Evaluating Global Health Partnerships: A Case Study of a Gavi HPV Vaccine Application Process in Uganda

Uptake of human papilloma virus vaccine and its determinants among females in East Africa: a systematic review and meta-analysis

INTRODUCTION

Cervical cancer is the most common malignant tumor among women. It is the main cause of death among women in sub-Saharan African countries. Particularly, the incidence and mortality rates are highest in East Africa. Even though the burden of human papilloma virus-related cervical cancer is high in East Africa, there is no conclusive evidence about the prevalence of human papilloma virus vaccine uptake and its predictors.

OBJECTIVE

To assess the pooled prevalence of human papilloma virus vaccine uptake and its determinants in East Africa.

METHOD

Eligible articles were searched on PubMed, Embase, Scopus, Cochrane Library, Google Scholar, and Google. Those articles incorporating the outcome of interest, both analytical and descriptive study designs, and published or unpublished articles at any time were included. Keywords and Medical Subjects Heading terms or synonyms of human papilloma virus vaccine and Boolean operators were used to retrieve the articles. To assure the quality of articles, Joana Brigg's Institute critical appraisal checklist for cross-sectional studies was used. Sensitivity analysis was conducted to assess the heterogeneity among the studies, and a random effect model was used to analyze the pooled effect size.

RESULT

A total of 29 articles were included, and the pooled prevalence of HPV vaccine uptake in East Africa was 35% (95% CI: 26-45%). Good knowledge (OR = 1.6, 95%CI; 1.43-1.8), positive attitude (OR = 2.54, 95% CI; 2.13-3.03), ever heard about HPV vaccine (OR = 1.41, 95% CI; 1.03-1.94), mother educational status above college (OR = 1.84, 95%CI; 1.03-3.31), middle wealth index (OR = 1.33, 95%CI; 1.04-1.7), ≥ 9 family size (OR = 0.76, 95%CI; 0.68-0.98), availability of promotion (OR = 2.53, 95%CI: 1.51-4.26), availability of adequate vaccine (OR = 4.84, 95%CI; 2.9-8.08), outreach vaccination practice (OR = 1.47, 95%CI; 1.02-2.12) and family support (OR = 4.3, 95% CI; 2.98-6.21) were the significant factors for the uptake of human papilloma virus vaccine.

CONCLUSION

As compared to the global strategic plan, the pooled prevalence of HPV vaccine uptake in east Africa was low. The uptake of the HPV vaccine was higher among adolescents than youths. Knowledge about the HPV vaccine, attitude towards the HPV vaccine, ever hearing about the HPV vaccine, residence, mother's educational status, mother's occupational status, wealth index, and family size were the significant determinants of HPV vaccine uptake. Therefore, we recommend focusing on awareness creation and behavioral change to expand the uptake of vaccines in East Africa.

Collaboration in a Partnership for Primary Health Care: A Case Study From Papua New Guinea

INTRODUCTION

In low- and middle-income countries, public-private partnerships (PPPs) are often used to support the delivery of primary health care (PHC). We explore the processes of collaboration in a corporate social responsibility investment in PHC that was delivered through a PPP model in Western Province, Papua New Guinea, in 2009-2018 to strengthen PHC services.

METHODS

Qualitative interviews were conducted with stakeholders in the PPP (N=20). Key program documents were also reviewed. Data were coded using a general inductive approach, and Actor-Network Theory (ANT) was used to frame the analysis.

RESULTS

Four dominant themes emerged: (1) interpersonal relationships accelerate collaboration, (2) collaboration requires time, (3) formal governance structures encourage collaboration, and (4) internal change disrupts collaboration. The research provides insight into the role of collaboration for more efficient, effective, and impactful design and implementation of PPP for PHC. It makes suggestions for how ANT may be used when designing PPPs and for the ongoing management of relationships between partners. We found ANT to be a useful framework to conceptualize the complex dynamics between the "actors" within the PPP and to identify opportunities for improvement where structural changes may be made to circumvent issues that may compromise effective collaboration.

CONCLUSION

Collaboration is key to the success of PPPs for PHC. We found collaboration is not formulaic but is driven by actors, relationships, time, and governance. ANT can assist in designing, understanding, and managing the complex relationships between stakeholders of a PPP, who often come with diverse agendas, experiences, values, and perspectives.

Equity in vaccine coverage in Uganda from 2000 to 2016: revealing the multifaceted nature of inequity

BACKGROUND

This study analyses vaccine coverage and equity among children under five years of age in Uganda based on the 2016 Uganda Demographic and Health Survey (UDHS) dataset. Understanding equity in vaccine access and the determinants is crucial for the redress of emerging as well as persistent inequities.

