Persuasion depended on the alignment of the policy with personal and organizational values. Compliance with the policy depended on enforcement by hierarchical authority and bottom-up pressure. We found that trust, perceived coercion, adherence to policy goals, perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor. First, in the state-owned hospital, which has a public-oriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. ![]() In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. We selected two hospitals with contrastive outcomes. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. ![]() Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. Similar to other low- and middle-income countries, its implementation showed mixed results. To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections.
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