Cheickna Toure

Du 28 avril au 1er mai 2014, une soixantaine d’experts internationaux se sont retrouvés à Bujumbura à la faveur d'un atelier organisé par la Communauté de Pratique Financement Basé sur la Performance. L’événement était organisé en partenariat avec le Joint Learning Network for Universal Health Coverage, avec le soutien financier de la Coopération Belge au Développement et la Banque Mondiale. Il visait à réunir les nombreux experts impliqués dans la conception, le développement, la mise en œuvre et l’utilisation des solutions technologiques conçues dans le domaine du financement des services de santé. Cheickna Toure (Union Technique de la Mutualité Malienne) nous rapporte les grands messages de l’atelier. 


C’est devenu un cliché de dire que les  technologies de l’information et de la communication (TIC) sont en train de  transformer profondément nos sociétés. Ce diagnostic s’applique également à la  conduite des systèmes de santé en Afrique. Durant les quatre jours d’atelier à  Bujumbura, nous avons pu apprécier la force du vent de dynamisme qui souffle sur  le secteur qui intéresse les lecteurs de ce blog : les mécanismes de  financement des services de santé.
 
Des opportunités certaines….
Au vu des nombreuses présentations (que vous  pouvez retrouver ici), il est clair que les TIC constituent une grande opportunité pour  améliorer la performance des systèmes de santé. Les gros progrès réalisés au  niveau des interfaces font que les outils technologiques sont aujourd’hui assez simples à prendre  en main ; cela permet un usage beaucoup plus ouvert que par le passé. Les  sessions sur la visualisation des données et les tableaux de bord furent l'occasion pour les participants d'en faire l'expérience.
 
Dès la session introductive, les participants ont perçu la manière dont  les TIC permettent de repousser les limites de la collecte des données. Parce  qu'elles ouvrent la possibilité de recueillir davantage d'informations et de  meilleure qualité au plus près de ceux qui utilisent les services de santé. Les  présentations sur les solutions de liquidation électronique des prestations ou  encore les dispositifs de bons électroniques (eVoucher) en ont fait la démonstration. Et pour les analyses de données, on  aura très prochainement des Systèmes Nationaux d’Information Sanitaire (SNIS) beaucoup plus  puissants et intégrés que par le passé. Il faut s'attendre à une convergence  entre les solutions qui traitent de la demande des services et celles qui gèrent  la fourniture des prestations. Cela va affiner la compréhension de l'utilisation des services et  permettre une meilleure planification des activités de santé pour anticiper les  besoins des usagers.
 
Par leur simplicité, les technologies actuelles telles que le SMS  sont à même de toucher les populations pauvres. De nouveaux espaces de transparence apparaissent (Voir par exemple  le portail FBR du Bénin) où sont rendues publiques une foule de données, accessibles aux  usagers, aux décideurs politiques, aux gestionnaires de programme et aux  bailleurs. La session sur la redevabilité sociale a mis en lumière le fait que  les TIC pouvaient être un puissant outil d'amélioration de la confiance des  bailleurs et des usagers (voir aussi la récente initiative de  Cordaid sur l’open data dans les projets de  développement). Concernant les usagers futurs, les intenses discussions ont  laissé entrevoir le développement encore plus soutenu des solutions mobiles dans  les années à venir.

 … sans doute des limites
Malgré les promesses des TIC, il existe encore des zones non  desservies ou non couvertes par les réseaux de communication. Beaucoup de  participants ont attiré l'attention sur l'isolement particulier des zones rurales. Les équipements (tablettes, smartphones et autres assistants numériques)  ne sont pas toujours accessibles financièrement.
 
Il a été relevé que certaines pesanteurs liées à l'illettrisme, à l'indigence, etc. limitent les possibilités  d'utilisation des technologies disponibles. L'introduction des TIC provoque parfois de la résistance au  changement (cf. l'exemple des agents hospitaliers face à l'implantation de la facturation électronique des prestations au  Mali) par crainte ou par méconnaissance des effets escomptés. La multiplication de l'offre des terminaux tout en renforçant les possibilités de collecte des données personnelles, pose avec acuité la problématique de leur protection.
 
Des débats parfois passionnés ont eu lieu sur  les incidences d'une utilisation exacerbée des TIC. Certains pensent qu'elle peut conduire à la déshumanisation de la relation des praticiens aux patients. D'autres évoquent les effets contreproductifs sur l'organisation du travail du personnel soignant.
 
