Institutionalization of Projects Into Districts in Low- and Middle-Income Countries Needs Stewardship, Autonomy, and Resources

What Underlies State Government Performance in Scaling Family Planning Programming? A Study of The Challenge Initiative State Partnerships in Nigeria

INTRODUCTION

Relatively few studies rigorously examine the factors associated with health systems strengthening and scaling of interventions at subnational government levels. We aim to examine how The Challenge Initiative (TCI) coaches subnational (state government) actors to scale proven family planning and adolescent and youth sexual and reproductive health approaches rapidly and sustainably through public health systems to respond to unmet need among the urban poor.

METHODS

This mixed-methods comparative case study draws on 32 semistructured interviews with subnational government leaders and managers, nongovernmental organization leaders, and TCI Nigeria staff, triangulated with project records and government health management information system (HMIS) data. Adapting the Consolidated Framework for Implementation Research (CFIR), we contrast experience across 2 higher-performing states and 1 lower-performing state (identified through HMIS data and selected health systems strengthening criteria from 13 states) to identify modifiable factors linked with successful adoption and implementation of interventions and note lessons for supporting scale-up.

RESULTS

Informants reported that several TCI strategies overlapping with CFIR were critical to states' successful adoption and sustainment of interventions, most prominently external champions' contributions and strengthened state planning and coordination, especially in higher-performing states. Government stakeholders institutionalized new interventions through their annual operational plans. Higher-performing states incorporated mutually reinforcing interventions (including service delivery, demand generation, and advocacy). Although informants generally expressed confidence that newly introduced service delivery interventions would be sustained beyond donor support, they had concerns about government financing of demand-side social and behavior change work.

CONCLUSION

As political and managerial factors, even more than technical factors, were most linked with successful adoption and scale-up, these processes and systems should be assessed and prioritized from the start. Government leaders, TCI coaches, and other stakeholders can use these findings to shape similar initiatives to sustainably scale social service interventions.

Institutionalization for good governance to reach sustainable health development: a framework analysis

BACKGROUND

This article explores the concept of institutionalization, which is the process of transforming ideas into programs and automating actions, in the context of health system governance and sustainable development. Institutionalization is a key mechanism for creating accountable and transparent institutions, which are essential for achieving health system resilience and sustainability. This study identifies the components and dimensions of institutionalization in the health system and its relationship with good governance and sustainable health development.

MAIN TEXT

We applied a scoping review method in five steps. First, we formulated a question for our research. Then, we concluded a comprehensive literature search in five electronic databases for identifying relevant studies. This review has two phases: identifying the concept of institutional approach and its components in health system, and its relationship with good governance to reach Sustainable Health Development (SHD). The third step was study selection, and the 1st author performed data abstraction. The key issues which are identified in our review, related to the concepts of SDH, its goals, pillars and principles; positive peace; good governance; components of institutional approach components, and their relations. Finally, we summarized and organized our findings in a format of a proposed conceptual framework, to underpin the role of institutionalization in the health system to achieve sustainable development.

CONCLUSION

Institutionalization is a key concept for achieving positive peace and good governance, which requires meaningful involvement of leaders, politicians, civil society, and public participation. It also depends on the conditions of justice, human rights, transparency, accountability and rule of law. In the wake of COVID-19, institutionalization is more crucial than ever for advancing sustainable development, especially in the context of low and middle-income countries (LMICs).

Achieving and Sustaining Change Through Capacity Building Train-the-Trainer Health Initiatives in Low- and Middle-Income Countries: A Systematic Review

INTRODUCTION

Given the anticipated health challenges, forecasted deficiencies in the global health workforce, and steady demands to work through resource constraints, effective and efficient training approaches to build capacity are direly needed. Although train-the-trainer (T3) is not a new approach, there has been considerable interest in using it to develop and sustain capacity, particularly in low- and middle-income countries. This systematic review aimed to better understand the factors to achieve and sustain change across multiple countries and levels through T3 approaches.

METHODS

A literature search was conducted of six scholarly, peer-reviewed, and gray literature databases. Data were extracted for the study method, design, characteristics, and implicit or explicit factors related to maximizing the likelihood of achieving and sustaining change. An existing conceptual framework for T3 interventions in global health guided the thematic analysis. The framework consisted of five factors pertinent to capacity building T3 initiatives: Talent, Resources, Alignment, Implementation, and Nurture and Development.

RESULTS

Twenty-two studies met the inclusion criteria. The T3 training spanned all geographical regions, but interventions were most prevalent in sub-Saharan Africa (46%). Nearly all studies (68%) quantitatively examined change at the individual level (95%), but some studies also explored change at the organizational (77%) and institutional (23%) levels. Implementation and Nurture/Development were the two most salient factors in achieving and sustaining change. The greatest hindrances involved Resources and Context , an additional theme that the data identified.

