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Razafinjato B, Rakotonirina L, Cordier LF, Rasoarivao A, Andrianomenjanahary M, Marovavy L, Hanitriniaina F, Andriamiandra IJ, Mayfield A, Palazuelos D, Cowley G, Ramarson A, Ihantamalala F, Rakotonanahary RJL, Miller AC, Garchitorena A, McCarty MG, Bonds MH, Finnegan KE. Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002888. [PMID: 38470906 DOI: 10.1371/journal.pgph.0002888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/17/2024] [Indexed: 03/14/2024]
Abstract
Despite widespread adoption of community health (CH) systems, there are evidence gaps to support global best practice in remote settings where access to health care is limited and community health workers (CHWs) may be the only available providers. The nongovernmental health organization Pivot partnered with the Ministry of Public Health (MoPH) to pilot a new enhanced community health (ECH) model in rural Madagascar, where one CHW provided care at a stationary CH site while additional CHWs provided care via proactive household visits. The program included professionalization of the CHW workforce (i.e., targeted recruitment, extended training, financial compensation) and twice monthly supervision of CHWs. For the first eighteen months of implementation (October 2019-March 2021), we compared utilization and proxy measures of quality of care in the intervention commune (local administrative unit) and five comparison communes with strengthened community health programs under a different model. This allowed for a quasi-experimental study design of the impact of ECH on health outcomes using routinely collected programmatic data. Despite the substantial support provided to other CHWs, the results show statistically significant improvements in nearly every indicator. Sick child visits increased by more than 269.0% in the intervention following ECH implementation. Average per capita monthly under-five visits were 0.25 in the intervention commune and 0.19 in the comparison communes (p<0.01). In the intervention commune, 40.3% of visits were completed at the household via proactive care. CHWs completed all steps of the iCCM protocol in 85.4% of observed visits in the intervention commune (vs 57.7% in the comparison communes, p-value<0.01). This evaluation demonstrates that ECH can improve care access and the quality of service delivery in a rural health district. Further research is needed to assess the generalizability of results and the feasibility of national scale-up as the MoPH continues to define the national community health program.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Alishya Mayfield
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel Palazuelos
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Partners In Health, Boston, Massachusetts, United States of America
| | | | | | - Felana Ihantamalala
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Rado J L Rakotonanahary
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ann C Miller
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Andres Garchitorena
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Institut de Recherche pour le Développement, MIVEGEC Laboratory, University of Montpellier, Centre National de la Recherche Scientifique, Antananarivo, Madagascar
| | | | - Matthew H Bonds
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Karen E Finnegan
- Pivot, Ranomafana, Fianarantsoa, Madagascar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Moyal-Smith R, Etheridge JC, Karlage A, Sonnay Y, Yuan CT, Havens JM, Brindle ME, Berry W. Defining re-implementation. Implement Sci Commun 2023; 4:60. [PMID: 37277862 DOI: 10.1186/s43058-023-00440-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/19/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND The first attempt to implement a new tool or practice does not always lead to the desired outcome. Re-implementation, which we define as the systematic process of reintroducing an intervention in the same environment, often with some degree of modification, offers another chance at implementation with the opportunity to address failures, modify, and ultimately achieve the desired outcomes. This article proposes a definition and taxonomy for re-implementation informed by case examples in the literature. MAIN BODY We conducted a scoping review of the literature for cases that describe re-implementation in concept or practice. We used an iterative process to identify our search terms, pilot testing synonyms or phrases related to re-implementation. We searched PubMed and CINAHL, including articles that described implementing an intervention in the same environment where it had already been implemented. We excluded articles that were policy-focused or described incremental changes as part of a rapid learning cycle, efforts to spread, or a stalled implementation. We assessed for commonalities among cases and conducted a thematic analysis on the circumstance in which re-implementation occurred. A total of 15 articles representing 11 distinct cases met our inclusion criteria. We identified three types of circumstances where re-implementation occurs: (1) failed implementation, where the intervention is appropriate, but the implementation process is ineffective, failing to result in the intended changes; (2) flawed intervention, where modifications to the intervention itself are required either because the tool or process is ineffective or requires tailoring to the needs and/or context of the setting where it is used; and (3) unsustained intervention, where the initially successful implementation of an intervention fails to be sustained. These three circumstances often co-exist; however, there are unique considerations and strategies for each type that can be applied to re-implementation. CONCLUSIONS Re-implementation occurs in implementation practice but has not been consistently labeled or described in the literature. Defining and describing re-implementation offers a framework for implementation practitioners embarking on a re-implementation effort and a starting point for further research to bridge the gap between practice and science into this unexplored part of implementation.
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Affiliation(s)
- Rachel Moyal-Smith
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor West, Boston, MA, 02215, USA.
| | - James C Etheridge
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor West, Boston, MA, 02215, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Ami Karlage
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor West, Boston, MA, 02215, USA
| | - Yves Sonnay
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor West, Boston, MA, 02215, USA
| | - Christina T Yuan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Joaquim M Havens
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor West, Boston, MA, 02215, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary E Brindle
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor West, Boston, MA, 02215, USA
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - William Berry
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, 401 Park Drive, 3Rd Floor West, Boston, MA, 02215, USA
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Earland DE, Bibe AF, Novela A, Ferrão J, Searle KM. Plasmodium falciparum community prevalence and health-seeking behaviours in rural Sussundenga District, Mozambique. Malar J 2022; 21:305. [PMID: 36307833 PMCID: PMC9615226 DOI: 10.1186/s12936-022-04326-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/18/2022] [Indexed: 11/29/2022] Open
Abstract
Background Impacts of nationally directed malaria control interventions hinge on understanding malaria transmission and prevention at the community level. The decision to seek care or health-seeking behaviours provide valuable insight on knowledge of malaria, access to care, and efficacy of malaria case management. Thus far, few studies have focused on central Mozambique. The aim was to describe community level Plasmodium falciparum prevalence and health-seeking behaviours among residents of Sussundenga, Mozambique, a rural village in Manica Province with high malaria incidence reported at the Sussundenga-Sede health centre (RHC). Methods A cross-sectional community-based survey was conducted from December 2019 to February 2020. A random household sampling method was used, based on enumerated households from satellite imagery. All consenting participants completed a survey about malaria risk, prevention, and health-seeking behaviours, and received a P. falciparum malaria rapid diagnostic test (RDT). Results The study enrolled 358 individuals from 96 households. The P. falciparum prevalence was 31.6% (95% CI [26.6–36.5%]). Ninety-three percent of participants reported using the Sussundenga-Sede RHC for healthcare. Sixty-six percent of participants (N = 233) experienced at least one malaria symptom in the past month, with self-reported fever most frequently reported (19.3%). Of these, 176 (76.5%) sought care in a health facility and 174 (79%) received an RDT with 130 (63%) having a positive test. Of those with a positive RDT, 127 (97%) received artemether-lumefantrine. Following treatment, 123 (97%) participants’ symptoms resolved within a median of 3 days (IQR: 3–5) ranging from 2 to 14 days. In this high transmission setting, a high proportion of participants recognized malaria related symptoms then received a proper diagnostic test and treatment in a health facility. Conclusions Future interventions that leverage this health-seeking behaviour and strengthen health systems for community interventions will improve malaria control and inform the efficacy of potential interventions at this particular international border.
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Affiliation(s)
| | | | - Anísio Novela
- Direcção Distrital de Saúde de Sussundenga, Manica, Mozambique
| | - João Ferrão
- Universidade Aberta ISCED, Beira, Mozambique
| | - Kelly M Searle
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Kinshella MLW, Boene H, Sevene E, Valá A, Sharma S, Vidler M, Magee LA, von Dadelszen P, Munguambe K, Payne BA. How Gender Influenced the Experience of Using a mHealth Intervention in Rural Mozambique: Secondary Qualitative Analysis of Community Health Worker Survey Data. Front Glob Womens Health 2022; 3:661000. [PMID: 35284909 PMCID: PMC8907823 DOI: 10.3389/fgwh.2022.661000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background The mixed-gender community health worker (CHW) program in Mozambique is a window into the different experiences that male and female CHWs may face in their work. The objective of this study is to investigate how gender influenced the experiences of community health workers using the PIERS on the Move (POM) mHealth app in Mozambique. Methods This is a secondary analysis by gender of health care workers involved in the Mozambique Community Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial (NCT01911494). A structured survey with 10 open-ended questions was used to elicit CHW experiences using the POM app. Data collection took place in 2017 after completion of the CLIP trial. This analysis examined emergent themes to consider how experiences may have been shaped by health worker gender. Results Of the 43 CHWs who used the POM app, there were 31 (72%) women and 12 (28%) men. Gender differences emerged in descriptions of how using POM increased their value and respect by pregnant women and community members. Fifty-eight percent of female CHWs (18/31) said that POM positively influenced their status in the community in comparison to 33% of their male counterparts (4/12). While the small sample sizes, particularly of male CHWs who used POM, preclude conclusions, these findings were supported by qualitative results. Female CHWs tended to elaborate more about community perceptions of their increased value and status as health care providers than male CHWs. Conclusion CHWs work within existing gender norms. While gender norms are perceived to support the comfort of women to speak to another woman about their maternal and child health issues, gender norms also work against female CHWs as their professionalism may be questioned more than for their male counterparts. CHW's narratives suggested that the mHealth intervention was valued beyond the technology itself because it also added symbolic clinical value and demonstrated a tangible investment in their professional capacities, which may have been especially appreciated by the female CHWs.