Des exigences aussi ….
L'interopérabilité des systèmes aura été une  thématique régulièrement abordée tout au long de cet atelier en tant qu'elle  constitue une réelle opportunité pour une approche plus holistique du  système de santé (voir à ce sujet la conception du schéma directeur  d'informatisation au Rwanda). En la matière, les pays africains gagneraient à s'accorder sur  un minimum de taxonomie pour faciliter les échanges inter systèmes. Ce travail  doit être enrichi par l'adoption au moins de dictionnaires nationaux de données  pour la santé. Une méthodologie et des prototypes ont été mis à disposition par  JLN. L'on retiendra le rôle catalytique des organisations régionales et sous régionales pour encourager l'adoption des systèmes ouverts. L'initiative de l'organisation ouest africaine de la santé OOAS pour la constitution d'une base de données régionale de la santé a montré une piste intéressante.
 
La flexibilisation des solutions a été identifiée comme un enjeu essentiel de l'utilisation des TIC dans les programmes de santé. Les technologies doivent constamment permettre d'ajuster les services proposés aux habitudes de consommation et comportements sociaux des personnes ciblées. L'adaptation des supports et des contenus est cruciale (voir par exemple  la campagne de suivi par mobile des femmes  enceintes en Tanzanie par Text-to-change). 
 
Mais chaque pays peut et doit inventer sa voie
On aura également compris que les nombreuses initiatives développées dans les différents pays méritent d'être mises en contact pour forger la créativité et booster l'intérêt pour l'utilisation des TIC. Les laboratoires d'idées du dernier jour furent des moments absolument exaltants, tant le travail collaboratif qui en a découlé, a permis aux participants d'imaginer des processus plus efficients pour la collecte des données, l'enregistrement électronique des données médicales, la gestion de l'assurance maladie, l'interopérabilité, la modélisation de l'évaluation des coûts dans le système FBR, les bons électroniques. Pour moi, ces laboratoires ont été un des moments les plus passionnants de  l'atelier.
 
Finalement j'ai retenu au terme des quatre jours d'échange d'expériences que la solution standard (ni en terme d'outils ni en terme de technologie) adaptée à toutes les situations n'existait nulle part; chaque pays  doit faire ses choix en fonction de la complexité de son système de gestion.

Isabelle Lange
 
The  Harmonization for Health in Africa  Communities of Practice are today firmly installed in the global health landscape. The Financial Access to Health  Services  CoP (FAHS CoP) for instance gathers more than 700 experts committed to progress  towards universal health coverage through strategies such as user fee removal, health equity funds, health insurance…  In this blog, Isabelle Lange, medical anthropologist at the London School of Hygiene and Tropical Medicine and FEMHealth researcher reports findings of her qualitative research on the FAHS CoP itself. 

 “[The FAHS CoP online group] is effective for sharing information, for networking, and for the exchange of experiences…. It’s- it’s extraordinary…. First, through the community I discovered, I had the opportunity to exchange with a lot of people and now after the workshop, I think that they are friends… I will try to maintain these relationships despite…. Even if the relationship is there and exists you have to reinforce it and care for it.”
– Policy Maker, North Africa
 
More and more actors in the global health community are tapping into the growing range of resources to widen their networks and information bases. Communities of Practice (CoPs) fit into this trend, and as they become a more popular tool in today’s information management methods in global health, there is the sense that the utilization of the Internet and strong content can bridge individuals to create or strengthen a community.  A CoP then could provide resources for knowledge sharing and potentially also for informed health policy and systems change, breaking the traditional direction of north to south information flow and communication barriers across professional silos.  However, achieving this model can be a complex process dependant on many contextual variables; exploring the processes of a particular CoP can shed light on its contribution to health policy as a mechanism for knowledge exchange. This was one of my ‘assignments’ under the FEMHealth project.  
 
