Les inégalités sociales de santé parmi les nouveau-nés en région bruxelloise sont décrites depuis plusieurs années. À travers les bulletins statistiques de naissance, il est possible de dresser un tableau de la santé périnatale, des inégalités sociales et de leur évolution depuis plus de dix ans. La mortalité fœto-infantile représente le sommet de l'iceberg des nombreuses issues défavorables de la santé périnatale et infantile. À partir des bulletins de naissance et de décès, une base de données reprenant pour chaque naissance entre 2000 et 2011, les données biomédicales et socio-économiques a été constituée (n = 205 336). Les liens entre mortalité et revenus du travail du ménage et l'éducation des mères ont été analysés de manière bivariée puis multivariée pour deux périodes : 2000–2003 et 2008–2011. La mortalité fœto-infantile diminue entre les deux périodes pour les différents groupes de revenus et d'éducation à l'exception des ménages disposant de deux revenus. Les ménages sans revenus ont une mortalité fœto-infantile qui passe de 12,3 ‰ à 10,4 ‰ entre les deux périodes tandis qu'elle passe de 5,1 ‰ à 5,6 ‰ pour les ménages à deux revenus. Les mères avec un niveau d'éducation secondaire inférieur ou moins ont une mortalité fœto-infantile qui passe de 11,1 ‰ à 4,8 ‰ alors qu'elle passe de 4,3 ‰ à 3,3 ‰ pour les mères plus éduquées (pour mille naissances totales). Malgré les limites propres aux données administratives et le petit nombre de naissances observées, les tendances sont significatives. Les mortalités fœtale, néonatale et post-néonatale n'évoluent pas à la même vitesse. Les hypothèses pour expliquer cette amélioration de la mortalité fœto-infantile et la réduction des inégalités sont à rechercher à différents niveaux : les facteurs biomédicaux et démographiques, l'évolution de la migration et l'évolution des politiques sociales et de santé doivent être explorés.

Financial barriers represent a major obstacle to access to health care in sub-Saharan Africa and thus to the implementation of the Bamako Initiative. We describe an experience in which a civil society organization financed a free healthcare campaign in a rural health district in Cameroon. In all, 2,073 patients received free consultations, laboratory tests, and drugs. Adults older than 40 years accounted for 55.7% of all patients. The most frequent diseases were: osteoarticular conditions (24.1%), malaria (20.8%), and intestinal parasitosis (12.5%). In health systems financed mainly by cost recovery, some population needs remain uncovered by health services. There is a need to involve and reinforce the role of civil society in health system financing. It can help to pool more funds and improve the management of health resources to increase financial access to health care for poor people.

Maria Paola Bertone (mpbertone@yahoo.com) Bruno Meessen (bmeessen@itg.be) Guy Clarysse (gclarysse@unicef.org) David Hercot (dhercot@itg.be) Allison Kelley (agkelley514@yahoo.com) Yamba Kafando (odnafak@yahoo.fr) Isabelle Lange (Isabelle.Lange@lshtm.ac.uk) Jérôme Pfaffmann (jpfaffmann@unicef.org) Valéry Ridde (valery.ridde@umontreal.ca) Isidore Sieleunou (isidoros2002@yahoo.fr) Sophie Witter (s.witter@abdn.ac.uk)

Communities of Practice (CoPs) are groups of people that interact regularly to deepen their knowledge on a specific topic. Thanks to information and communication technologies, CoPs can involve experts distributed across countries and adopt a 'transnational' membership. This has allowed the strategy to be applied to domains of knowledge such as health policy with a global perspective. CoPs represent a potentially valuable tool for producing and sharing explicit knowledge, as well as tacit knowledge and implementation practices. They may also be effective in creating links among the different 'knowledge holders' contributing to health policy (e.g., researchers, policymakers, technical assistants, practitioners, etc.). CoPs in global health are growing in number and activities. As a result, there is an increasing need to document their progress and evaluate their effectiveness. This paper represents a first step towards such empirical research as it aims to provide a conceptual framework for the analysis and assessment of transnational CoPs in health policy.The framework is developed based on the findings of a literature review as well as on our experience, and reflects the specific features and challenges of transnational CoPs in health policy. It organizes the key elements of CoPs into a logical flow that links available resources and the capacity to mobilize them, with knowledge management activities and the expansion of knowledge, with changes in policy and practice and, ultimately, with an improvement in health outcomes. Additionally, the paper addresses the challenges in the operationalization and empirical application of the framework.

