes incluses dans le dépistage organisé afin d’établir leur score individuel de risque de cancer du sein au cours d'un suivi de 12 ans grâce à un modèle de Cox et à l’estimateur de Breslow. Grâce à ce score, nous avons ensuite, estimé deux seuils de risque optimaux pour créer, au sein de la population actuellement considérée à risque "moyen" trois groupes à risque gradué : risque plus bas, risque moyen et risque plus élevé. En conclusion, nous avons proposé une nouvelle stratégie pour un dépistage organisé personnalisé en fonction du niveau de risque.

Ce chapitre présente une analyse spatiale d’une intervention qui vise à évaluer si des valeurs similaires d’un résultat sont plus susceptibles de former des grappes dans une zone d’étude. Cette méthode appelée « indicateurs locaux d’association spatiale » (local indicators of spatial association – LISA) permet d’identifier les zones où les valeurs sont spatialement dépendantes les unes des autres. LISA a été utilisé pour évaluer l’effet d’une intervention communautaire visant à contrôler le moustique responsable de la propagation de la dengue Aedes aegypti dans deux quartiers de Ouagadougou, capitale du Burkina Faso. L’évaluation finale de l’intervention à l’aide de cette méthode a montré que les groupes de larves ont disparu dans le quartier qui a reçu l’intervention alors qu’ils persistaient dans le quartier témoin. This chapter present a spatial analysis of an intervention which aims at assessing whether similar values of an outcome are more likely to form clusters in a study area. This method called local indicators of spatial association (LISA) enable to identify areas where values are spatialy dependant with one another. LISA has been used to evaluate the effect of a community-based intervention which aims at controlling the mosquito responsable for spreading Dengue, Aedes aegypti in two neighborhoods of Ouagadougou the capital city of Burkina Faso. The final evalutation of the intervention using this method showed that larva clusters disappeared in the neighborhood which received the intervention while they persisted in the control neighborhood. Este capítulo presenta un análisis espacial de una intervención para evaluar si los valores similares de un resultado tienen más probabilidades de formar grupos en un área de estudio. Este método, denominado « indicadores locales de asociación espacial » (LISA), identifica áreas en las que los valores dependen espacialmente unos de otros. LISA se utilizó para evaluar el impacto de una intervención comunitaria para controlar al mosquito responsable de la propagatión del dengue Aedes aegypti en dos barrios de Uagadugû, la capital de Burkina Faso. La evaluación final de la intervención utilizando este método mostró que los grupos de larvas desaparecieron en el área que recibió la intervención mientras persistían en el área de control.

Une couverture universelle des soins de santé en 2030 pour tous les êtres humains, du Nord au Sud ? Réaliser cet objectif de développement durable aussi ambitieux que nécessaire exigera une exceptionnelle volonté politique, mais aussi de solides données probantes sur les moyens d’y arriver, notamment sur les interventions de santé mondiale les plus efficaces. Savoir les évaluer est donc un enjeu majeur. On ne peut plus se contenter de mesurer leur efficacité : il nous faut comprendre pourquoi elles l’ont été (ou pas), comment et dans quelles conditions. Cet ouvrage collectif réunissant 27 auteurs et 12 autrices de différents pays et de disciplines variées a pour but de présenter de manière claire et accessible, en français, un florilège d’approches et de méthodes avancées en évaluation d’interventions : quantitatives, qualitatives, mixtes, permettant d’étudier l’évaluabilité, la pérennité, les processus, la fidélité, l’efficience, l’équité et l’efficacité d’interventions complexes. Chaque méthode est présentée dans un chapitre à travers un cas réel pour faciliter la transmission de ces savoirs précieux.

