Supply-centred RBF is the provision of incentives financial or else linked to the production and the quality of specific services. Theoretically, this link between incentives and targeted services would allow a better adequacy between supply and demand for care services [ 7 , 10 , 11 ]. There is however no clear consensus around the effects of RBF, depending on the different settings, types of services or RBF designs [ 12 — 15 ]. Many questions are currently asked concerning project implementation: are the projects effective, cost-efficient in the long run or do they cease to exist at the end of their budget [ 18 ]?
The growing study of sustainability starts giving some answers to researchers and project managers but remains very limited and does not offer a consensus around the concept of sustainability [ 18 — 20 ].
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Supporting this idea, the concept of sustainability is often distorted in many terminologies: institutionalisation, diffusion, appropriation, consolidation, durability, integration, perpetuation, routinisation, permanency, maintenance, and many more [ 21 ]. However, the aspects of temporality and integration to a structure remain preponderant in the conceptualisation of sustainability as a process and as a status at a point in time [ 21 — 23 ].
Many models represent sustainability as the main goal of a project [ 21 , 23 ].
PROCESS EVALUATION FOR COMMUNITY PARTICIPATION
Chambers et al. This model is considered more realistic by better reflecting the organisational reality than a model considering sustainability as a mere final step [ 24 , 25 ]. A sustainable status can be categorised into five levels: i null, if no activities from the intervention subsisted within the host organisation, ii precarious, when some activities subsisted but still are unofficial, dependant from specific actors and do not correspond to the intervention framework, iii weak, if activities officially continue, but do not systematically show the determinants of a routine and can easily disappear in the short term, iv moderate, when activities are stable and totally routinized, and v high when those routinized activities are institutionalised at a higher level of implementation e.
Routinisation represents the first 4 levels of activity integration within a host organisation, all this through four main determinants: organisational memory, values and codes, rules and procedures, and adaptation to contexts [ 21 ]. Organisational memory is the ability to maintain the structure of the organisation social network, archive system, etc. Rules and procedures are the framework in which actions are taken and decided for the implementation of the intervention.
Being the fifth degree of sustainability, institutionalisation refers to a systematic level of integration through social norms, standards, legal frameworks, etc. As a pilot, this project cannot be expected to be evaluated against the goal of institutionalisation. However, it can be assessed in regards to its routinisation process. It is therefore through routines via its main determinants that sustainability will be measured; routines being acquired activities by the organisations thanks to the pilot [ 27 ]. Very few studies deal with sustainability of developmental projects in Africa [ 28 ] and even less concerning RBF projects as a routinisation process more specifically [ 14 , 17 , 29 — 31 ].
Therefore, the objective of this study is to evaluate the degree of sustainability of a RBF pilot project and to better understand its sustainability process. To respond to these objectives, a case study [ 32 ] was made of the RBF pilot project in Mali. Concerning this country, it is administration is perceived as highly decentralised. National, specialised and regional hospitals are public autonomous establishments and represent tertiary health centres at the national level and in the eight regions. First line services are given by the community health centres CSCOM which are situated at the health area level and managed by community health associations ASACO with communes or communal councils.
RBF consisted in granting workers and health organisations performance bonuses linked to the provision of quality services. The bonuses received by health care personnel could represent more than double the normal revenue [ 35 ]. The conceptual framework used for this study comes from the integration of the propositions of Johnson et al.
Our framework proposes a representation of sustainability as a processual concept including: i its determinants, ii the process of sustainability, iii the contexts within which sustainability takes place, iv critical events influencing sustainability, and v degrees of sustainability resulting from the previous elements.
Sustainability framework. Adapted from Johnson et al. First, according to the literature, five determinants are to be considered in regards to the capacity of an intervention to be sustainable: i the adaptation to the different contexts of implementation, ii the creation of organisational memory, iii the match between values and codes of the intervention and the ones of the host organisation, iv the establishment of rules and procedures, and v the relationship between the project stakeholders [ 22 , 24 , 25 ].
Third, sustainability must be linked to its contexts that can be categorised into five different implementation contexts, going from the most intervention-centred to the most general: i the intervention itself, ii the individuals working directly in the intervention, iii the host organisation englobing the intervention, iv the local environment and its different actors, and v the external system of values politics, economics, laws, morality.
Those implementation contexts integrate sustainability determinants and its process, as well as the degree of sustainability. Fourth, critical events are also integrated into this framework since they can directly influence implementation contexts or the different determinants of sustainability.
Critical events are normally shared between actors and therefore represent turning points in the history of a project. Finally, degrees of sustainability are divided into five which were described previously. Collection sites were selected based on their ability to provide maximum variation sampling. This was performed with the help of key informants working in two CSREF and according to different criteria: physical access, diversification of sites urban vs. Interviews were individual and within the work place or the health centre.