Financial barriers represent a major obstacle to access to health care in sub-Saharan Africa and thus to the implementation of the Bamako Initiative. We describe an experience in which a civil society organization financed a free healthcare campaign in a rural health district in Cameroon. In all, 2,073 patients received free consultations, laboratory tests, and drugs. Adults older than 40 years accounted for 55.7% of all patients. The most frequent diseases were: osteoarticular conditions (24.1%), malaria (20.8%), and intestinal parasitosis (12.5%). In health systems financed mainly by cost recovery, some population needs remain uncovered by health services. There is a need to involve and reinforce the role of civil society in health system financing. It can help to pool more funds and improve the management of health resources to increase financial access to health care for poor people.

Researchers from developing countries, French-speaking nations in particular, are underrepresented in the international biomedical and health literature. Various initiatives seek to address this problem. This article presents the experience of the Emerging Voices for Global Health (EV4GH) program. This initiative provided 52 young researchers from developing countries with intensive skills and content training, with an assortment of complementary components: training in scientific writing and presenting skills, immersion in global health and health systems research, an innovative presentation of their work at the 52nd colloquium of the Institute of Tropical Medicine in Antwerp, and an active role in the first Global Symposium on Health Systems Research, supervised by a team of experienced researchers/coaches who supported them in the publication of a scientific essay. This approach targeting researchers in developing countries and combining the development of skills and knowledge through the publication process, merits reproduction and encouragement. Young researchers from developing countries should not miss out on the second version of this program in October 2012 in Beijing, China.

Introduction: In recent years, a number of African countries, including Niger, have adopted policies abolishing user fees at point of service, targeting categories of people or services. These policies do not take account of geographical and financial accessibility for cases that require medical evacuation from primary to secondary level. This paper documents an experiment illustrating the importance of considering the place of medical evacuation in fee exemption schemes for vulnerable population groups. Methods: Quantitative analysis of routine statistical data was performed preand post-experiment. The data was taken from monthly activity and financial reports supplied by the 16 IHCs (Integrated Health Centers), the district hospital and the regional hospital for the period from 2008 to 2010, and was analyzed using MS Excel. Results: A medical evacuation reserve fund was set up, with 77% of it made up of “extra centime” payments from the free-healthcare target groups. A large increase (more than twofold) was recorded in the number of cases evacuated, from 191 in 2008 to 460 in 2009. Detailed analysis shows that more than 72% of the people evacuated belong to the free-healthcare target groups. The average transportation cost for an evacuation is about €37. Conclusion: The introduction of a solidarity-based financing mechanism resulted in an increase in the number of evacuations, for which the average cost was too high for most rural households. Policies aimed at abolishing direct user fees by integrating the cost of medical evacuations offer an effective strategy for health risk coverage and for counteracting the impoverishment caused by ill health.

Introduction: In recent years, a number of African countries, including Niger, have adopted policies abolishing user fees at point of service, targeting categories of people or services. These policies do not take account of geographical and financial accessibility for cases that require medical evacuation from primary to secondary level. This paper documents an experiment illustrating the importance of considering the place of medical evacuation in fee exemption schemes for vulnerable population groups. Methods: Quantitative analysis of routine statistical data was performed pre- and post-experiment. The data was taken from monthly activity and financial reports supplied by the 16 IHCs , the district hospital and the regional hospital for the period from 2008 to 2010, and was analyzed using MS Excel. Results: A medical evacuation reserve fund was set up, with 77% of it made up of “extra centime” payments from the free-healthcare target groups. A large increase (more than twofold) was recorded in the number of cases evacuated, from 191 in 2008 to 460 in 2009. Detailed analysis shows that more than 72% of the people evacuated belong to the free-healthcare target groups. The average transportation cost for an evacuation is about €37. Conclusion: The introduction of a solidarity-based financing mechanism resulted in an increase in the number of evacuations, for which the average cost was too high for most rural households. Policies aimed at abolishing direct user fees by integrating the cost of medical evacuations offer an effective strategy for health risk coverage and for counteracting the impoverishment caused by ill health.

Several authors have stressed the fact that many policy reforms fail because of poor formulation or implementation. On the other hand, the health financing literature provides little guidance to policy makers in low-income countries on how to implement a health care financing reform in ways that enhance its chance of achieving policy objectives, even less so for a user fee removal reform.This paper presents the framework used for a multi-country review of the policy process of removing user fees in six sub-Saharan African countries. The review aimed at developing operational guidance for health managers involved in user fee removal reform. Drawing broadly on Walt and Gilson's 'health policy analysis triangle' (context-actor-process-content), we focused particularly on understanding the process of planning and implementing the reform led by central-level policy actors. Our core analytic strategy was the verification of a list of 'good practice hypotheses' that might be expected in a health financing policy reform against experience.This framework offers an approach for how to analyse health financing policy reform processes in low-income countries. It allows for an explicit and transparent review of multiple experiences against a set of clear hypotheses. This approach might be a step in the direction of research that supports better formulation and implementation of policies in resource-poor settings.