The CoP FAHS and the FEMHealth: three years of collaboration 
 
The FEMHealth project was a 3-year multi-disciplinary evaluation of maternal health user fee removal policies in Morocco, Mali, Burkina Faso and Benin. I carried out a semi-external view of FAHS CoP as a part of the health policy research. The health policy analysis aimed to understand the origin of the policies in these countries and why similar measures were taken around the same time period to reduce the financial burden of childbirth costs on women and their families.  There we explored whose voices were heard, which agendas were pushed and what evidence was influential in driving these strategies.  The FAHS CoP offered an arena to deepen that research by observing the current debates and actors, in addition to serving as its own study area on this mechanism as a
vehicle for knowledge sharing and transfer.  It also offered a channel to connect the FEMHealth researchers in with the wider community interested in their topic. As FEMHealth had supported the establishment of the CoP, it was also interested in understanding how well the CoP was meeting its goals of knowledge creation and exchange. In my capacity as anthropologist working on the health policy analysis research, I attended three FAHS CoP workshops (in Bamako 2011, Marrakech 2012 and Ouagadougou 2013) and alongside informal exchanges and observation of the content during those meetings, carried out in-depth interviews with the facilitators and about 25 participants – following up with a selection of them over the years to gain an idea of the value of the CoP within their professional and personal lives. 
 
CoP workshops

According to my informants, the CoP workshops cut across geographic, disciplinary and linguistic boundaries that frequently hamper knowledge exchange amongst different profiles of actors. The magic  formula for this was, according to participants: an appropriate participant body  – with engaged, knowledgeable actors there to learn and make a difference, not  just to collect per diems; dynamic, skilled facilitation; plenty of time for informal exchange (during coffee breaks or on field visits); quality simultaneous translation between French and English; pertinent technical content; and a format that allowed for questions, discussion, learning and problem-solving, not just presentations and “being spoken at.” 
 
A particular wish of participants was to have the beneficiary community voice present in the discussions, based on the feeling that they did not have space carved out to be legitimately heard in the usual pathways of decision-making. “I think that often we meet just amongst us, actors in the ministry of health, or those who implement the program, without taking many things into account because we can’t imagine the perspectives of the user or beneficiaries of the service”, stated a West African policy maker. “They have to be there to tell us ‘what you did like this, should have been done like this instead.”  This view was echoed in reference to other stakeholder groups, including health workers and researchers, underlining the absence of meaningful cross-silo exchanges in typical/existing professional structures. 

Importance of the online community

These workshops are an important part of the FAHS CoP identity – strengthening the membership and committing to action a core tenet of the knowledge-sharing mandate of CoPs. What was clear, however, was that the CoP workshops had another special component:  the online community that served as a base to these workshops.  This group offers a continuity and home to the technical content and face-to-face exchanges that similar conferences did not have. While many of the attendees at the workshops were not CoP members (at the time), the community thread ran through the conference and made its presence:
member participants were asked to summarize debates and presentations which were posted to the 700+ subscribers, who could then continue the discussion via email and feed back to the conference attendees with further thoughts and questions.  One workshop participant who is also a community member said, “I see these face-to-face meetings (as) very important. That's what feeds new community members and that feeds the online life to the next workshop. And so there are these two mechanisms – face-to-face - that are then a good trigger for online knowledge movement and communication and discussions.” 
    
In its own right, the online community served as a valuable link to work being done in health financing on a broader scale than many members were involved in their day-to-day professional lives.  Access to grey and academic literature, unpublished experiences, and especially the diverse opinions of fellow community
members on these pieces proved to be a reason why the online group was valued and, for some, ‘boosted confidence’ in their own capacity and was considered a unique contribution to the resources available in this field. 
  
Further reflections and future steps

The enactment of policy-relevant knowledge in more dynamic ways – through interactive meetings, continuous facilitation, editorials, and community building, among others – was seen to be a strong point of the community of practice model in providing both personal and professional benefits to members. But questions remain about strategies that can create a lasting impact in a world where many are over-worked and access to a surplus of material and resources can at times seem to be a burden rather than a benefit.  The CoP offers a reference point and an organizational component to information, people and networks, which, as one agency participant says, is “the key to the whole thing…. It’s knowledge dissemination, knowledge production, capacity building.” But, he continues, “a community of practice is not just there for the management, but to build something.” Over the past three years we have watched the FAHS CoP grow into a network of more than 700 individuals and as an organization have seen its presence at numerous conferences and affiliation with other professional bodies. Discussions around its ideal future structure emphasize its need to remain non-normative, independent and be member-driven,
not only member-responsive, in order to be able to contribute to shaping an environment that constructively and innovatively brings about positive policy advances through knowledge sharing. 
 
