Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions

The Kenyan assistive technology ecosystem: a network analysis

BACKGROUND

Assistive technology is central to the realization of the rights of persons with disabilities. However, there remains limited access to assistive technology throughout much of the world, with particularly poor access in lower- and middle-income countries. Evaluating stakeholder engagement in assistive technology networks has been used as a successful strategy to understand and address gaps in the assistive technology ecosystem.

OBJECTIVE

The objective of this research was to provide an overview of the Kenyan Assistive Technology Ecosystem, including available assistive products and related services, and an understanding of the nature and strength of relationships between stakeholders.

METHODS

In this study, we employed an online qualitative stakeholder survey (2021) with representatives of organizations involved in assistive technology in Kenya.

RESULTS

The assistive technology network in Kenya is distributed, with Government Ministries and Agencies and Organizations of persons with disabilities central to the network. The strength of relationships is concentrated on awareness and communication, with fewer organizations actively collaborating. Innovation training organizations are not yet well integrated into the network.

CONCLUSIONS

Improving access to assistive technology in Kenya will benefit from greater collaboration amongst all assistive technology stakeholders.

Mentorship to strengthen health system leadership: A case study of the Walungu rural health zone in the eastern Democratic Republic of Congo

From 2015 to 2019, the "RIPSEC" program launched a mentorship program, transforming the Walungu health zone, in eastern crisis-affected Democratic Republic of Congo, into a "Learning and Research Zone" (LRZ). As part of the program, a local university was tasked with strengthening the LRZ manager's leadership capacities, including efforts to troubleshoot challenges related to the proliferation of informal healthcare facilities (IHFs). IHFs are unregulated healthcare structures operating on the fringes of the law, and claiming to offer cheaper, higher-quality care to the local population. This study evaluates the impact of RIPSEC mentorship on leadership development and the performance in the Walungu LRZ, particularly concerning the utilization of integrated curative health services in competition with IHFs. We used a mixed method approach, combining retrospective analysis of some key health indicators before (2014) and during RIPSEC program (2014 vs. 2015-2019), and in-depth qualitative interviews with members of the LRZ management team. Quantitative data were presented as frequencies and proportions. Simple linear regression (p<0.05) measured the influence of IHFs on service use. The LRZ's functionality and performance were assessed using an internal benchmarking approach, with results presented as trend curves. Deductive analysis of interviews allowed for a deeper exploration of quantitative trends. Despite efforts by the LRZ managers to regulate IHFs, these structures negatively impact the use of curative services by diverting patients away from integrated healthcare options. RIPSEC mentorship notably enhanced manager's leadership skills, leading to more effective management. While the use of curative health services slightly increased during the program, rates remained below 50%, and gains were not sustained post-program. RIPSEC mentorship has positively impacted leadership and performance in Walungu. However, financial challenges and the persistent influence of IHFs continue to impede the sustainability of these gains. Comprehensive strategies beyond enhancing managerial leadership solely, are necessary.

From understanding to action: a juncture-factor framework for advancing social responsiveness in health professions education

Background

Low- to middle-income countries face critical healthcare challenges. Equipping graduates with social responsiveness, the ability to address community health needs effectively, is essential. Despite its importance, research on integrating social responsiveness principles into medical and pharmacy curricula remains limited. This study explores how understanding of social responsiveness translates to practice in a resource-constrained context and identifies critical factors for future direction.

Methods

Semi-structured focus groups were conducted with curriculum developers, academic staff, and alumni (n = 27) using purposive sampling. Thematic analysis yielded an emergent "juncture-factor" framework for integrating SR into curricula.

Results

Our analysis revealed a four-stage framework for integrating social responsiveness. It categorizes existing and evolving efforts into four key junctures (points in time) and 12 factors for consideration at each juncture. The Illuminate juncture emphasizes raising awareness, fostering agreement, and aligning institutional values with community needs. The Construct stage focuses on inclusivity, contextualizing learning, developing relevant content, and employing appropriate pedagogy. The Influence juncture ensures validated social responsiveness action, effective implementation, and faculty and student capacity building. Finally, the Coalesce juncture promotes collaboration and internalization of social responsiveness principles among stakeholders.

Conclusion

This framework aligns with international social responsiveness literature while offering a unique low-to middle income country perspective. It acknowledges the complexities of integrating social responsiveness and provides practical ways to address them. This framework serves as a valuable tool for curriculum review in resource-constrained contexts. Future research could explore its applicability across diverse settings, and investigate its long-term impact on student learning and professional development, ultimately shaping future healthcare professionals equipped to address their communities' needs.

Challenges in accessing patient-centered care and patient empowerment in selected Ghanaian hospitals

Background

Patient-centred care (PCC) and patient empowerment (PE) are crucial for better healthcare outcomes, in lower-middle-income countries like Ghana, which continues to encounter many challenges.

Aim

The study sought to determine the factors affecting the implementation of PCC and PE in Ghana through the voices of patients and healthcare providers.

Setting

The study is based in Ghana, West Africa, and includes three healthcare facilities representing primary, secondary and tertiary care.

Methods

A qualitative exploratory descriptive research design was employed to investigate the study's objective by engaging healthcare workers and patients in selected facilities through purposive sampling. While 33 healthcare service providers participated in in-depth interviews, focus group discussions were held with four patient groups. The collected data were analysed thematically to identify key themes and insights.

Results

The analysis revealed three overarching themes: organisational-, individual-, and environmental-level factors influencing PCC and PE. Findings presented under 10 sub-themes show that resource constraints and staff shortages hinder PCC, while patient agency and communication impact PE. In addition, the ability to pay and geographical barriers further hinder access to patient-centred services, affecting overall healthcare delivery.

Conclusion

The findings from this study emphasise that without system-wide interventions to address these issues - including improving resource allocation, enhancing communication, and reducing geographical and financial barriers - achieving Universal Health Coverage (UHC) by 2030 remains highly aspirational.

Contribution

The contribution of the study is inherent in the relevance of contextual findings towards improving health service delivery.

Expanding technical assistance: a call for a more nuanced approach for sustainable HIV programs in Sub-Saharan Africa

An anticipated decline in external funding in sub-Saharan Africa (SSA) necessitates a re-evaluation of HIV response sustainability strategies. While institutional capacity building (ICB) has yielded positive outcomes, including strengthened technical expertise and institutional frameworks, it faces challenges. These include overemphasis on technical expertise neglecting resource mobilization, and a limited focus on policy advocacy. To achieve long-term sustainability, ICB efforts must equip local institutions with skills for tailored donor engagement, data-driven advocacy, and collaborative policy influence. This multi-pronged approach, coupled with efforts to diversify funding and integrate HIV responses, is crucial to empower local ownership and ensure the long-term viability of effective HIV responses in SSA.

Evaluating Neurosurgical Care Perception Across Mexico: Insights from a Nationwide Survey

BACKGROUND

Most of the scientific and healthcare resources in Mexico are limited to the large major cities. However, many communities with complex socioeconomic and cultural backgrounds have limited access to neurosurgical care. A cross-sectional study aiming to evaluate the population's perception regarding neurosurgical care was conducted.

METHODS

A nationwide online survey, conducted starting February 2023, assessed public perception of neurosurgical care. Data analysis was performed based on sociodemographic characteristics such as age, socioeconomic status, religion, and education. Pearson's chi-square and odds ratio were employed for statistical comparisons of categorical variables.

RESULTS

A total of 508 participants consented to the survey. Younger participants and higher education levels correlated with greater perceived knowledge about neurosurgery (P = <0.001) and higher confidence in neurosurgical healthcare personnel (P = 0.021 and P = 0.022, respectively). Lower educational levels were prone to perceive neurosurgical care as less safe and effective (P = 0.002) and preferred to seek initial alternative/traditional treatments for neurosurgical issues (P = 0.012). A higher income level was associated with a preference for private healthcare over public services P = <0.001). Odds ratio analysis corroborated these findings. Healthcare personnel emerged as the most common source of information for neurosurgical diseases (71.4%).

