Problématique : Dans les pays africains où les soins de santé sont encore payants au point de service, la barrière financière est un des obstacles majeurs au recours aux soins. Les indigents, qui sont les plus démunis, en sont les plus affectés. Pour faire face à ce défi, certains pays ont entrepris l’élaboration de programmes de santé ciblant les indigents pour leur permettre d’avoir un meilleur recours aux soins de santé par l’intermédiaire d’une exemption du paiement. Mais il existe un réel défi à identifier les indigents. De plus, peu d’études ont évalué l’impact de programmes d’exemption du paiement sur leur recours aux soins. Les indigents sont en majorité des personnes âgées avec des besoins importants en santé. Les personnes âgées en Afrique consultent très peu les professionnels de santé et les déterminants de leur recours aux soins sont peu connus. Pourtant, leur proportion est en augmentation dans les pays à faibles et moyens revenus. Ils sont en perte d’autonomie, ont de faibles revenus et présentent une prévalence élevée de maladies chroniques et d’incapacités fonctionnelles. Ces affections surviennent de façon précoce surtout chez les femmes. Objectifs : Cette thèse a pour objectifs : i) de déterminer le caractère équitable d’un processus de sélection communautaire des indigents au Burkina Faso qui vise à les faire bénéficier d’une exemption du paiement des soins; ii) de mesurer l’impact de ce programme d’exemption sur le recours aux soins de santé des indigents ; iii) d’analyser les facteurs associés au recours aux soins de santé par les personnes âgées au Nigéria. Méthode : Le cadre conceptuel de cette étude est le modèle d’Andersen et Newman qui regroupe les déterminants de l’utilisation des soins de santé en facteurs prédisposants (âge, sexe, état matrimonial, occupation), en facteurs facilitants (revenu, existence d’un recours à une aide financière, alimentaire ou instrumentale, cohabitation) et en besoins (présence de maladies chroniques et de limites de la vision, de la force musculaire et de la mobilité). Dans un premier temps, pour déterminer le caractère équitable d’une sélection communautaire des indigents, nous avons réalisé une étude transversale en 2010 dans le district de Ouargaye au Burkina Faso. Au cours de cette enquête, 1687 indigents ont été interrogés. La variable dépendante est la possession de la carte d’exemption du paiement des soins. Des analyses bivariées et une régression logistique ont été réalisées. Dans un deuxième temps, à partir d’un devis quasi expérimental pré/post, nous avons évalué les effets de ce programme d’exemption du paiement des soins sur le recours aux soins de santé des personnes en situation d’indigence au Burkina Faso. Au cours de cette recherche, 1224 indigents ont été interrogés en 2010 sur leur recours aux soins de santé. Parmi eux, 540 ont été sélectionnés et ont reçu une carte d’exemption du paiement des soins. Un an plus tard, un suivi a été réalisé avec un taux de rétention de 55,3%. Des analyses bivariées et une régression logistique ont été réalisées. Dans un troisième temps, à partir des données d’une étude transversale nationale, le General Household Survey de 2012-2013 du Nigéria qui couvre toutes les régions du pays, nous avons étudié le recours aux soins de 3587 personnes âgées dont 850 ont déclaré avoir été malades. Nous avons tenté d’identifier les facteurs qui y sont associés. Des analyses pondérées bivariées et une regression de Poisson pondérée ont été effectuées. Résultats : Au Burkina Faso, l’exemption du paiement des soins a été accordée en majorité aux veufs (ves) (OR=1,40 IC 95% [1,10-1,78]), à ceux qui ne bénéficient pas d’aide financière de leur ménage pour recourir aux soins de santé (OR=1,58 IC 95% [1,26-1,97], qui vivent seuls (OR=1,28 IC 95% [1,01-1,63]), qui vivent avec leurs époux/se (OR=2,00 IC 95% [1,35-2,96], qui ont des troubles de la vision (OR=1,45 IC 95% [1,14-1,84]), qui ont une faible force musculaire et une bonne mobilité (OR=1,73 IC 95% [1,28-2,33]). Le processus de sélection communautaire des indigents n’est pas parfaitement équitable, car très restrictif, bien qu’il ait permis de sélectionner les plus démunis. Il existe des différences de genre concernant les déterminants du recours aux soins chez les indigents. Être veufs (OR=0,53 IC 95% [0,33-0,81]) et avoir des troubles de la vision (OR=0,42 IC 95% [0,28-0,63]) freinent le recours aux soins