Read the accompanying policy brief for the facilitators’ perspectives on growing a CoP, and don’t hesitate to get in touch with any thoughts or ideas.  

Fahdi Dkhimi, Maymouna Ba and Kadi Kadiatou

From 24 to 27 September 2012, Financial Access to Health Services Community of Practice organized, in collaboration with the Ministry of Health of Morocco and JLN network, a workshop in Marrakech. In this blogpost, three members of FA CoP get back on the event. This blog post was also published as an editorial in the journal “Global Health Promotion”.

While most everyone today agrees that countries should begin moving toward universal health coverage (UHC), how to practically implement this worthy ambition remains less than clear. One of the major challenges is to strengthen equity in health financing, and more precisely, to improve access to healthcare for the poor. For many countries, particularly low-income countries, the access of the poorest to good quality health care remains a distant dream. If the problem of ensuring adequate resources is important, the issue of knowledge management is also crucial. The implementation of many initiatives is hindered by inadequate knowledge sharing, which leads to repeating the same errors in different places. Hence the idea to create effective platforms for the production and sharing of knowledge, known as communities of practice.

The ‘Financial Access to Health Services’ Community of Practice (CoP FAHS) is one such innovative effort in Africa. Its objective is to promote the exchange and coordination among actors working on the issue of health financing and access to care. This CoP also aims to promote better consideration and use of evidence in the policy-making process (1). It largely operates through virtual interactions among its 400 members, but also through periodic face-to-face encounters at workshops organized around specific themes.

In September 2012, a workshop organized by the CoP FAHS was held in Marrakech, in collaboration with the Joint Learning Network (JLN) for Universal Health Coverage (funded by the Rockefeller Foundation, among others) and with a strong partnership and investment from the Ministry of Health of Morocco. The purpose of this meeting was to bring together a wide range of actors, from policy makers, to scholars and implementers, as well as members of the JLN network or the CoP, to address a key issue for achieving universal health coverage (UHC): health coverage for the poorest.

Ninety participants, including 11 country delegations took part in the meeting that had a number of innovative aspects: bilingual (French- English), working groups between peer countries, flexible organization of the 3 days, and content constantly being adapted to the needs of participants. But the most remarkable innovation was undoubtedly the workshop’s organization of a field visit - with strong support from the Ministry of Health of Morocco - to three sites where RAMED is being implemented, the Medical Assistance Program for Moroccan citizens identified as ‘poor’ or ‘vulnerable’. This “hands-on” aspect of the workshop has fueled in-depth exchanges and reflections on the challenges faced by African countries in the implementation of pro-poor strategies and medical assistance. It also gave the host country the opportunity to obtain the views of an expert panel on the RAMED, a program which began the crucial phase of nationwide scale-up in April 2012.

Beyond such positive feedback, the workshop’s theme - how to reach the poorest - is revealing of the magnitude of the task facing the CoP in the near future if it is to truly unleash effective knowledge sharing that informs and shapes the policy-making process (2). The key challenge remains its capacity to open up an area of health that has traditionally operated in a silo; one that has had great difficulty in incorporating multisectoral approaches. Even the process of selecting participants for this workshop demonstrated this problem: there was an overrepresentation of personnel of the ministries responsible for public health, whereas the organizations of civil society and the private sector, as well as other administrative services involved in reaching the poorest were virtually absent.

This lack of heterogeneity has introduced a bias in the technocratic thinking on the issue of access to care for the poorest. If the technical problems - the resolution of which is necessary but not sufficient in our opinion - have been widely discussed (identification of the poor, registration of beneficiaries, funding assistance, etc.), the presence of actors working in other spheres not related to health, especially the representatives of the poorest themselves, was missing in the debate, making it impossible to face up to structural issues in which inequalities in access to health care and in access to public resources find their roots.

The issue of access to care for the poorest is a major challenge for African health systems in their ambition to reach the UHC. Disparities in access and use are indeed a reflection of power dynamics that perpetuate structural inequalities of distribution of resources within a society and generate social determinism to access to care. These processes have been particularly highlighted by the work of the Commission on Social Determinants of Health, through its Social Exclusion Knowledge Network (SEKN) (3). This determinism plays full even when alternative mechanisms of financing health care are implemented - exemption, grant, gratuity, etc. - and partly explains the mixed results produced by these initiatives (4), see also Health Inc Research Project. A more structural analysis and a multi-sectoral approach is needed to understand all of the issues relating to access to health care for the poor and provide an effective solution.