CONCLUSIONS

Our findings suggest that sociodemographic factors such as age, education, and income correlate with the population's self-perceived knowledge, trust and beliefs about safety and effectiveness regarding neurosurgical care in Mexico. These findings can be instrumental for developing healthcare policies that address the needs of Mexico's patient population.

The Use of a Theory of Change Model to Guide the Implementation of a Comprehensive Surgical Specialty Training Program in Equatorial Guinea

Background: Equatorial Guinea (EG) is located on the African west coast, with only 0.4 trained physicians per 1,000 resident population. The country has one medical school and there is no specialist training program. From 2000 to 2022, 524 doctors have received their medical degree. However, the number of national surgical specialists in the entire country is currently 42. Objective: Formación Especializada Sanitaria en Guinea Ecuatorial (FES Guinea) is a program specifically aimed at designing and implementing a long-term national surgical specialist training program. Methods: Más Que Salud (+QS), which means "More than Health" in Spanish, is a nonprofit organization leading the FES Guinea program. We used the theory of change (ToC) framework to evaluate the work accomplished and implement subsequent phases. The initial phase (A) included a needs assessment and mapping of available resources. An intermediate phase (B) started with a memorandum of understanding to implement a Train the Trainer program. The consolidation phase (C) consists of educational interventions and future advanced training projects. Findings: The ToC model allowed us an analyses of initial and intermediate phases. The needs assessments and resources mapping were executed while several scientific meetings and workshops were given. Scholarships to support specialist training abroad benefited six physicians in a diverse set of surgical disciplines. A regulatory commission to implement the FES Guinea program and the National Medical Council of EG were created. Working directly with the EG Ministry of Health, +QS codesigned a National Health Development Plan that began implementation in 2021 to continue until 2025. Conclusions: The ToC model allowed us to predict the current and future potential effects of FES Guinea on surgical workforce development in EG. This is a unique surgical training program, which combined effective initiatives spearheaded initially by an NGO that successfully incorporated both local health and academic authorities, ensuring sustainability.

Integrating interventions supported by development assistance for health into local health system: evidence from a China-World Bank-UK rural health system strengthening project (1998-2007)

INTRODUCTION

To empirically investigate sustainability of development assistance for health (DAH), we conducted a retrospective case study on the Basic Health Services Project (BHSP) for rural health system strengthening, supported by the World Bank and the UK in China between 1998 and 2007. Specifically, this study examines the integration of the BHSP interventions into China's health system.

METHODS

From December 2021 to December 2022, we reviewed 64 published papers and project or policy documents, and conducted semistructured interviews with 22 key informants, ranging from managers of donor agencies and the government to township-level hospital directors. From February to March 2023, the data were analysed under an analytical framework for integration of targeted health interventions into health systems.

RESULTS

Evidence of the BHSP shows that the integration outcomes can vary by the levels of integration (national or subnational), geographical coverage (project areas or both project and non-project areas) and approach to integration (policy or routinisation). The country's health system reform facilitated the integration of the interventions relevant to the reform policies, as the BHSP was one of the pilot schemes. However, interventions incompatible with this broad context were integrated to a limited extent. This integration occurred through embedding the project within the existing system, with a higher degree of embeddedness leading to smoother integration. Cross-sectoral leading groups and a technical support system heightened the project visibility and enabled contextualised local adaptation, contributing to the smooth integration of the project interventions.

CONCLUSION

The DAH-supported interventions can achieve sustainability by being integrated into the local health system. This integration can take various forms to improve health outcomes, including being accepted and internalised, modified as well as innovated and expanded. The host country and development partners can promote DAH sustainability by contextually integrating these interventions within the project scope.

Nurturing transformative local structures of multisectoral collaboration for primary health care: qualitative insights from select states in India

BACKGROUND

Multisectoral collaboration is essential for advancing primary health care (PHC). In low- and middle-income countries (LMICs), limited institutional capacities, governance issues, and inadequate stakeholder engagement impede multisectoral collaboration. India faces similar challenges, especially at the meso-level (districts and subdistricts). Owing to its dependence on context, and insufficient evidence, understanding "How" to improve multisectoral collaboration remains challenging. This study aims to elicit specific recommendations to strengthen meso-level stewardship in India for multisectoral collaboration. The findings from this study may offer lessons for other LMICs.

METHODS

Using purposive, maximum variation sampling, the study team conducted semi-structured interviews with 20 diverse participants, including policymakers, implementers, development agency representatives, and academics experienced in multisectoral initiatives. The interviews delved into participants' experiences, the current situation, enablers, and recommendations for enhancing stakeholder engagement and capacities at the meso-level for multisectoral collaboration.

RESULTS

Context and power are critical elements to consider in fostering effective collaboration. Multisectoral collaboration was particularly successful in three distinct governance contexts: the social-democratic context as in Kerala, the social governance context in Chhattisgarh, and the public health governance context in Tamil Nadu. Adequate health system input and timely guidance instil confidence among local implementers to collaborate. While power plays a role through local leadership's influence in setting agendas, convening stakeholders, and ensuring accountability. To nurture transformative local leaders for collaboration, holistic, equity-driven, community-informed approaches are essential. The study participants proposed several concrete steps: at the state level, establish "central management units" for supervising local implementers and ensuring bottom-up feedback; at the district level, rationalise committees and assign deliverables to stakeholders; and at the block level, expand convergence structures and involve local self-governments. Development partners can support data-driven priority setting, but local implementers with contextual familiarity should develop decentralised plans collaboratively, articulating rationales, activities, and resources. Finally, innovative training programs are required at all levels, fostering humility, motivation, equity awareness, leadership, problem- solving, and data use proficiency.

CONCLUSION

This study offers multiple solutions to enhance local implementers' engagement in multisectoral efforts, advocating for the development, piloting, and evaluation of innovative approaches such as the block convergence model, locally-led collaboration efforts, and novel training methods for local implementers.

A study of primary health care service efficiency and its spatial correlation in China

BACKGROUND

China's primary health care system has undergone major changes since the new round of medical reform in 2009, but the current status of primary health care institution service efficiency is still unsatisfactory. The purpose of this study is to compare and evaluate the China's primary health care institution service efficiency and provide a reference for improving the efficiency and promoting the development of primary health care institution.

METHODS

Based on panel data of 31 provinces (municipalities directly under the central government and autonomous regions) in mainland China from 2011 to 2020, using the super efficiency slack-based measure-data envelopment analysis model, to analyze the data from a static perspective, and the changes in the efficiency of primary health care services were analyzed from a dynamic perspective by using the Malmquist index method. Spatial autocorrelation analysis method was used to verify the spatial correlation of primary health care service efficiency among various regions.

RESULTS

The number of Primary health care institutions increased from 918,000 in 2011 to 970,000 in 2020. The average primary health care institution service efficiency in the northeastern region including Jilin (0.324), Heilongjiang (0.460), Liaoning (0.453) and northern regions such as Shaanxi (0.344) and Neimenggu (0.403) was at a low level, while the eastern coastal regions such as Guangdong (1.116), Zhejiang (1.211), Shanghai (1.402) have higher average service efficiency levels. The global Moran's I showed the existence of spatial autocorrelation, and the local Moran's I index suggested that the problem of uneven regional development was prominent, showing a contiguous regional distribution pattern. Among them, H-H (high-efficiency regions) were mainly concentrated in Jiangsu, Anhui and Shanghai, and L-L regions (low-efficiency regions) were mostly in northern and northeastern China.

