Facteurs contextuels dans l'évaluation d'une politique de santé maternelle au Burkina Faso

This thesis focuses on the influence of contextual factors on the implementation and the effects of a maternal health policy in Burkina Faso. The policy – called the subsidy EMOC – aims to increase the coverage of facility based-deliveries in public health facilities by acting on the economic accessibility of households. A process evaluation of this maternal health policy has been conducted. The analytical framework is based on theoretical propositions emanating form health policy approach (actors and power relations) and critical medical anthropology (representations).  The study has taken place in Djibo district in the Sahel region. A multiple case study was undertaken. Each public health facility represents a case. The methodological approach is qualitative. Several methods of data collection were mobilized: a long immersion on the field, in-depth interviews, discussion groups, non- participant observations and documentary analysis. The preliminary results of the study were presented to stakeholders.  The first article analyzes the implementation of the policy at the district and primary care levels. It describes the influence of power relations on the implementation process of the policy. The results indicate that all components of the policy have been implemented except for the grant for the worst-off and some components related to the technical quality of care such as surveys for the beneficiaries. Health workers and managers have perceived difficulties in implementing the policy due to a lack of clarity of the official guidelines.   Power relations have an influence on the implementation of the policy. Relations between staff managers and health workers are based on formal authority and hierarchy. The district managers control health workers and they impose changes over implementation of the policy. The perceptions of the relationship between health workers and patients are mixed. In some health facilities, the relation is perceived positively, while in others is perceived negatively. The perceptions of the relationship between health workers and traditional birth attendants are also ambivalent. On the one hand, traditional birth attendants are seen as an obstacle to the policy because they continue to perform deliveries in villages against the aim of the policy. On the other hand, they are considered as a potential ally in inciting women to use maternal health services. The lack of understanding the modality of reimbursement between health workers and management committee members has strained the relationship between the two groups.   The second article aims to understand the variation observed on the coverage of facility-based deliveries between primary health care centers after the implementation of the policy. Contextual factors especially human have an important influence on the coverage of facility-based deliveries. Health worker’s leadership which is characterized by personal initiatives, professional ethics and the building a trust relation between the population and the health teams explain the difference observed on the coverage of facility-based deliveries.  The objective of the third article is to show how health workers use ethno-cultural factors to justify the partial failure of this policy. The reference to these factors essentially seeks to normalize and legitimize the lack of effect of the policy on the coverage of facility-based deliveries. The results show that the reference to ethno-cultural factors was also used to blame communities. Finally the use of these factors tends to eliminate the socioeconomic and political interpretations that underlie the problem of facility –based deliveries.   This thesis provides insight into the process of implementing a maternal health policy. It shows that the dimensions of equity and quality of care were neglected during this process. This research shows the difficulties faced by health workers on the implementation of this policy. It also highlights the factors that explain the heterogeneity observed on the coverage of facility –based deliveries after the implementation of this policy.   This thesis shows the importance of identifying power relations exerted between the actors involved in health policies. This research shows the importance of taking into consideration the context in which health policies are implemented. Finally, this research reveals the importance of social representations of the actors for understanding the effects of policies. This thesis contributes to the development of knowledge in the field of public health policies in terms of the topics covered (implementation, power relations) and the methodological approach (fieldwork) used. It also participates in theoretical reflections on the concept of leadership for health professionals in Africa.

Keyphrases: Burkina Faso, Étude qualitative, Maternal health policy, Process evaluation, Facility-based deliveries, Heterogeneity of effects, Qualitative study, Contextual factors