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Helena Boene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Esperança Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Anifa Valá
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Laura A. Magee
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Beth A. Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
- *Correspondence: Beth A. Payne
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Boene H, Valá A, Kinshella MLW, La M, Sharma S, Vidler M, Magee LA, von Dadelszen P, Sevene E, Munguambe K, Payne BA. Implementation of the PIERS on the Move mHealth Application From the Perspective of Community Health Workers and Nurses in Rural Mozambique. Front Glob Womens Health 2021; 2:659582. [PMID: 34816216 PMCID: PMC8593977 DOI: 10.3389/fgwh.2021.659582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background:mHealth is increasingly regarded as having the potential to support service delivery by health workers in low-resource settings. PIERS on the Move (POM) is a mobile health application developed to support community health workers identification and management of women at risk of adverse outcomes from pre-eclampsia. The objective of this study was to evaluate the impact of using POM in Mozambique on community health care workers' knowledge and self-efficacy related to caring for women with pre-eclampsia, and their perception of usefulness of the tool to inform implementation. Method: An evaluation was conducted for health care workers in the Mozambique Community Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial from 2014 to 2016 in Maputo and Gaza provinces (NCT01911494). A structured survey was designed using themes from the Technology Acceptance Model, which describes the likelihood of adopting the technology based on perceived usefulness and perceived ease of use. Surveys were conducted in Portuguese and translated verbatim to English for analysis. Preliminary analysis of open-ended responses was conducted to develop a coding framework for full qualitative analysis, which was completed using NVivo12 (QSR International, Melbourne, Australia). Results: Overall, 118 community health workers (44 intervention; 74 control) and 55 nurses (23 intervention; 32 control) were surveyed regarding their experiences. Many community health workers found the POM app easy to use (80%; 35/44), useful in guiding their activities (68%; 30/44) and pregnant women received their counseling more seriously because of the POM app (75%; 33/44). Almost a third CHWs reported some challenges using the POM app (30%; 13/44), including battery depletion after a full day's activity. Community health workers reported increases in knowledge about pre-eclampsia and other pregnancy complications and increases in confidence, comfort and capacity to advise women on health conditions and deliver services. Nurses recognized the increased capacity of community health workers and were more confident in their clinical and technological skills to identify women at risk of obstetric complications. Conclusions: Many of the community health workers reported that POM improved knowledge, self-efficacy and strengthened relationships with the communities they serve and local nurses. This helped to strengthen the link between community and health facility. However, findings highlight the need to consider program and systematic challenges to implementation.
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Affiliation(s)
- Helena Boene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Anifa Valá
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Michelle La
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Department of Women and Children's Health, King's College London, London, United Kingdom
| | - Esperança Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique.,Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique.,Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Beth A Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
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Singh NS, Scott K, George A, LeFevre AE, Ved R. A tale of 'politics and stars aligning': analysing the sustainability of scaled up digital tools for front-line health workers in India. BMJ Glob Health 2021; 6:bmjgh-2021-005041. [PMID: 34312147 PMCID: PMC8728367 DOI: 10.1136/bmjgh-2021-005041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/27/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION India has become a lighthouse for large-scale digital innovation in the health sector, particularly for front-line health workers (FLHWs). However, among scaled digital health solutions, ensuring sustainability remains elusive. This study explores the factors underpinning scale-up of digital health solutions for FLHWs in India, and the potential implications of these factors for sustainability. METHODS We assessed five FLHW digital tools scaled at the national and/or state level in India. We conducted in-depth interviews with implementers, technology and technical partners (n=11); senior government stakeholders (n=5); funders (n=1) and evaluators/academics (n=3). Emergent themes were grouped according to a broader framework that considered the (1) digital solution; (2) actors; (3) processes and (4) context. RESULTS The scale-up of digital solutions was facilitated by their perceived value, bounded adaptability, support from government champions, cultivation of networks, sustained leadership and formative research to support fit with the context and population. However, once scaled, embedding digital health solutions into the fabric of the health system was hampered by challenges related to transitioning management and ownership to government partners; overcoming government procurement hurdles; and establishing committed funding streams in government budgets. Strong data governance, continued engagement with FLHWs and building a robust evidence base, while identified in the literature as critical for sustainability, did not feature strongly among respondents. Sustainability may be less elusive once there is more consensus around the roles played between national and state government actors, implementing and technical partners and donors. CONCLUSION The use of digital tools by FLHWs offers much promise for improving service delivery and health outcomes in India. However, the pathway to sustainability is bespoke to each programme and should be planned from the outset by investing in people, relationships and service delivery adjustments to navigate the challenges involved given the dynamic nature of digital tools in complex health systems.
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Affiliation(s)
- Neha S Singh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kerry Scott
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Asha George
- School of Public Health, University of the Western Cape, Faculty of Community and Health Sciences, Cape Town, Western Province, South Africa
| | - Amnesty Elizabeth LeFevre
- School of Public Health and Family Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Rajani Ved
- National Health Systems Resource Centre, New Delhi, Delhi, India
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Story WT, Pritchard S, Hejna E, Olivas E, Sarriot E. The role of integrated community case management projects in strengthening health systems: case study analysis in Ethiopia, Malawi and Mozambique. Health Policy Plan 2021; 36:900-912. [PMID: 33930137 DOI: 10.1093/heapol/czaa177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 11/14/2022] Open
Abstract
Integrated community case management (iCCM) has now been implemented at scale globally. Literature to-date has focused primarily on the effectiveness of iCCM and the systems conditions required to sustain iCCM. In this study, we sought to explore opportunities taken and lost for strengthening health systems through successive iCCM programmes. We employed a systematic, embedded, multiple case study design for three countries-Ethiopia, Malawi and Mozambique-where Save the Children implemented iCCM programmes between 2009 and 2017. We used textual analysis to code 62 project documents on nine categories of functions of health systems using NVivo 11.0. The document review was supplemented by four key informant interviews. This study makes important contributions to the theoretical understanding of the role of projects in health systems strengthening by not only documenting evidence of systems strengthening in multi-year iCCM projects, but also emphasizing important deficiencies in systems strengthening efforts. Projects operated on a spectrum, ranging from gap-filling interventions, to support, to actual strengthening. While there were natural limits to the influence of a project on the health system, all successive projects found constructive opportunities to try to strengthen systems. Alignment with the Ministry of Health was not always static and simple, and ministries themselves have shown pluralism in their perspectives and orientations. We conclude that systems strengthening remains 'everybody's business' and places demands for realism and transparency on government and the development architecture. While mid-size projects have limited decision space, there is value in better defining where systems strengthening contributions can actually be made. Furthermore, systems strengthening is not solely about macro-level changes, as operational and efficiency gains at meso and micro levels can have value to the system. Claims of 'systems strengthening' are, however, bounded within the quality of evaluation and learning investments.
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Affiliation(s)
- William T Story
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Susannah Pritchard
- Formerly Save the Children, Health Department, 1 St. John's Lane, London EC1M 4AR, UK
| | - Emily Hejna
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Elijah Olivas
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Eric Sarriot
- Formerly Save the Children, Department of Global Health, 899 North Capitol St NE #900, Washington, DC 20002, USA
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Sevene E, Boene H, Vidler M, Valá A, Macuacua S, Augusto O, Fernandes Q, Bique C, Macete E, Sidat M, von Dadelszen P, Munguambe K. Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique. Reprod Health 2021; 18:145. [PMID: 34229709 PMCID: PMC8259411 DOI: 10.1186/s12978-021-01192-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/24/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals. METHOD The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals. RESULTS Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility. CONCLUSIONS This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level.
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Affiliation(s)
- Esperança Sevene
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
- Department of Physiologic Science, Clinical Pharmacology, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Helena Boene
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, and The Child and Family Research Unit, University of British Columbia, Vancouver, BC Canada
| | - Anifa Valá
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Salésio Macuacua
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Orvalho Augusto
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
- Department of Community Health, Faculty of Medicine,, Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Cassimo Bique
- Ministério da Saúde, Maputo, Mozambique
- Hospital Central de Maputo, Maputo, Mozambique
| | - Eusébio Macete
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
- Ministério da Saúde, Maputo, Mozambique
| | - Mohsin Sidat
- Department of Community Health, Faculty of Medicine,, Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | - Khátia Munguambe
- Maternal Health Unit, Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
- Department of Community Health, Faculty of Medicine,, Universidade Eduardo Mondlane, Maputo, Mozambique
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Allen KC, Whitfield K, Rabinovich R, Sadruddin S. The role of governance in implementing sustainable global health interventions: review of health system integration for integrated community case management (iCCM) of childhood illnesses. BMJ Glob Health 2021; 6:bmjgh-2020-003257. [PMID: 33789866 PMCID: PMC8016094 DOI: 10.1136/bmjgh-2020-003257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 02/26/2021] [Accepted: 03/04/2021] [Indexed: 01/16/2023] Open
Abstract
Improving health outcomes in countries with the greatest burden of under-5 child mortality requires implementing innovative approaches like integrated community case management (iCCM) to improve coverage and access for hard-to-reach populations. ICCM improves access for hard-to-reach populations by deploying community health workers to manage malaria, diarrhoea and pneumonia. Despite documented impact, challenges remain in programme implementation and sustainability. An analytical review was conducted using evidence from published and grey literature from 2010 to 2019. The goal was to understand the link between governance, policy development and programme sustainability for iCCM. A Governance Analytical Framework revealed thematic challenges and successes for iCCM adaptation to national health systems. Governance in iCCM included the collective problems, actors in coordination and policy-setting, contextual norms and programmatic interactions. Key challenges were country leadership, contextual evidence and information-sharing, dependence on external funding, and disease-specific stovepipes that impede funding and coordination. Countries that tailor and adapt programmes to suit their governance processes and meet their specific needs and capacities are better able to achieve sustainability and impact in iCCM.