METHODS

Applied to the UDHS for 2000, 2006, 2011, and 2016, the Vaccine Economics Research for Sustainability and Equity (VERSE) Equity Toolkit provides a multivariate assessment of immunization coverage and equity by (1) ranking the sample population with a composite direct unfairness index, (2) generating quantitative measure of efficiency (coverage) and equity, and (3) decomposing inequity into its contributing factors. The direct unfairness ranking variable is the predicted vaccination coverage from a logistic model based upon fair and unfair sources of variation in vaccination coverage. Our fair source of variation is defined as the child's age - children too young to receive routine immunization are not expected to be vaccinated. Unfair sources of variation are the child's region of residence, and whether they live in an urban or rural area, the mother's education level, the household's socioeconomic status, the child's sex, and their insurance coverage status. For each unfair source of variation, we identify a "more privileged" situation.

RESULTS

The coverage and equity of the Diphtheria-Pertussis-Tetanus vaccine, 3rd dose (DPT3) and the Measles-Containing Vaccine, 1st dose (MCV1) - two vaccines indicative of the health system's performance - improved significantly since 2000, from 49.7% to 76.8% and 67.8% to 82.7%, respectively, and there are fewer zero-dose children: from 8.4% to 2.2%. Improvements in retaining children in the program so that they complete the immunization schedule are more modest (from 38.1% to 40.8%). Progress in coverage was pro-poor, with concentration indices (wealth only) moving from 0.127 (DPT3) and 0.123 (MCV1) in 2000 to -0.042 and -0.029 in 2016. Gains in overall equity (composite) were more modest, albeit significant for most vaccines except for MCV1: concentration indices of 0.150 (DPT3) and 0.087 (MCV1) in 2000 and 0.054 and 0.055 in 2016. The influence of the region and settings (urban/rural) of residence significantly decreased since 2000.

CONCLUSION

The past two decades have seen significant improvements in vaccine coverage and equity, thanks to the efforts to strengthen routine immunization and ongoing supplemental immunization activities such as the Family Health Days. While maintaining the regular provision of vaccines to all regions, efforts should be made to alleviate the impact of low maternal education and literacy on vaccination uptake.

Planning, implementation, and sustaining high coverage of human papillomavirus (HPV) vaccination programs: What works in the context of low-resource countries?

Cervical cancer due to human papillomavirus (HPV) infection is a leading cause of mortality among women in low-resource settings. Many Sub-Saharan African countries have introduced HPV vaccination programs at the national level in the last few years. However, countries are struggling to maintain sustainable coverage. This study focuses on the introduction and sustainability challenges, context-specific key lessons learned, and mechanisms of action to achieve high sustainable coverage from low and lower-middle-income countries (LLMICs) that have introduced HPV vaccination programs by collating evidence from a literature review and key informant interviews. Local data availability was a challenge across countries, with the lack or absence of registries, data collection and reporting mechanisms. Multi-sectoral coordination and early involvement of key stakeholders were cited as an integral part of HPV programs and facilitators for sustainable coverage. Key informants identified periodic sensitization and training as critical due to high staff turnover. Health workforce mobilization was fundamental to ensure that the health workforce is aware of the disease etiology, eligibility requirements, and can dispel misinformation. Schools were reported to be an ideal sustainable platform for vaccination. However, this required teachers to be trained, which was often not considered in the programs. District-level staff were often poorly informed and lacked the technical and logistic capacity to support vaccination rounds and data collection. To improve the sustainability of HPV vaccination programs, there is a need for timely microplanning, efficient preparedness assessment, assessing training approaches, periodic training, finding innovative ways to achieve equity and adoption of a bottom-up approach to ensure that processes between districts and central level are well-connected and resources are distributed efficiently.

Exploring the Multidimensionality of Trust in Participatory Health Partnerships - A Network Approach

Introduction

Previous studies have identified “trust” as a key mechanism to achieve sustainable partnerships in participatory health research, which themselves can represent social networks. A recent review discussed the potential for social network analysis to investigate the development and maintenance of trust and its effects on partnership functioning in participatory health research partnerships. This review also recommended considering a comprehensive, nuanced and multidimensional approach to conceptualizing, operationalizing and measuring trust in research partnerships. Thus, this study aims to explore empirically the conceptualizing, operationalizing and measuring of trust in a multidimensional manner, approaching each trust dimension as an individual trust network, as well as combined as an overall trust network.

Methods

We sampled the whole network, recruiting from a newly established network of 57 individuals that must collaborate to achieve a common goal. These individuals represented academic, service and community organizations of an existing participatory partnership, the Public and Patient Involvement Ignite Network in Ireland. Of the 57 individuals invited to take part in the study, 75% (n = 43) individuals completed the network survey. A survey about trust was designed based on literature in the area and was administered via Qualtrics. The survey included eight network questions: one on collaboration, and seven on specific dimensions of trust. From this, we constructed a network for each trust dimension. We compared several core network measures of each to identify structural differences between the dimensions of trust. To statistically validate them, we compared them to a random and preferential null model.

Results

All the networks had a high reciprocity but were decentralized. Key differences were identified across trust dimensions, particularly in terms of integrity and shared values, visions and goals. None of the networks compared well to the null models indicating participants did not randomly or preferentially (based on how much trust they receive for a particular trust dimension) trust other partners.

