Implementation of the fee exemption for caesarean section policy (FECSP) in non-state health facilities in Benin: Does it work (or not)? Why (not)? How to improve it?

Although there is good evidence concerning cost-effective strategies to decrease maternal and neonatal morbi-mortality, their implementation in low-income countries, like Benin, often fails. This project uses the Fee Exemption for Caesarean Section Policy to study the causes of implementation failure. It will develop a policy implementation score, assess policy implementation in state and in non-state facilities, and assess why, how and in which conditions policy implementation succeeded or failed. This study combines a multiple case study design with a cross-sectional study design. First, a comprehensive policy implementation score will be developed. Second, the policy implementation will be measured through a cross-sectional study in a representative sample of policy beneficiaries. Third, 4 comparative case studies (in 2 state and 2 non-state facilities) will be conducted using the realist evaluation approach. For each case, the policy implementation score will be the outcome of interest, and policy uptake adoption and implementation will be assessed, as well as the context conditions that facilitate or hinder implementation. This study should allow for a better understanding of policy implementation by comparing state and non-state facilities and provide insights that may guide the design and implementation of other policies, including Universal Health Coverage policies.