Challenges that must be met successfully by the CoP will therefore be to become available to other sectors, other actors beyond technicians and experts in the field of health. It is on the basis of this capacity of the CoP to open up that it will be in a position to make a difference and provide opportunities for its members to leave the debates yet too restricted to technical issues, and which often cause erratic political processes (5).

References
1.     Meessen B, Kouanda S, Musango L, Richard F, Ridde V, Soucat A. Communities of practice: the missing link for knowledge management on implementation issues in low-income countries? Trop Med Int Health. 2011; 16(8): 1007–1014. doi:10.1111/j.1365-3156.2011.02794.x;
2.     Groves T. Development of health systems and universal coverage should be evidence based, says WHO. BMJ. 2012; 345 (2): e7530–e7530. doi:10.1136/bmj.e7530;
3.     Popay J. Understanding and tackling social exclusion. J Res Nurs. 2010; 15(4): 295–297. doi:10.1177/1744987110370529;
4.     Babajanian B, Hagen-Zanker J. Social protection and social exclusion: an analytical framework to assess the links. London, UK: ODI; October 2012: 12. Retrieved from http://www.odi.org.uk/publications/6889-social-protection-social-exclusion-design-analytical-framework;
5.     Mckee M, Balabanova D, Basu S, Ricciardi W, Stuckler D. Universal Health Coverage : A Quest for All Countries But under Threat in Some. Value in Health. 2012: 1–7. doi:10.1016/j.jval.2012.10.001;

Bruno Meessen

The Performance Based Financing Community of Practice (PBF CoP) started 3 years ago in Bujumbura and hasn't stopped growing since then.  We have the pleasure to present you Dr. Fodé Cissé who, two weeks ago, became the 1000th member of the PBF CoP. We wish him a warm welcome and hope that he will enjoy our knowledge community. Fodé registered from Kigali, where he was following a PBF training.


Dear Fodé, we would like to know more about the 1000th member of the PBF CoP. Could you please introduce yourself?

I am 39 years old and I have the Guinean nationality. I'm married and father of 3. I'm a medical doctor, specialized in the management of health services. After having finished my medical studies, I worked for Médecins Sans Frontières Belgium from 2000 till 2002, on a project taking care of Tuberculosis and HIV in Guinea. After that I joined the Ministry of Public Health in 2004 after having finished my Master in Management of Health Services. There, I was responsible for the follow-up evaluation of the TB Program (2004-2007).  I was also Head of the Global Fund project (2007-2012). In this position, I did several international consultancies dealing with the design and implementation of health projects.  At the moment, I work for the Strategies and Development Office of the Ministry of Public Health, where I am in charge of studies and planning.

You registered to the CoP from Kigali. Could you please tell us a bit about what you learned from your stay in Rwanda?

It was my second stay in Rwanda. Every time I come here, I think about the principles of non-violence and the love of one’s neighbor. The genocide sufficiently proves that mankind is ready to do anything in order to achieve its goals. This tragedy should inspire all people of the world in general and African people in particular who are getting introduced to democracy. This introduction sometimes causes a fratricidal struggle between brothers and sisters of the same village who have lived together peacefully for a long time. As far as the health system of Rwanda is concerned, I found that, compared to our system, it has a high standard. The Performance Based Financing system is already operational; I've also been able to see that it has been adapted to the Rwandese situation.

Do you think that PBF has a future in Guinea?  According to you, what problems of the health system could this strategy, at least partly, address?

To your question whether the FBP has any future in Guinea I can say "yes", without any doubt. The Guinean health system  – just like the health system of other countries of the sub-region - suffers from structural weaknesses, which impede to achieve the Millennium Development Goals.  Among these weaknesses, I particularly think of the problem of financing the sector, the lack of access to quality care and the poor governance. Looking at these shortcomings, the introduction of the PBF will undoubtedly allow breathing new life into the health system of my country: the Primary Health Care strategy, as it has been implemented till now, has shown its limitations.

Therefore, I call upon the Guinean health authorities on all levels, as well as their technical and financial partners, to adopt PBF as a new instrument to resolve the recurring problems which our health system is currently facing.