Discussion/Conclusion

This novel empirical social network analysis of trust in a real-world partnership elucidates the nuances and multidimensional nature of trust. This provides support for expanding this research direction to enhance understanding of and interventions for trust in participatory health research.

The Evolution of Trust Within a Global Health Partnership With the Private Sector: An Inductive Framework

BACKGROUND

Public-private partnerships (PPPs) in global health are increasingly common to support sustainable development and strengthen health systems in low- and middle-income countries. Since the release of the Sustainable Development Goals (SDGs) in 2015 culminating in a discrete goal "to revitalize the global partnership for sustainable development," public health scholars have sought to understand what makes PPPs successful in different contexts. While trust has long been identified as a key component of successful strategic alliances in the private sector, less is known about how trust emerges between public- and private- sector partners, particularly in global health. Therefore, we investigated how trust between partners evolved in the context of Project Last Mile (PLM), a global health partnership that translates the business acumen of The Coca-Cola Company to strengthen public health systems across Africa.

METHODS

This study draws upon secondary analysis of qualitative data generated as part of the longitudinal, mixed-methods evaluation of PLM across country settings. Seventy-seven interviews with a purposeful sample of key stakeholders were conducted in Mozambique, South Africa and eSwatini between August 2016 and July 2018. Trained qualitative interviewers followed a standard discussion guide, and audio-recorded interviews with participants' consent. In this secondary analysis, we analyzed qualitative data to understand how trust between partners was cultivated across settings.

RESULTS

We drew upon stakeholder experiences to inform an inductive framework for how trust develops over time. Our analysis revealed five domains that were foundational to building trust: (1) reputational context, (2) team composition, (3) tangible outputs, (4) shared values, and (5) effective communication.

CONCLUSION

The framework may be useful for private and public sector entities seeking to establish and sustain trust within their global health partnerships.

The Equity Tool for Valuing Global Health Partnerships

There is a need to more comprehensively identify and respond to equity in global health partnerships. The Equity Tool can support dialogue at any stage of a partnership, by individuals at any level. This assists partnerships to embrace ways of recognizing, understanding, and advancing equity in all their processes.

Global health partnerships (GHPs) involve complex relationships between individuals and organizations, often joining partners from high-income and low- or middle-income countries around work that is carried out in the latter. Therefore, GHPs are situated in the context of global inequities and their underlying sociopolitical and historical causes, such as colonization. Equity is a core principle that should guide GHPs from start to end. How equity is embedded and nurtured throughout a partnership has remained a constant challenge. We have developed a user-friendly tool for valuing a GHP throughout its lifespan using an equity lens. The development of the EQT was informed by 5 distinct elements: a scoping review of scientific published peer-reviewed literature; an online survey and follow-up telephone interviews; workshops in Canada, Burkina Faso, and Vietnam; a critical interpretive synthesis; and a content validation exercise. Findings suggest GHPs generate experiences of equity or inequity yet provide little guidance on how to identify and respond to these experiences. The EQT can guide people involved in partnering to consider the equity implications of all their actions, from inception, through implementation and completion of a partnership. When used to guide reflective dialogue with a clear intention to advance equity in and through partnering, this tool offers a new approach to valuing global health partnerships. Global health practitioners, among others, can apply the EQT in their partnerships to learning together about how to cultivate equity in their unique contexts within what is becoming an increasingly diverse, vibrant, and responsive global health community.

Conceptualising, operationalising, and measuring trust in participatory health research networks: a scoping review

BACKGROUND

There are many described benefits of community-based participatory research (CBPR), such as increased relevance of research for those who must act on its findings. This has prompted researchers to better understand how CBPR functions to achieve these benefits through building sustainable research partnerships. Several studies have identified "trust" as a key mechanism to achieve sustainable partnerships, which themselves constitute social networks. Although existing literature discusses trust and CBPR, or trust and social networks, preliminary searches reveal that none link all three concepts of trust, CBPR, and social networks. Thus, we present our scoping review to systematically review and synthesize the literature exploring how trust is conceptualised, operationalised, and measured in CBPR and social networks.

METHODS

This review follows the guidance and framework of Peters et al. which is underpinned by the widely used framework of Levac and colleagues. Levac and colleagues provided enhancements to the methodological framework of Arksey and O'Malley. We explored several electronic databases including Scopus, Medline, PubMed, Web of Science, CINAHL, Cochrane Library, Google Scholar, and PsychINFO. A search strategy was identified and agreed upon by the team in conjunction with a research librarian. Two independent reviewers screened articles by title and abstract, then by full-text based on pre-determined exclusion/inclusion criteria. A third reviewer arbitrated discrepancies regarding inclusions/exclusions. A thematic analysis was then conducted to identify relevant themes and sub-themes.