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Affiliation(s)
- Koya C Allen
- Malaria Eradication Scientific Alliance (MESA), Barcelona Institute for Global Health, Hospital Clínic - Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Kate Whitfield
- Malaria Eradication Scientific Alliance (MESA), Barcelona Institute for Global Health, Hospital Clínic - Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Regina Rabinovich
- Malaria Elimination Initiative, Barcelona Institute for Global Health, Hospital Clínic - Universitat de Barcelona, Barcelona, Catalunya, Spain.,ExxonMobil Malaria Scholar in Residence, Department of Immunology and Infectious Diseases, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Salim Sadruddin
- Child Health, MOMENTUM Country and Global Leadership, Washington, DC, USA
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Win Han Oo, Hoban E, Gold L, Kyu Kyu Than, Thazin La, Aung Thi, Fowkes FJI. Optimizing Myanmar's community-delivered malaria volunteer model: a qualitative study of stakeholders' perspectives. Malar J 2021; 20:79. [PMID: 33557847 PMCID: PMC7871594 DOI: 10.1186/s12936-021-03612-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/28/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In parallel with the change of malaria policy from control to elimination and declines in the malaria burden in Greater Mekong Sub-region, the motivation and social role of malaria volunteers has declined. To address this public health problem, in Myanmar, the role and responsibilities of malaria volunteers have been transformed into integrated community malaria volunteers (ICMV), that includes the integration of activities for five additional diseases (dengue, lymphatic filariasis, tuberculosis, HIV/AIDS and leprosy) into their current activities. However, this transformation was not evidence-based and did not consider inputs of different stakeholders. Therefore, qualitative stakeholder consultations were performed to optimize future malaria volunteer models in Myanmar. METHODS Semi-structured interviews were conducted with key health stakeholders from the Myanmar Ministry of Health and Sports (MoHS) and malaria implementing partners to obtain their perspectives on community-delivered malaria models. A qualitative descriptive approach was used to explore the experiences of the stakeholders in policymaking and programme implementation. Interview topic guides were used during the interviews and inductive thematic data analysis was performed. RESULTS While ICMVs successfully provided malaria services in the community, the stakeholders considered the ICMV model as not optimal and suggested that many aspects needed to be improved including better training, supervision, support, and basic health staff's recognition for ICMVs. Stakeholders believe that the upgraded ICMV model could contribute significantly to achieving malaria elimination and universal health care in Myanmar. DISCUSSION AND CONCLUSION In the context of high community demand for non-malaria treatment services from volunteers, the integrated volunteer service package must be developed carefully in order to make it effective in malaria elimination programme and to contribute in Myanmar's pathway to universal health coverage (UHC), but without harming the community. An evidenced-based, community-delivered and preferred model, that is also accepted by the MoHS, is yet to be developed to effectively contribute to achieving malaria elimination and UHC goals in Myanmar by 2030.
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Affiliation(s)
- Win Han Oo
- School of Health and Social Development, Faculty of Health, Deakin University, VIC, Australia. .,Disease Elimination Program, Burnet Institute, VIC, Australia.
| | - Elizabeth Hoban
- School of Health and Social Development, Faculty of Health, Deakin University, VIC, Australia
| | - Lisa Gold
- School of Health and Social Development, Faculty of Health, Deakin University, VIC, Australia
| | - Kyu Kyu Than
- Disease Elimination Program, Burnet Institute, VIC, Australia
| | - Thazin La
- Disease Elimination Program, Burnet Institute, VIC, Australia
| | - Aung Thi
- Department of Public Health, Myanmar Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Freya J I Fowkes
- Disease Elimination Program, Burnet Institute, VIC, Australia.,Melbourne School of Population and Global Health, University of Melbourne, VIC, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, VIC, Australia
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11
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Lennox L, Linwood-Amor A, Maher L, Reed J. Making change last? Exploring the value of sustainability approaches in healthcare: a scoping review. Health Res Policy Syst 2020; 18:120. [PMID: 33050921 PMCID: PMC7556957 DOI: 10.1186/s12961-020-00601-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/07/2020] [Indexed: 12/18/2022] Open
Abstract
Background Numerous models, tools and frameworks have been produced to improve the sustainability of evidence-based interventions. Due to the vast number available, choosing the most appropriate one is increasingly difficult for researchers and practitioners. To understand the value of such approaches, evidence warranting their use is needed. However, there is limited understanding of how sustainability approaches have been used and how they have impacted research or practice. This review aims to consolidate evidence on the application and impact of sustainability approaches in healthcare settings. Methods A systematic scoping review was designed to search for peer-reviewed publications detailing the use of sustainability approaches in practice. A 5-stage framework for scoping reviews directed the search strategy, and quality assessment was performed using the Mixed Method Appraisal Tool. Searches were performed through electronic citation tracking and snowballing of references. Articles were obtained through Web of Science, PubMed and Google Scholar. Six outcome variables for sustainability were explored to ascertain impact of approaches. Results This review includes 68 articles demonstrating the application of sustainability approaches in practice. Results show an increase in the use of sustainability approaches in peer-reviewed studies. Approaches have been applied across a range of healthcare settings, including primary, secondary, tertiary and community healthcare. Approaches are used for five main purposes, namely analysis, evaluation, guidance, assessment and planning. Results outline benefits (e.g. improved conceptualisation of sustainability constructs and improved ability to interpret sustainability data) and challenges (e.g. issues with approach constructs and difficulty in application) associated with using a sustainability approach in practice. Few articles (14/68) reported the sustainability outcome variables explored; therefore, the impact of approaches on sustainability remains unclear. Additional sustainability outcome variables reported in retrieved articles are discussed. Conclusions This review provides practitioners and researchers with a consolidated evidence base on sustainability approaches. Findings highlight the remaining gaps in the literature and emphasise the need for improved rigour and reporting of sustainability approaches in research studies. To guide future assessment and study of sustainability in healthcare settings an updated list of sustainability outcome variables is proposed. Trial Registration This review was registered on the PROSPERO database CRD 42016040081 in June 2016.
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Affiliation(s)
- L Lennox
- National Institute for Health Research, Applied Research Collaboration North West London. Imperial College London, 369 Fulham Road, SW10 9NH, London, United Kingdom.
| | - A Linwood-Amor
- Ministry of Health, Environment, Culture and Housing, George Town, Grand Cayman KY1-9000, Cayman Islands
| | - L Maher
- Ko Awatea Health System Innovation and Improvement, Middlemore Hospital, 100 Hospital Road, Otahuhu, New Zealand
| | - J Reed
- Julie Reed Consultancy, 27 Molasses House, London, SW113TN, United Kingdom
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12
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Sevene E, Sharma S, Munguambe K, Sacoor C, Vala A, Macuacua S, Boene H, Mark Ansermino J, Augusto O, Bique C, Bone J, Dunsmuir DT, Lee T, Li J, Macete E, Singer J, Wong H, Nathan HL, Payne BA, Sidat M, Shennan AH, Tchavana C, Tu DK, Vidler M, Bhutta ZA, Magee LA, von Dadelszen P. Community-level interventions for pre-eclampsia (CLIP) in Mozambique: A cluster randomised controlled trial. Pregnancy Hypertens 2020; 21:96-105. [PMID: 32464527 PMCID: PMC7471842 DOI: 10.1016/j.preghy.2020.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/28/2020] [Accepted: 05/09/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Pregnancy hypertension is the third leading cause of maternal mortality in Mozambique and contributes significantly to fetal and neonatal mortality. The objective of this trial was to assess whether task-sharing care might reduce adverse pregnancy outcomes related to delays in triage, transport, and treatment. STUDY DESIGN The Mozambique Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trial (NCT01911494) recruited pregnant women in 12 administrative posts (clusters) in Maputo and Gaza Provinces. The CLIP intervention (6 clusters) consisted of community engagement, community health worker-provided mobile health-guided clinical assessment, initial treatment, and referral to facility either urgently (<4hrs) or non-urgently (<24hrs), dependent on algorithm-defined risk. Treatment effect was estimated by multi-level logistic regression modelling, adjusted for prognostically-significant baseline variables. Predefined secondary analyses included safety and evaluation of the intensity of CLIP contacts. MAIN OUTCOME MEASURES 20% reduction in composite of maternal, fetal, and newborn mortality and major morbidity. RESULTS 15,013 women (15,123 pregnancies) were recruited in intervention (N = 7930; 2·0% loss to follow-up (LTFU)) and control (N = 7190; 2·8% LTFU) clusters. The primary outcome did not differ between intervention and control clusters (adjusted odds ratio (aOR) 1·31, 95% confidence interval (CI) [0·70, 2·48]; p = 0·40). Compared with intervention arm women without CLIP contacts, those with ≥8 contacts experienced fewer primary outcomes (aOR 0·79 (95% CI 0·63, 0·99); p = 0·041), primarily due to improved maternal outcomes (aOR 0·72 (95% CI 0·53, 0·97); p = 0·033). INTERPRETATION As generally implemented, the CLIP intervention did not improve pregnancy outcomes; community implementation of the WHO eight contact model may be beneficial. FUNDING The University of British Columbia (PRE-EMPT), a grantee of the Bill & Melinda Gates Foundation (OPP1017337).