CONCLUSION

The service efficiency of primary health care institution in China showed a rising trend in general, but the overall average efficiency was still at a low level, and there were significant geographical differences, which showed a spatial distribution of "high in the east and low in the west, high in the south and low in the north". The northwestern region, after receiving relevant support, has seen a rapid development of primary health care, and its efficiency was steadily improving and gradually reaching a high level. The average primary health care institution service efficiency in the northeastern region including the northern region of China was at a low level, while the average efficiency in the eastern coastal region and some economically developed regions was high, which also verifies the dependence and high symbiosis of primary health care institution service efficiency on regional economy.

One Health—Key to Adequate Intervention Measures against Zoonotic Risks

Zoonotic diseases are a heterogenous group of infections transmittable between humans and vertebrate animal species. Globally, endemic and emerging zoonoses are responsible for high social and economic costs. Due to the particular positioning of zoonoses at the human-animal-environment interface, zoonotic disease control is an integral part of One Health, which recognizes the close link between human, animal and ecosystem health. During recent years, the validity of the One Health approach has been recognized by academia and policy makers. However, gaps are still evident, particularly in the implementation of the concept as a unifying, integrated approach for different sectors and disciplines for the control of zoonoses. For example, while cooperation between human and veterinary medicine has made significant progress, networking with environmental sciences leaves room for improvement. Examination of individual intervention measures can help to gain valuable insights for future projects, and help to identify existing gaps. This is also a task for the One Health High-Level Expert Panel, which was established by WHO, OIE, FAO and UNEP to give science-based strategic advice on One Health measures. Overall, we should aim to learn from current situations, and to identify the best practice examples available, to continuously develop and improve One Health concepts for the control of zoonoses.

Health managers and community representatives' views of a system-wide intervention to strengthen public healthcare in the Free State, South Africa

Background

A system-wide health system strengthening (HSS) initiative, the Health Systems Governance and Accountability (HSGA) intervention, was developed, translated to policy, and implemented in the Free State province. This study assessed health managers (HMs) and community representatives' (CRs) views of the intervention and whether it improved integration and performance.

Method

A questionnaire survey among 147 HMs and 78 CRs and 14 focus group discussions (FGDs) with a mean of 10.3 participants and a total of 102 HMs and 42 CRs, were conducted. The questionnaire and FGD data were descriptively and thematically analysed to triangulate findings.

Results

Many HMs (44%) mostly positioned at the operational levels indicated that implementation of the HSGA intervention did contribute to integration of health services. Most CRs (54%) believed that communities were actively involved in the intervention. However, both the self-administered questionnaire and the FGD data evidenced lack of policy awareness among, especially, operational-level HMs.

Conclusion

From the perspectives of HMs and CRs, the implementation of the intervention was viewed as a step forward in strengthening public healthcare to respond to system deficiencies in the Free State province. Earlier engagement of especially operational-level HMs during reforms may be beneficial in successfully implementing HSS interventions.

Health Coverage and Financial Protection in Uganda: A Political Economy Perspective

BACKGROUND

As countries health financing policies are expected to support progress towards universal health coverage (UHC), an analysis of these policies is particularly relevant in low- and middle-income countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition.

METHODS

The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 key informant interviews (KIIs) in the health sector.

RESULTS

We find that the current political situation is not yet conducive for implementing a UHC system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship.

CONCLUSION

By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.

National public health institutes: A scoping review

During the last century, national public health institutes emerged to address enduring and emergency public health challenges. Previous outbreaks often compelled countries to establish national institutes of public health. Despite historic legacies and contributions to public health, no review of this literature has been published. The aim of this scoping review is to provide an overview of this literature and map characteristics including format, authorship, geographic focus, methods, language, focal topic and public health capacity building domains. The scoping review was guided the Arksey and O'Malley methodological framework and utilised the PRISMA-ScR checklist. A systematic search of Medline OVID and Scopus databases yielded 5731 records. In total, 43 articles met the eligibility criteria. Articles were published in English, Spanish, French and Russian and included perspectives from over 20 countries in Africa, Europe, North America and South America. Three reported methods or collected primary data. Findings reveal a longstanding international interest in leveraging national institutes to address complex public health challenges. Lack of studies reporting methods reveals the need for future research utilising robust methodology. Several articles recommend investment in national public health institutes as a strategy to respond to crises and strengthen countries' public health systems.

Health sector reform at the COVID cross-roads: Public goods or health markets - An agenda for health systems research

The debate around approaches to health sector reform is one of the foundational questions around which the discipline of health policy and systems research has grown. In the immediate postwar period, health and health care were recognized as areas of market failure, requiring state action in the provision of free or subsidized services. In the eighties and nineties, due to both geopolitical and ideological reasons, this understanding changed, leading to a wave of market-based health sector reforms. An academic discourse built around neoliberal economics initiated, shaped, and legitimized these reforms. Faced with worsening health outcomes and costs of care after a decade of such reforms, there was a partial reversal of policy toward improving health sector performance that relied on nonmarket solutions built around notions of solidarity, trust, and rights. In India, this took the form of the National Rural Health Mission. Examples of health systems research that supported this direction of change are discussed. In the last decade, a second wave of health sector reforms sought to make markets work by repositioning government as purchaser of health care from private providers through insurance and contracts. There is little evidence that this worked. The need to rely on public services to cope with the COVID-19 pandemic, further questioned this direction of reform. We emphasize the need to expand and develop a framework of health systems and policy studies that are more appropriate to the achievement of universal health care, health equity, and health rights in the Indian context.

Pursuing health systems strengthening through disease-specific programme grants: experiences in Tanzania and Sierra Leone

Introduction

Disease-specific ‘vertical’ programmes and health system strengthening (HSS) ‘horizontal’ programmes are not mutually exclusive; programmes may be implemented with the dual objectives of achieving both disease-specific and broader HSS outcomes. However, there remains an ongoing need for research into how dual objective programmes are operationalised for optimum results.

Methods

A qualitative study encompassing four grantee programmes from two partner countries, Tanzania and Sierra Leone, in the Comic Relief and GlaxoSmithKline ‘Fighting Malaria, Improving Health’ partnership. Purposive sampling maximised variation in terms of geographical location, programme aims and activities, grantee type and operational sector. Data were collected via semi-structured interviews. Data analysis was informed by a general inductive approach.

Results

51 interviews were conducted across the four grantees. Grantee organisations structured and operated their respective projects in a manner generally supportive of HSS objectives. This was revealed through commonalities identified across the four grantee organisations in terms of their respective approach to achieving their HSS objectives, and experienced tensions in pursuit of these objectives. Commonalities included: (1) using short-term funding for long-term initiatives; (2) benefits of being embedded in the local health system; (3) donor flexibility to enable grantee responsiveness; (4) the need for modest expectations; and (5) the importance of micro-innovation.

Conclusion

Health systems strengthening may be pursued through disease-specific programme grants; however, the respective practice of both the funder and grantee organisation appears to be a key influence on whether HSS will be realised as well as the overall extent of HSS possible.

Mobilizing health district management teams through digital tools: Lessons from the District.Team initiative in Benin and Guinea using an action research methodology

BACKGROUND

Improving capacities of health systems to quickly respond to emerging health issues, requires a health information system (HIS) that facilitates evidence-informed decision-making at the operational level. In many sub-Saharan African countries, HIS are mostly designed to feed decision-making purposes at the central level with limited feedback and capabilities to take action from data at the operational level. This article presents the case of an eHealth innovation designed to capacitate health district management teams (HDMTs) through participatory evidence production and peer-to-peer exchange.

METHODS

We used an action research design to develop the eHealth initiative called "District.Team," a web-based and facilitated platform targeting HDMTs that was tested in Benin and Guinea from January 2016 to September 2017. On District.Team, rounds of knowledge sharing processes were organized into cycles of five steps. Quantitative and qualitative data were collected to assess the participation of HDMTs and identify enablers and barriers of using District.Team.