In Burkina Faso, as in most developing countries, the operational level of the health system is made up of Health Districts (HDs), the activities of which are typically coordinated by the District Team (DT). Assessing the the core functions of DTs, as described by WHO, shows two important weaknesses. Firstly, instructions from "above" are often implemented rather passively: DTs tend not to display much leadership. Secondly, the current organisation, based on input financing and centralised planning, does not sufficiently promote either the vision or research functions of DTs. In this article, we report our experience in the Orodora HD in Burkina Faso, where the DT's leadership and vision proved to be essential ingredients for effective health action in the district. Our description of six interventions implemented between 2004 and 2008 shows how DT leadership and vision have improved outputs at the HD level. Until 2004, the district applied static health planning. The health system was insufficiently financed and performed poorly. Faced with this situation, the DT decided to set up several priority interventions based on health care access criteria and patient concerns, while respecting and contextualizing national norms and objectives. Six interventions were then implemented. The first was ensure that quality blood (meeting transfusion security norms) was available at the District Hospital (DH), by picking blood up from the regional blood transfusion center weekly. This speeded up care at the DH, reduced the number of cases referred to the regional hospital for transfusion, and reduced neonatal and maternal mortality. The second intervention sought to improve the skills of health workers in managing emergency cases and to improve relationships with the referral hospital through the reintroduction of counter-referral procedures. This led to a decrease in unnecessary referrals and also reduced the mortality rates of serious cases. The third intervention, by implementing a decentralized approach to tuberculosis detection, succeeded in improving access to care and enabled us to quantify the rate of tuberculosis-HIV co-infection in the HD. The fourth intervention improved financial access to emergency obstetric care by providing essential drugs and consumables for emergency obstetric surgery free of charge. The fifth intervention boosted the motivation of health workers by an annual 'competition of excellence', organised for workers and teams in the HD. Finally, our sixth intervention was the introduction of a "culture" of evaluation and transparency, by means of a local health journal, used to interact with stakeholders both at the local level and in the health sector more broadly. We also present our experiences regularly during national health science symposia. Although the DT operates with limited resources, it has over time managed to improve care and services in the HD, through its dynamic management and strategic planning. It has reduced inpatient mortality and improved access to care, particularly for vulnerable groups, in line with the Primary Health Care and Bamako Initiative principles. This case study would have benefited from a stronger methodology. However, it shows that in a context of limited resources it is still possible to strengthen the local health system by improving management practices. To progress towards universal health coverage, all core functions of a DT are worth implementing, including leadership and vision. National and international health strategies should thus include a plan to provide for and train local health system managers who can provide both leadership and strategic vision.