RESULTS

Based on the 26 extracted references, several key themes and sub-themes were identified which highlighted the complexity and multidimensionality of trust as a concept. Our analysis revealed an additional emergent category that highlighted another important dimension of trust-outcomes pertaining to trust. Further, variation within how the studies conceptualised, operationalised, and measured trust was illuminated. Finally, the multidimensionality of trust provided important insight into how trust operates as a context, mechanism, and outcome.

CONCLUSIONS

Findings provide support for future research to incorporate trust as a lens to explore the social-relational aspects of partnerships and the scope to develop interventions to support trust in partnerships.

A conceptual framework for analysing partnership and synergy in a global health alliance: case of the UK Public Health Rapid Support Team

Partnerships have become increasingly important in addressing complex global health challenges, a reality exemplified by the COVID-19 pandemic and previous infectious disease epidemics. Partnerships offer opportunities to create synergistic outcomes by capitalizing on complimentary skills, knowledge and resources. Despite the importance of understanding partnership functioning, research on collaboration is sparse and fragmented, with few conceptual frameworks applied to evaluate real-life partnerships in global health. In this study, we aimed to adapt and apply the Bergan Model of Collaborative Functioning (BMCF) to analyse partnership functioning in the UK Public Health Rapid Support Team (UK-PHRST), a government-academic partnership, dedicated to outbreak response and research in low- and middle-income countries. We conducted a literature review identifying important elements to adapt the framework, followed by a qualitative case study to characterize how each element, and the dynamics between them, influenced functioning in the UK-PHRST, exploring emerging themes to further refine the framework. Elements of the BMCF that our study reinforced as important included the partnership's mission, partner resources (skills, expertise and networks), leadership, the external environment, management systems and communication. Additional elements identified in the literature and critical to partnership functioning of the UK-PHRST included governance and financial structures adopted, trust and power balance, organizational culture, strategy and evaluation and knowledge management. Because of the way the UK-PHRST was structured, fostering team cohesion was an important indicator of synergy, alongside collaborative advantage. Dividing the funding and governance equally between organizations was considered crucial for maintaining institutional balance; however, diverse organizational cultures, weak communication practices and perceived power imbalances compromised team cohesion. Our analysis allowed us to make recommendations to improve partnership functioning at a critical time in the evolution of the UK-PHRST. The analysis approach and framework presented here can be used to evaluate and strengthen the management of global health partnerships to realize synergy.

Evaluation of Public–Private Partnership in the Veterinary Domain Using Impact Pathway Methodology: In-depth Case Study in the Poultry Sector in Ethiopia

Public–private partnerships (PPPs) in the veterinary domain are joint approaches in which public veterinary services and private actors such as private veterinarians, producers' associations, or private companies work together to address complex animal health challenges. They are implemented worldwide and can help to strengthen the capacities of veterinary services, but few have been evaluated. None of the evaluations developed in the veterinary domain explicitly addressed PPPs, their complex program design, their evolving governance, and coordination system, and their impacts. This work represents the first application of the participatory impact pathway methodology for the evaluation of a PPP in the veterinary domain. The PPP evaluated aimed at developing the poultry sector in Ethiopia and improving poultry health service coverage, particularly in remote areas. The combination of semi-structured interviews (n = 64) and collective reflection during three workshops (n participants = 26, 48, 18), captured the viewpoints of public and private partners, actors who influenced the partnership, and actors impacted by it. The context of the PPP was analyzed, and the causal relationships between the PPP and its impacts were investigated. This work showed that collaboration between the public and private sector occurred at several administrative levels. The actors considered a variety of impacts, on the economy, business, trust, and health, which were then measured through different indicators. The actors also identified the added value of the PPP to enrich those impacts. The participatory impact pathway methodology helped to strengthen the engagement of actors in the PPP and to formulate recommendations at the policy level to favor positive results. This case study represents a milestone in building a participatory evaluation framework of PPP in the veterinary domain.

Partnership evaluation: An application of a developmental framework to the Governance and Local Development project in Senegal

This study explores the valued-added of USAID/Senegal's Governance for Local Development (GOLD) project's integrated approach to working with four sector projects: two in health, one in water and sanitation, and one in nutrition. The study builds on a partnership evaluation framework that identifies practices related to preconditions, factors linked with success, implementation structures and processes, contribution of collaboration to performance, and collaboration outcomes. A survey instrument developed statements of positive practices and asked respondents to agree or disagree with each one. The analysis includes exploration of differences in perception. Respondents generally expressed agreement with the statements in the survey instrument associated with the various dimensions of effective partnerships. All projects mentioned the presence of partnership champions. Problems with joint action (e.g., planning, budgeting, managing) were the most frequently cited constraints. The study confirms most of the hypotheses embedded in the evaluation framework regarding partnership's potential for creating synergies and improved outcomes and affirms the framework's usefulness as a developmental evaluation tool. Positive outcomes result from intentional efforts to build relationships, cultivate champions, and design systems and processes that support a partnership culture and contribute to each partners' success as well as the success of the partnership itself.

