Free cesarean section policy in Benin: Elicitating the program-theory of the implementation from the perspective of policy-makers

Background Western Africa has the highest maternal mortality ratio in the word with 675 maternal deaths per 100000 lives births. Although cost-effective strategies exist and have been introduced throughout the region in an... [ view full abstract ]

Background
Western Africa has the highest maternal mortality ratio in the word with 675 maternal deaths per 100000 lives births. Although cost-effective strategies exist and have been introduced throughout the region in an effort to reduce this burden, their micro-implementation usually failed and the timely and equitable access to quality services is insufficient. Little is known about what explains these failures, for whom and in which circumstances.
Our case study was the free cesarean section (CS) policy of 2008, which was implemented in with mixed implementation outcome in 44 public and private hospitals nationwide in Benin. The study aim was to make explicit what about this policy, was expected to make it implemented as planned.
Methods
This is a qualitative exploratory study, using the top-down policy passages theory of Berman (1978) as a conceptual framework. We adopted the policy-scientific approach to reconstruct the implementation program theory. We conducted in-depth interviews with 25 policy-makers purposively selected, and reviewed policy documents until saturation. The transcripts and memos were managed using NVIVO 10. Field and desk retroductive analyses were conducted following an adaptive, iterative and cumulative process.

Results
Local health managers were expected to adopt the policy following compliance and persuasion. The top-down administrative authority and the bottom-up pressure from users were the main enforcement factors expected to trigger compliance. The inclusive and evidence based policy-making process, the equal distribution of resources between facilities, the timely provision of all the required resources and the frequent feedback meetings were expected to promote mutual trust, goals alignment, and social exchanges that would trigger persuasion.
Providing sufficient resources to facilities (150 € per CS, consumables and materials), was expected to lead to the provision of necessary resources for CS to health workers, who would provide a timely CS to all women actually in need, without additional charge. Thus policy-makers were expecting variations in the implementation outcome, based on fees facilities used to charge before: in cases where this fee was less than 150 €, a full removal was expected; in the other case, users would pay the balance.
Conclusion
A rich set of implicit hypothesis supports the design of the implementation of the free CS policy in Benin. Making this explicit provides room for empirical testing and refinement, to strengthen the adaptive and implementation capacities of the whole health system. In similar contexts, the refined theory and this process may have great benefits for the micro-implementation of all the Universal Health Coverage policies.