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      No impact of performance-based financing on the availability of essential medicines in Burkina Faso: A mixed-methods study

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          Abstract

          Access to safe, effective, and affordable essential medicines (EM) is critical to quality health services and as such has played a key role in innovative health system strengthening approaches such as Performance-based Financing (PBF). Available literature indicates that PBF can improve EM availability, but has not done so consistently in the past. Qualitative explorations of the reasons are yet scarce. We contribute to expanding the literature by estimating the impact of PBF on EM availability and stockout in Burkina Faso and investigating mechanisms of and barriers to change. The study used an explanatory mixed methods design. The quantitative study component followed a quasi-experimental design (difference-in-differences), comparing how EM availability and stockout had changed three years after implementation in 12 PBF and in 12 control districts. Qualitative data was collected from purposely selected policy and implementation stakeholders at all levels of the health system and community, using in-depth interviews and focus group discussions, and explored using deductive coding and thematic analysis. We found no impact of PBF on EM availability and stockouts in the quantitative data. Qualitative narratives converge in that EM supply had increased as a result of PBF, albeit not fully satisfactorily and sustainably so. Reasons include persisting contextual challenges, most importantly a public medicine procurement monopoly; design challenges, specifically a disconnect and disbalance in incentive levels between service provision and service quality indicators; implementation challenges including payment delays, issues around performance verification, and insufficient implementation of activities to strengthen stock management skills; and concurrently implemented policies, most importantly a national user fee exemption for children and pregnant women half way through the impact evaluation period. The case of PBF and EM availability in Burkina Faso illustrates the difficulty of incentivizing and effecting holistic change in EM availability in the presence of strong contextual constraints and powerful concurrent policies.

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          Using the framework method for the analysis of qualitative data in multi-disciplinary health research

          Background The Framework Method is becoming an increasingly popular approach to the management and analysis of qualitative data in health research. However, there is confusion about its potential application and limitations. Discussion The article discusses when it is appropriate to adopt the Framework Method and explains the procedure for using it in multi-disciplinary health research teams, or those that involve clinicians, patients and lay people. The stages of the method are illustrated using examples from a published study. Summary Used effectively, with the leadership of an experienced qualitative researcher, the Framework Method is a systematic and flexible approach to analysing qualitative data and is appropriate for use in research teams even where not all members have previous experience of conducting qualitative research.
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            How Much Should We Trust Differences-In-Differences Estimates?

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              Bootstrap-Based Improvements for Inference with Clustered Errors

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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: Editor
                Journal
                PLOS Glob Public Health
                PLOS Glob Public Health
                plos
                PLOS Global Public Health
                Public Library of Science (San Francisco, CA USA )
                2767-3375
                23 March 2022
                2022
                : 2
                : 3
                : e0000212
                Affiliations
                [1 ] London School of Hygiene & Tropical Medicine, London, United Kingdom
                [2 ] Institute of Global Health, Heidelberg University Hospital and Medical Faculty, Heidelberg, Germany
                [3 ] Centre MURAZ, Bobo-Dioulasso, Burkina Faso
                [4 ] UFR/SEA, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
                [5 ] Health, Nutrition and Population Global Practice, World Bank, Washington, DC, United States of America
                University of California San Francisco, UNITED STATES
                Author notes

                We have read the journal’s policy and the authors of this manuscript have the following competing interests: This work was supported by The World Bank through the Health Results Innovation Trust Fund (HRITF). The World Bank was engaged in the overall design of the intervention and the impact evaluation (IE), but had no role in data collection, data management, data analysis and interpretation, preparation, review and approval of the manuscript. MDA was the Principal Investigator of the IE, but received no direct compensation from the World Bank. JL, SB, and JLK were fully or partially funded by the HRITF grant to the University and worked on the IE (data collection, management, and reporting to the World Bank), but received no direct payment by the Bank nor any compensation for manuscript preparation (which occurred outside the framework of the contract with the World Bank). SMAS is an employee of Centre MURAZ, but not directly funded by the HRITF grant allocated to Centre MURAZ for data collection. PJR is a World Bank employee and Co-PI of the impact evaluation, but participated in writing of this paper independently of his professional engagement. The views reported in this paper represent the views of the authors exclusively and not those of the funding agency.

                ‡ JL and SB share first authorship on this work.

                Author information
                https://orcid.org/0000-0003-4136-9296
                https://orcid.org/0000-0001-5397-7008
                https://orcid.org/0000-0001-9855-9395
                Article
                PGPH-D-21-00763
                10.1371/journal.pgph.0000212
                10021144
                36962391
                50172d25-3b16-4821-a0ea-e77125a24e81
                © 2022 Lohmann et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 5 October 2021
                : 2 March 2022
                Page count
                Figures: 1, Tables: 5, Pages: 21
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100004421, World Bank Group;
                Award Recipient :
                This study was funded by The World Bank through the Health Results Innovation Trust Fund (HRITF), through grants to the Heidelberg University Hospital (principal investigator: MDA) for overall scientific coordination as well as for the qualitative study, and for quantitative data collection to Centre MURAZ, Burkina Faso (principal investigator: Hervé Hien). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Health Care
                Health Care Facilities
                Social Sciences
                Economics
                Finance
                Research and Analysis Methods
                Research Design
                Qualitative Studies
                Social Sciences
                Economics
                Health Economics
                Medicine and Health Sciences
                Health Care
                Health Economics
                Social Sciences
                Economics
                Industrial Organization
                Monopolies
                Medicine and Health Sciences
                Health Care
                Health Care Policy
                Health Systems Strengthening
                Medicine and Health Sciences
                Pediatrics
                Social Sciences
                Economics
                Commerce
                Procurement
                Custom metadata
                The quantitative datasets analyzed in the current study is available upon request in the World Bank’s Central Microdata Catalogue. Baseline: https://microdata.worldbank.org/index.php/catalog/2761 Endline: https://microdata.worldbank.org/index.php/catalog/3504 The qualitative data analyzed are not publicly available as they cannot be sufficiently anonymized. Many of the interviews are with higher-level stakeholders who are likely identifiable from their responses, and confidentiality therefore cannot be guaranteed.

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