PhD defence Kéfilath Bello

Supervisors

• Prof. dr. em. Bart Criel (ITM) 

• Prof. dr. em. Jan De Lepeleire (KU Leuven) 

• Prof. dr Djimon Marcel Zannou (University of Abomey Calavi, Benin)

• Dr. Ludwig Apers (ITM) 

Summary

Background

In Benin, like in many other African countries, non-physician clinicians have traditionally provided primary care, with physicians mainly stationed at hospitals. Recently, however, the number of physicians in primary care has been gradually increasing. While this rise in primary care physicians (PCPs) could be expected to improve healthcare, it is not guaranteed without appropriate policies guiding their work. Additionally, at the outset of this doctoral research, little was known about the number, characteristics, and practices of PCPs in Benin. 

Objectives

The general objective was to analyse primary care physician practices in Benin and to investigate how best to support their contribution to quality primary care and the effective implementation of primary health care.

The specific objectives were:

• Obj 1: Describe the various types of PCP practices in sub-Saharan Africa and identify the main issues related to these practices.

• Obj 2: Conduct an in-depth mapping of PCP practices in four health districts in Benin and propose a typology of these practices.

• Obj 3: Identify, across the different types of practice, the factors that can support the performance of PCP practices.

• Obj 4: Cocreate, in collaboration with stakeholders and based on the evidence generated, a policy framework to guide PCP practices in Benin. 

Methodology

This research used a mixed-methods study design, combining quantitative and qualitative approaches. 

Results

The thesis is structured into five chapters (excluding the introduction and discussion chapters).

In chapter 1, we reviewed the literature on PCP practices in sub-Saharan Africa, focusing on the characteristics of these practices, the challenges encountered, and their contribution to effective primary care. This scoping review (2000–2021) used both Anglophone and Francophone literature. The review resulted in the construction of an initial typology of the PCP practices in sub-Saharan Africa, the development of a conceptual framework for analysing PCP practices, and a more precise identification of knowledge gaps. A key gap was the lack of sound policy frameworks to guide PCP practices in many African countries, including Benin.

Chapters 2 and 3 reported two mixed methods studies that aimed to acquire a more precise knowledge of the professional characteristics, activities, support received and types of practices of the PCPs in four health districts in Benin. The first study (December 2019–July 2020) provided a typology of PCP practices, starting with an analysis of the practices of all physicians working at first-line facilities (or primary care facilities) and discussing which of them can be considered PCPs. The second study (April–August 2020) explored their experiences with COVID-19. These two studies provided an in-depth mapping of PCP practices in the four health districts and confirmed the need for stronger policies and governance to support PCP practices and enhance their contributions to primary health care.

Chapter 4 consisted of a multiple case study (April–June 2022), investigating factors contributing to the performance of PCP practices in eight typical cases across five health districts. The findings from the observation of 180 consultations, 40 in-depth interviews, and 16 focus group discussions were crucial in identifying performance factors that informed the development of the policy framework.

Chapter 5 aimed to cocreate, with the PCPs and other stakeholders, a policy framework to guide PCP practices in Benin. This cocreation started at the very start of the doctoral research, involving long-term stakeholders’ engagement and culminating in a two-day workshop in Cotonou on 25 and 26 October 2022. The policy framework integrated both the empirical findings and information gathered during the cocreation workshop. 

Conclusion 

This doctoral research makes several contributions to scientific knowledge, including a typology of PCP practices and a conceptual framework for analyzing these practices in sub-Saharan Africa. It also provides the first empirical description and analysis of PCP practices in Benin, identifying factors that shape their performance. The cocreated policy framework resulting from this work offers practical recommendations for improving the governance of PCP practices in Benin and similar settings, aiming to strengthen primary care delivery and guide human resource planning. These insights lay a foundation for policy dialogue and actions that could enhance primary healthcare implementation in resource-constrained contexts.