Building a middle-range theory of free public healthcare seeking in sub-Saharan Africa: a realist review

Abstract

Realist reviews are a new form of knowledge synthesis aimed at providing middle-range theories (MRTs) that specify how interventions work, for which populations, and under what circumstances. This approach opens the ‘black box’ of an intervention by showing how it triggers mechanisms in specific contexts to produce outcomes. We conducted a realist review of health user fee exemption policies (UFEPs) in sub-Saharan Africa (SSA). This article presents how we developed both the intervention theory (IT) of UFEPs and a MRT of free public healthcare seeking in SSA, building on Sen’s capability approach. Over the course of this iterative process, we explored theoretical writings on healthcare access, services use, and healthcare seeking behaviour. We also analysed empirical studies on UFEPs and healthcare access in free care contexts. According to the IT, free care at the point of delivery is a resource allowing users to make choices about their use of public healthcare services, choices previously not generally available to them. Users’ ability to choose to seek free care is influenced by structural, local, and individual conversion factors. We tested this IT on 69 empirical studies selected on the basis of their scientific rigor and relevance to the theory. From that analysis, we formulated a MRT on seeking free public healthcare in SSA. It highlights three key mechanisms in users’ choice to seek free public healthcare: trust, risk awareness and acceptability. Contextual elements that influence both users’ ability and choice to seek free care include: availability of and control over resources at the individual level; characteristics of users’ and providers’ communities at the local level; and health system organization, governance and policies at the structural level.

Removing user fees for health services: A multi-epistemological perspective on access inequities in Senegal

“…Sen's capability approach (1999) is again useful for interpreting these empirical results in order to identify underlying causal mechanisms from a critical realist perspective. This interpretation of our results is supported by a recent realist review of user fee removal in SSA (Robert et al, 2017). Sen provides five underlying reasons why people may not actually achieve developmental ends (in our case accessing PS), despite having the means to do so (in our case albeit…”

The emergence of the national medical assistance scheme for the poorest in Mali

“…However, several user fee exemption policies (HIV in 2004, caesarean in 2005, anti-malaria for children and pregnant women in late 2006) have been put in place, decisions which were highly political and technically contested in their formulation [27]. Championed by the Health Ministry and widely supported internationally [3], these initiatives occupied the forefront of the political scene and attracted widespread attention, eclipsing the development of the social protection system and health cover for the poor.…”

“…Academic texts addressing social protection policies in low-income countries remain a rarity, especially those concerning the most vulnerable groups such as the poorest or the elderly [1,2]. Recently, however, Africa has seen the development of numerous user fee exemption policies for children and pregnant women, who are classed as vulnerable groups in the eld of social protection, and these policies have been very widely analysed with regard to both their emergence (agenda-setting) and their effects [3]. In an edited book from 2013, we sought to review the policies aimed at the poorest in Africa [4], and the observation made then regarding the lack of papers on the subject remains applicable, especially when the desire is to study public policies rather than one-off interventions or speci c projects, which we know only rarely represent reality and are not suitable for scaling-up.…”

Using implementation science theories and frameworks in global health

“…The realist approach starts from the intervention theory and moves to a middle-range theory that considers multiple contextual influences to make sense of expected and unexpected outcomes of an intervention. In global health, an example would be the middle-range theory on user fee exemption policies in Africa proposed by Robert et al 79 This middle-range theory is based on Sen's capability approach. It also considers theories and frameworks on access to healthcare to explain why such policies may lead to heterogeneous outcomes in different places or at different times.…”