International audience; In Mauritania, obstetrical risk insurance (ORI) has been progressively implemented at the health district level since 2002 and was available in 25% of public healthcare facilities in 2015. The ORI scheme is based on pre-payment scheme principles and focuses on increasing the quality of and access to both maternal and perinatal healthcare. Compared with many community-based health insurance schemes, the ORI scheme is original because it is not based on risk pooling. For a pre-payment of 16–18 USD, women are covered during their pregnancy for antenatal care, skilled delivery, emergency obstetrical care [including caesarean section (C-section) and transfer] and a postnatal visit. The objective of this study is to evaluate the impact of ORI enrolment on maternal and child health services using data from the Multiple Indicator Cluster Survey (MICS) conducted in 2015. A total of 4172 women who delivered within the last 2 years before the interview were analysed. The effect of ORI enrolment on the outcomes was estimated using a propensity score matching estimation method. Fifty-eight per cent of the studied women were aware of ORI, and among these women, more than two-thirds were enrolled. ORI had a beneficial effect among the enrolled women by increasing the probability of having at least one prenatal visit by 13%, the probability of having four or more visits by 11% and the probability of giving birth at a healthcare facility by 15%. However, we found no effect on postnatal care (PNC), C-section rates or neonatal mortality. This study provides evidence that a voluntary pre-payment scheme focusing on pregnant women improves healthcare services utilization during pregnancy and delivery. However, no effect was found on PNC or neonatal mortality. Some efforts should be exerted to improve communication and accessibility to ORI.

Improving access to maternal health services is a critical policy concern, especially in Sub- Saharan Africa (SSA) where maternal mortality rates remain very high, particularly so among the poorest segments of society. Hence, following the global call to reduce maternal mortality embedded in the Sustainable Development Goal 3, multiple interventions have been designed and implemented across SSA countries to foster progress towards Universal Health Coverage (UHC) of maternal health services, including skilled birth attendance. While evidence on the impact of these interventions on access to service use is increasing, evidence on the distributional incidence of the financial investment they entail is still limited. This paper aims to close this gap in knowledge by conducting a quasi-longitudinal benefit incidence analysis to assess equality of both public and overall health spending on maternal health services in three Sub-Saharan African countries: Burkina Faso, Malawi and Zambia. The study relied on healthcare utilization data derived from different nationallevel household surveys (including Demographic and Health Survey, Performance based Financing Survey, and Zambia Household Health and Expenditure Survey) and health expenditure data derived from National Health Accounts. The findings demonstrate increasing equality in health spending over time, but also considerable persistent heterogeneity in distributional incidence across provinces/regions/districts. These findings suggest that the implementation of UHC-specific reforms targeting maternal care was effective in increasing equality in health spending, meaning that more financial resources reached the poorest segments of society, but was not yet sufficient to remove differences across provinces/regions/districts. Further research is needed to investigate sources of regional disparities and identify strategies to overcome them.

Additional file 1. Sensitivity analysis: Results from the regression model exploring the factors related to excessive OOPE at the individual level using Medium-high expenditure threshold

Additional file 2. Sensitivity analysis: Results from the regression model exploring the factors related to excessive OOPE at the individual level using Extreme high expenditure threshold

Additional file 2. Questionnaire Endline.

Additional file 1.

Additional file 3. Sensitivity analysis: Results from the regression model exploring the factors related to excessive OOPE at the individual level, excluding the three extreme cases where ultra-poor had to accommodate over 100.000 FCFA to cover their healthcare costs.

Not a single low-income country reduced its road injury rates", said Etienne Krug as the Stockholm Declaration on Road Traffic Safety was adopted during the ministerial conference in February 2020, marking the end of the UN Decade of Action for Road Safety (2011-2020). It reaffirms the global character of road traffic safety which calls for international cooperation and multisector partnerships.

Ce chapitre présente une analyse spatiale d'une intervention qui vise à évaluer si des valeurs similaires d'un résultat sont plus susceptibles de former des grappes dans une zone d'étude. Cette méthode appelée " indicateurs locaux d'association spatiale " (local indicators of spatial association - LISA) permet d'identifier les zones où les valeurs sont spatialement dépendantes les unes des autres. LISA a été utilisé pour évaluer l'effet d'une intervention communautaire visant à contrôler le moustique responsable de la propagation de la dengue Aedes aegypti dans deux quartiers de Ouagadougou, capitale du Burkina Faso. L'évaluation finale de l'intervention à l'aide de cette méthode a montré que les groupes de larves ont disparu dans le quartier qui a reçu l'intervention alors qu'ils persistaient dans le quartier témoin.