RESULTS

Participation of HDMTs in District.Team varied between cycles and steps. In Benin, 79% to 94% of HDMTs filled in the online questionnaire per cycle compared to 61% to 100% in Guinea per cycle. In Benin, 26% to 41% of HDMTs shared a commentary on the results published on the platform while 21% to 47% participated in the online discussion forum. In Guinea, only 3% to 8% of HDMTs shared a commentary on the results published on the platform while 8% to 74% participated in the online discussion forum. Five groups of factors affected the participation: characteristics of the digital tools, the quality of the facilitation, profile of participants, shared content and data, and finally support from health authorities.

CONCLUSION

District.Team has shown that knowledge management platforms and processes valuing horizontal knowledge sharing among peers at the decentralized level of health systems are feasible in limited resource settings.

A longitudinal surgical systems strengthening research program for medical students: the exploration of a model for global health education

BACKGROUND

In response to the staggering global burden of conditions requiring emergency and essential surgery, the development of international surgical system strengthening (SSS) is fundamental to achieving universal, timely, quality, and affordable surgical care. Opportunity exists in identifying optimal collaborative processes that both promote global surgery research and SSS, and include medical students. This study explores an education model to engage students in academic global surgery and SSS via institutional support for longitudinal research.

OBJECTIVES

We set out to design a program to align global health education and longitudinal health systems research by creating an education model to engage medical students in academic global surgery and SSS.

PROGRAM DESIGN AND IMPLEMENTATION

In 2015, medical schools in the United States and Colombia initiated a collaborative partnership for academic global surgery research and SSS. This included development of two longitudinal academic tracks in global health medical education and academic global surgery, which we differentiated by level of institutional resourcing. Herein is a retrospective evaluation of the first two years of this program by using commonly recognized academic output metrics.

MAIN ACHIEVEMENTS

In the first two years of the program, there were 76 total applicants to the two longitudinal tracks. Six of the 16 (37.5%) accepted students selected global surgery faculty as mentors (Acute Care Surgery faculty participating in SSS with Colombia). These global surgery students subsequently spent 24 total working weeks abroad over the two-year period participating in culminating research experiences in SSS. As a quantitative measure of the program's success, the students collectively produced a total of twenty scholarly pieces in the form of accepted posters, abstracts, podium presentations, and manuscripts in partnership with Colombian research mentors.

POLICY IMPLICATIONS

The establishment of scholarly global health education and research tracks has afforded our medical students an active role in international SSS through participation in academic global surgery research. We propose that these complementary programs can serve as a model for disseminated education and training of the future global systems-aware surgeon workforce with bidirectional growth in south and north regions with traditionally under-resourced SSS training programs.

Public health consequences after ten years of the Syrian crisis: a literature review

Ten years of the Syrian war had a devastating effect on Syrian lives, including millions of refugees and displaced people, enormous destruction in the infrastructure, and the worst economic crisis Syria has ever faced. The health sector was hit hard by this war, up to 50% of the health facilities have been destroyed and up to 70% of the healthcare providers fled the country seeking safety, which increased the workload and mental pressure for the remaining medical staff. Five databases were searched and 438 articles were included according to the inclusion criteria, the articles were divided into categories according to the topic of the article.

Through this review, the current health status of the Syrian population living inside Syria, whether under governmental or opposition control, was reviewed, and also, the health status of the Syrian refugees was examined according to each host country. Public health indicators were used to summarize and categorize the information. This research reviewed mental health, children and maternal health, oral health, non-communicable diseases, infectious diseases, occupational health, and the effect of the COVID − 19 pandemic on the Syrian healthcare system. The results of the review are irritating, as still after ten years of war and millions of refugees there is an enormous need for healthcare services, and international organization has failed to respond to those needs. The review ended with the current and future challenges facing the healthcare system, and suggestions about rebuilding the healthcare system.

Through this review, the major consequences of the Syrian war on the health of the Syrian population have been reviewed and highlighted. Considerable challenges will face the future of health in Syria which require the collaboration of the health authorities to respond to the growing needs of the Syrian population. This article draws an overview about how the Syrian war affected health sector for Syrian population inside and outside Syria after ten years of war which makes it an important reference for future researchers to get the main highlight of the health sector during the Syrian crisis.

Assessing community health research capacity across stakeholders: adapting a tool

Multi-sectoral collaborative approaches with strong community engagement are essential for addressing health disparities. A valid tool for assessing organizational research and capacity for community health research stakeholders could help strengthen organizational capacity for engagement in such collaborations. This study was conducted to validate an innovative tool for assessing research activity and capacity of a spectrum of stakeholder organizations to provide support for strengthening community health research capacity in Bhutan. In-person interviews with academics (n = 10), clinicians (n = 10), government staff (n = 10), consultants (n = 2) and management of health-related civil society organizations (CSOs; n = 12 interviews/organizations, 13 individuals) were recorded and transcribed. Questions covered individual and organizational research activity and capacity, research networks and an international version of the Community Research Assessment Tool (CREAT-I). Almost all participants (84%) had participated in community health research projects. Social network analysis showed a large, interconnected cluster with a few key individuals linking across sectors. CREAT-I responses identified the highest capacity in organizational support for research among academic participants, while clinical and CSO participants reported highest capacity in practical research experiences and government participants reported highest capacity in research specific experiences. The CREAT-I tool showed strong internal reliability (Cronbach's α = 0.91) and validity. Limited money, time and skilled staff were identified as barriers to research. The CREAT-I assesses community health research capacity of organizations, and such a tool could be useful in identifying research capacity needs, monitoring impact of research capacity-building activities and contributing to a greater capacity for multi-sectoral collaborative approaches to community health research in international settings.

Improving Pediatric Neuro-Oncology Survival Disparities in the United States-Mexico Border Region: A Cross-Border Initiative Between San Diego, California, and Tijuana, Mexico

PURPOSE

Treatment of children with CNS tumors (CNSTs) demands a complex, interdisciplinary approach that is rarely available in low- and middle-income countries. We established the Cross-Border Neuro-Oncology Program (CBNP) between Rady Children's Hospital, San Diego (RCHSD), and Hospital General, Tijuana (HGT), Mexico, to provide access to neuro-oncology care, including neurosurgic services, for children with CNSTs diagnosed at HGT. Our purpose was to assess the feasibility of the CBNP across the United States-Mexico border and improve survival for children with CNSTs at HGT by implementing the CBNP.

PATIENTS AND METHODS

We prospectively assessed clinicopathologic profiles, the extent of resection, progression-free survival, and overall survival (OS) in children with CNSTs at HGT from 2010 to 2017.

RESULTS

Sixty patients with CNSTs participated in the CBNP during the study period. The most common diagnoses were low-grade glioma (24.5%) and medulloblastoma (22.4%). Of patients who were eligible for surgery, 49 underwent resection at RCHSD and returned to HGT for collaborative management. Gross total resection was achieved in 78% of cases at RCHSD compared with 0% at HGT (P < .001) and was a predictor of 5-year OS (hazard ratio, 0.250; 95% CI, 0.067 to 0.934; P = .024). Five-year OS improved from 0% before 2010 to 52% in 2017.

CONCLUSION

The CBNP facilitated access to complex neuro-oncology care for underserved children in Mexico through binational exchanges of resources and expertise. Survival for patients in the CBNP dramatically improved. Gross total resection at RCHSD was associated with higher OS, highlighting the critical role of experienced neurosurgeons in the treatment of CNSTs. The CBNP model offers an attractive alternative for children with CNSTs in low- and middle-income countries who require complex neuro-oncology care, particularly those in close proximity to institutions in high-income countries with extensive neuro-oncology expertise.