chez les hommes, mais pas chez les femmes. Les maladies chroniques demeurent un obstacle commun aux hommes (OR=4,05 IC 95% [2,84-5,77]) et aux femmes (OR=2,14 IC 95% [1,54 – 2,97]). Le fait d’être exempté du paiement des soins n’est pas associé à l’augmentation de l’utilisation des services de santé (OR=1,1 IC 95% [0,80-1,51]). Qu’ils aient bénéficié ou pas de l’exemption du paiement des soins, les indigents qui ont un âge supérieur à 69 ans (OR=1,66 IC 95% [1,05-2,64]), qui appartiennent au genre masculin (OR=1,44 IC 95% [0,99-2,08]), qui appartiennent à un ménage à faible revenu (OR=1,71 IC 95% [1,15-2,54]) et ceux qui ont recours à l’aide financière familiale pour accéder aux soins de santé (OR=1,59 IC 95% [1,1-2,28]), sont les plus susceptibles d’augmenter leur utilisation des soins de santé. Au Nigéria, seulement 53% des personnes âgées ont consulté un agent de santé suite à un épisode de maladie. L’absence de scolarisation (PR = 0.73, 95% CI [0.6 0–0.8]), la faiblesse du revenu de ménage (PR = 0.75, 95% CI [0.5–0.9]), et le fait de résider dans les zones du Sud-Sud (PR = 0.59 95% CI [0.4–0.7]) et du Sud-Ouest (PR = 0.60 95% CI [0.4–0.7]), constituent des freins à la consultation d’un agent de santé. Conclusion La sélection communautaire est une des méthodes qui semble avoir permis de sélectionner les indigents avec une prévalence élevée de besoins en santé et d’obstacles économiques au recours aux soins. Cependant, l’exemption du paiement des soins n’est pas suffisante pour améliorer leur recours aux soins. Les déterminants de leur recours aux soins différent selon le genre, mais les maladies chroniques constituent un motif commun. Les personnes âgées et les indigents ont des caractéristiques communes telles que l’âge avancé, mais certains facteurs qui déterminent leurs recours aux soins diffèrent. Le déterminant commun est le facteur financier, soit la capacité contributive de ces personnes dans un contexte où l’utilisateur des services de santé est le payeur. En attendant la couverture universelle de soins, il serait approprié que les interventions pour améliorer le recours aux soins ciblent en premier lieu les populations ayant des besoins importants telles que les indigents et les personnes âgées en ôtant la barrière financière. Pour les indigents par contre, il faudrait y ajouter des mesures additionnelles comme, par exemple l’accompagnement, le transport et les frais d’hébergement. Enfin, les interventions doivent aussi considérer les différences de genre qui existent dans les facteurs qui déterminent leur recours aux soins. / Problem In African countries with point-of-service healthcare user fees, financial barriers are one of the major obstacles to healthcare-seeking behaviour, and the indigent, the poorest members of society, are the most affected. To address this issue, some countries have begun developing health programs targeting indigent people to help them gain better access to healthcare by waiving healthcare fees. Unfortunately, it is a genuine challenge to identify those who are indigent. In addition, few studies have assessed the impact of user fees exemption programs on healthcare-seeking behaviour. The majority of indigent people are older with significant health needs. Older people in Africa do not often consult health professionals. The determinants regarding healthcare-seeking behaviour by older people is little-known, although proportionately, their numbers are increasing in low- and middle- income countries. They are losing their autonomy, have little income and have a high prevalence of chronic diseases and functional disabilities. These problems occur early on, especially among women. Objectives The objectives of this thesis are as follows: (i) to determine the equitable nature of a community-based selection process for indigent people in Burkina Faso that aims to exempt them from paying healthcare user fees; (ii) to measure the impact of this user fees exemption program on healthcare-seeking behaviour among indigent people; (iii) to analyze the factors associated with healthcare-seeking behaviour by older people in Nigeria. Method The conceptual framework of this study is based on the model developed by Andersen and Newman, which groups healthcare use determinants into predisposing factors (age, gender, marital status, occupation), enabling factors (income, means and know-how to access financial, food or instrumental