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Affiliation(s)
- Esperança Sevene
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Faculdade de Medicina, Universidade Eduardo Mondlane, Av. Salvador Allende nr. 702, Maputo, Mozambique.
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Khátia Munguambe
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Faculdade de Medicina, Universidade Eduardo Mondlane, Av. Salvador Allende nr. 702, Maputo, Mozambique
| | - Charfudin Sacoor
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique
| | - Anifa Vala
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique
| | - Salésio Macuacua
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Direcção Provincial de Saúde, Ministério da Saúde, Av. Eduardo Mondlane n(o) 1008, CP 264 Maputo, Mozambique
| | - Helena Boene
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique
| | - J Mark Ansermino
- Centre for International Child Health, University of British Columbia, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Orvalho Augusto
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Faculdade de Medicina, Universidade Eduardo Mondlane, Av. Salvador Allende nr. 702, Maputo, Mozambique
| | - Cassimo Bique
- Departamento de Ginecologia e Obstetrícia, Hospital Central de Maputo, Av. Agostinho Neto n(o) 167, CP 1164 Maputo, Mozambique
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Dustin T Dunsmuir
- Centre for International Child Health, University of British Columbia, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Tang Lee
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Jing Li
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Eusébio Macete
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Instituto Nacional de Saúde, Ministério da Saúde, Distrito de Marracuene, Estrada Nacional N(o) 1, Maputo, Mozambique
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver V6Z 1Y6, Canada
| | - Hubert Wong
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver V6Z 1Y6, Canada
| | - Hannah L Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Place Road, London SE1 7EH, UK
| | - Beth A Payne
- Centre for International Child Health, University of British Columbia, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Mohsin Sidat
- Faculdade de Medicina, Universidade Eduardo Mondlane, Av. Salvador Allende nr. 702, Maputo, Mozambique
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Place Road, London SE1 7EH, UK
| | - Corssino Tchavana
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique
| | - Domena K Tu
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, 525 University Avenue, Suite 702, Toronto M5G 2L3, Canada
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Place Road, London SE1 7EH, UK
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Place Road, London SE1 7EH, UK
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Steege R, Taegtmeyer M, Ndima S, Give C, Sidat M, Ferrão C, Theobald S. Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique's community health workforce. HUMAN RESOURCES FOR HEALTH 2020; 18:37. [PMID: 32448359 PMCID: PMC7245854 DOI: 10.1186/s12960-020-00476-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 05/05/2020] [Indexed: 05/23/2023]
Abstract
BACKGROUND Mozambique's community health programme has a disproportionate number of male community health workers (known as Agentes Polivalentes Elementares (APEs)). The Government of Mozambique is aiming to increase the proportion of females to constitute 60% to improve maternal and child health outcomes. To understand the imbalance, this study explored the current recruitment processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience and retention of APEs in Maputo Province, Mozambique. METHODS We employed qualitative methods with APEs, APE supervisors, community leaders and a government official in two districts within Maputo Province. Interviews were recorded, transcribed and translated. A coding framework was developed in accordance with thematic analysis to synthesise the findings. FINDINGS In-depth interviews (n = 30), key informant interviews (n = 1) and focus group discussions (n = 3) captured experiences and perceptions of employment processes. Intra-household decision-making structures mean women may experience additional barriers to join the APE programme, often requiring their husband's consent. Training programmes outside of the community were viewed positively as an opportunity to build a cohort. However, women reported difficulty leaving family responsibilities behind, and men reported challenges in providing for their families during training as other income-generating opportunities were not available to them. These dynamics were particularly acute in the case of single mothers, serving both a provider and primary carer role. Differences in attrition by gender were reported: women are likely to leave the programme when they marry, whereas men tend to leave when offered another job with a higher salary. Age and geographic location were also important intersecting factors: younger male and female APEs seek employment opportunities in neighbouring South Africa, whereas older APEs are more content to remain. CONCLUSION Gender norms, roles and power dynamics intersect with other axes of inequity such as marital status, age and geographic location to impact recruitment and retention of APEs in Maputo Province, Mozambique. Responsive policies to support gender equity within APE recruitment processes are required to support and retain a gender-equitable APE cadre.
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Affiliation(s)
- Rosalind Steege
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom.
| | - Miriam Taegtmeyer
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom
| | - Sozinho Ndima
- Universidade Eduardo Mondlane, 3453 Avenida Julius Nyerere, Maputo, Mozambique
| | - Celso Give
- Universidade Eduardo Mondlane, 3453 Avenida Julius Nyerere, Maputo, Mozambique
| | - Mohsin Sidat
- Universidade Eduardo Mondlane, 3453 Avenida Julius Nyerere, Maputo, Mozambique
| | - Clara Ferrão
- Universidade Eduardo Mondlane, 3453 Avenida Julius Nyerere, Maputo, Mozambique
| | - Sally Theobald
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom
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14
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Yourkavitch J, Davis LM, Hobson R, Arscott-Mills S, Anson D, Baugh G, Sadruddin S, Mantshumba JC, Sambou B, Bakukulu JT, Leya PN, Luhanga M, Mgalula L, Jenda G, Nsona H, Nassivila SA, de Carvalho E, Smith M, Absi M, Aboubakar F, Konate AT, Wahab M, Ufere J, Isiguzo C, Ozor L, Gimba PB, Ndaliman I. Integrated community case management: planning for sustainability in five African countries. J Glob Health 2019; 9:010802. [PMID: 31275567 PMCID: PMC6596361 DOI: 10.7189/jogh.09.010802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The World Health Organization (WHO) launched an initiative to plan for the sustainability of integrated community case management (iCCM) programmes supported by the Rapid Access Expansion (RAcE) Programme in five African countries in 2016. WHO contracted experts to facilitate sustainability planning among Ministries of Health, WHO, nongovernmental organisation grantees, and other stakeholders. Methods We designed an iterative and unique process for each RAcE project area which involved creating a sustainability framework to guide planning; convening meetings to identify and prioritise elements of the framework; forming technical working groups to build country ownership; and, ultimately, creating roadmaps to guide efforts to fully transfer ownership of the iCCM programmes to host countries. For this analysis, we compared priorities identified in roadmaps across RAcE project sites, examined progress against roadmaps via transition plans, and produced recommendations for short-term actions based on roadmap priorities that were unaddressed or needed further attention. Results This article describes the sustainability planning process, roadmap priorities, progress against roadmaps, and recommendations made for each project area. We found a few patterns among the prioritised roadmap elements. Overall, every project area identified priorities related to policy and coordination of external stakeholders including funders; supply chain management; service delivery and referral system; and communication and social mobilisation, indicating that these factors have persisted despite iCCM programme maturity, and are also of concern to new programmes. We also found that a facilitated process to identify and document programme priorities in roadmaps, along with deliberately planning for transition from an external implementer to a national system could support the sustainability of iCCM programmes by facilitating teams of stakeholders to accomplish explicit tasks related to transitioning the programme. Conclusions Certain common elements are of concern for sustaining iCCM programmes across countries, among them political leadership, supply chain management, data processes, human resources, and community engagement. Adapting and using a sustainability planning approach created an inclusive and comprehensive dialogue about systemic factors that influence the sustainability of iCCM services and facilitated changes to health systems in each country.