Partnering for rotavirus vaccine introduction in India: A retrospective analysis

BACKGROUND

The pre-existing partner network created in India for the delivery of polio vaccines was initially used to eradicate polio and later on embedded in the health systems network to promote routine immunization and other health interventions efficiently. The experience from this network offered lessons for strengthening the health care systems and provided a well-established network that could be utilized for other vaccine initiatives. It has also been established that successful partnerships between a broad range of stakeholders provide support, strengthen the health system, and accelerate vaccine innovation, introduction, access, logistics, and communication support. However, beyond polio eradication, there have not been too many documented success stories of vaccine introduction, which could be replicated in other new vaccine introductions and allied health initiatives. The authors have reviewed the successful and time-bound introduction of rotavirus vaccine (RVV) in India in the present article.

METHODS

The review was conducted based on a partnership framework which analysed multiple factors-partnership prerequisites, partnership model, partnership process, and partnership performance, thereby providing a comprehensive insight into the successful utilization of partnership networks for rotavirus vaccine introduction under the Universal Immunization Program in India.

RESULTS & CONCLUSION

The review also highlights the role of a lead agency in creating a fertile ground for lush, efficient, and effective partnerships amongst different stakeholders. The already existing RVV partnership framework reviewed by the authors can be successfully utilized for future new vaccine introductions.

Advancing sustainable development goals through immunization: a literature review

BACKGROUND

Immunization directly impacts health (SDG3) and brings a contribution to 14 out of the 17 Sustainable Development Goals (SDGs), such as ending poverty, reducing hunger, and reducing inequalities. Therefore, immunization is recognized to play a central role in reaching the SDGs, especially in low- and middle-income countries (LMICs). Despite continuous interventions to strengthen immunization systems and to adequately respond to emergency immunization during epidemics, the immunization-related indicators for SDG3 lag behind in sub-Saharan Africa. Especially taking into account the current Covid19 pandemic, the current performance on the connected SDGs is both a cause and a result of this.

METHODS

We conduct a literature review through a keyword search strategy complemented with handpicking and snowballing from earlier reviews. After title and abstract screening, we conducted a qualitative analysis of key insights and categorized them according to showing the impact of immunization on SDGs, sustainability challenges, and model-based solutions to these challenges.

RESULTS

We reveal the leveraging mechanisms triggered by immunization and position them vis-à-vis the SDGs, within the framework of Public Health and Planetary Health. Several challenges for sustainable control of vaccine-preventable diseases are identified: access to immunization services, global vaccine availability to LMICs, context-dependent vaccine effectiveness, safe and affordable vaccines, local/regional vaccine production, public-private partnerships, and immunization capacity/capability building. Model-based approaches that support SDG-promoting interventions concerning immunization systems are analyzed in light of the strategic priorities of the Immunization Agenda 2030.

CONCLUSIONS

In general terms, it can be concluded that relevant future research requires (i) design for system resilience, (ii) transdisciplinary modeling, (iii) connecting interventions in immunization with SDG outcomes, (iv) designing interventions and their implementation simultaneously, (v) offering tailored solutions, and (vi) model coordination and integration of services and partnerships. The research and health community is called upon to join forces to activate existing knowledge, generate new insights and develop decision-supporting tools for Low-and Middle-Income Countries' health authorities and communities to leverage immunization in its transformational role toward successfully meeting the SDGs in 2030.

How to evaluate the implementation of complex health programmes in low-income settings: the approach of the Gavi Full Country Evaluations

Vaccination, like most other public health services, relies on a complex package of intervention components, functioning systems and committed actors to achieve universal coverage. Despite significant investment in immunization programmes, national coverage trends have slowed and equity gaps have grown. This paper describes the design and implementation of the Gavi Full Country Evaluations, a multi-country, prospective, mixed-methods approach whose goal was to monitor and evaluate processes, inputs, outputs and outcomes of immunization programmes in Bangladesh, Mozambique, Uganda and Zambia. We implemented the Full Country Evaluations from 2013 to 2018 with the goal of identifying the drivers of immunization programme improvement to support programme implementation and increase equitable immunization coverage. The framework supported methodological and paradigmatic flexibility to respond to a broad range of evaluation and implementation research questions at global, national and cross-country levels, but was primarily underpinned by a focus on evaluating processes and identifying the root causes of implementation breakdowns. Process evaluation was driven by theories of change for each Gavi funding stream (e.g. Health Systems Strengthening) or activity, ranging from global policy development to district-level programme implementation. Mixing of methods increased in relevance and rigour over time as we learned to build multiple methods into increasingly tailored evaluation questions. Evaluation teams in country-based research institutes increasingly strengthened their level of embeddedness with immunization programmes as the emphasis shifted over time to focus more heavily on the use of findings for programme learning and adaptation. Based on our experiences implementing this approach, we recommend it for the evaluation of other complex interventions, health programmes or development assistance.