assistance, social relationships), and needs (presence of chronic disease and vision, muscle strength and mobility limitations). To determine the equitable nature of a community-based selection of indigent people, we carried out a cross-sectional study in 2010 in the Ouargaye District of Burkina Faso, in which 1687 indigent people were interviewed. The dependent variable was possession of an exemption card. Bivariate analyses and logistic regression were performed. Next, using a quasi-experimental before/after approach, we assessed the effects of this user fees exemption program on healthcare-seeking behaviour by indigent people in Burkina Faso. To that end, 1224 indigent people were interviewed in 2010 about their healthcare-seeking behaviour. Among them, 540 were selected and received an exemption card. One year later, a follow-up was conducted, with a 55.3% retention rate. Bivariate analyses and logistic regression were performed. Finally, using data from a national cross-sectional study, the Nigerian 2012–2013 General Household Survey, which covers all the country’s regions, we studied healthcare-seeking behaviour by 3587 older people, of whom 850 stated that they were ill. We attempted to identify the associated factors. Weighted bivariate analyses and a weighted Poisson regression were performed. Results In Burkina Faso, healthcare payment waivers were mainly granted to widows or widowers (OR=1.40 IC 95% [1.10–1.78]), to those who do not receive financial support from their household for healthcare (OR=1.58 IC 95% [1.26–1.97], or those who live alone (OR=1.28 IC 95% [1.01–1.63]), or with their spouse (OR=2.00 IC 95% [1.35-2.96], who have vision impairment (OR=1.45 IC 95% [1.14–1.84]), who have limited muscle strength and good mobility (OR=1.73 IC 95% [1.28–2.33]). The community-based selection process of indigent people is not completely equitable, although it did enable the most needy to be selected. There are gender differences concerning healthcare-seeking behaviour determinants among indigent people. Being a widower (OR=0.53 IC 95% [0.33–0.81]), and having vision impairment (OR=0.42 IC 95% [0.28–0.63]) were factors limiting healthcare-seeking behaviour among men but not among women. Chronic diseases remain a common obstacle among men (OR=4.05 IC 95% [2.84–5.77]) and women (OR=2.14 IC 95% [1.54–2.97]). User fees exemption is not associated with an increased use of healthcare services (OR=1.1 IC 95% [0.80–1.51]). Whether they received or did not receive exemption cards, indigent people over the age of 69 (OR=1.66 IC 95% [1.05–2.64]), who were male (OR=1.44 IC 95% [0.99–2.08]), who belong to a low-income household (OR=1.71 IC 95% [1.15–2.54]), and those who had financial assistance from family to access healthcare (OR=1.59 IC 95% [1.1–2.28]), are more likely to increase their use of healthcare. In Nigeria, only 53% of older people consulted a health practitioner after an episode of illness. Lack of education (PR = 0.73, 95% CI [0.60–0.8]), low household income (PR = 0.75, 95% CI [0.5–0.9]), and residence in Nigeria’s South South (PR = 0.59 95% CI [0.4–0.7]) and South West zones (PR = 0.60 95% CI [0.4–0.7]) constituted limitations to consulting a health practitioner. Conclusion Community-based selection is one method that appears to have made it possible to select indigent people with a high prevalence of health needs and obstacles to seeking healthcare. Healthcare payment waivers are not sufficient to increase their healthcare-seeking behaviour. Healthcare use determinants differ according to gender, but chronic disease constitutes a common theme. Elderly and indigent people have common characteristics, such as advanced age, but some factors that determine their healthcare-seeking behaviour differ. The common determinant is the financial factor, i.e., the contributory capacity of these people in a context where the user pays. Until there is universal healthcare coverage, it would be appropriate to ensure that activities to improve healthcare-seeking behaviour primarily target populations with significant needs, such as indigent and elderly people, by removing financial barriers. For indigent people, however, additional measures must be included, such as accompaniment, transportation and accommodation expenses. And activities must also take existing gender differences into account among the factors determining their healthcare-seeking behaviour.

