BackgroundAfrican policy-makers are increasingly considering abolishing user fees as a solution to improve access to health care systems. There is little evidence on this subject in West Africa, and particularly in countries that have organized their healthcare system on the basis of the Bamako Initiative. This article presents a process evaluation of an NGO intervention to abolish user fees in Niger for children under five years and pregnant women.MethodsThe intervention was launched in 2006 in two health districts and 43 health centres. The intervention consisted of abolishing user fees and improving the quality of services (drugs, ambulance, etc.). We carried out a process evaluation in April 2007 using qualitative and quantitative data. Three data collection methods were used: i) individual in-depth interviews (n = 85) and focus groups (n = 8); ii) participant observation in 12 health centres; and iii) self-administered structured questionnaires (n = 51 health staff).ResultsThe population favoured abolition; health officials and local decision-makers were in favour, but they worried about its sustainability. Among health workers, opposition to providing free services was more widespread. The strengths of the process were: a top-down phase of information and raising community awareness; appropriate incentive measures; a good drug supply system; and the organization of a medical evacuation system. The major weaknesses of the process were: the perverse effects of incentive bonuses; the lack of community-based management committees' involvement in the management; the creation of a system running in parallel with the BI system; the lack of action to support the service offer; and the poor coordination of the availability of free services at different levels of the health pyramid. Some unintended outcomes are also documented.ConclusionThe linkages between systems in which some patients pay (Bamako Initiative) and some do not should be carefully considered and organized in accordance with the local reality. For the poorest patients to really benefit, it is essential that, at the same time, the quality of services be improved and mechanisms be put in place to prevent abuses. Much remains to be done to generate knowledge on the processes for abolishing fees in West Africa.

As in other areas of international development, we are witnessing the proliferation of ‘traveling models’ developed by international experts and introduced in an almost identical format across numerous countries to improve some aspect of maternal health systems in low- and middle-income countries. These policies and protocols are based on ‘miracle mechanisms’ that have been taken out of their original context but are believed to be intrinsically effective in light of their operational devices.In reality, standardised interventions are, in Africa and elsewhere, confronted with pragmatic implementation contexts that are always varied and specific, and which lead to drifts, distortions, dismemberments and bypasses. The partogram, focused antenatal care, the prevention of mother-to-child transmission of HIV or performance-based payment all illustrate these implementation gaps, often caused by the routine behaviour of health personnel who follow practical norms (and a professional culture) that are often distinct from official norms – as is the case with midwives.Experiences in maternal and child health in Africa suggest that an alternative approach would be to start with the daily reality of social and practical norms instead of relying on models, and to promote innovations that emerge from within local health systems.

Analyses of health policy in low- and middle-income countries frequently mention but rarely adequately explore power dynamics, whether or not the policy in question targets the poor. We present a case study in Niger of integrated community case management (iCCM), a policy to provide basic care for poor rural children sick with malaria, diarrhoea and pneumonia, which has contributed to measurable reductions in child mortality. We focus on the three dimensions of power in policymaking: political authority, financial resources and technical expertise. Data collection took place March to August 2012 and included semi-structured interviews with policy actors (N = 32), a document review (N = 103) and contextual analysis. Preliminary data analysis relied on process tracing methodology to examine why iCCM was prioritized and identify dimensions of power most relevant to the Nigerien case; we then applied theoretical categories deductively to our data. We find that political authorities, namely President Mamadou Tandja, created the underlying health infrastructure for the policy ('health huts') as a way to distribute rents from development aid through client networks while claiming the mantle of political legitimacy. Conditional influxes of financial resources created an incentive to declare fee exemptions for children below 5 years, a key condition for the policy's success. Technical expertise was concentrated among international actors from multi-lateral and bilateral agencies who packaged and delivered scientific arguments in support of iCCM to Nigerien policymakers, whose input was limited mainly to operational decisions. The Nigerien case sheds light on the dimensions of power in health policymaking, particularly in neo-patrimonial African regimes, and provides insights on how external actors can work within these contexts to promote pro-poor policies.

When user fee exemptions were introduced for children under five years of age in Niger, front-line staff in the health system were not consulted in advance, and various obstacles seriously hindered the policy's implementation. Health workers developed two types of coping strategies. The first dealt with shortcomings of the policy implementation process related to management tools, drug stocks, co-existence of the fee exemption and cost recovery systems, and, above all, supply management for medicines (ordering from private companies, issuing makeshift prescriptions). The second involved clientelism, circumvention of regulations, and misappropriation of resources. Adverse effects have arisen due to both the failings of the health system and the practices of health workers. These include a focus on the commercial management of patients, the most 'costly' of whom sometimes find themselves being refused treatment, patients roaming in search of medicines and treatment, and a decline in quality of care.

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