By Sophie Witter and Bruno Marchal
What explains whether and how policies are put into effect in local health systems? Whether the resources they bring are used to improve health and systems or to serve the self-interest of entrenched groups? These were among the questions we examined in a recent research project, FEMHealth, looking at implementation of maternal fee removal policies in four countries in West and North Africa. We found divergent practices in different sites within the same countries, indicating that regardless of policy design and implementation modalities, local configurations of actors and contexts affect how policies are adopted or adapted, positively or negatively. The research raised some important points for people-centred health systems, including:
- The need to use more dynamic models of the health system, which understand the linkages between the different ‘building blocks’ and which put communities, providers and managers at the heart of the interaction.
- The need for more focus on the stewardship function (defined as coordination, management and regulation of all health actors and safeguarding the public interest) within local health systems, as it explains how resources are managed to produce socially beneficial outcomes (or not) and how actors are held accountable.
- That insufficient attention has been paid in most (and certainly in low and middle income) settings into how to boost capacity and space for stewardship, which we found to be absent in most sites. The role of ensuring public accountability, in particular, was found to be underdeveloped or even not mandated clearly.
- That there should be a focus on enabling effective stewardship at the local level by reinforcing competences and setting up institutional arrangements to enable positive management of resources.
The FEMHealth (Fee Exemption for Maternal Health) project was a research collaboration funded from the European Union Seventh Framework Programme (FP7/2007-13) under grant agreement no 261449. The research consortium was led by the University of Aberdeen and included eight partners in the UK, Belgium, Benin, Burkina Faso, Mali and Morocco. In 2011-14 we conducted multi-disciplinary evaluations of four national policies to increase access to obstetric care. Amongst other research tools, we used realist evaluation techniques to understand variable implementation and performance of the policies in local hospitals and districts.