University of Conakry and Centre National de Formation et Recherche de Maferinyah (Guinea).

No abstract

It is very exceptional that a new disease becomes a true pandemic. Since its emergence in Wuhan, China, in late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, has spread to nearly all countries of the world in only a few months. However, in different countries, the COVID-19 epidemic takes variable shapes and forms in how it affects communities. Until now, the insights gained on COVID-19 have been largely dominated by the COVID-19 epidemics and the lockdowns in China, Europe and the USA. But this variety of global trajectories is little described, analysed or understood. In only a few months, an enormous amount of scientific evidence on SARS-CoV-2 and COVID-19 has been uncovered (knowns). But important knowledge gaps remain (unknowns). Learning from the variety of ways the COVID-19 epidemic is unfolding across the globe can potentially contribute to solving the COVID-19 puzzle. This paper tries to make sense of this variability—by exploring the important role that context plays in these different COVID-19 epidemics; by comparing COVID-19 epidemics with other respiratory diseases, including other coronaviruses that circulate continuously; and by highlighting the critical unknowns and uncertainties that remain. These unknowns and uncertainties require a deeper understanding of the variable trajectories of COVID-19. Unravelling them will be important for discerning potential future scenarios, such as the first wave in virgin territories still untouched by COVID-19 and for future waves elsewhere.

This paper questions the view that performance-based financing (PBF) in the health sector is an effective, efficient and equitable approach to improving the performance of health systems in low-income and middle-income countries (LMICs). PBF was conceived as an open approach adapted to specific country needs, having the potential to foster system-wide reforms. However, as with many strategies and tools, there is a gap between what was planned and what is actually implemented. This paper argues that PBF as it is currently implemented in many contexts does not satisfy the promises. First, since the start of PBF implementation in LMICs, concerns have been raised on the basis of empirical evidence from different settings and disciplines that indicated the risks, cost and perverse effects. However, PBF implementation was rushed despite insufficient evidence of its effectiveness. Second, there is a lack of domestic ownership of PBF. Considering the amounts of time and money it now absorbs, and the lack of evidence of effectiveness and efficiency, PBF can be characterised as a donor fad. Third, by presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. Too little care is given to system-wide and long-term effects, so that PBF can actually damage health services and systems. This paper ends by proposing entry points for alternative approaches.

This article presents the results of an evaluation of the free delivery and caesarean policy (FDCP) in Senegal. The policy was introduced into five poor regions in 2005 and in 2006 was extended at regional hospital level to all regions apart from the capital (Dakar). The evaluation was carried out in 2006-7. There were four research components, all focused on selected facilities and districts within the five FDCP regions: a financial analysis of expenditure on the policy and wider health financing in the five regions and nationally; 54 key informant interviews from national down to facility level; 10 focus group discussions and 8 in-depth interviews; and analysis based on clinical record extraction of 761 major obstetric interventions. The evaluation found significant implementation difficulties, especially related to the allocation of funds and kits and the adequacy of their contents. Despite that, significant increases in utilization in normal deliveries (from 40% to 44% of expected deliveries in FDCP areas over 2004-5) and in caesarean rates (rising from 4.2% to 5.6% in FDCP areas) were recorded. National data suggested that these trends were not found in non-FDCP regions. Using the evaluation data, the cost per additional caesarean under the policy was US$467 and the cost per additional supervised normal delivery was US$21. The article concludes that, in order to achieve its full potential, the FDCP requires improved systems for planning and allocating resources, and new channels to reimburse lower level facilities. It is also important that all complicated deliveries (not just caesareans) are included in the package. In the case of Senegal, a complementary strategy of investment in facilities, transportation and staffing is required to bring greater geographical access and upgrade services. These findings are likely to be relevant to other countries currently experimenting with similar approaches to reducing financial barriers to skilled attendance at delivery.