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Affiliation(s)
| | | | | | | | - Daniel Anson
- Independent Consultant, Silver Spring, Maryland, USA; formerly ICF, Rockville, Maryland, USA
| | | | | | | | - Bacary Sambou
- World Health Organization, Kinshasa, Democratic Republic of Congo
| | | | - Pascal Ngoy Leya
- Abt Associates; formerly International Rescue Committee, Kinshasa, Democratic Republic of Congo
| | | | | | | | | | | | | | | | | | | | | | | | - Joy Ufere
- World Health Organization, Abuja, Nigeria
| | | | - Lynda Ozor
- World Health Organization, Abuja, Nigeria
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15
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Topp SM, Chetty-Makkan CM, Smith HJ, Chimoyi L, Hoffmann CJ, Fielding K, Reid SE, Olivier AJ, Hausler H, Herce ME, Charalambous S. "It's Not Like Taking Chocolates": Factors Influencing the Feasibility and Sustainability of Universal Test and Treat in Correctional Health Systems in Zambia and South Africa. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:189-202. [PMID: 31249019 PMCID: PMC6641809 DOI: 10.9745/ghsp-d-19-00051] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/09/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sub-Saharan African correctional facilities concentrate large numbers of people who are living with HIV or at risk for HIV infection. Universal test and treat (UTT) is widely recognized as a promising approach to improve the health of individuals and a population health strategy to reduce new HIV infections. In this study, we explored the feasibility and sustainability of implementing UTT in correctional facilities in Zambia and South Africa. METHODS Nested within a UTT implementation research study, our qualitative evaluation of feasibility and sustainability used a case-comparison design based on data from 1 Zambian and 3 South African correctional facilities. Primary data from in-depth interviews with incarcerated individuals, correctional managers, health care providers, and policy makers were supplemented by public policy documents, study documentation, and implementation memos in both countries. Thematic analysis was informed by an empirically established conceptual framework for health system analysis. RESULTS Despite different institutional profiles, we were able to successfully introduce UTT in the South Africa and Zambian correctional facilities participating in the study. A supportive policy backdrop was important to UTT implementation and establishment in both countries. However, sustainability of UTT, defined as relevant government departments' capacity to independently plan, resource, and administer quality UTT, differed. South Africa's correctional facilities had existing systems to deliver and monitor chronic HIV care and treatment, forming a "scaffolding" for sustained UTT despite some human resources shortages and poorly integrated health information systems. Notwithstanding recent improvements, Zambia's correctional health system demonstrated insufficient material and technical capacity to independently deliver quality UTT. In the correctional facilities of both countries, inmate population dynamics and their impact on HIV-related stigma were important factors in UTT service uptake. CONCLUSION Findings demonstrate the critical role of policy directives, health service delivery systems, adequate resourcing, and population dynamics on the feasibility and likely sustainability of UTT in corrections in Zambia and South Africa.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia. .,Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | | | - Helene J Smith
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | | | | | | | - Stewart E Reid
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.,Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA
| | | | | | - Michael E Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.,Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Abstract
OBJECTIVE To assess the current prevalence, awareness, treatment and control of arterial hypertension in Mozambican population, including adolescents and young adults, and to appraise their trends over the past decade, for the 25-64 years old population. METHODS A cross-sectional study of a representative sample of the population aged 15-64 years (n = 2965) was conducted in 2014-2015, following the Stepwise Approach to Chronic Disease Risk Factor Surveillance. Data from a survey conducted in 2005 using the same methodological approach was used to assess trends in the age group of 25-64 years. RESULTS The prevalence of hypertension increased significantly, from 33.1 to 38.9% (P = 0.048), whereas awareness (2005 vs. 2014-2015: 14.8 vs. 14.5%, P = 0.914) and treatment among the aware (2005 vs. 2014-2015: 51.9 vs. 50.1%, P = 0.770) remained similar. Control among the treated increased (from 39.9 to 44.5%, P = 0.587), although not significantly. Mean blood pressure values increased (SBP: from 132.1 to 134.6 mmHg, P = 0.089; DBP: from 78.2 to 82.5 mmHg, P < 0.001). Among participants aged 15-24 years, in 2014-2015 the prevalence of hypertension was 13.1% (95% confidence interval: 9.8-16.4). CONCLUSION Our findings show that the prevalence of hypertension in Mozambique is among the highest in developing countries, both in adults and adolescents, portraying an ample margin for reduction of the morbidity and mortality burden because of high blood pressure.
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Hobday K, Hulme J, Prata N, Wate PZ, Belton S, Homer C. Scaling Up Misoprostol to Prevent Postpartum Hemorrhage at Home Births in Mozambique: A Case Study Applying the ExpandNet/WHO Framework. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:66-86. [PMID: 30926738 PMCID: PMC6538124 DOI: 10.9745/ghsp-d-18-00475] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/03/2019] [Indexed: 11/15/2022]
Abstract
Facilitating factors for this community-level scale up in 35 districts included strong government support, local champions, and a national policy on preventing postpartum hemorrhage (PPH). Challenges included a lack of a systematic scale-up strategy, limited communication of the PPH policy, a shift from a universal distribution policy to application of eligibility criteria, difficulties engaging remote traditional birth attendants, and implementation of a parallel M&E system. Background: Mozambique has a high maternal mortality ratio, and postpartum hemorrhage (PPH) is a leading cause of maternal deaths. In 2015, the Mozambican Ministry of Health (MOH) commenced a program to distribute misoprostol at the community level in selected districts as a strategy to reduce PPH. This case study uses the ExpandNet/World Health Organization (WHO) scale-up framework to examine the planning, management, and outcomes of the early expansion phase of the scale-up of misoprostol for the prevention of PPH in 2 provinces in Mozambique. Methods: Qualitative semistructured interviews were conducted between February and October 2017 in 5 participating districts in 2 provinces. Participants included program stakeholders, health staff, community health workers (CHWs), and traditional birth attendants (TBAs). Interviews were analyzed using the ExpandNet/WHO framework alongside national policy and planning documents and notes from a 2017 national Ministry of Health maternal, newborn, and child health workshop. Outcomes were estimated using misoprostol coverage and access in 2017 for both provinces. Results: The study revealed a number of barriers and facilitators to scale-up. Facilitators included a supportive political and legal environment; a clear, credible, and relevant innovation; early expansion into some Ministry of Health systems and a strong network of CHWs and TBAs. Barriers included a reduction in reach due to a shift from universal distribution to application of eligibility criteria; fear of misdirecting misoprostol for abortion or labor induction; limited communication and understanding of the national PPH prevention strategy; inadequate monitoring and evaluation; challenges with logistics systems; and the inability to engage remote TBAs. Lower coverage was found in Inhambane province than Nampula province, possibly due to NGO support and political champions. Conclusion: This study identified the need for a formal review of the misoprostol program to identify adaptations and to develop a systematic scale-up strategy to guide national scale-up.
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Affiliation(s)
- Karen Hobday
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia.
| | - Jennifer Hulme
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Ndola Prata
- Bixby Center for Population, Health and Sustainability, University of California-Berkeley, Berkeley, CA, USA
| | - Páscoa Zualo Wate
- Department of Women's and Child Health, Ministry of Health, Maputo, Mozambique
| | - Suzanne Belton
- Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
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Davlantes E, Salomao C, Wate F, Sarmento D, Rodrigues H, Halsey ES, Lewis L, Candrinho B, Zulliger R. Malaria case management commodity supply and use by community health workers in Mozambique, 2017. Malar J 2019; 18:47. [PMID: 30791915 PMCID: PMC6385463 DOI: 10.1186/s12936-019-2682-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/14/2019] [Indexed: 11/25/2022] Open
Abstract
Background Community health workers (CHWs) provide preventive care and integrated community case management (iCCM) to people with low healthcare access worldwide. CHW programmes have helped reduce mortality in myriad countries, but little data on malaria supply chain management has been shared. This project evaluated the current composition, use, and delivery of malaria iCCM kit commodities in Mozambique—rapid diagnostic tests (RDTs) and artemether–lumefantrine (AL) treatments—to better tailor existing resources to the needs of CHWs in diverse practice settings. Methods Health facilities in Maputo (low malaria burden), Inhambane (moderate), and Nampula (high) Provinces were selected using probability proportionate to the number of CHWs at each facility. All CHWs and their supervisors at selected facilities were interviewed using a structured questionnaire to document experiences with kit commodities. Data were analysed to assess CHW commodity stock levels by province and season. Results In total, 216 CHWs and 56 supervisors were interviewed at 56 health facilities. CHWs reported receiving an average of 6.7 kits in the last year, although they are intended to receive kits monthly. One-tenth of CHWs reported receiving kits with missing RDTs, and 28% reported lacking some AL treatments. Commodity use was highest in the rainy season. Stockouts were reported by CHWs in all provinces, more commonly in the rainy season. Facility-level stockouts of RDTs or some AL formulation in the past year were reported by 66% of supervisors. Use of CHW kit materials by health facilities was reported by 43% of supervisors; this was most common at facilities experiencing stockouts. Conclusions Variations in geographic and seasonal malaria commodity needs should be considered in CHW kit distribution planning in Mozambique. Improvements in provision of complete, monthly CHW kits are needed in parallel with improvements in the broader commodity system strengthening. The findings of this evaluation can help other CHW programmes determine best practices for management of iCCM supply chains. Electronic supplementary material The online version of this article (10.1186/s12936-019-2682-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elizabeth Davlantes
- Epidemic Intelligence Service, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS A-06, Atlanta, GA, 30333, USA. .,Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Cristolde Salomao
- National Institute of Health, Ministry of Health, Maputo, Mozambique.,Field Epidemiology Training Programme, African Field Epidemiology Network, Maputo, Mozambique
| | - Flavio Wate
- United States President's Malaria Initiative, US Agency for International Development, Maputo, Mozambique
| | - Deonilde Sarmento
- Field Epidemiology Training Programme, African Field Epidemiology Network, Maputo, Mozambique
| | - Humberto Rodrigues
- National Community Health Worker Programme, Ministry of Health, Maputo, Mozambique
| | - Eric S Halsey
- United States President's Malaria Initiative, US Centers for Disease Control and Prevention, Atlanta, GA, USA.,Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lauren Lewis
- United States President's Malaria Initiative, US Centers for Disease Control and Prevention, Atlanta, GA, USA.,Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Baltazar Candrinho
- National Malaria Control Programme, Ministry of Health, Maputo, Mozambique
| | - Rose Zulliger
- United States President's Malaria Initiative, US Centers for Disease Control and Prevention, Atlanta, GA, USA.,Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, GA, USA
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Galle A, Vermandere H, Griffin S, de Melo M, Machaieie L, Van Braeckel D, Degomme O. Quality of care in family planning services in rural Mozambique with a focus on long acting reversible contraceptives: a cross-sectional survey. BMC Womens Health 2018; 18:201. [PMID: 30541528 PMCID: PMC6291923 DOI: 10.1186/s12905-018-0692-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Mozambique, both the government and partners have undertaken efforts over the last decade to improve FP (family planning) services, especially through training health care providers and promoting the uptake of LARCs (Long Acting Reversible Contraceptives). Despite this, uptake of FP methods has not increased significantly. This study aims to examine women's knowledge on LARCs, including their main sources of information, and the quality of care of FP services in rural areas. METHODS We conducted a repeated cross-sectional study, interviewing 417 women leaving FP consultations in 15 health facilities in Maputo Province, Mozambique. The main quality outputs measured were: 1)discussed, preferred and received contraceptive methods, 2)information received on usage and side-effects, 3)client-provider interaction, 4)being informed about the need for a follow-up visit 5)health examinations conducted and travel time to the facility. In addition, knowledge on LARCs was measured among the clients as well as sources of information regarding FP methods. Taking into account the design effect of the study, Chi-square statistics were used to detect differences between groups and linear regression analyses to identify associations between sources of information and higher knowledge. RESULTS We found that IUDs (intrauterine devices) and implants were discussed in 23 and 33% of the consultations respectively, but only administered in a very few cases(< 1%). Half of the women were counselled on side-effects of contraceptives; this did not differ between first time clients and follow-up clients. Almost all women(98%) were satisfied with the received service and 83% of the women found the waiting time acceptable. Health examinations were performed on 18% of the women. Overall, women's knowledge about LARCs was poor and misconceptions are still common. Women who had received FP information through outreach activities had better knowledge than those counselled at a facility. CONCLUSIONS Our study highlights that only a minority of the women received information regarding LARCs during the consultation and that usage is almost non-existent. Counseling about all types of contraceptives during the consultation is sub-optimal, resulting in poorly informed clients. Multifaceted long-term interventions, focusing on both users and providers, are needed to improve uptake of contraceptives (including LARCs) in rural areas.