Assessing how global health partnerships function: an equity-informed critical interpretive synthesis

Background

Global health partnerships (GHPs) are situated in complex political and economic relationships and involve partners with different needs and interests (e.g., government agencies, non-governmental organizations, corporations, universities, professional associations, philanthropic organizations and communities). As part of a mixed methods study designed to develop an equity-sensitive tool to support more equity-centred North-South GHPs, this critical interpretive synthesis examined reported assessments of GHPs.

Results

We examined 30 peer-reviewed articles for power dynamics, equity and inequities, and contradictions or challenges encountered in North-South partnerships. Among articles reviewed, authors most often situated GHPs around a topical focus on research, capacity-building, clinical, or health services issues, with the ‘work’ of the partnership aiming to foster skills or respond to community needs.

The specific features of GHPs that were assessed varied widely, with consistently-reported elements including the early phases of partnering; governance issues; the day-to-day work of partnerships; the performance, impacts and benefits of GHPs; and issues of inclusion. Articles shared a general interest in partnering processes and often touched briefly on issues of equity; but they rarely accounted for the complexity of sociopolitical and historical contexts shaping issues of equity in GHPs. Further, assessments of GHPs were often reported without inclusion of voices from all partners or named beneficiaries.

GHPs were frequently portrayed as inherently beneficial for Southern partners, without attention to power dynamics and inequities (North-South, South-South). Though historical and political dynamics of the Global North and South were inconsistently examined as influential forces in GHPs, such dynamics were frequently portrayed as complex and characterized by asymmetries in power and resources. Generally, assessments of GHPs paid little attention to the macroeconomic forces in the power and resource dynamics of GHPs highlights the importance of considering the broader political. Our findings suggest that GHPs can serve to entrench both inequitable relationships and unfair distributions of power, resources, and wealth within and between countries (and partners) if inequitable power relationships are left unmitigated.

Conclusions

We argue that specific practices could enhance GHPs’ contributions to equity, both in their processes and outcomes. Enhancing partnering practices to focus on inclusion, responsiveness to North-South and South-South inequities, and recognition of GHPs as situated in a broader (and inequitable) political economy. A relational and equity-centred approach to assessing GHPs would place social justice, humility and mutual benefits as central practices—that is, regular, routine things that partners involved in partnering do intentionally to make GHPs function well. Practicing equity in GHPs requires continuous efforts to explicitly acknowledge and examine the equity implications of all aspects of partnering.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00726-z.

Using Trellis software to enhance high-quality large-scale network data collection in the field

Trellis is a mobile platform created by the Human Nature Lab at the Yale Institute for Network Science to collect high-quality, location-aware, off-line/online, multi-lingual, multi-relational social network and behavior data in hard-to-reach communities. Respondents use Trellis to identify their social contacts by name and photograph, a procedure especially useful in low-literacy populations or in contexts where names may be similar or confusing. We use social network data collected from 1,969 adult respondents in two villages in Kenya to demonstrate Trellis' ability to provide unprecedented metadata to monitor and report on the data collection process including artifactual variability based on surveyors, time of day, or location.

Combinations of Conditions for Network Effectiveness: A Fuzzy-Set Qualitative Comparative Analysis of 37 International Development Intervention Cases

Most international development projects that aim to eradicate poverty and improve the quality of life of people in low- and middle-income countries are implemented through a collaborative network of multiple parties, including non-governmental organizations (NGOs). However, how network effectiveness in international development projects can be achieved remains unclear. Using fuzzy-set qualitative comparative analysis, this study explores the causal conditions of network effectiveness of 37 international development projects implemented by South Korean NGOs based on a theoretical lens of collaborative networks. Findings revealed two causal configurations for network effectiveness. Even under a lack of network management capacity and unintegrated networks, or under resource deficiency and lack of network management capacity, high-level local capacity or high-quality collaboration among partners was shown to produce network effectiveness. An in-depth analysis of two cases with successful network effectiveness was also conducted to achieve a more thorough and comprehensive understanding of the causal conditions. The findings suggest practical solutions to manage collaborative networks and compensate for deficiencies of diverse conditions to improve network effectiveness.

Lessons Learned From Implementing Prospective, Multicountry Mixed-Methods Evaluations for Gavi and the Global Fund

Lessons learned from implementing evaluations for Gavi, the Vaccine Alliance and the Global Fund for AIDS, Tuberculosis, and Malaria can help inform the design and implementation of ongoing or future evaluations of complex interventions. We share 5 lessons distilled from over 7 years of experience implementing evaluations in 7 countries.

Introduction:

As global health programs have become increasingly complex, corresponding evaluations must be designed to assess the full complexity of these programs. Gavi and the Global Fund have commissioned 2 such evaluations to assess the full spectrum of their investments using a prospective mixed-methods approach. We aim to describe lessons learned from implementing these evaluations.

Methods:

This article presents a synthesis of lessons learned based on the Gavi and Global Fund prospective mixed-methods evaluations, with each evaluation considered a case study. The lessons are based on the evaluation team’s experience from over 7 years (2013–2020) implementing these evaluations. The Centers for Disease Control and Prevention Framework for Evaluation in Public Health was used to ground the identification of lessons learned.