The implementation of pharmaceutical services in public hospitals in Mexico: an analysis of the legal framework and organizational practice

BACKGROUND

The implementation of pharmaceutical services in hospitals contributes to the appropriate use of medicines and patient safety. However, the relationship of implementation with the legal framework and organizational practice has not been studied in depth. The objective of this research is to determine the role of these two factors (the legal framework and organizational practice) in the implementation of pharmaceutical services in public hospitals of the Ministry of Health of Mexico.

METHODS

Semi-structured interviews were conducted with four groups of actors involved. The analysis focused on the legal framework, defined as the rules, laws and regulations, and on organizational practice, defined as the implementation of the legal framework by related individuals, that is, how they put it into practice.

RESULTS

The main problems identified were the lack of alignment between the rules and the incentives for compliance. Decision-makers identified the lack of managerial capacity in hospitals as the main implementation barrier, while hospital pharmacists pointed to poor regulation and the lack of clarity of the legal framework as the problems to consider.

CONCLUSIONS

Although the legal framework related to hospital pharmaceutical services in Mexico is inadequate, organizational factors (such as adequate skills of professional pharmacists and the support of the hospital director) have facilitated gradual implementation. To improve implementation, priority should be given to evaluation and modification of the current legislation along with the development of an official minimum standard for activities and services in hospital pharmacies.

What do we mean by individual capacity strengthening for primary health care in low- and middle-income countries? A systematic scoping review to improve conceptual clarity

BACKGROUND

Capacity strengthening of primary health care workers is widely used as a means to strengthen health service delivery, particularly in low- and middle-income countries. Despite the widespread recognition of the importance of capacity strengthening to improve access to quality health care, how the term 'capacity strengthening' is both used and measured varies substantially across the literature. This scoping review sought to identify the most common domains of individual capacity strengthening, as well as their most common forms of measurement, to generate a better understanding of what is meant by the term 'capacity strengthening' for primary health care workers.

METHODS

Six electronic databases were searched for studies published between January 2000 and October 2020. A total of 4474 articles were screened at title and abstract phase and 323 full-text articles were reviewed. 55 articles were ultimately identified for inclusion, covering various geographic settings and health topics.

RESULTS

Capacity strengthening is predominantly conceptualised in relation to knowledge and skills, as either sole domains of capacity, or used in combination with other domains including self-efficacy, practices, ability, and competencies. Capacity strengthening is primarily measured using pre- and post-tests, practical evaluations, and observation. These occur along study-specific indicators, though some pre-existing, validated tools are also used.

CONCLUSION

The concept of capacity strengthening for primary health care workers reflected across a number of relevant frameworks and theories differs from what is commonly seen in practice. A framework of individual capacity strengthening across intra-personal, inter-personal, and technical domains is proposed, as an initial step towards building a common consensus of individual capacity strengthening for future work.

Trends in reproductive, maternal, newborn and child health and nutrition indicators during five years of piloting and scaling-up of Ananya interventions in Bihar, India

BACKGROUND

The Ananya program in Bihar implemented household and community-level interventions to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) in two phases: a first phase of intensive ancillary support to governmental implementation and innovation testing by non-government organisation (NGO) partners in eight focus districts (2012-2014), followed by a second phase of state-wide government-led implementation with techno-managerial assistance from NGOs (2014 onwards). This paper examines trends in RMNCHN indicators in the program's implementation districts from 2012-2017.

METHODS

Eight consecutive rounds of cross-sectional Community-based Household Surveys conducted by CARE India in 2012-2017 provided comparable data on a large number of indicators of frontline worker (FLW) performance, mothers' behaviours, and facility-based care and outreach service delivery across the continuum of maternal and child care. Logistic regression, considering the complex survey design and sample weights generated by that design, was used to estimate trends using survey rounds 2-5 for the first phase in the eight focus districts and rounds 6-9 for the second phase in all 38 districts statewide, as well as the overall change from round 2-9 in focus districts. To aid in contextualising the results, indicators were also compared amongst the formerly focus and the non-focus districts at the beginning of the second phase.

RESULTS

In the first phase, the levels of 34 out of 52 indicators increased significantly in the focus districts, including almost all indicators of FLW performance in antenatal and postnatal care, along with mother's birth preparedness, some breastfeeding practices, and immunisations. Between the two phases, 33 of 52 indicators declined significantly. In the second phase, the formerly focus districts experienced a rise in the levels of 14 of 50 indicators and a decline in the levels of 14 other indicators. There was a rise in the levels of 22 out of 50 indicators in the non-focus districts in the second phase, with a decline in the levels of 13 other indicators.

CONCLUSIONS

Improvements in indicators were conditional on implementation support to program activities at a level of intensity that was higher than what could be achieved at scale so far. Successes during the pilot phase of intensive support suggests that RMNCHN can be improved statewide in Bihar with sufficient investments in systems performance improvements.

STUDY REGISTRATION

ClinicalTrials.gov number NCT02726230.

Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

This paper reports a study from Cape Town, South Africa, that tested an existing framework of everyday health system resilience (EHSR) in examining how a local health system responded to the chronic stress of large-scale organizational change. Over two years (2017–18), through cycles of action-learning involving local managers and researchers, the authorial team tracked the stress experienced, the response strategies implemented and their consequences. The paper considers how a set of micro-governance interventions and mid-level leadership practices supported responses to stress whilst nurturing organizational resilience capacities. Data collection involved observation, in-depth interviews and analysis of meeting minutes and secondary data. Data analysis included iterative synthesis and validation processes. The paper offers five sets of insights that add to the limited empirical health system resilience literature: 1) resilience is a process not an end-state; 2) resilience strategies are deployed in combination rather than linearly, after each other; 3) three sets of organizational resilience capacities work together to support collective problem-solving and action entailed in EHSR; 4) these capacities can be nurtured by mid-level managers’ leadership practices and simple adaptations of routine organizational processes, such as meetings; 5) central level actions must nurture EHSR by enabling the leadership practices and micro-governance processes entailed in everyday decision-making.

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Resilience to chronic stress will prepare health systems to face acute shocks.

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Collective problem-solving and sensemaking enable everyday resilience.

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Distributed leadership, feeling safe and reflective practice are key processes.

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New forms of health system strengthening are needed to nurture resilience.

Health-related publications on people living in fragile states in the alert zone: a bibliometric analysis

Background

Fragile states pose a global challenge. Assessing health research activity on people living in these states can help identify neglected health domains in fragile settings. The objective of the current study was to assess and describe health research activity on people living in fragile states in the alert zone.

Method

A bibliometric method was applied using SciVerse Scopus. Research articles published on people in fragile states in the alert zone were retrieved and analyzed. The Fragile State Index (FSI) score was used for selection of states in the alert zone. The analysis was limited to 1 year; 2018.

Results

The search query found 2299 research articles giving an average of 2 research articles per one million population per year in the selected fragile states. The number of research articles per one million population was not significantly correlated (p = 0.053; r = − 0.349) with FSI scores. However, it was significantly correlated with the extent of international research collaboration (p < 0.01, r = 065). Research on communicable diseases was the largest research domain (763 articles; 33.2%) followed by maternal/women’s health (430 articles; 18.7%), non-communicable diseases (291 articles; 12.7%), health system/policy (271 articles; 11.8%) and psychosocial and mental health (89; 3.9%). There were three research themes in the research domain of infectious diseases: HIV/AIDS; water-borne infectious diseases; and miscellaneous infectious diseases such as tuberculosis and malaria. The top ten cited articles were mainly on infectious diseases, particularly on malaria and Lassa fever. Of all the retrieved documents, 727 (31.6%) research articles appeared in national/regional journals while the remaining appeared in international journals. The World Health organization was the most active funding organization for research on fragile states. Top ten active institutions were mainly based in fragile states with the lowest FSI score, specifically Ethiopia, Uganda, Nigeria, and Pakistan.