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Affiliation(s)
- Anna Galle
- International Centre for Reproductive Health, Ghent University, Corneel Heymanslaan 10, UZP 114, 9000 Ghent, Belgium
| | - Heleen Vermandere
- International Centre for Reproductive Health, Ghent University, Corneel Heymanslaan 10, UZP 114, 9000 Ghent, Belgium
| | - Sally Griffin
- International Centre for Reproductive Health, Rua das Flores no 34, Impasse 1085/87, Maputo, Mozambique
| | - Málica de Melo
- International Centre for Reproductive Health, Rua das Flores no 34, Impasse 1085/87, Maputo, Mozambique
| | - Lino Machaieie
- International Centre for Reproductive Health, Rua das Flores no 34, Impasse 1085/87, Maputo, Mozambique
| | - Dirk Van Braeckel
- International Centre for Reproductive Health, Ghent University, Corneel Heymanslaan 10, UZP 114, 9000 Ghent, Belgium
| | - Olivier Degomme
- International Centre for Reproductive Health, Ghent University, Corneel Heymanslaan 10, UZP 114, 9000 Ghent, Belgium
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Hobday K, Hulme J, Homer C, Zualo Wate P, Belton S, Prata N. "My job is to get pregnant women to the hospital": a qualitative study of the role of traditional birth attendants in the distribution of misoprostol to prevent post-partum haemorrhage in two provinces in Mozambique. Reprod Health 2018; 15:174. [PMID: 30326927 PMCID: PMC6192310 DOI: 10.1186/s12978-018-0622-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 10/03/2018] [Indexed: 11/10/2022] Open
Abstract
Background Post-partum haemorrhage is the leading cause of maternal deaths in Mozambique. In 2015, the Mozambican Ministry of Health launched the National Strategy for the Prevention of Post-Partum Haemorrhage at the Community Level. The strategy included the distribution of misoprostol to women in advance at antenatal care and via Traditional Birth Attendants who directly administer the medication. The study explores the role of Traditional Birth Attendants in the misoprostol program and the views of women who used misoprostol to prevent post-partum haemorrhage. Methods This descriptive study collected data through in-depth interviews and focus group discussions. Traditional Birth Attendants between the ages of 30–70 and women of reproductive age participated in the study. Data was collected between June–October 2017 in Inhambane and Nampula Provinces. Line by line thematic analysis was used to interpret the data using Nvivo (v.11). Results The majority of TBAs in the study were satisfied with their role in the misoprostol program and were motivated to work with the formal health system to encourage women to access facility based births. Women who used misoprostol were also satisfied with the medication and encouraged family and friends to access it when needed. Women in the community and Traditional Birth Attendants requested assistance with transportation to reach the health facility to avoid home births. Conclusions This study contributes to the evidence base that Traditional Birth Attendants are an appropriate channel for the distribution of misoprostol for the prevention of post-partum haemorrhage at the community level. More support and resources are needed to ensure Traditional Birth Attendants can assist women to have safe births when they are unable to reach the health facility. A consistent supply of misoprostol is needed to ensure women at the community level receive this life saving medication.
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Affiliation(s)
- Karen Hobday
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
| | - Jennifer Hulme
- Department of Emergency Medicine, University Health Network, University of Toronto, Toronto, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Caroline Homer
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia.,Honorary Fellow, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Maternal and Child Health Program, Burnet Institute, Melbourne, Australia
| | - Páscoa Zualo Wate
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Suzanne Belton
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Ndola Prata
- Bixby Center for Population, Health and Sustainability, School of Public Health, University of California, Berkeley, USA
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21
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George AS, LeFevre AE, Schleiff M, Mancuso A, Sacks E, Sarriot E. Hubris, humility and humanity: expanding evidence approaches for improving and sustaining community health programmes. BMJ Glob Health 2018; 3:e000811. [PMID: 29946489 PMCID: PMC6014224 DOI: 10.1136/bmjgh-2018-000811] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/03/2018] [Accepted: 05/03/2018] [Indexed: 11/16/2022] Open
Abstract
Community-based approaches are a critical foundation for many health outcomes, including reproductive, maternal, newborn and child health (RMNCH). Evidence is a vital part of strengthening that foundation, but largely focuses on the technical content of what must be done, rather than on how disparate community actors continuously interpret, implement and adapt interventions in dynamic and varied community health systems. We argue that efforts to strengthen evidence for community programmes must guard against the hubris of relying on a single approach or hierarchy of evidence for the range of research questions that arise when sustaining community programmes at scale. Moving forward we need a broader evidence agenda that better addresses the implementation realities influencing the scale and sustainability of community programmes and the partnerships underpinning them if future gains in community RMNCH are to be realised. This will require humility in understanding communities as social systems, the complexity of the interventions they engage with and the heterogeneity of evidence needs that address the implementation challenges faced. It also entails building common ground across epistemological word views to strengthen the robustness of implementation research by improving the use of conceptual frameworks, addressing uncertainty and fostering collaboration. Given the complexity of scaling up and sustaining community RMNCH, ensuring that evidence translates into action will require the ongoing brokering of relationships to support the human creativity, scepticism and scaffolding that together build layers of evidence, critical thinking and collaborative learning to effect change.
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Affiliation(s)
- Asha S George
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Amnesty E LeFevre
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Emma Sacks
- Johns Hopkins University, Baltimore, Maryland, USA.,Maternal and Child Survival Program, USAID, Washington, District of Columbia, USA
| | - Eric Sarriot
- Maternal and Child Survival Program, USAID, Washington, District of Columbia, USA.,Save the Children, Washington, District of Columbia, USA
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22
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Guenther T, Sadruddin S, Finnegan K, Wetzler E, Ibo F, Rapaz P, Koepsell J, Khan IUH, Amouzou A. Contribution of community health workers to improving access to timely and appropriate case management of childhood fever in Mozambique. J Glob Health 2018; 7:010402. [PMID: 28400951 PMCID: PMC5344010 DOI: 10.7189/jogh.07.010402] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Large scale evaluations in several settings have demonstrated that lay community health workers can be trained to provide quality case management of childhood illnesses. In 2010, Mozambique introduced the integrated community case management (iCCM) strategy to reach children in remote areas with care provided through Agentes Polivalentes Elementares (APEs). We assessed the contribution of the program to improved care–seeking and appropriate treatment of childhood febrile illness in Nampula Province. Methods We used a post–test quasi–experimental design with three intervention and one comparison districts to compare access and appropriateness of care for sick children in Nampula province. We carried out a household survey in the study districts to measure levels of care–seeking and treatment of childhood fever after approximately two years of full implementation of the iCCM program in the intervention districts. We also assessed consistency of care with standard case management protocols comparing children receiving care from (APEs) to those receiving care from first–level health facilities. Results A total of 773 children 6–59 months with fever in the last two weeks were included in the study. In iCCM served areas, APEs were the predominant source of care and treatment; 87.1% (95% confidence interval CI 80.8–93.4) of children 6–59 months with fever who sought care were taken first to an APE and APEs accounted for 86.2% (95% CI 79.7–92.7) of all first–line antimalarial treatments. Public health facilities were the leading source of care in comparison areas, providing care to 86.1% (95% CI 79.0–93.3) of children with fever taken for care outside the home. Timeliness of treatment was significantly better in intervention areas, where 63.9% (95% CI 54.4–73.3) of children received treatment within 24 hours of symptom onset compared to 37.5% (95% CI 31.1–43.9) in comparison areas. Children taken first to an APE were more likely to receive a rapid diagnostic test (RDT) (68.1%; 95% CI 57.2–79.0) and to have their respiratory rate assessed (60.0%; 95% CI 45.4–74.6) compared to children taken to health facilities (41.4%; 95% CI33.7–49.2 and 19.4%; 95% CI 8.4–30.5, respectively). Overall, 61.3% (95% CI 51.5–71.0) of children with fever receiving care from APEs received the correct drug within 24 hours and for the correct duration compared to 26.0% (95% CI 18.2–33.9) of those receiving care from health facilities. Conclusion iCCM contributed to improved timely and appropriate treatment for fever for children living far from facilities. Trained, supplied and supervised APEs provided care consistent with iCCM protocols and performed significantly better than first level facilities on most measures of adherence to case management protocols. These findings reinforce the need for comprehensive efforts to strengthen the health system in Mozambique to enable reliable support for quality of case management of childhood illness at both health facility and community levels.