Results:

We identified 5 lessons learned that build on existing evaluation best practices and include a mix of practical and conceptual considerations. The lessons cover the importance of (1) including an inception phase to engage stakeholders and inform a relevant, useful evaluation design; (2) aligning on the degree to which the evaluation is embedded in the program implementation; (3) monitoring programmatic, organizational, or contextual changes and adapting the evaluation accordingly; (4) hiring evaluators with mixed-methods expertise and using tools and approaches that facilitate mixing methods; and (5) contextualizing recommendations and clearly communicating their underlying strength of evidence.

Conclusion:

Global health initiatives, particularly those leveraging complex interventions, should consider embedding evaluations to understand how and why the programs are working. These initiatives can learn from the lessons presented here to inform the design and implementation of such evaluations.

Partnership and Participation-A Social Network Analysis of the 2017 Global Fund Application Process in the Democratic Republic of the Congo and Uganda

Background

The Global Fund to Fight AIDS, Tuberculosis and Malaria was founded in 2002 as a public-private partnership between governments, the private sector, civil society, and populations affected by the three diseases. A key principle of the Global Fund is country ownership in accessing funding through "engagement of in-country stakeholders, including key and vulnerable populations, communities, and civil society." Research documenting whether diverse stakeholders are actually engaged and on how stakeholder engagement affects processes and outcomes of grant applications is limited.

Objective

To examine representation during the 2017 Global Fund application process in the Democratic Republic of the Congo (DRC) and Uganda and the benefits and drawbacks of partnership to the process.

Methods

We developed a mixed-methods social network survey to measure network structure and assess perceptions of how working together in partnership with other individuals/organizations affected perceived effectiveness, efficiency, and country ownership of the application process. Surveys were administered from December 2017-May 2018, initially to a set of central actors, followed by any individuals named during the surveys (up to 10) as collaborators. Network analyses were conducted using R.

Findings

Collaborators spanning many organizations and expertise areas contributed to the 2017 applications (DRC: 152 nodes, 237 ties; Uganda: 118 nodes, 241 ties). Participation from NGOs and civil society representatives was relatively strong, with most of their ties being to different organization types, Uganda (63%), and DRC (67%), highlighting their collaborative efforts across the network. Overall, the perceived benefits of partnership were high, including very strong ratings for effectiveness in both countries. Perceived drawbacks of partnership were minimal; however, less than half of respondents thought partnership helped reduce transaction costs or financial costs, suggesting an inclusive and participatory process may come with short-term efficiency tradeoffs.

Conclusions

Social network analysis can be useful for identifying who is included and excluded from the process, which can support efforts to ensure stronger, more meaningful engagement in future Global Fund application processes.

Health systems constraints and facilitators of human papillomavirus immunization programmes in sub-Saharan Africa: a systematic review

Given the vast investments made in national immunization programmes (NIPs) and the significance of NIPs to public health, it is important to understand what influences the optimal performance of NIPs. It has been established that well-performing NIPs require enabling health systems. However, systematic evidence on how the performance of health systems impacts on NIPs is lacking, especially from sub-Saharan Africa. We conducted a qualitative systematic review to synthesize the available evidence on health systems constraints and facilitators of NIPs in sub-Saharan Africa, using human papillomavirus immunization programmes as a proxy. Fifty-four articles published between 2008 and 2018 were found to be eligible. Data extraction was guided by an analytical model on the interface between NIPs and health systems. A cross-cutting thematic analysis of the extracted data was performed. This systematic review provides evidence necessary for informing ongoing health systems strengthening initiatives in sub-Saharan Africa. There is evidence to suggest that NIPs in sub-Saharan Africa have surmounted significant health systems constraints and have achieved notable public health success. This success can be attributed to strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist in service delivery, vaccine communication, community engagement, the capacity of the health workforce and sustainable financing. These constraints could derail further progress if not addressed through health systems strengthening efforts. There is a need to expand the research agenda to include the comprehensive evaluation of health systems constraints and facilitators of NIPs within sub-Saharan Africa.

Global health systems partnerships: a mixed methods analysis of Mozambique's HPV vaccine delivery network actors

Background

Global health partnerships have expanded exponentially in the last two decades with Gavi, the Vaccine Alliance considered the model’s pioneer and leader because of its vaccination programs’ implementation mechanism. Gavi, relies on diverse domestic and international partners to carry out the programs in low- and middle-income countries under a partnership engagement framework (PEF). In this study, we utilized mixed methods to examine Mozambique’s Gavi driven partnership network which delivered human papillomavirus (HPV) vaccine during the demonstration phase.

Methods

Qualitative tools gauged contextual factors, prerequisites, partner performance and practices while a social network analysis (SNA) survey measured the partnership structure and perceived added value in terms of effectiveness, efficiency and country ownership. Forty key informants who were interviewed included frontline Ministry of Health workers, Ministry of Education staff and supporting partner organization members, of whom 34 participated in the social network analysis survey.