Masters in Public Administration - MPA / The problems of the predispositions of municipal public officials and the professionalization of the public service have in the recent past come into the spotlight in service delivery protests involving poor people and unemployed youth. The criticism levelled at bureaucrats within the public service relates to administrative systems, bad policies as well as unresponsive attitudes among frontline staff. The existing perception is that South African street-level bureaucrats are lazy, uncaring, self-serving, unethical, and conceive of the poor in derogatory terms. They are generally only in public service because it is a means of employment or enrichment. Most recent literature on municipal water and free basic services focused on exposing the cost recovery drive of the state and its associated forms of oppressive neoliberal surveillance of the poor. The research sought to primarily understand the attitudes of street-level bureaucrats (SLB’s) within two B-category municipalities in the Western Cape, South Africa. This was done by identifying what motivates them to work in the public sector, how they see and interact with identified poor members of the public (usually defined as municipal indigents), what their value orientations are, and if and how principles of Batho Pele are understood by frontline workers. It explored how these principles are applied when interacting with indigent citizens in their everyday work environment. Additionally, the research explored how poor citizens view their experience of interacting with the state. A qualitative study, using semi-structured questionnaires, was conducted in the Cape Agulhas municipality which is the most southern municipality and the Matzikama municipality which is the most northern municipality of the WC on the west coast. Interviews with frontline municipal employees, senior bureaucrats and residents were conducted. The interviews were conducted, to obtain three different views on the problem, with a total of 71 participants. The participants comprised of 15 street-level bureaucrats, 8 senior staff, with a minimum of 5 years’ tenure, and a total of 43 indigent citizens. Given the sample size, composition and the demographics relating to these municipalities, the research is not generalizable. The public workers in the case studies, I found, cared deeply for the community and the community in turn are very appreciative of this. I also found that indigent citizens were not ashamed of their indigent status although there were those who outright denied being indigent and therefore were not interviewed.

Made available in DSpace on 2015-04-22T22:18:26Z (GMT). No. of bitstreams: 1 Josali do Amaral.pdf: 3943576 bytes, checksum: 873e45ca38c00a8d164d35a17cda8689 (MD5) Previous issue date: 2011-11-29 / This research encompasses the creation of shelters destined to mendicants and indigents in the city of Manaus, at the end of the Imperial regime and at the beginning of the Republic. Subjacent to this process, we worked on the mechanisms of intensification of the social differences from the creation of the Province in 1852, and therefore, poverty became not only visible to governors, but also a disturb to the emerging mercantilist and bureaucratic élite. The adequation of production and consumering relations to the liberal forms of production, coincident to the organization of Brazilian nation conducted the deliberation of a series of public politics which aimed at adapting individuals and space to the modern demands. Habits, customs, traditions and ways of living had to be submitted to a rigid control, and behavior changing was fundamental to that. Within this reforming picture, those who did not want or could not be immediately absorved by the productive process due to a series of reasons which included orfanity and mendicancy, started to be regarded with mistrust and became an aim to cohibiting politics which conducted them to enclosure. The creation of shelters destined to poor people had an educational character for children, as well as a medical aspect to sick and indigent people. This process was conducted within a philanthropic discourse which hid both the growth of poverty and a series of segregation intentions / A pesquisa aqui apresentada aborda a criação das casas de abrigo destinadas a desvalidos e indigentes na cidade de Manaus, no período final do regime Imperial e anos iniciais da República. Subjacente a este processo, dissertamos acerca dos mecanismos de intensificação da diferenciação social desencadeada no Amazonas a partir da criação da Província em 1852, no qual a exclusão social e, por conseguinte, a pobreza tornou-se não só visível aos olhos dos governantes, mas ainda incômoda para uma elite mercantil e burocrática emergente. A adequação das relações de produção e consumo às formas liberais de produção, coincidentes com a organização da nação brasileira, conduziu a deliberação de uma série de políticas públicas que visavam adaptar os indivíduos e o espaço às demandas modernas. Hábitos, costumes, tradições e modos de vida deveriam ser submetidos a um rígido controle, para o que a mudança comportamental era fundamental. Neste quadro reformador, aqueles que não queriam ou não podiam ser imediatamente absorvidos pelo processo produtivo, por motivos diversos que vão da orfandade à mendicância, passaram a ser vistos com desconfiança e tornaram-se alvo de medidas coercitivas e que conduziam ao enclausuramento. A criação das casas de abrigo destinadas aos pobres, em geral de caráter educacional para crianças e médico-hospitalares para enfermos, alienados e indigentes, foi realizada a partir de um discurso filantrópico que mascarava não só o crescimento da pobreza, como uma série de intenções segregadoras.