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Affiliation(s)
| | | | - Karen Finnegan
- Johns Hopkins University, Institute of International Programs, Baltimore, Maryland, USA
| | | | - Fatima Ibo
- Save the Children International, Maputo, Mozambique
| | - Paulo Rapaz
- Save the Children International, Maputo, Mozambique
| | | | | | - Agbessi Amouzou
- Johns Hopkins University, Institute of International Programs, Baltimore, Maryland, USA
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23
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Ortu G, Williams O. Neglected tropical diseases: exploring long term practical approaches to achieve sustainable disease elimination and beyond. Infect Dis Poverty 2017; 6:147. [PMID: 28950893 PMCID: PMC5615470 DOI: 10.1186/s40249-017-0361-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/07/2017] [Indexed: 02/06/2023] Open
Abstract
Background Remarkable progress has been made in the fight against neglected tropical diseases, but new challenges have emerged. Innovative diagnostics, better drugs and new insecticides are often identified as the priority; however, access to these new tools may not be sufficient to achieve and sustain disease elimination, if certain challenges and priorities are not considered. Main body The authors summarise key operational challenges, and based on these, identify two major priorities: strengthening the capacity of the primary health care health system in correctly diagnosing and managing neglected tropical diseases; and establishing an effective disease surveillance process. Five steps are proposed as concrete actions to build an effective primary health care service for neglected tropical diseases, and a health management information system capable of accurately reporting these diseases. Community engagement and formalization of community health workers role are proposed as essential components of these steps. Shift of financial support from disease oriented programmes to disease integrated interventions, improved access to international guidelines for primary health care staff, and availability of donated drugs in health care structures are also suggested as key elements of the proposed process. Conclusion The authors conclude that failure to address these priorities now may lead to further challenges on the long path towards neglected tropical disease elimination and beyond. Electronic supplementary material The online version of this article (doi: 10.1186/s40249-017-0361-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giuseppina Ortu
- Malaria Consortium, Development House, 56-54 Leonard street, London, EC24 4LT, UK.
| | - Oliver Williams
- Malaria Consortium, Development House, 56-54 Leonard street, London, EC24 4LT, UK
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Lennox L, Doyle C, Reed JE, Bell D. What makes a sustainability tool valuable, practical and useful in real-world healthcare practice? A mixed-methods study on the development of the Long Term Success Tool in Northwest London. BMJ Open 2017; 7:e014417. [PMID: 28947436 PMCID: PMC5623390 DOI: 10.1136/bmjopen-2016-014417] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Although improvement initiatives show benefits to patient care, they often fail to sustain. Models and frameworks exist to address this challenge, but issues with design, clarity and usability have been barriers to use in healthcare settings. This work aimed to collaborate with stakeholders to develop a sustainability tool relevant to people in healthcare settings and practical for use in improvement initiatives. DESIGN Tool development was conducted in six stages. A scoping literature review, group discussions and a stakeholder engagement event explored literature findings and their resonance with stakeholders in healthcare settings. Interviews, small-scale trialling and piloting explored the design and tested the practicality of the tool in improvement initiatives. SETTING National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London (CLAHRC NWL). PARTICIPANTS CLAHRC NWL improvement initiative teams and staff. RESULTS The iterative design process and engagement of stakeholders informed the articulation of the sustainability factors identified from the literature and guided tool design for practical application. Key iterations of factors and tool design are discussed. From the development process, the Long Term Success Tool (LTST) has been designed. The Tool supports those implementing improvements to reflect on 12 sustainability factors to identify risks to increase chances of achieving sustainability over time. The Tool is designed to provide a platform for improvement teams to share their own views on sustainability as well as learn about the different views held within their team to prompt discussion and actions. CONCLUSION The development of the LTST has reinforced the importance of working with stakeholders to design strategies which respond to their needs and preferences and can practically be implemented in real-world settings. Further research is required to study the use and effectiveness of the tool in practice and assess engagement with the method over time.
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Affiliation(s)
- Laura Lennox
- Department of Medicine, CLAHRC for Northwest London, London, UK
- Department of Medicine, Imperial College London, London, UK
| | | | - Julie E Reed
- NIHR CLAHRC for Northwest London, London, UK
- Department of Public Health and Primary Care, Imperial College London, London, UK
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Escribano Ferrer B, Hansen KS, Gyapong M, Bruce J, Narh Bana SA, Narh CT, Allotey NK, Glover R, Azantilow NC, Bart-Plange C, Sagoe-Moses I, Webster J. Cost-effectiveness analysis of the national implementation of integrated community case management and community-based health planning and services in Ghana for the treatment of malaria, diarrhoea and pneumonia. Malar J 2017; 16:277. [PMID: 28679378 PMCID: PMC5498878 DOI: 10.1186/s12936-017-1906-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 06/26/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Ghana has developed two main community-based strategies that aim to increase access to quality treatment for malaria, diarrhoea and suspected pneumonia: the integrated community case management (iCCM) and the community-based health planning and services (CHPS). The aim of the study was to assess the cost-effectiveness of these strategies under programme conditions. METHODS A cost-effectiveness analysis was conducted. Appropriate diagnosis and treatment given was the effectiveness measure used. Appropriate diagnosis and treatment data was obtained from a household survey conducted 2 and 8 years after implementation of iCCM in the Volta and Northern Regions of Ghana, respectively. The study population was carers of children under-5 years who had fever, diarrhoea and/or cough in the last 2 weeks prior to the interview. Costs data was obtained mainly from the National Malaria Control Programme (NMCP), the Ministry of Health, CHPS compounds and from a household survey. RESULTS Appropriate diagnosis and treatment of malaria, diarrhoea and suspected pneumonia was more cost-effective under the iCCM than under CHPS in the Volta Region, even after adjusting for different discount rates, facility costs and iCCM and CHPS utilization, but not when iCCM appropriate treatment was reduced by 50%. Due to low numbers of carers visiting a CBA in the Northern Region it was not possible to conduct a cost-effectiveness analysis in this region. However, the cost analysis showed that iCCM in the Northern Region had higher cost per malaria, diarrhoea and suspected pneumonia case diagnosed and treated when compared to the Volta Region and to the CHPS strategy in the Northern Region. CONCLUSIONS Integrated community case management was more cost-effective than CHPS for the treatment of malaria, diarrhoea and suspected pneumonia when utilized by carers of children under-5 years in the Volta Region. A revision of the iCCM strategy in the Northern Region is needed to improve its cost-effectiveness. Long-term financing strategies should be explored including potential inclusion in the National Health Insurance Scheme (NHIS) benefit package. An acceptability study of including iCCM in the NHIS should be conducted.
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Affiliation(s)
- Blanca Escribano Ferrer
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
- Dodowa Health Research Center, Ghana Health Service, Dodowa, Ghana
| | | | - Margaret Gyapong
- Dodowa Health Research Center, Ghana Health Service, Dodowa, Ghana
| | - Jane Bruce
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Clement T. Narh
- School of Public Health, University of Health and Allied Sciences, Hohoe, Volta Region Ghana
| | | | - Roland Glover
- National Malaria Control Programme, Ghana Health Service, Accra, Ghana
| | | | | | | | - Jayne Webster
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
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Sunguya BF, Mlunde LB, Ayer R, Jimba M. Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review. Malar J 2017; 16:10. [PMID: 28049486 PMCID: PMC5209914 DOI: 10.1186/s12936-016-1667-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 12/22/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Human resource for health crisis has impaired global efforts against malaria in highly endemic countries. To address this, the World Health Organization (WHO) recommended scaling-up of community health workers (CHWs) and related cadres owing to their documented success in malaria and other disease prevention and management. Evidence is inconsistent on the roles and challenges they encounter in malaria interventions. This systematic review aims to summarize evidence on roles and challenges of CHWs and related cadres in integrated community case management for malaria (iCCM). METHODS This systematic review retrieved evidence from PubMed, CINAHL, ISI Web of Knowledge, and WHO regional databases. Terms extracted from the Boolean phrase used for PubMed were also used in other databases. The review included studies with Randomized Control Trial, Quasi-experimental, Pre-post interventional, Longitudinal and cohort, Cross-sectional, Case study, and Secondary data analysis. Because of heterogeneity, only narrative synthesis was conducted for this review. RESULTS A total of 66 articles were eligible for analysis out of 1380 studies retrieved. CHWs and related cadre roles in malaria interventions included: malaria case management, prevention including health surveillance and health promotion specific to malaria. Despite their documented success, CHWs and related cadres succumb to health system challenges. These are poor and unsustainable finance for iCCM, workforce related challenges, lack of and unsustainable supply of medicines and diagnostics, lack of information and research, service delivery and leadership challenges. CONCLUSIONS Community health workers and related cadres had important preventive, case management and promotive roles in malaria interventions. To enable their effective integration into the health systems, the identified challenges should be addressed. They include: introducing sustainable financing on iCCM programmes, tailoring their training to address the identified gaps, improving sustainable supply chain management of malaria drugs and diagnostics, and addressing regulatory challenges in the local contexts.