Results

Partnership structure SNA connectivity measurement scores of reachability (100%) and average distance (2.5), were high, revealing a network of very well-connected HPV vaccination implementation collaborators. Such high scores reflect a network structure favorable for rapid and widespread diffusion of information, features necessary for engaging and handling multiple implementation scales. High SNA effectiveness and efficiency measures for structural holes (85%) and low redundancy (30%) coupled with high mean perceived effectiveness (97.6%) and efficiency (79.5%) network outcome scores were observed. Additionally, the tie strength average score of 4.1 on a scale of 5 denoted high professional trust. These are all markers of a collaborative partnership environment in which disparate institutions and organizations leveraged each entity’s comparative advantage. Lower perceived outcome scores for country ownership (24%) were found, with participants citing the prominent role of several out-of-country partner organizations as a major obstacle.

Conclusions

While there is room for improvement on the country ownership aspects of the partnership, the expanded, diverse and inclusive collaboration of institutions and organizations that implemented the Mozambique HPV vaccine demonstration project was effective and efficient. We recommend that the country adapt a similar model during national scale up of HPV vaccination.

The Binds of Global Health Partnership: Working out Working Together in Sierra Leone

Global health partnerships (GHPs) are the conceptual cousin of partnerships in the development sphere. Since their emergence in the 1990s, the GHP mode of working and funding has mainly been applied to single-disease, vertical interventions. However, GHPs are increasingly being used to enact Health Systems Strengthening and to address the global health worker shortage. In contrast to other critical explorations of GHPs, we explore in this article how the fact, act, and aspiration of binding different actors together around the ideology and modes of partnership working produces the perpetual state of being in a bind. This is an original analytical framework drawing on research in Sierra Leone and London. We offer new insights into the ways in which GHPs function and are experienced, showing that along with the successes of partnership work, such arrangements are often and unavoidably tense, uncomfortable, and a source of frustration and angst.

The Core Roles of Transparency and Accountability in the Governance of Global Health Public-Private Partnerships

This article introduces a simplified model for assessing and designing the governance of global health public-private partnerships (PPPs) based on the two concepts of transparency and accountability. The article reviews the literature on partnership governance, which shows many frameworks and recommendations but limited implementation of the proposals. The article proposes a matrix to provide a high-level analytical and planning tool applicable to different types of PPPs in global health. The matrix arranges transparency and accountability as two orthogonal and separate governance dimensions. In the literature, transparency and accountability are two of the most commonly discussed dimensions of governance but they have not been used in this manner to create a model of governance. Transparency is important on its own because it allows learning, contributes to accountability, and shapes organizational performance. Accountability provides a tool to assure that a PPP is achieving its public interest goals and also contributes to improved organizational performance. Both contribute to democracy and public perception. The matrix analyzes transparency and accountability according to three dimensions (relationships, contents, and mechanisms) and assesses the level of each dimension. Using a hypothetical PPP example, the article illustrates how the matrix could be used in practice. The matrix provides a method to assess the levels of transparency and accountability but does not indicate how much of either is good or desirable. The matrix is proposed to improve conceptual clarity and help identify concrete options for action in planning, assessing, and adjusting PPP governance.

All Health Partnerships, Great and Small: Comparing Mandated With Emergent Health Partnerships Comment on "Evaluating Global Health Partnerships: A Case Study of a Gavi HPV Vaccine Application Process in Uganda"

The plurality of healthcare providers and funders in low- and middle-income countries (LMICs) has given rise to an era in which health partnerships are becoming the norm in international development. Whether mandated or emergent, three common drivers are essential for ensuring successful health partnerships: trust; a diverse and inclusive network; and a clear governance structure. Mandated and emergent health partnerships operate as very different models and at different scales. However, there is potential for sharing and learning between these types of partnerships. Emergent health partnerships, especially as they scale up, may learn from mandated partnerships about establishing clear governance mandates for larger and more complex partnerships. By combining social network analysis, which can detect key actors and stakeholders that could add value to existing emergent partnerships, with Brinkerhoff ’s comprehensive framework for partnership evaluation, we can identify a set of tools that could be used to evaluate the effectiveness and sustainability of emergent health partnerships.

Passed the Age of Puberty: Organizational Networks as a Way to Get Things Done in the Health Field Comment on "Evaluating Global Health Partnerships: A Case Study of a Gavi HPV Vaccine Application Process in Uganda"

In this commentary I will demonstrate that the case study of Uganda’s Human papilloma virus (HPV) vaccine application partnership provides an excellent example of widening our lens by evaluating the successful HPV vaccine coverage from a network-centric perspective. That implies that the organizational network is seen as the locus of production and that network theories become indispensable to analyze the situation at hand. The case study is, as said, an excellent example of how this can be done and my comments have to be read as an endorsement and a broadening of the discussion of what Carol Kamya and colleagues have presented. It is demonstrated that an organizational network approach can be considered a serious and mature way in understanding public health issues.