Cette thèse revient sur les moyens de la prise en charge publique et par les associations de défunts dits ‘indigents’. Si la littérature sur ce sujet insistait grandement sur la catégorie des personnes de la rue et sur les idées de délaissement et de sacrifice, ce travail met en avant les différentes facettes, parfois conflictuelles, de l’intérêt public porté à ces morts. Cette recherche est principalement l’aboutissement d’une ethnographie menée auprès de l’association parisienne du Collectif les Morts de la Rue. Cette association dénonce depuis 2001 les conditions de vie et de morts des personnes de la rue et s’occupe, depuis 2003, des cérémonies funéraires pour tous les corps non-réclamés de la ville de Paris. L’enquête revient sur les motivations des deux groupes de bénévoles coexistant au sein de la même association, l’un se concentrant sur l’activisme en faveur des personnes de la rue (‘gueuler’) et l’autre sur les rituels des défunts non-réclamés, quelle que soit leur origine sociale (‘pleurer’). Ces deux groupes créent des communautés symboliques de morts et de vivants à travers des cérémonies, émotions et rituels. L’insistance du groupe des fondateurs sur l’activisme en faveur des vivants de la rue est parfois en contradiction avec l’implication plus générale de certains bénévoles pour tous les défunts non-réclamés. La thèse revient sur leur cohabitation au sein de la même association et montre comment des références communes à la fraternité humaine et à l’universalité de la mort ne suffisent pas à couvrir des motifs d’engagements divergents. / This research analyzes what happens to the deceased labeled as ‘paupers’ and managed through non-governmental organizations and public means in France. Where previous literature on the subject emphasized social categories such as homeless people and theories of sacrifice, this work puts forward conflicting public interests given to the dead labeled as ‘paupers’. This recearch draws mostly on ethnographic fieldwork with the Collectif Les Morts de la Rue, a parisian organization denouncing the life and death conditions of homeless people since 2001, and in charge of the funeral ceremony of any unclaimed body since 2003. The investigation shows how two groups of volunteers with two different primary interests developed over time. The first group is mainly concerned with political activism in favor of people living and dying on the streets. The second group focuses more on non-political rituals for all unclaimed bodies, regardless of their social status. The two groups coexist with mutual references to the dead and to humanity after death. Through rituals and public ceremonies using emotions, they create symbolic communities gathering both the living and dead. The strong emphasis of the first group on inequality and socio-economic structure is sometimes at odds with the more general emphasis of the second group on the universal bond between human beings, showing how shared references to death and humanity are not enough to cover diverging motivations inside the same organisation.

Le rôle de la protection sociale dans un pays, au-delà de son importance pour l’équilibre des rapports sociaux, doit nécessairement tendre vers l’inclusion sociale et le respect de la dignité humaine. Ce travail sur la protection sociale en Mauritanie dénonce et critique toutes formes d’injustice sociale par rapport à l’accès non égalitaire à l’assurance maladie et à la sécurité sociale. En effet, une partie infime de la population mauritanienne bénéficie de ce système, il s’agit des fonctionnaires, agents de l’état, parlementaires, les forces armés en position d’activité.et certains salariés du secteur privé. Le régime de protection sociale en Mauritanie incarne l’exclusion pour une grande majorité de la population mauritanienne. La protection sociale en Mauritanie comme en France a pour objectif de garantir l’individu, la famille contre tous les risques sociaux, d’origine professionnelle ou non professionnelle, susceptibles de diminuer leur revenu en portant atteinte à la capacité de travail (la maladie, l’accident, la vieillesse, le chômage, la maladie à la naissance). Divers systèmes de couverture du risque maladie et de protection sociale sont pratiqués en Mauritanie. Il serait approprié d’engager une vaste réflexion pour assurer l’harmonie et la cohérence du régime mauritanien de protection sociale afin que ce dernier puisse suivre le sillage de la politique française en la matière pour parvenir à un système de protection sociale digne de ce nom, c'est-à-dire universelle. / The role of social protection in a country, beyond its importance for the balance of social relations, must necessarily get to word social inclusion and respect of human dignity. This work on social protection in Mauritania denounces and criticizes all forms of social injustice as non equal access to health insurance and social security is concerned. In fact a very small part of the Mauritanian population benefits of this system, such as official works, state agents, parliamentarians, armed forces in position of activity and some private sector employees. The system of the social protection in Mauritania incarnates the exclusion of a large majority of the population. The social protection in Mauritania as in France is for guarantee the individual, the family against all social risks litters professional or non professional, nature likely to reduce their income by infirming the capacity for work ( illness, accident, old age, joblessness, illness at birth). Various systems of health and social protection converge are applied in Mauritania. It would be appropriate to put in place a wide reflection in order sure the harmony coherence of the Mauritanian social protection system so as it on follow the wake of French policy in this field to achieve a social protection system as result worthy of this name, that means universal.

