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Introduction : Cette etude avait pour objectif d’identifier les facteurs ayant influence la faible performance du projet d’Observatoire communautaire sur l’acces aux services de sante (Ocass) pendant sa mise en œuvre, de 2014 a 2017 en Guinee et de formuler des recommandations pour la suite du projet.Methodes : Il s’agissait d’une etude qualitative utilisant le cadre de performance multipolaire de B. Marchal et al., adapte du Modele d’evaluation globale et integrale de la performance des systemes de sante (Egipss), du cadre de Sicotte. Les donnees ont ete collectees a l’aide d’une feuille de calcul Excel® developpee conformement aux quatre fonctions du cadre d’analyse : prestation des services, atteinte des buts, interaction avec l’environnement et sauvegarde des valeurs et la culture organisationnelle.Resultats : L’absence d’une evaluation initiale des capacites techniques, operationnelles et organisationnelles de l’organe de mise en œuvre et la non-prise en compte des besoins specifiques du projet en termes de ressources (financieres, materielles et humaines) ont ete determinantes dans la faible performance de l’Ocass. La faible implication des acteurs nationaux, l’epidemie d’Ebola et la multiplicite des acteurs autour de l’Observatoire ont egalement joue un grand role dans la non-atteinte de l’objectif du projet.Conclusion : Notre etude a revele que la prise en compte du contexte national dans la mise en place de projet de responsabilite sociale est essentielle. La realisation d’une evaluation de base demeure quant a elle demeure une etape fondamentale pour garantir son succes.

Maintained dedication to primary care has fostered a public health delivery system with exceptional outcomes in Costa Rica. For more than a decade, management commitments have been part of Costa Rican health reform. We assessed the effect of the Costa Rican management commitments on access and quality of care and on compliance with their intended objectives. We constructed seven hypotheses on opinions of primary care providers. Through a mixed qualitative and quantitative approach, we tested these hypotheses and interpreted the research findings. Management commitments consume an excessive proportion of consultation time, inflate record-keeping, reduce comprehensiveness in primary care consultations, and induce a disproportionate consumption of hospital emergency services. Their formulation relies on norms in need of optimization, their control on unreliable sources. They also affect professionalism. In Costa Rica, management commitments negatively affect access and quality of care and pose a threat to the public service delivery system. The failures of this pay-for-performance-like initiative in an otherwise well-performing health system cast doubts on the appropriateness of pay-for-performance for health systems strengthening in less advanced environments.

This paper explores the role of evidence in maternal health policy processes in Vietnam, India and China. Both formal and informal types of evidence were used; and differences were found between the stages of policy processes. Evidence used mostly covered easily quantifiable issues and clearly identifiable technical solutions. Different policy actors were involved; actors’ evidence preferences were affected by their power, agendas, values and perceived characteristics of robust evidence. To enhance evidence role there is a need to: develop culture of evidence-informed policies; value different evidence types; ensure evidence use throughout policy processes; recognise and manage actors’ agendas; and develop context-specific strategies.

Community health insurance (CHI) is a specific health insurance arrangement serving a social purpose, generally operating at the local level of the health system, and largely thriving on community solidarity. This article describes the origins, formats, and evolution of CHI in Africa and Asia. It discusses strengths and weaknesses of CHI from different perspectives: its contribution to health-care access, to health sector financing, to provider responsiveness and quality of care, and to wider developmental objectives. The potential of CHI in the worldwide endeavor for universal health coverage and the conditions for CHI to possibly play a role of significance are critically analyzed.

Since 2010, the national conferences on bringing Evidence into Public Health Policy (EPHP) serve as a unique platform to promote exchanges among researchers, practitioners and policymakers for better population health in India. With the central objective of contributing to informed policy and action, each EPHP focuses on concepts and initiatives of significant importance for health in India where informed policymaking can make a difference. The first EPHP in 2010 focused on ‘Five years of National Rural Health Mission’.1 The National Rural Health Mission—now National Health Mission taking into its ambit the National Urban Health Mission—was and remains a significant structural reform in the Indian health landscape. Paving the road for improved healthcare delivery, the mission connected the health system again with the community by introducing Accredited Social Health Activists, community monitoring …

[Graphic][1] Acknowledgements All EPHP 2016 abstracts were independently peer-reviewed by two experts. We thank the following experts, in alphabetical order: Asha Kilaru, Ashish Kumar Upadhyay, Amitabha Sarkar, Bart Criel, Bontha Babu, … [1]: /embed/inline-graphic-1.gif