Conclusion

Research on fragile states was relatively low. Research on mental health and health system/policy should be encouraged. Collaboration and funding might help academic institutions in fragile states to make health problems in these countries more visible.

How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana

Introduction: District health managers (DHMs) play a pivotal role in the operation of district health systems in low-and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system in which they are embedded. The objective of this paper is to explore how district health management emerges from contextual, organizational, and individual factors in order to demonstrate that capacity strengthening efforts at district level need to transcend individual competencies to take on more systemic approaches. Methods: Semi-structured interviews (n = 21) were conducted to gain insight into aspects that affect district health management in the Eastern Region of Ghana. Interviews were conducted with DHMs (n = 15) from six different districts, as well as with their superiors at the regional level (n = 4) and peers from non-governmental organizations (n = 2). A thematic analysis was conducted by using an analytical approach based on systems theory. Results: Contextual aspects, such as priorities among elected officials, poor infrastructure and working conditions, centralized decision-making, delayed disbursement of funds and staff shortages, affect organizational processes and the way DHMs carry out their role. Enabling organizational aspects that provide DHMs with direction and a clear perception of their role, include positive team dynamics, good relations with supervisors, job descriptions, appraisals, information systems, policies and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by vertical programs and limited opportunities for professional development provide DHMs with limited authority to make decisions and dampens their motivation. The DHMs ability to carry out their role effectively depends on their perception of their role and the effort they expend, in addition to their competencies. In regards to competencies, a need for more general management and leadership skills were called for by DHMs as well as by their superiors and peers. Conclusion: Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management.

Assessing the efficiency of Iran health system in making progress towards universal health coverage: a comparative panel data analysis

BACKGROUND

Building upon decades of continuous reforms, Iran has been implementing various initiatives to reach universal health coverage (UHC). Improving efficiency is a crucial intermediate policy objective for UHC. Therefore, this article aimed to measure the efficiency and productivity changes of the Iranian health system in making progress towards UHC during 2010-2015 in comparison with 36 selected other upper-middle-income countries.

METHODS

We used panel data to measure the variations in technical efficiency (TE) and total factor productivity (TFP) through an extended data envelopment analysis (EDEA) and Malmquist productivity index, respectively. General government health expenditure (GGHE) per capita (International dollar) was selected as the input variable. Service coverage of diphtheria, tetanus and pertussis; family planning; antiretroviral therapy; skilled attendants at birth; Tuberculosis treatment success rate; and GGHE as  % of total health expenditure (THE) were considered as output variables. The data for each indicator were taken from the Global Health Observatory data repository and World Development Indicator database, for 6 years (2010-2015).

RESULTS

The TE scores of Iran's health system were 0.75, 0.77, 0.74, 0.74, 0.97, and 0.84 in the period 2010-2015, respectively. TFP improved in 2011 (1.02), 2013 (1.01), and 2014 (1.30, generally). The overall efficiency and TFP increased in 2014. Changes made in CCHE per capita and GGHE/THE attributed to the increase of efficiency.

CONCLUSION

There is a growing demand for efficiency improvements in the health systems to achieve UHC. While there are no defined set of indicators or precise methods to measure health system efficiency, EDEA helped us to draw the picture of health system efficiency in Iran. Our findings highlighted the essential need for targeted and sustained interventions, i.e., allocation of enough proportion of public funds to the health sector, to improve universal financial coverage against health costs aiming to enhance the future performance of Iran's health system, ultimately. Such tailored interventions may also be useful for settings with similar context to speed up their movement towards improving efficiency, which in turn might lead to more resources to reach UHC.

Capacity building for implementation research: a methodology for advancing health research and practice

BACKGROUND

Implementation research is increasingly being recognised as an important discipline seeking to maximise the benefits of evidence-based interventions. Although capacity-building efforts are ongoing, there has been limited attention on the contextual and health system peculiarities in low- and middle-income countries. Moreover, given the challenges encountered during the implementation of health interventions, the field of implementation research requires a creative attempt to build expertise for health researchers and practitioners simultaneously. With support from the Special Programme for Research and Training in Tropical Diseases, we have developed an implementation research short course that targets both researchers and practitioners. This paper seeks to explain the course development processes and report on training evaluations, highlighting its relevance for inter-institutional and inter-regional capacity strengthening.

METHODS

The development of the implementation research course curriculum was categorised into four phases, namely the formation of a core curriculum development team, course content development, internal reviews and pilot, and external reviews and evaluations. Five modules were developed covering Introduction to implementation research, Methods in implementation research, Ethics and quality management in implementation research, Community and stakeholder engagement, and Dissemination in implementation research. Course evaluations were conducted using developed tools measuring participants' reactions and learning.

RESULTS

From 2016 to 2018, the IR curriculum has been used to train a total of 165 researchers and practitioners predominantly from African countries, the majority of whom are males (57%) and researchers/academics (79.4%). Participants generally gave positive ratings (e.g. integration of concepts) for their reactions to the training. Under 'learnings', participants indicated improvement in their knowledge in areas such as identification of implementation research problems and questions.

CONCLUSION

The approach for training both researchers and practitioners offers a dynamic opportunity for the acquisition and sharing of knowledge for both categories of learners. This approach was crucial in demonstrating a key characteristic of implementation research (e.g. multidisciplinary) practically evident during the training sessions. Using such a model to effectively train participants from various low- and middle-income countries shows the opportunities this training curriculum offers as a capacity-building tool.

A Scientometric Analysis of Global Health Research

With the development and deepening of the process of global integration, global health is gaining increasing attention. An increasing number of studies have examined global health from diverse perspectives to promote the realization of global public health. The purpose of this research is to systematically and comprehensively evaluate the knowledge structure, knowledge domain, and evolution trend in the field of global health research. Based on the 14,692 document data retrieved from Web of Science Core Collection from 1996 to 2019, this article carried out a visual analysis of global health research from the perspective of scientific output characteristics, scientific research cooperation networks, keywords, and highly cited literature. The results show that scholars’ interest in global health research is increasing, especially after the outbreak of SARS. USA, England, Canada, Australia, and China have the most prominent contributions to global health research. Significant authors, high impact journals and core institutions also identified. The study found that “global health governance”, “global health diplomacy”, “medical education”, “global health education” and “antimicrobial resistance” are the research frontiers and hot spots. This study provides an overview and valuable guidance for researchers and related personnel to find the research direction and practice of global health.

Improving health equity among the African ethnic minority through health system strengthening: a narrative review of the New Zealand healthcare system

Background

In New Zealand, health equity is a pressing concern and reaching disadvantaged populations has become the goal to close the inequity gap. Building and strengthening health systems is one way to secure better outcomes. However, the discourse to date has predominately focussed on inequities in health outcomes for Māori. This study has interest in the African ethnic minority community in New Zealand. It undertakes a narrative review of the New Zealand health system which aims to identify literature around the attainment of health equity of African minority by: (i) providing a critical overview of the healthcare delivery system using World Health Organization’s six inter-related building blocks of health system strengthening; (ii) developing a summary and discussions of the research results and; (iii) identifying priorities and recommendations for future research.

Method

A narrative review of 27 articles published between January 2010 and June 2019 were selected from CINAHL, PubMed, Scopus, Google Scholar. Grey literature also informed the review. Articles excluded studies: (i) non-related to New Zealand; (ii) with no focus on equity on ethnic minority in the delivering of healthcare; (iii) had no full text available.

Findings

Literature on Africans health outcomes were scarce regarding the six building blocks. However, findings show inequities in accessibility of health services, a non-ethnic inclusive health workforce, a leadership and governance which lack political will on migrant health and resultantly an under-performing health information system which influences resource allocation.