Background: Availing equitable and affordable health services for citizens is becoming a problem for governments of developing countries. In Ethiopia, the government has been implementing fee waiver scheme since 1998 to advance the health access by the poor, though it is still a crucial challenge of the health sector. Purpose: The intent of the study was to evaluate the effectiveness of fee waiver scheme in improving access to health by the poor in Addis Ababa and to propose implementation framework to improve its outcome. Method: This study employed qualitative research approach to evaluate the program effectiveness and to propose implementation framework in two phases. Exploratory and descriptive case study designs, and Delphi techniques were utilized to evaluate the scheme’s effectiveness and to validate the proposed implementation framework. The researcher employed purposive and convenience sampling methods to sample the study populations, and used Atlas ti 7.5 software to analyze the findings. Result: This study revealed that the commencement of the scheme has benefited considerable poor population in the city. However, its effectiveness in terms of addressing the needy population, services coverage and protecting the poor from financial hardship is not yet achieved. Poor health facilities capacity, poor program management and lack of comprehensive monitoring and accountability system were found major factors that affected its success. As a result, the researcher proposed an implementation framework with the aim of addressing these problems. Conclusion: Achieving Universal Health Coverage without addressing the indigents’ health need is impossible. Lack of comprehensive health services, in adequate population coverage and poor financial protection were among the major findings. Hence, prior attentions should be given to equip health facilities with necessary infrastructures and ensure the inclusion of all needy populations through effective monitoring, governance and leadership mechanisms to improve its intended outcomes. If utilized properly, the findings and the implementation framework of this study will serve as valuable resources for immediate decisions and directions by the policy makers / Health Studies / D. Litt. et Phil. (Health Studies)

Contexte : La mauvaise qualité et la faible utilisation des services de santé contribuent aux taux élevés de morbidité et de mortalité dans plusieurs pays à faible et à moyen revenu. Face à cette situation, le gouvernement du Burkina Faso a testé une intervention novatrice qui combine le financement basé sur la performance (FBP) à des mesures d'équité en santé. Les formations sanitaires ont reçu des prix unitaires pour des services de santé fournis ainsi que des bonus conditionnels à la qualité des soins. Des comités communautaires ont sélectionné les indigents pour leur octroyer des exemptions de paiements des soins. Malgré le peu d’études sur le sujet, des acteurs en santé mondiale craignent que l’intervention puisse avoir des conséquences non intentionnelles importantes. Objectif : Cette thèse vise à accroître les connaissances scientifiques sur les conséquences non intentionnelles du FBP combiné à des mesures d'équité en santé dans un environnement à faible revenu. Méthodes : Nous avons développé un cadre conceptuel basé sur la théorie de la diffusion des innovations. Une étude de cas multiples a été réalisée avec neuf formations sanitaires au Burkina Faso. Cinq mois sur le terrain ont permis d’effectuer 104 entrevues semi-structurées, 266 séances d'observation et des conversations informelles avec un large éventail d'acteurs incluant les prestataires de soins, les patients et les vérificateurs. Les données qualitatives ont été codées avec QDA miner pour faciliter l’analyse thématique. Nous avons également utilisé des données quantitatives du système de gestion pour décrire l'évolution des services et trianguler les résultats. Résultats : La nature et la mise en œuvre de l'intervention ont interagi avec le système social et les caractéristiques de ses membres pour engendrer des conséquences non intentionnelles importantes, dont la plupart étaient indésirables. Les prestataires de soins ont démontré une fixation sur les mesures de rendement, ont falsifié les registres médicaux et ont enseigné de mauvaises pratiques aux stagiaires pour augmenter leurs subsides et bonus. Comme conséquence non intentionnelle désirable, certaines formations sanitaires ont limité la vente de médicaments sans prescriptions pour encourager les consultations. Les vérifications communautaires, durant lesquelles les patients