DISCUSSION

The findings and recommendations from this first systematic review exploring antecedents influencing change through health-related T3 interventions can inform training and capacity-building investments, improve existing T3 initiatives, and steer planning for future approaches.

Enhancing Partner Nation Security: A Mixed-Methods Evaluation of A Peacekeeping Public Health Capacity Building Initiative

INTRODUCTION

One way the U.S. Department of Defense (DoD) works to achieve national security is through security cooperation, by way of building and enhancing partner nation capacity. This study evaluated a health-related security cooperation training initiative delivered by the DoD to military peacekeepers. The study specifically examined outcomes of change, including the beginning phase of sustainability.

MATERIALS AND METHODS

The U.S. DoD employed a train-the-trainer model in Ghana, Rwanda, Senegal, and Uganda to support the African Peacekeeping Rapid Response Partnership program. U.S. instructors trained 192 peacekeepers through 11 training iterations between December 2016 and March 2020. A mixed-method explanatory sequential design was used to explore training outcomes. Quantitatively, three hypotheses were tested using nonparametric statistical analysis. Qualitative analysis of documents was used to inform and contextually understand the quantitative results. This study was submitted to the George Washington University Institutional Review Board and was fully approved (NCR202918).

RESULTS

Quantitative and qualitative results indicated improved short-term public health knowledge and upskill among partner nation participants. There was the beginning of a cascade effect of the partner nations' ability to autonomously teach tasks and skills to their military to sustain the initiative. Differences in achieving and maintaining change outcomes were related to student characteristics, the training course, and the partner nation.

CONCLUSIONS

This research serves as the first published study to empirically examine health-related security cooperation train-the-trainer initiative change outcomes. This research is an essential building block to empirically evaluate and capture change outcomes from security cooperation capacity building training initiatives. The findings and recommendations inform security cooperation policy and associated investments.

Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study

Introduction

Facility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes.

Methods

We conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO’s Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for ‘comparison’. We interviewed 43 facility managers and 818 providers, observed 1516 client–provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality.

Results

EMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems.

Conclusion

Institutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.

RAISE: A Management and Organizational Sustainability Tool for Local Governments to Systematically Self-Evaluate the Effectiveness of Their Programs

CONTEXT

Many donor-driven public health programs are now seeking evidence for sustainability prior to investment, creating the need for tools to better appraise these capabilities. Assessing the sustainability of programs and interventions at the local level remains a community-wide challenge.

PROGRAM

This article presents a new self-assessment tool, the Reflection and Action to Improve Self-reliance and Effectiveness (RAISE) Tool ("the Tool"), modeled after The Challenge Initiative's (TCI) Sustainability Pillars. It describes the evolution of the Tool, explores its structure and applications, demonstrates its data analysis capabilities, and illustrates how it can be used for continuous program self-assessment by local governments, which TCI considers an indicator of program sustainability at the local level.

IMPLEMENTATION

Developed in 2019, the Tool has been adapted, adopted, and implemented by 92 local governments across 11 countries. The Challenge Initiative works with these local governments over a minimum of 3 years, providing management and technical coaching on high-impact interventions. Using the Tool, local governments self-assess and evaluate the quality and effectiveness of their activity implementation and identify gaps for improvement. The Tool helps both local governments and TCI track their readiness toward becoming self-reliant and taking ownership of their family planning programs.

EVALUATION

As of June 30, 2021, 39 of the 92 local governments reached the final stage of maturity, self-reliance.

DISCUSSION

Experts have stated that it can take 15 years for a sustainability assessment tool such as RAISE to be adopted into government policies. After 2 years of using the Tool on a quarterly basis, on average 87.3% of eligible local governments completed the self-assessments, made course corrections, and have taken steps toward program independence. The 39 local governments that successfully progressed to self-reliance continue to use the Tool without TCI's coaching support and have expressed interest in adapting the Tool for other health interventions.

Institutionalization of Organizational Change Outcomes in Development Cooperation Projects: The Mediating Role of Internal Stakeholder Change-Related Beliefs