Internationally, Adolescent Reproductive and Sexual Health (ARSH) has become a priority programme approach to help the future generations have a safe, healthy and satisfactory life. India is yet to develop a comprehensive policy on ARSH mainly due to lack of inter-ministerial collaboration, socio-cultural and politico-religious factors, even though evidence from surveys and non- governmental organization projects has corroborated the case for ARSH since late 1980s. Fortunately, recent evidence provided by Sample Registration Survey (SRS) 1999, Census 2001, National Family Health Survey (NFHS)-II and District Level Household Survey (DLHS) 2004 particularly on early marriage, teen pregnancy, anaemia and unmet need for contraception has led GoI to recognize the importance of adolescent health. However, a comprehensive ARSH policy is yet to emerge, since components of adolescent health are being addressed by separate ministries and departments. Adolescent health in India is still in an infant stage and at the risk of infanticide. From “health for the adolescents” to “health with the adolescents”, it is still a long way to go.

1 Research Centre for Longitudinal and Life Course Studies, University of Antwerp, Belgium2 Unit of Health Policy and Financing, Institute of Tropical Medicine, Antwerp, Belgium3 Institute of Public Health, Bangaluru, India4 Institute of Development Policy and Management, University of Antwerp, Belgium5 Herman Deleeck Centre for Social Policy, University of Antwerp, Belgium

Background Selective vertical programs prevailed over comprehensive primary health care in Latin America. In Bolivia and Ecuador, socialist governments intend to redirect health policy. We outline both countries’ health system’s features after reform, explore their efforts to rebuild primary health care, identify and explain policy gaps, and offer considerations for improvement. Methods Qualitative document analysis. Findings Earlier reform left Bolivia’s and Ecuador’s population in bad health, with limited access to a fragmented health system. Today, both countries focus their policy on household and community-based promotion and prevention. The negative effects on access to care of decentralization, dual employment, vertical programming and targeting are largely left unattended. Neglecting care is understandable in the light of particular interpretations of social medicine and social determinants, international policy pressures, reliance on external funding and institutional inertia. Current policy choices preserve key elements of selective care and consolidate commodification. It might not improve health and worsen poverty. Interpretation Care can be considered as a social determinant on its own. Key to the accomplishment of primary care is an integrated application of family medicine, taking advantage of individual care as one of the ways to act on social determinants. It deserves a central place on the policy-makers’ priority list, in Bolivia and Ecuador as elsewhere.

Summary This paper presents an overview of the development of Community Health Insurance (CHI) in subSaharan Africa. In 2003, nearly 600 CHI initiatives were registered in a dozen countries of francophone West Africa alone. At regional level, coordination networks have been created in Africa with the aim to support and monitor the developments of this innovative model of health care financing. At national level, governments are preparing the necessary legal frameworks for CHI implementation. CHI is increasingly seen as a strategy to meet other development goals than only health. It constitutes an interesting model to finance health care, to pool financial resources in a fair way and to empower health care users. The CHI movement however still faces many challenges. The relevance of more professional inputs in the management of CHI and the need for careful subsidy of CHI schemes are increasingly recognized. There is also need to optimize the relationship of CHI with the other actors in the health system and to scale-up CHI so as to gain in effectiveness and efficiency. The boom in the number of schemes in Africa during the last years is an indicator of the increasing attractiveness of the model. In practice however, enrolment rates per scheme remain low or are only slowly increasing. Context-specific research is needed on the reasons that prevent people from enrolling in larger numbers. On that basis, relevant action to be taken locally can be identified.

Background: Lack of access to health care is a persistent condition for most African indigents, to which the common technical approach of targeting initiatives is an insufficient antidote. To overcome the standstill, an integrated technical and political approach is needed. Such policy shift is dependent on political support, and on alignment of international and national actors. We explore if the analytical framework of social exclusion can contribute to the latter. Methods: We produce a critical and evaluative account of the literature on three themes: social exclusion, development policy, and indigence in Africa–and their interface. First, we trace the concept of social exclusion as it evolved over time and space in policy circles. We then discuss the relevance of a social exclusion perspective in developing countries. Finally, we apply this perspective to Africa, its indigents, and their lack of access to health care. Results: The concept of social exclusion as an underlying process of structural inequalities has needed two decades to find acceptance in international policy circles. Initial scepticism about the relevance of the concept in developing countries is now giving way to recognition of its universality. For a variety of reasons however, the uptake of a social exclusion perspective in Africa has been limited. Nevertheless, social exclusion as a driver of poverty and inequity in Africa is evident, and manifestly so in the case of the African indigents. Conclusion: The concept of social exclusion provides a useful framework for improved understanding of origins and persistence of the access problem that African indigents face, and for generating political space for an integrated approach.