In his Perspectives piece, Jeffrey Sachs (Sept 18, p 950)1Sachs J The MDG decade: looking back and conditional optimism for 2015.Lancet. 2010; 376: 950-951Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar emphasises that the key to making rapid progress towards the Millennium Development Goals (MDGs) is to increase the amount of global health aid substantially and to channel it through multilateral global health initiatives such as the Global Fund to fight AIDS, Tuberculosis and Malaria, the GAVI Alliance, and UNICEF. Both recommendations are sensible. We disagree though on “how” this increased multilateral funding should reach countries.In Niger, most funding available through UNICEF is earmarked for the implementation of interventions with a short-term effect on maternal and child survival—the so-called “quick win” interventions.2Millennium ProjectUN Millennium Project “quick wins”.http://www.unmillenniumproject.org/resources/quickwins.htmGoogle Scholar Massive funds are for example invested in the supply of artemisinin-based combination therapies, bednets, and oral rehydration solution that will yield results in the short term but fail to improve the long-term capacity of the system to provide high-impact interventions sustainably.Furthermore, more often than not these funds are poorly aligned to national planning and management mechanisms. Most funding is made available in an unpredictable manner and has to be spent within a year or two. This situation is favoured by the still common “raise it, spend it, prove it” culture3Feachem R Fourth Board Meeting of the Global Fund: report of the Executive Director Richard G.A. Feachem.http://www.theglobalfund.org/documents/board/04/GF%20B4%2004%20Report%20of%20the%20ED.pdfDate: 29 January 2003Google Scholar of multilateral institutions. We would rather see funding mechanisms that reinforce the ability of the government to exercise ownership4Tedros AG Achieving the health MDGs: country ownership in four steps.Lancet. 2010; 376: 1127-1128Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar and engage in health-system-strengthening activities such as the recruitment and motivation of health workers.5Ooms G Hercot D Assefa Y Van Damme W The new dichotomy in health systems strengthening and the role of global health initiatives: what can we learn from Ethiopia?.J Public Health Policy. 2010; 31: 102-109Google Scholar Otherwise it is like providing intravenous glucose to a hungry child while his parents cannot feed his siblings.MF was Health Minister in Niger from June, 2009, to February, 2010, and was previous to that General Secretary for more than 3 years. DH worked with UNICEF in Niger from 2005 to 2008. In his Perspectives piece, Jeffrey Sachs (Sept 18, p 950)1Sachs J The MDG decade: looking back and conditional optimism for 2015.Lancet. 2010; 376: 950-951Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar emphasises that the key to making rapid progress towards the Millennium Development Goals (MDGs) is to increase the amount of global health aid substantially and to channel it through multilateral global health initiatives such as the Global Fund to fight AIDS, Tuberculosis and Malaria, the GAVI Alliance, and UNICEF. Both recommendations are sensible. We disagree though on “how” this increased multilateral funding should reach countries. In Niger, most funding available through UNICEF is earmarked for the implementation of interventions with a short-term effect on maternal and child survival—the so-called “quick win” interventions.2Millennium ProjectUN Millennium Project “quick wins”.http://www.unmillenniumproject.org/resources/quickwins.htmGoogle Scholar Massive funds are for example invested in the supply of artemisinin-based combination therapies, bednets, and oral rehydration solution that will yield results in the short term but fail to improve the long-term capacity of the system to provide high-impact interventions sustainably. Furthermore, more often than not these funds are poorly aligned to national planning and management mechanisms. Most funding is made available in an unpredictable manner and has to be spent within a year or two. This situation is favoured by the still common “raise it, spend it, prove it” culture3Feachem R Fourth Board Meeting of the Global Fund: report of the Executive Director Richard G.A. Feachem.http://www.theglobalfund.org/documents/board/04/GF%20B4%2004%20Report%20of%20the%20ED.pdfDate: 29 January 2003Google Scholar of multilateral institutions. We would rather see funding mechanisms that reinforce the ability of the government to exercise ownership4Tedros AG Achieving the health MDGs: country ownership in four steps.Lancet. 2010; 376: 1127-1128Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar and engage in health-system-strengthening activities such as the recruitment and motivation of health workers.5Ooms G Hercot D Assefa Y Van Damme W The new dichotomy in health systems strengthening and the role of global health initiatives: what can we learn from Ethiopia?.J Public Health Policy. 2010; 31: 102-109Google Scholar Otherwise it is like providing intravenous glucose to a hungry child while his parents cannot feed his siblings. MF was Health Minister in Niger from June, 2009, to February, 2010, and was previous to that General Secretary for more than 3 years. DH worked with UNICEF in Niger from 2005 to 2008.

In recent years, governments of several low-income countries have taken decisive action by removing fully or partially user fees in the health sector. In this study, we review recent reforms in six sub-Saharan African countries: Burkina Faso, Burundi, Ghana, Liberia, Senegal and Uganda. The review describes the processes and strategies through which user fee removal reforms have been implemented and tries to assess them by referring to a good practice hypotheses framework. The analysis shows that African leaders are willing to take strong action to remove financial barriers met by vulnerable groups, especially pregnant women and children. However, due to a lack of consultation and the often unexpected timing of the decision taken by the political authorities, there was insufficient preparation for user fee removal in several countries. This lack of preparation resulted in poor design of the reform and weaknesses in the processes of policy formulation and implementation. Our assessment is that there is now a window of opportunity in many African countries for policy action to address barriers to accessing health care. Mobilizing sufficient financial resources and obtaining long-term commitment are obviously crucial requirements, but design details, the formulation process and implementation plan also need careful thought. We contend that national policy-makers and international agencies could better collaborate in this respect.

The Millennium Development Goals (MDGs) were defined in 2001, making poverty the central focus of the global political agenda. In response to MDG targets for health, new funding instruments called Global Health Initiatives were set up to target specific diseases, with an emphasis on 'quick win' interventions, in order to show improvements by 2015. In 2005 the UN Millennium Project defined quick wins as simple, proven interventions with 'very high potential short-term impact that can be immediately implemented', in contrast to 'other interventions which are more complicated and will take a decade of effort or have delayed benefits'. Although the terminology has evolved from 'quick wins' to 'quick impact initiatives' and then to 'high impact interventions', the short-termism of the approach remains. This paper examines the merits and limitations of MDG indicators for assessing progress and their relationship to quick impact interventions. It then assesses specific health interventions through both the lens of time and their integration into health care services, and examines the role of health systems strengthening in support of the MDGs. We argue that fast-track interventions promoted by donors and Global Health Initiatives need to be complemented by mid-and long-term strategies, cutting across specific health problems. Implementing the MDGs is more than a process of 'money changing hands'. Combating poverty needs a radical overhaul of the partnership between rich and poor countries and between rich and poor people within countries.

This brief paper addresses some of the difficulties inherent in international ideological approaches to solving the complex problems of health care financing and delivery in poor countries using Ghana as an example. It concludes with an appeal for problem solving approaches involving informed debate as to optimal ways forward to solve low income country health financing woes that are open minded about possible options rather than vested in particular positions.