Un militaire français a été tué dans un attentat au Mali, où 49 soldats maliens et un civil sont également morts ce weekend. Pourtant, malgré la dangerosité de la zone sahélienne, les scientifiques doivent pouvoir continuer à mener leurs travaux sans lesquels les choix politiques, comme l'action de développement économique, sont uniquement dépendants des militaires. Il est donc urgent de s'interroger sur les protocoles de sécurité qui empêchent de facto toute recherche française aujourd'hui dans la région.

En 2019, la France va tenter de combler le retard qu'elle a pris vis-à-vis de ses engagements pour l'aide publique au développement, notamment dans le domaine de la santé. Pour cela, une loi de programmation et d'orientation de l'aide publique au développement est en cours d'élaboration. Toutefois, le recours à un processus technocratique, non participatif et non fondé sur des preuves concernant les choix techniques soulève des inquiétudes et pousse à suggérer la mise en place urgente d'un dialogue délibératif.

Background In Africa, the magnitude of dengue virus (DENV) transmission is largely unknown. In Burkina Faso, several outbreaks have been reported and data are often based on findings from outbreak investigations. Methods To better understand dengue epidemiology and clinical characteristics in Burkina Faso, a fever surveillance study was conducted among patients aged 1-55 years, who presented with non-malarial febrile illness at five primary healthcare facilities in Ouagadougou, Burkina Faso from December 2014 to February 2017, encompassing a 3-month dengue outbreak in September-November 2016. Acute and convalescent blood samples were collected within an interval of 10-21 days between visits. Acute samples were tested with dengue rapid diagnostic tests (RDT) and a selected subset with RT-PCR, and all acute/convalescent samples with IgM/IgG ELISA. Results Among 2929 non-malarial febrile patients, 740 (25%) were dengue-positive based on RTPCR and/or IgM/IgG ELISA; 428 out of 777 patients (55%) and 312 out of 2152 (14%) were dengue-positive during outbreak and non-outbreak periods, respectively. There were 11% (316/2929) and 4% (129/2929) patients showing positive for NS1 and IgM, on the RDT, respectively. DENV 2 predominated during the outbreak, whereas DENV 3 predominated before the outbreak. Only 25% of dengue-positive cases were clinically diagnosed with suspected dengue. The odds of requiring observation for

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

International audience

Search strategy. (DOCX 31 kb)

Les dialogues délibératifs, de plus en plus utilisés sur le continent africain, représentent une avenue possible pour favoriser le transfert des connaissances et l'utilisation de la recherche. Suite à un projet de recherche réalisé au Burkina Faso sur les accidents et les traumatismes de la route, une journée de restitution des résultats sous forme de dialogue délibératif a été organisée en novembre 2015. L'objectif de cette activité était de réunir tous les acteurs impliqués dans le domaine de la sécurité routière afin de leur présenter les résultats de la recherche, de proposer des recommandations pour améliorer la situation et de développer un plan d'action concerté. Une évaluation utilisant une méthode mixte a été conduite suite à l'activité pour comprendre l'utilité de la démarche tout comme pour en mesurer les effets sur l'utilisation des résultats de la recherche. Cependant, l'évaluation de telles initiatives de transfert de connaissances pose encore de nombreux défis : la difficulté à définir et mesurer le concept d'utilisation de la recherche, le manque d'outils de mesure validés tout comme le délai incertain entre les activités et leurs effets potentiels. Ainsi, l'objectif principal de ce chapitre est de décrire le processus d'évaluation et de relever les enjeux liés à l'utilisation des méthodes mixtes en transfert de connaissances. Tout d'abord, le devis d'évaluation mixte sera présenté en expliquant les objectifs d'évaluation, les outils choisis pour collecter les données (questionnaires d'évaluation quantitatifs et entretiens semi-structurés avec les participants) ainsi que les processus d'analyse et d'intégration des données qualitatives et quantitatives. Finalement, certaines limites de cette évaluation mixte seront discutées comme le choix des outils de mesure, le moment et le processus de collecte de données, la complexité du concept à mesurer et la stratégie de transfert de connaissances évaluée.