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Affiliation(s)
- Bruno F. Sunguya
- Department of Community Health, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Linda B. Mlunde
- Management for Development and Health, Dar es Salaam, Tanzania
| | - Rakesh Ayer
- Department of Community and Global Health, The University of Tokyo, Tokyo, Japan
| | - Masamine Jimba
- Department of Community and Global Health, The University of Tokyo, Tokyo, Japan
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Boene H, Vidler M, Augusto O, Sidat M, Macete E, Menéndez C, Sawchuck D, Qureshi R, von Dadelszen P, Munguambe K, Sevene E. Community health worker knowledge and management of pre-eclampsia in southern Mozambique. Reprod Health 2016; 13:105. [PMID: 27719683 PMCID: PMC5056526 DOI: 10.1186/s12978-016-0220-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Mozambique has drastically improved an array of health indicators in recent years, including maternal mortality rates which decreased 63 % from 1990–2013 but the rates still high. Pre-eclampsia and eclampsia constitute the third major cause of maternal death in the country. Women in rural areas, with limited access to health facilities are at greatest risk. This study aimed to assess the current state of knowledge and the regular practices regarding pre-eclampsia and eclampsia by community health workers in southern Mozambique. Methods This mixed methods study was conducted from 2013 to 2014, in Maputo and Gaza Provinces, southern Mozambique. Self-administered questionnaires, in-depth interviews and focus group discussions were conducted with CHWs, district medical officers, community health workers’ supervisors, Gynaecologists-Obstetricians and matrons. Quantitative data were entered into a database written in REDCap and subsequently analyzed using Stata 13. Qualitative data was imported into NVivo10 for thematic analysis. Results Ninety-three percent of CHW had some awareness of pregnancy complications. Forty-one percent were able to describe the signs and symptoms of hypertension. In cases of eclampsia, CHWs reported to immediately refer the women. The vast majority of the CHWs surveyed reported that they could neither measure blood pressure nor proteinuria (90 %). Fewer reported confidence in providing oral antihypertensives (14 %) or injections in pregnancy (5 %). The other community health care providers are matrons. They do not formally offer health services, but assists pregnant women in case of an emergency. Regarding pre-eclampsia and eclampsia, matrons were unable to recognise these biomedical terms. Conclusions Although CHWs are aware of pregnancy complications, they hold limited knowledge specific to pre-eclampsia and eclampsia. There is a need to promote studies to evaluate the impact of enhancing their training to include additional content related to the identification and management of pre-eclampsia and eclampsia. Electronic supplementary material The online version of this article (doi:10.1186/s12978-016-0220-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Helena Boene
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Vila da Manhiça, CP 1929, Moçambique
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, and the Child and Family Research Institute, University of British Columbia, 950 West 28th Avenue, Vancouver, V5Z4H4, Canada
| | - Orvalho Augusto
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Vila da Manhiça, CP 1929, Moçambique.,Universidade Eduardo Mondlane, Faculdade de Medicina, Av. Salvador Allende, 702 R/C, Maputo, Moçambique
| | - Mohsin Sidat
- Universidade Eduardo Mondlane, Faculdade de Medicina, Av. Salvador Allende, 702 R/C, Maputo, Moçambique
| | - Eusébio Macete
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Vila da Manhiça, CP 1929, Moçambique.,Ministério da Saúde, Av. Eduardo Mondlane, Maputo, 1008, Moçambique
| | - Clara Menéndez
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Vila da Manhiça, CP 1929, Moçambique.,Barcelona Institute for Global Health (ISGlobal) /Hospital Clinic - Universitat de Barcelona, Calle Rosselló, 132, Barcelona, 08036, Spain
| | - Diane Sawchuck
- Department of Research, Vancouver Island Health Authority, Victoria, V8R 1J8, Canada
| | - Rahat Qureshi
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, St George's University London, London, SW17 0RE, UK
| | - Khátia Munguambe
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Vila da Manhiça, CP 1929, Moçambique.,Universidade Eduardo Mondlane, Faculdade de Medicina, Av. Salvador Allende, 702 R/C, Maputo, Moçambique
| | - Esperança Sevene
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Vila da Manhiça, CP 1929, Moçambique. .,Universidade Eduardo Mondlane, Faculdade de Medicina, Av. Salvador Allende, 702 R/C, Maputo, Moçambique.
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Jacinto A, Mobaracaly MR, Ustáb MB, Bique C, Blazer C, Weidert K, Prata N. Safety and Acceptability of Community-Based Distribution of Injectable Contraceptives: A Pilot Project in Mozambique. GLOBAL HEALTH: SCIENCE AND PRACTICE 2016; 4:410-21. [PMID: 27651076 PMCID: PMC5042697 DOI: 10.9745/ghsp-d-16-00133] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/05/2016] [Indexed: 11/17/2022]
Abstract
Trained community health workers, including traditional birth attendants (TBAs), safely and effectively administered injectables in northern Mozambique; two-thirds of the women choosing injectables had never used contraception before. Including TBAs in the Ministry of Health’s recent task sharing strategy can improve rural women’s access to injectables and help meet women’s demand for contraception. Mozambique has witnessed a climbing total fertility rate in the last 20 years. Nearly one-third of married women have an unmet need for family planning, but the supply of family planning services is not meeting the demand. This study aimed to explore the safety and effectiveness of training 2 cadres of community health workers—traditional birth attendants (TBAs) and agentes polivalentes elementares (APEs) (polyvalent elementary health workers)—to administer the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), and to provide evidence to policy makers on the feasibility of expanding community-based distribution of DMPA in areas where TBAs and APEs are present. A total of 1,432 women enrolled in the study between February 2014 and April 2015. The majority (63% to 66%) of women in the study started using contraception for the first time during the study period, and most women (over 66%) did not report side effects at the 3-month and 6-month follow-up visits. Very few (less than 0.5%) experienced morbidities at the injection site on the arm. Satisfaction with the performance of TBAs and APEs was high and improved over the study period. Overall, the project showed a high continuation rate (81.1%) after 3 injections, with TBA clients having significantly higher continuation rates than APE clients after 3 months and after 6 months. Clients’ reported willingness to pay for DMPA (64%) highlights the latent demand for modern contraceptives. Given Mozambique’s largely rural population and critical health care workforce shortage, community-based provision of family planning in general and of injectable contraceptives in particular, which has been shown to be safe, effective, and acceptable, is of crucial importance. This study demonstrates that community-based distribution of injectable contraceptives can provide access to family planning to a large group of women that previously had little or no access.
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Affiliation(s)
- Ana Jacinto
- Pathfinder International, Watertown, MA, USA
| | | | - Momade Bay Ustáb
- Mozambican Association of Obstetricians and Gynaecologist, Maputo, Mozambique
| | - Cassimo Bique
- Mozambican Association of Obstetricians and Gynaecologist, Maputo, Mozambique
| | - Cassandra Blazer
- University of California, Bixby Center for Population, Health and Sustainability, Berkeley, CA, USA
| | - Karen Weidert
- University of California, Bixby Center for Population, Health and Sustainability, Berkeley, CA, USA
| | - Ndola Prata
- University of California, Bixby Center for Population, Health and Sustainability, Berkeley, CA, USA
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Morgan R, George A, Ssali S, Hawkins K, Molyneux S, Theobald S. How to do (or not to do)… gender analysis in health systems research. Health Policy Plan 2016; 31:1069-78. [PMID: 27117482 DOI: 10.1093/heapol/czw037] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2016] [Indexed: 11/13/2022] Open
Abstract
Gender-the socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for males, females and other genders-affects how people live, work and relate to each other at all levels, including in relation to the health system. Health systems research (HSR) aims to inform more strategic, effective and equitable health systems interventions, programs and policies; and the inclusion of gender analysis into HSR is a core part of that endeavour. We outline what gender analysis is and how gender analysis can be incorporated into HSR content, process and outcomes Starting with HSR content, i.e. the substantive focus of HSR, we recommend exploring whether and how gender power relations affect females and males in health systems through the use of sex disaggregated data, gender frameworks and questions. Sex disaggregation flags female-male differences or similarities that warrant further analysis; and further analysis is guided by gender frameworks and questions to understand how gender power relations are constituted and negotiated in health systems. Critical aspects of understanding gender power relations include examining who has what (access to resources); who does what (the division of labour and everyday practices); how values are defined (social norms) and who decides (rules and decision-making). Secondly, we examine gender in HSR process by reflecting on how the research process itself is imbued with power relations. We focus on data collection and analysis by reviewing who participates as respondents; when data is collected and where; who is present; who collects data and who analyses data. Thirdly, we consider gender and HSR outcomes by considering who is empowered and disempowered as a result of HSR, including the extent to which HSR outcomes progressively transform gender power relations in health systems, or at least do not further exacerbate them.
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Affiliation(s)
- Rosemary Morgan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Asha George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Sarah Ssali
- School of Women and Gender Studies, Makerere University, Kampala, Uganda
| | | | - Sassy Molyneux
- Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme, Kilifi, Kenya Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, Oxford University, Oxford, UK Nuffield Department of Population Health, Ethox Centre, Oxford University, Oxford, UK and
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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George A, Rodríguez DC, Rasanathan K, Brandes N, Bennett S. iCCM policy analysis: strategic contributions to understanding its character, design and scale up in sub-Saharan Africa. Health Policy Plan 2015; 30 Suppl 2:ii3-ii11. [DOI: 10.1093/heapol/czv096] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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