Recommendation and conclusion

An improvement and well-functioning health information system is pivotal to capture the unmet needs of the African population. There is a need for research and political will to invest in African minority health and diverse workforce that understands the background of the African population; and action to address structural and institutional racism and white privilege to address root causes of inadequate access and care processes for ethnic minorities.

Développement des Zones de Santé d'Apprentissage et de Recherche en République Démocratique du Congo : enseignements utiles d'une évaluation qualitative des expériences antérieures en Afrique Subsaharienne

Trois Zones d'Apprentissage et de Recherche (ZAR) sont développées par le programme RIPSEC en République Démocratique duCongo (RDC). Cette stratégie consiste à utiliser un district sanitaire comme substrat pour former des managers des districts de santé et mener des recherches sur les systèmes de santé. L'objet de cet article est d'explorer les principes, les effets et les conditions de succès de cette stratégie à travers une évaluation qualitative des expériences ZAR antérieures en Afrique Subsaharienne. Elle concerne quatre expériences, deux menées au Niger, une en RDC et une au Congo-Brazzaville. Les données proviennent des témoignages de responsables du développement des expériences, présentés dans un séminaire en 2014 et approfondis par des entretiens en 2015, et des publications traitant des expériences. Les faits communs aux quatre expériences sont la diffusion nationale et souvent internationale des bonnes pratiques et des modèles organisationnels, leur développement inscrit dans le long-terme et l'implication des managers des ZAR dans tous les volets de leur transformation. Le centrage de la recherche sur les problèmes de la ZAR et la promotion de la réflexivité dans les décisions managériales sont importants pour cette transformation. L'utilisation des résultats par le programme RIPSEC, les logiques imbriquées dans le concept ZAR et l'apport potentiel de l'implication d'écoles de santé publiques nationales dans leur développement sont ensuite discutés. La validité de l'étude est limitée mais renforcer le leadership des managers des districts sanitaires est un défi fréquent pour les systèmes de santé aux ressources limitées. Cet article peut aider à développer une stratégie pour le renforcer.

Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge

Multisectoral action is key to addressing many pressing global health challenges and critical for achieving the Sustainable Development Goals, but to-date, understanding about how best to promote and support multisectoral action for health is relatively limited. The challenges to multisectoral action may be more acute in low-income and middle-income countries (LMICs) where institutions are frequently weak, and fragmentation, even within the health sector, can undermine coordination. We apply the lens of governance to understand challenges to multisectoral action. This paper (1) provides a high level overview of possible disciplines, frameworks and theories that could be applied to enrich analyses in this field; (2) summarises the literature that has sought to describe governance of multisectoral action for health in LMICs using a simple political economy framework that identifies interests, institutions and ideas and (3) introduces the papers in the supplement. Our review highlights the diverse, but often political nature of factors influencing the success of multisectoral action. Key factors include the importance of high level political commitment; the incentives for competition versus collaboration between bureaucratic agencies and the extent to which there is common understanding across actors about the problem. The supplement papers seek to promote debate and understanding about research and practice approaches to the governance of multisectoral action and illustrate salient issues through case studies. The papers here are unable to cover all aspects of this topic, but in the final two papers, we seek to develop an agenda for future action. This paper introduces a supplement on the governance of multisectoral action for health. While many case studies exist in this domain, we identify a need for greater theory-based conceptualisation of multisectoral action and more sophisticated empirical investigation of such collaborations.

Using concept mapping to develop a human rights based indicator framework to assess country efforts to strengthen rehabilitation provision and policy: the Rehabilitation System Diagnosis and Dialogue framework (RESYST)

BACKGROUND

Rehabilitation is crucial for the realization of the right to health and a proper concern of global health. Yet, reliable information to guide rehabilitation service planning is unavailable in many countries in part due to the lack of appropriate indicators. To ensure universal health coverage and meet the central imperative of "leaving no one behind" countries must be able to assess key aspects of rehabilitation policy and provision and monitor how they have discharged their human rights responsibilities towards those most disadvantaged, including people with disability. This article describes the process of developing an expert guided indicator framework to assess governments' efforts and progress in strengthening rehabilitation in line with the Convention on the Rights of Persons with Disabilities.

METHODS

A systems methodology - concept mapping - was used to capture, aggregate and confirm the knowledge of diverse stakeholders on measures thought to be useful for monitoring the implementation of the Convention with respect to health related rehabilitation. Fifty-six individuals generated a list of 107 indicators through online brainstorming which were subsequently sorted by 37 experts from the original panel into non overlapping categories. Forty-one participants rated the indicators for importance and feasibility. Multivariate statistical techniques where used to explore patterns and themes in the data and create the indicators' organizing framework which was verified and interpreted by a select number of participants.

RESULTS

A concept map of 11 clusters of indicators emerged from the analysis grouped into three broader themes: Governance and Leadership (3 clusters); Service Delivery, Financing and Oversight (6 clusters); and Human Resources (2 clusters). The indicator framework was comprehensive and well aligned with the Convention. On average, there was a moderately positive correlation between importance and feasibility of the indicators (r = .58) with experts prioritizing the indicators contained in the clusters of the Governance and Leadership domain. Two of the most important indicators arose from the Service Delivery, Financing and Oversight domain and reflect the need to monitor unmet needs and barriers in access to rehabilitation. In total, 59 indicators achieved above average score for importance and comprised the two-tiered priority set of indicators.

CONCLUSION

Concept mapping was successful in generating a shared model that enables a system's view of the most critical legal, policy and programmatic factors that must be addressed when assessing country efforts to reform, upscale and improve rehabilitation services. The Rehabilitation Systems Diagnosis and Dialogue framework provides a data driven basis for the development of standardized data collection tools to facilitate comparative analysis of rehabilitation systems. Despite agreement on the importance and feasibility of 59 indicators, further research is needed to appraise the applicability and utility of the indicators and secure a realistic assessment of rehabilitation systems.

Management training in global health education: a Health Innovation Fellowship training program to bring healthcare to low-income communities in Central America

Background: Interprofessional education is increasingly recognized as essential for health education worldwide. Although effective management, innovation, and entrepreneurship are necessary to improve health systems, business schools have been underrepresented in global health education. Central America needs more health professionals trained in health management and innovation to respond to health disparities, especially in rural communities.

Objective:  This paper explores the impact of the Health Innovation Fellowship (HIF), a new training program for practicing health professionals offered jointly by the Central American Healthcare Initiative and INCAE Business School, Costa Rica. Launched in 2014, HIF’s goal is to create a network of highly trained interdisciplinary health professionals in competencies to improve health of Central American communities through better health management.

Methods: The program’s fellows carried out innovative healthcare projects in their local regions. The first three annual cohorts (total of 43 fellows) represented all health-related professions and sectors (private, public, and civil society) from six Central American countries. All fellows attended four 1-week, on-site modular training sessions, received ongoing mentorship, and stayed connected through formal and informal networks and webinars through which they exchange knowledge and support each other. CAHI stakeholders supported HIF financially.

Results: Impact evaluation of the three-year pilot training program is positive: fellows improved their health management skills and more than 50% of the projects found either financial or political support for their implementation.

Conclusions: HIF’s strengths include that both program leaders and trainees come from the Global South, and that HIF offers a platform to collaborate with partners in the Global North. By focusing on promoting innovation and management at a top business school in the region, HIF constitutes a novel capacity-building effort within global health education. HIF is a capacity-building effort that can be scaled up in the region and other low- and middle-income countries.