This paper investigated how change outcomes of development cooperation projects can be institutionalized within the beneficiary organization. While a lot of attention has been paid to sustainability in scientific research on issues, projects, and policies related to environmental, industrial, and agricultural production and sustainability management, there are limited studies on the sustainability of organizational-level change outcomes of aid-based project interventions. Using the lens of organizational change institutionalization models, we examined how internal stakeholders’ change-related beliefs, organizational characteristics, and project characteristics relate to the institutionalization process of project outcomes. Data were collected using a questionnaire returned by 130 respondents from a university in the Global South implementing institutional development cooperation projects. Using partial least squares structural equation modeling (PLS-SEM) to analyze the data, we found that organizational characteristics and change-related beliefs both had direct positive effects on the institutionalization process, while project characteristics had negative effects. Additionally, this study reveals that stakeholder change-related beliefs mediated the relationship between organizational and project characteristics and the institutionalization process. The findings support the continual engagement of organizational internal stakeholders in institutionalization efforts throughout the project life cycle, rather than waiting for the project to end. In contrast to the mechanistic, linear result chain approaches that dominate development project discourses, there is a need for more iterative approaches that allow the development of necessary attitudes and behaviors among the beneficiary organization’s internal stakeholders to sustain the project-induced changes.

Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services

Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.

Improving Post-discharge Practice of Kangaroo Mother Care: Perspectives From Communities in East-Central Uganda

INTRODUCTION

Kangaroo mother care (KMC) is among the most cost-effective and easily accessible solutions for improving the survival and wellbeing of small newborns. In this study, we examined the barriers and facilitators to continuity of KMC at home following hospital discharge in rural Uganda.

METHODS

We conducted this study in five districts in east-central Uganda, within six hospitals and at the community level. We used a qualitative approach, with two phases of data collection. Phase 1 comprised in-depth interviews with mothers who practiced KMC with their babies and caretakers who supported them and key informant interviews with health workers, district health office staff, community health workers, and traditional birth attendants. We then conducted group discussions with mothers of small newborns and their caretakers. We held 65 interviews and five group discussions with 133 respondents in total and used a thematic approach to data analysis.

RESULTS

In hospital, mothers were sensitized and taught KMC. They were expected to continue practicing it at home with regular returns to the hospital post-discharge. However, mothers practiced KMC for a shorter time at home than in the hospital. Reasons included being overburdened with competing domestic chores that did not allow time for KMC and a lack of community follow-up support by health workers. There were increased psycho-social challenges for mothers, alongside some dangerous practices like placing plastic cans of hot water near the baby to provide warmth. Respondents suggested various ways to improve the KMC experience at home, including the development of a peer-to-peer intervention led by mothers who had successfully done KMC and community follow-up of mothers by qualified health workers and community health workers.

CONCLUSION

Despite wide acceptance of KMC by health workers, challenges to effective implementation persist. Amid the global and national push to scale up KMC, potential difficulties to its adherence post-discharge in a rural, resource-limited setting remain. This study provides insights on KMC implementation and sustainability from the perspectives of key stakeholders, highlighting the need for a holistic approach to KMC that incorporates its adaptability to community settings and contexts.

Institutionalizing a Regional Model for Improving Quality of Newborn Care at Birth Across Hospitals in Eastern Uganda: A 4-Year Story

A locally developed, low-cost package of interventions implemented in a regional network of hospitals resulted in significant reductions in mortality for mothers and newborns as well as the institutionalization of the quality improvement initiative. This work demonstrates that it is possible to achieve the World Health Organization/United Nations Children's Fund Quality of Care targets in hospitals.

Introduction:

Despite the rapid increase in facility deliveries in Uganda, the number of adverse birth outcomes (e.g., neonatal and maternal deaths) has remained high. We aimed to codesign and co-implement a locally designed package of interventions to improve the quality of care in hospitals in the Busoga region.

Design and Implementation:

This project was designed and implemented in 3 phases in the 6 main hospitals in east-central Uganda from 2013 to 2016. First, the inception phase engaged health system managers to codesign the intervention. Second, the implementation phase involved training health providers, strengthening the data information system, and providing catalytic equipment and medicines to establish newborn care units (NCUs) within the existing infrastructure. Third, the hospital collaborative phase focused on clinical mentorship, maternal and perinatal death reviews (MPDRs), and collaborative learning sessions.

Achievements:

In all 6 participating hospitals, we achieved institutionalization of NCUs in maternity units by establishing kangaroo mother care areas, resuscitation corners, and routine MPDRs. These improvements were associated with reduced maternal and neonatal deaths. Facilitators of success included a simple, low-cost, and integrated package designed with local health managers; the emergence of local neonatal care champions; implementation and support over a reasonably long period; decentralization of newborn care services; and use of mainly existing local resources (e.g., physical space, human resources, and commodities). Barriers to success related to limited hospital resources, unstable electricity, and limited participation from doctors. More advanced NCUs have been established in 3 of the 6 hospitals, and 7 high-volume comprehensive health centers have been established with functional NCUs.

Conclusion:

The involvement of local health workers and leaders was the foundation for designing, sustaining, and scaling up feasible interventions by harnessing available resources. These findings are relevant for the quality of care improvement efforts in Uganda and other resource-restrained settings.