CBHI has achieved low population coverage in West Africa and elsewhere. Studies which seek to explain this point to inequitable enrolment, adverse selection, lack of trust in scheme management and information and low quality of health care. Interventions to address these problems have been proposed yet enrolment rates remain low. This exploratory study proposes that an under-researched determinant of CBHI enrolment is social capital. Fieldwork comprising a household survey and qualitative interviews was conducted in Senegal in 2009. Levels of bonding and bridging social capital among 720 members and non-members of CBHI across three case study schemes are compared. The results of the logistic regression suggest that, controlling for age and gender, in all three case studies members were significantly more likely than non-members to be enrolled in another community association, to have borrowed money from sources other than friends and relatives and to report having control over all community decisions affecting daily life. In two case studies, having privileged social relationships was also positively correlated with enrolment. After controlling for additional socioeconomic and health variables, the results for borrowing money remained significant. Additionally, in two case studies, reporting having control over community decisions and believing that the community would cooperate in an emergency were significantly positively correlated with enrolment. The results suggest that CBHI members had greater bridging social capital which provided them with solidarity, risk pooling, financial protection and financial credit. Qualitative interviews with 109 individuals selected from the household survey confirm this interpretation. The results ostensibly suggest that CBHI schemes should build on bridging social capital to increase coverage, for example by enrolling households through community associations. However, this may be unadvisable from an equity perspective. It is concluded that since enrolment in CBHI was less common not only among the poor, but also among those with less social capital and less power, strategies should focus on removing social as well as financial barriers to financial protection from the cost of ill health.

PURPOSE: Recently, the Indian government launched health insurance schemes for the poor both to protect them from high health spending and to improve access to high-quality health services. This article aims to review the potentials of health insurance interventions in order to improve access to quality care in India based on experiences of community health insurance schemes. DATA SOURCES: PubMed, Ovid MEDLINE (R), All EBM Reviews, CSA Sociological Abstracts, CSA Social Service Abstracts, EconLit, Science Direct, the ISI Web of Knowledge, Social Science Research Network and databases of research centers were searched up to September 2010. An Internet search was executed. STUDY SELECTION: One thousand hundred and thirty-three papers were assessed for inclusion and exclusion criteria. Twenty-five papers were selected providing information on eight schemes. Data extraction A realist review was performed using Hirschman's exit-voice theory: mechanisms to improve exit strategies (financial assets and infrastructure) and strengthen patient's long voice route (quality management) and short voice route (patient pressure). RESULTS OF DATA SYNTHESIS: All schemes use a mix of measures to improve exit strategies and the long voice route. Most mechanisms are not effective in reality. Schemes that focus on the patients' bargaining position at the patient-provider interface seem to improve access to quality care. CONCLUSION: /st> Top-down health insurance interventions with focus on exit strategies will not work out fully in the Indian context. Government must actively facilitate the potential of CHI schemes to emancipate the target group so that they may transform from mere passive beneficiaries into active participants in their health.

This article analyses the influence of the World Bank on reforms of the health sector in Bolivia during the period 1986–2006, and assesses their impact on the health care delivery system to date. The article examines the transformation of health services undertaken by the current socialist government since 2006. A literature review and interviews with decision-makers critically examine the outcome of reforms on criteria linked to health system integration. The study illustrates that Bolivia applied quite comprehensively the WB recommendations. Among others these included indirect privatization through public health services’ restriction of access to a basic package of care and decentralization with devolution. In consequence, the segmentation and fragmentation of the health system was exacerbated, accessibility and quality of care suffered and health status barely improved. The article attempts to locate the relationship between policy, health care delivery and health systems functioning.

Confident in the infinity of time, a certain conception of history discerns only the rhythm, faster or slower, at which men and times move along the path of progress. Walter Benjamin, 1915. La vie des etudiants. In: W. Benjamin, Œuvres I, Folio Essais, Editions Gallimard, 2000, p. 125. Plato was the first to discern between those who know without acting and those who act without knowing while in the past, action was divided in enterprise and achievement: the result was that the knowledge of action to accomplish and its implementation became two radically different concepts. H. Arendt. Condition de l'homme moderne. Calmann Levy Ed., Paris, 1983, p. 286. After 15 years of neoliberal international health policy, data from 26 sub-Saharan countries reveals that more than 50% of the poorest children receive no health care when sick (Marek et al., 2005). Data from 44 low- to middle-income countries (LMICs) suggest that the greater the participation of the private sector in primary health care (PHC), the higher the exclusion from treatment and care (Macintosh & Koivusalo, 2005) across sectors. This is a textbook about public health with a difference. Firstly, it addresses policies relating to the delivery of health care – while the study of public health has historically evolved around issues of disease control. This book makes a case for alternative policies that could shape the structure and provision of universally accessible, polyvalent, discretionary health care, rather than making it work through its commodification and the priorities of cost-effective interventions in public services.