The everyday practice of supporting health system development: learning from how an externally-led intervention was implemented in Mozambique

Health system strengthening (HSS) has often been undertaken by global health actors working through vertical programmes. However, experience has shown the challenges of this approach, and the need to recognize health systems as open complex adaptive systems—which in turn has implications for the design and implementation approach of more ‘horizontal’ HSS interventions. From 2009 to 2016, the Doris Duke Charitable Foundation supported the African Health Initiative, establishing Population Health Implementation and Training partnerships in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia). Each partnership was designed as a large-scale, long-term, complex health system strengthening intervention, at a primary care or district level—and in each country the intervention was adapted to suit that specific health systems context. In Mozambique, the Population Health Implementation and Training partnership sought to strengthen integrated health systems management at district and provincial levels (through a variety of capacity-development intervention activities, including in-service training and mentoring); to improve the quality of routine data and develop appropriate tools to facilitate decision-making for provincial and district managers; and to build capacity to design and conduct innovative operations research in order to guide integration and system-strengthening efforts. The success of this intervention, as assessed by outcome measures, has been reported elsewhere. In this paper, the implementation practice of this horizontal HSS intervention is assessed, focusing on the key features of how implementation occurred and the implementation approach. A case study focusing on HSS implementation practice was conducted by external researchers from 2014 to 2017. The importance of an accompanying implementation research approach is emphasized—especially for HSS interventions where the ‘complex adaptive system’ (complex and constantly changing context) forces constant adaptations to the intervention design and approach.

Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa

Surgery has the potential to address one of the largest, neglected burdens of disease in low- and middle-income countries (LMICs), especially in sub-Saharan Africa (SSA). The Lancet Commission on Global Surgery (LCoGS) has provided a blueprint for a systems approach to making safe emergency and elective surgery accessible and affordable and has started to enable African governments to develop national surgical plans. This editorial outlines an important gap, which is the need for surgical systems research, especially at district hospitals which are the first point of surgical care for rural communities, to inform the implementation of country plans. Using the Lancet Commission as a starting point and illustrated by two European Union (EU) funded research projects, we point to the need for implementation research to develop and evaluate contextualised strategies. As illustrated by the case study of Zambia, coordination by global and external stakeholders can enable governments to lead national scale-up of essential surgery, supported by national partners including surgical specialist associations.

Action to address the household economic burden of non-communicable diseases

The economic burden on households of non-communicable diseases (NCDs), including cardiovascular diseases, cancer, respiratory diseases, and diabetes, poses major challenges to global poverty alleviation efforts. For patients with NCDs, being uninsured is associated with 2-7-fold higher odds of catastrophic levels of out-of-pocket costs; however, the protection offered by health insurance is often incomplete. To enable coverage of the predictable and long-term costs of treatment, national programmes to extend financial protection should be based on schemes that entail compulsory enrolment or be financed through taxation. Priority should be given to eliminating financial barriers to the uptake of and adherence to interventions that are cost-effective and are designed to help the poor. In concert with programmes to strengthen national health systems and governance arrangements, comprehensive financial protection against the growing burden of NCDs is crucial in meeting the UN's Sustainable Development Goals.

How institutional forces, ideas and actors shaped population health planning in Australian regional primary health care organisations

Background

Worldwide, there are competing norms driving health system changes and reorganisation. One such norm is that of health systems’ responsibilities for population health as distinct from a focus on clinical services. In this paper we report on a case study of population health planning in Australian primary health care (PHC) organisations (Medicare Locals, 2011–2015). Drawing on institutional theory, we describe how institutional forces, ideas and actors shaped such planning.

Methods

We reviewed the planning documents of the 61 Medicare Locals and rated population health activities in each Medicare Local. We also conducted an online survey and 50 interviews with Medicare Local senior staff, and an interview and focus group with Federal Department of Health staff.

Results

Despite policy emphasis on population health, Medicare Locals reported higher levels of effort and capacity in providing clinical services. Health promotion and social determinants of health activities were undertaken on an ad hoc basis. Regulatory conditions imposed by the federal government including funding priorities and time schedules, were the predominant forces constraining population health planning. In some Medicare Locals, this was in conflict with the normative values and what Medicare Locals felt ought to be done. The alignment between the governmental and the cultural-cognitive forces of a narrow biomedical approach privileged clinical practice and ascribed less legitimacy to action on social determinants of health. Our study also shed light on the range of PHC actors and how their agency influenced Medicare Locals’ performance in population health. The presence of senior staff or community boards with a strong commitment to population health were important in directing action towards population health and equity.

Conclusions

There are numerous institutional, normative and cultural factors influencing population health planning. The experience of Australian Medicare Locals highlights the difficulties of planning in such a way that the impact of the social determinants on health and health equity are taken into account. The policy environment favours a focus on clinical services to the detriment of health promotion informed by a social determinants focus.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5273-4) contains supplementary material, which is available to authorized users.

Complexity Sciences

Complexity sciences, in plain English, are the sciences of interconnectedness.

The aim of complexity sciences is to understand the many different facets of phenomena. Complexity sciences employs a variety of different methodological approaches to describe and to analyse multifaceted phenomena like health, the economy, or environmental systems.

Basically, a system consists of a number of parts that are connected to each other. Systems differ depending on the nature of their connectedness. Simple systems have one-to-one relationships and their behaviour is precisely predictable. Complicated systems have one-to-many relationships with mostly predictable behaviours.

This book deals with complex adaptive systems with many-to-many relationships. Their many-to-many relationships make their behaviour emergent, hence their outcomes are unpredictable. Complex adaptive systems have a special characteristic, the members of the system can learn from feedback and experiences. The relationships in complex adaptive systems change constantly allowing the system to evolve over time in light of changing demands. However, a system’s overall behaviour, despite its adaptation to changing circumstances, remains relatively stable within boundaries, but occasionally, its behaviour may change abruptly and dramatically for no apparent reason.

One can compare the behaviour of complex adaptive systems to that of a family; most of the time a family stays together despite ups and downs, but occasionally a family can abruptly break apart to the surprise of its members and its surroundings.

Another important characteristic of complex adaptive systems is its nonlinear behaviour to change, i.e. the magnitude of change in one member of the system shows a disproportional change in that of others. As experience shows, small changes in the behaviour of a system member often show dramatic changes in the behaviour of the whole system, whereas a major change in the behaviour of that member typically results in little or no change.

Studying complex adaptive systems aims to understand the relationships and the dynamics between the members of the systems. This understanding allows for better responses when the system as a whole is challenged by constraints and/or unfamiliar challenges.

A special characteristic of social systems is their “goal-delivering” nature. In organisational terms these are codified by their purpose, goals, and values statements.

Considerations for Assessing the Appropriateness of High-Cost Pediatric Care in Low-Income Regions

It may be difficult to predict the consequences of provision of high-cost pediatric care (HCC) in low- and middle-income countries (LMICs), and these consequences may be different to those experienced in high-income countries. An evaluation of the implications of HCC in LMICs must incorporate considerations of the specific context in that country (population age profile, profile of disease, resources available), likely costs of the HCC, likely benefits that can be gained versus the costs that will be incurred. Ideally, the process that is followed in decision making around HCC should be transparent and should involve the communities that will be most affected by those decisions. It is essential that the impacts of provision of HCC are carefully monitored so that informed decisions can be made about future provision medical interventions.

"Contract to Volunteer": South African Community Health Worker Mobilization for Better Labor Protection

In this paper, we explore the increasing activity around labor rights for South African community health workers (CHWs). Contextualizing this activity within broader policy and legal developments, we track the emergence of sporadic mobilizations for decent work (supported by local health activist organizations) and subsequently, the formation of a CHW union. The National Union of Care Workers of South Africa (NUCWOSA) was inaugurated in 2016, hoping to secure formal and secure employment through government and the consequent labor and occupational health protections. Various tensions were observed during fieldwork in the run up to NUCWOSA's formation and raise important questions about representation, legitimacy, and hierarchies of power. We close by offering suggestions for future research in this developing space.