sont retrouvés pour vérifier les services déclarés, ont entraîné la falsification des données de vérification, la perte de la confidentialité des patients et certaines craintes chez les patients, bien que certains étaient heureux de partager leurs opinions. Enfin, les prestataires de soins ont limité les services offerts gratuitement aux indigents, ce qui a déclenché des conflits. Discussion : Cette thèse contribue au développement des connaissances scientifiques sur la façon dont le FBP, combiné à des mesures d'équité, peut engendrer des conséquences non intentionnelles. Les résultats sont utiles pour affiner ce type d’intervention et éclairer une mise en œuvre efficace dans le secteur du financement de la santé. Plus largement, cette thèse démontre la faisabilité et la valeur ajoutée d'utiliser un cadre conceptuel pour étudier les conséquences non intentionnelles. Elle pourra guider les chercheurs à élargir leur angle d’analyse afin de rendre compte des conséquences intentionnelles et non intentionnelles des interventions complexes en santé. / Background: Poor quality and low utilization of healthcare services contribute to high levels of morbidity and mortality in many low- and middle-income countries (LMICs). In response, the government of Burkina Faso tested an innovative intervention that combines performance-based financing (PBF) with health equity measures. Healthcare facilities received unit fees for targeted services and bonuses conditional upon the quality of care. To reduce inequities in access to care, community-based committees selected indigents, i.e., the poorest segment of the population, to offer them user fee exemptions. Facilities were also paid more for services delivered to indigents. Despite the potential of this type of intervention, many global health actors argue that it could lead to important unintended consequences that influence its overall impact. Yet, little attention has been given to studying the unintended consequences of this complex intervention. Objective: This thesis aims to increase the scientific knowledge on the unintended consequences of PBF combined with health equity measures in a low-income setting. Methods: We developed a conceptual framework based on the diffusion of innovations theory. Using a multiple case study design, we selected nine healthcare facilities in Burkina Faso. Over five months of fieldwork, we collected multiple sources of qualitative data including 104 semi-structured interviews, 266 recorded observation sessions, informal conversations and documentation. Participants included a wide range of stakeholders, such as providers, patients, and PBF verifiers. Data were coded using QDA miner to conduct a thematic analysis. We also used secondary data from the PBF routine management system to describe the evolution of services and triangulate results. Results: Interactions between the nature and implementation of the intervention, the nature of the social system, and its members’ characteristics led to important unintended consequences, most of which were undesirable. Providers were fixated on performance measures rather than on underlying objectives, falsified medical registers, and taught trainees improper practices to increase subsidies and bonuses. As a desirable unintended consequence, we found that some facilities limited the sale of non-prescribed medication to encourage patients to consult. Community verifications, in which patients are traced to verify the authenticity of reported services and patient satisfaction, also led to unintended consequences, such as the falsification of verification data, the loss of patient confidentiality, and fears among patients, although some were pleased to share their views. Lastly, health equity measures also triggered changes that were not intended by program planners. For example, providers limited the free services and medication delivered to indigents, which led to conflicts between parties. Discussion: This thesis contributes to the development of scientific knowledge on how PBF interventions, combined with equity measures, can trigger unintended consequences in a low-income setting. The results are useful to inform effective implementation and refine interventions, particularly in the health financing sector. More broadly, this thesis demonstrates the feasibility and added value of using a conceptual framework to study the unintended consequences of complex health interventions. This thesis can inspire and guide future researchers to broaden their analytical horizons to capture both intended and unintended consequences of health interventions.