List of included references. (DOCX 52 kb)

Multilingual abstracts in the five official working languages of the United Nations. (PDF 879 kb)

INTRODUCTION: Dengue is an important and well-documented public health problem in the Asia-Pacific and Latin American regions. However, in Africa, information on disease burden is limited to case reports and reports of sporadic outbreaks, thus hindering the implementation of public health actions for disease control. To gather evidence on the undocumented burden of dengue in Africa, epidemiological studies with standardised methods were launched in three locations in Africa. METHODS AND ANALYSIS: In 2014-2017, the Dengue Vaccine Initiative initiated field studies at three sites in Ouagadougou, Burkina Faso; Lambaréné, Gabon and Mombasa, Kenya to obtain comparable incidence data on dengue and assess its burden through standardised hospital-based surveillance and community-based serological methods. Multidisciplinary measurements of the burden of dengue were obtained through field studies that included passive facility-based fever surveillance, cost-of-illness surveys, serological surveys and healthcare utilisation surveys. All three sites conducted case detection using standardised procedures with uniform laboratory assays to diagnose dengue. Healthcare utilisation surveys were conducted to adjust population denominators in incidence calculations for differing healthcare seeking patterns. The fever surveillance data will allow calculation of age-specific incidence rates and comparison of symptomatic presentation between patients with dengue and non-dengue using multivariable logistic regression. Serological surveys assessed changes in immune status of cohorts of approximately 3000 randomly selected residents at each site at 6-month intervals. The age-stratified serosurvey data will allow calculation of seroprevalence and force of infection of dengue. Cost-of-illness evaluations were conducted among patients with acute dengue by Rapid Diagnostic Test. ETHICS AND DISSEMINATION: By standardising methods to evaluate dengue burden across several sites in Africa, these studies will generate evidence for dengue burden in Africa and data will be disseminated as publication in peer-review journals in 2018.

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

In a recent Viewpoint in the Lancet , some of us shared our experience of censorship in donor-funded evaluation research and warned about a potential trend in which donors and their implementing partners use ethical and methodological arguments to undermine research.1 Reactions to the Viewpoint—and lively debate at the 2018 Global Symposium on Health Systems Research —suggest that similar experiences are common in implementation and policy research commissioned by international donors to study and evaluate large-scale, donor-funded health interventions and programmes, which are primarily implemented in low resource settings. ‘We all have the same stories’, was one of the first comments on the Viewpoint, followed by many private messages divulging instances of personal and institutional pressure, intimidation and censorship following attempts to disseminate unwanted findings. Such pressure comes from major donors and from international non-governmental organisations (NGOs) obliged to have an external assessment but who then maintain a high degree of confidentiality and control. That such experiences are widespread reflects the deeply political nature of the field of ‘global health’ and the interconnections between priority setting, policy making and project implementation, which sit within a broader set of deeply entrenched power structures.2 3 Researchers in this field routinely find themselves working within—and studying—complex power relations and so experience challenges in negotiating their own position between interests of commissioning agencies and funders, implementers and country governments, as well as those of their own research institutions and their partnerships with other researchers spanning high-income, middle-income and low-income countries.4–7 They often receive research funding from major donor agencies like the UK Department of International Development (DFID), the US Agency for International Development (USAID), the Agence Francaise de Developpement (AFD), UNITAID and the Bill and Melinda Gates Foundation,8 who commission evaluations for their own funded projects, even though they have …