While the audio was recorded, notes were also taken during the interviews for better data analysis. An interpreter was also trained by a senior researcher to facilitate interviews in Bambara AC.
Minor modifications were made and pre-test data was also used for the analysis. Both audio recordings and interview notes were transcribed verbatim.
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Audio recordings were also re-played and listened to and the verbatim re-read MS exception of the Bambara interviews to ensure their validity and integrity, as well as to perform an iterative analysis of the data. A code tree was created MS and reviewed VR according to the conceptual framework of the study [ 32 ].absfiregroup.com/wp-content/2019-05-28/4467.php
Evaluation for Participation and Sustainability in Planning : Angela Hull :
This tree was refined with the addition of new themes emerging from the iterative analysis. Preliminary results were presented to different actors linked to RBF during a workshop in Bamako [ 39 ]. Comments helped to identify other actors and to validate some data and analysis. A documentary research was also done to triangulate data from the interviews and to better understand the functioning of the project.
Few documents were available due to confidentiality and administrative constraints. Precautions were also taken during the study to follow different rigorous criteria such as the credibility, authenticity or integrity of the results.
To ensure transferability, details relating to the context, process, intervention, etc. Results stayed anonymous and confidential at every step of the study. After the iterative analysis of data, results showed that the RBF pilot project in Mali had weak degree of sustainability, which will be explained through the following empirical data. Many types of investments improved the quality and quantity of services: material resources construction of maternity wards, medical furniture, motorbike repairs, access to water and electricity, etc.
For example, many obstetrical nurses were recruited before the first purchase of services to ensure quality deliveries.
Evaluation for Participation and Sustainability in Planning
Many investments in buildings hangars, renovations, houses, etc. In preparation for RBF, workshops were given to different stakeholders to perfect their knowledge in regards to their respective roles within the project.
So there in budgeting terms, there was quite confusion at the beginning… and that makes financial planning more complicated. Few organisational risks were taken during the implementation of RBF. Despite being perceived as risky large amounts of money, uncertainty regarding the purchase of the services , some investments were made with the aim of stabilising and increasing the resources of the centres construction of laboratories for analysis, awareness-raising campaigns, etc.
They did not limit themselves to what we told them, they went to verify in the villages. A gap between the different roles management vs. Despite a rapprochement during RBF, a gap still seemed to be present between the operational health agents and the community levels ASACO and communes.
According to the different centres, many rituals were instituted or reinforced around activities due to RBF: planning meetings, hygiene practices, AS, etc. Nevertheless, the end of the project brought the lessening of those activities, which needed a certain level of investment. Many participants mentioned that cheaper rituals were still maintained: the use of minutes or administrative support, punctuality and better reception of the beneficiaries, the production of monthly reports or the attendance to monthly CSCOM meetings some of these rituals being there already before RBF.
As long as there is no monitoring, we harvest nothing. However, those components did not all continue after the project. According to different interviewees, the quality of the contact with beneficiaries and the use of registries were the elements that were the most sustained. PCs and a health commissions part of the CCs were also reinforced during RBF with the objective to provide a better monitoring and involvement of elected representatives in the health sector. Almost the entirety of participants declared the RBF tasks were clear and corresponded to their prior tasks.
With RBF, the tasks were nonetheless clarified which enabled the specialisation of some workers: e. Personnel engagement forms were signed linking workers to their tasks; yet, no collected data can demonstrate the sustainment of those forms. But regarding the document… not really. Being perceived as a winning formula, few modifications of procedures took place during the RBF project. We talked about vaccination, good quality vaccination, vaccines maintenance… That was to increase our points. Also, if you are coming for the vaccination of the child, we do not accept until you paid the penalty.
According to different stakeholders, those modifications to RBF procedures show a certain pressure made by the purchase of services on health providers; even leading to data falsification e. It is worth noting that due to the political situation and the impossibility of the country to conduct local elections, much of the communal personnel mayors and members of CC was simply maintained, which helped sustain the expertise acquired by the local authorities during the project.
Some specific aspects of each health organisation were not taken into account during evaluations. This could then penalise certain types of centres. A centre with a smaller area of service could rapidly cap the possible quantity of services offered; a centre with a low population density would have higher costs for certain services e. SA ; or a centre with a large area of service could have difficulties in providing continued access to some quality services in remote villages or hamlets. Adaptation was mainly done to ensure the implication of the communities communes and circles more especially in the project since the Malian health system is highly decentralised.
The project was therefore well adapted to the Malian health system general structure, using the hierarchy and organisations already in place for the RBF implementation. Tasks and procedures were all perceived as pertinent and with visible global effects attendance to the centres, quality of services, investments, etc.