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Strengthening the Stewardship Function of Local Health Systems in Francophone West African Countries: is the Direct Financing Approach a valuable Approach?

Dia, Fatim (2017)
Master's Thesis (111 pages)
Committee Chair / Thesis Adviser: McFarland, Deborah A
Committee Members: Winskell Enger, Kate
Research Fields: Public health; Health care management
Partnering Agencies: International Non-governmental organization (e.g., CARE, Inc.)
Keywords: Stewardship; Decentralization; Contracting practice
Program: Rollins School of Public Health, Hubert Department of Global Health
Permanent url:


If most African countries are implementing on-going reforms to better decentralize their health systems (Lambo and al., 2003), they are still facing major challenges including inadequate funding, lack of autonomy and poor governance of local health systems (WHO, 2002). There is growing evidence suggesting that a broader concept of governance is required. The World Health Organization (WHO) proposed in 2000 the notion of stewardship applied to health systems. It combines accountability and sense of service, cost-effectiveness, and equity.

Previous research has demonstrated that stewardship is a complex concept, challenging to apply and neglected as a research topic for effective health reforms (Murray and Evans, 2003.) There is, in particular, a need for studies on how to strengthen the stewardship function at a decentralized level in West African French-speaking countries.

The purpose of this study is, therefore, to examine approaches to improving the stewardship function at a decentralized level, in the context of health reform. This present study is based on a literature review and a case study on a contracting practice implemented in Senegal by USAID and Abt. Associates: the direct financing mechanism[1]. It contributes to answering the following research question: is the direct financing mechanism relevant for reinforcing stewardship at the decentralized level in Francophone African countries?

This exploratory study demonstrates that this mechanism has several strengths that could benefit initiatives intended to improve the stewardship function at a local health system level. These strengths include the direct provision of additional resources reinforcing the autonomy in decision-making processes, improved financial management capacities and the building of partnerships with the major players at the decentralized level. The direct financing mechanism could be considered as a conducive environment for effective stewardship and more effective health reforms. The findings of this thesis contribute to a more comprehensive understanding of the concept of stewardship as compared to governance and argue in favor of the adoption of stewardship as an entry point to health system reform in Africa.

[1] In this document, the direct financing mechanism is also referred as a project.

Table of Contents

Abstract. 4

Acknowledgements. 6

Acronyms. 7

Table of contents. 9

List of tables. 12

List of figures. 12


1.1 Context and rationale. 13

1.2 Problem statement. 15

1.3 Purpose statement and research questions. 16

1.4 Significance statement. 17

1.5 Glossary. 18

1.6 Organization of the document. 19


2.1 Stewardship. 21

2.1.1 Clarification of the concept and its evolution in the health literature. 21

2.1.2 Stewardship functions. 22

2.1.3 Stewardship versus Governance. 24

2.2 The stewardship function in Africa. 27

2.3 The Senegalese context. 29

2.3.1 Overview of the Senegalese Health System.. 29

2.3.2 Decentralization model and process. 31

2.3.3 Health Financing system in Senegal 38

Chapter 3: Methodology. 43

3.1 Introduction. 43

3.2 Study design. 43

3.3 Analytical framework. 44

3.4 Different steps. 46

3.4.1 Data collection. 46

3.4.2 Hypothesis development and conceptual framework. 47

3.4.3 Data analysis and interpretation. 48

3.5 Data quality and integrity. 48

3.6 Ethical considerations. 49

3.7 Limitations and Delimitations. 49

Chapter 4: RESULTS. 51

4. 1 Overview of the direct financing mechanism.. 51

4.1.1 Background and rationale. 51

4.1.2 Description and Implementation. 53

4.1.3 Goal, objectives, and principles. 53

4.2 Direct contributions to the stewardship function. 54

4.2.1 Effects on the implementation of the stewardship sub-functions. 55

4.2.2 Effects on stewards. 69

4.2.3 Effects on the level of governance. 72

4.3 Indirect contributions to the stewardship function. 76

4.3.1 Regional coordination. 77

4.3.2 National contracting policy. 78

4.3.3 Organizational Reforms Agenda. 79

4.4 Summary of the main findings. 80


5.1 Making sense of the concept of stewardship in a francophone context. 81

5.2 Strengthening the stewardship function at a decentralized level: significance of the findings and lessons from the direct financing mechanism.. 83

5.2.1 Approaches to strengthening the stewardship function of local health systems. 84

5.2.2 Analyzing the direct financing mechanism in a perspective of stewardship capacity building at a decentralized level 85

5.2.3 Potential for West African French-speaking countries. 90

5.3 Questioning the analytical framework of this case-study and its potential to scale. 92


CHAPTER 7: practical Implications and recommendations. 96

8. References. 98

9. Appendix. 106

9.1 List of analyzed documents. 106

9.2 Code tree. 107


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