Teamwork in community health committees: a case study in two urban informal settlements

BACKGROUND

Community health committees (CHCs) are mechanisms for community participation in decision-making and overseeing health services in several low-and middle-income countries (LMICs). There is little research that examines teamwork and internal team relationships between members of these committees in LMICs. We aimed to assess teamwork and factors that affected teamwork of CHCs in an urban slum setting in Nairobi, Kenya.

METHODS

Using a qualitative case-study design, we explored teamwork of two CHCs based in two urban informal settlements in Nairobi. We used semi-structured interviews (n = 16) to explore the factors that influenced teamwork and triangulated responses using three group discussions (n = 14). We assessed the interpersonal and contextual factors that influenced teamwork using a framework for assessing teamwork of teams involved in delivering community health services.

RESULTS

Committee members perceived the relationships with each other as trusting and respectful. They had regular interaction with each other as friends, neighbors and lay health workers. CHC members looked to the Community Health Assistants (CHAs) as their supervisor and "boss", despite CHAs being CHC members themselves. The lay-community members in both CHCs expressed different goals for the committee. Some viewed the committee as informal savings group and community-based organization, while others viewed the committee as a structure for supervising Community Health Promoters (CHPs). Some members doubled up as both CHPs and CHC members. Complaints of favoritism arose from CHC members who were not CHPs whenever CHC members who were CHPs received stipends after being assigned health promotion tasks in the community. Underlying factors such as influence by elites, power imbalances and capacity strengthening had an influence on teamwork in CHCs.

CONCLUSION

In the absence of direction and support from the health system, CHCs morph into groups that prioritize the interests of the members. This redirects the teamwork that would have benefited community health services to other common interests of the team. Teamwork can be harnessed by strengthening the capacity of CHC members, CHAs, and health managers in team building and incorporating content on teamwork in the curriculum for training CHCs.

Master's degree in sexual and reproductive health: enhancing career development opportunities for midwives in Mali

BACKGROUND

Midwives' contribution to improving outcomes for women and newborns depends on factors such as quality of pre-service training, access to continuing professional development, and the presence of an enabling work environment. The absence of opportunities for career development increases the likelihood that health professionals, including midwives, will consider leaving the profession due to a lack of incentives to sustain and increase motivation to remain in the field. It also limits the opportunities to better contribute to policy, training, and research. This study aimed to assess the influence of a Master in Sexual and Reproductive Health (SRH) at the INFSS on midwives' career progression in Mali.

METHODS

This mixed methods study was conducted using an online questionnaire, semi-structured interviews, and a document review. The study participants included graduates from two cohorts (N = 22) as well as employers, managers, and teachers of the graduates (N = 20). Data were analysed according to research questions, comparing, and contrasting answers between different groups of respondents.

RESULTS

The study revealed that graduates enrolled in the programme primarily to improve their knowledge and skills in management and public health. The graduates' expected roles are those of programme and health project manager and participation in planning and monitoring activities at national or sub-national level. The managers expected the programme to reflect the needs of the health system and equip midwives with skills in management and planning. The Master enhanced opportunities for graduates to advance their career in fields they are not usually working in such as management, research, and supervision. However, the recognition of the master's degree and of the graduates' profile is not yet fully effective.

CONCLUSION

The master's degree in SRH is a capacity building programme. Graduates developed skills and acquired advanced knowledge in research and management, as well as a postgraduate degree. However, the master programme needs to be better aligned with health system needs to increase the recognition of graduates' skills and have a more positive impact on graduates' careers.

Human Resources for Health in Conflict Affected Settings: A Scoping Review of Primary Peer Reviewed Publications 2016-2022

BACKGROUND

Conflict has devastating effects on health systems, especially on healthcare workers (HCWs) working in under-resourced and hostile environments. However, little evidence is available on how policy-makers, often together with development partners, can optimize the organization of the health workforce and support HCWs to deliver accessible and trustworthy health services in conflict-affected settings (CAS).

METHODS

A scoping review was conducted to review recent evidence (2016-2022) on human resources for health (HRH) in CAS, and critically discuss HRH challenges in these settings. Thirty-six studies were included in the review and results were presented using an adapted version of the health labour market (HLM) framework.

RESULTS

Evidence from CAS highlights that conflict causes specific constraints in both the education sector and in the HLM, and deepens any existing disconnect between those sectors. Parallel and inadequate education and performance management systems, attacks on health facilities, and increased workload and stress, amongst other factors, affect HCW motivation, performance, distribution, and attrition. Short-term, narrowly focused policy-making undermines the long-term sustainability and resilience of the health workforce in CAS, and also contributes to the limited and narrow available research base.

CONCLUSION

While HRH and workforce issues in CAS include those found in many other low- and middle-income countries (LMICs), an additional set of challenges for HCWs, governance dynamics and institutional constraints in CAS 'multiply' negative effects on the health workforce. HRH policies, programmes and interventions must be aligned with the political and broader societal context, including the stage, severity and other dynamics of conflict. During conflict, it is important to try to monitor in- and outflow of HCWs and provide HCWs the support they need at local level or through remote measures. The post-conflict situation may present opportunities for improvement in HRH, but a clear understanding of political economy dynamics is required to better act on any such a window of opportunity.

Using the integration of human resource management strategies at district level to improve workforce performance: analysis of workplan designs in three African countries

BACKGROUND

There is a worldwide shortage of health workers against WHO recommended staffing levels to achieve Universal Health Coverage. To improve the performance of the existing health workforce a set of integrated human resources (HR) strategies are needed to address the root causes of these shortages. The PERFORM2Scale project uses an action research approach to support district level management teams to develop appropriate workplans to address service delivery and workforce-related problems using a set of integrated human resources strategies. This paper provides evidence of the feasibility of supporting managers at district level to design appropriate integrated workplans to address these problems.

METHODS

The study used content analysis of documents including problem trees and 43 workplans developed by 28 district health management teams (DHMT) across three countries between 2018 and 2021 to identify how appropriate basic planning principles and the use of integrated human resource and health systems strategies were used in the design of the workplans developed. Four categories of HR strategies were used for the analysis (availability, direction, competencies, rewards and sanctions) and the relationship between HR and wider health systems strategies was also examined.

RESULTS

About half (49%) of the DHMTs selected service-delivery problems while others selected workforce performance (46%) or general management (5%) problems, yet all workplans addressed health workforce-related causes through integrated workplans. Most DHMTs used a combination of strategies for improving direction and competencies. The use of strategies to improve availability and the use of rewards and sanctions was more common amongst DHMTs in Ghana; this may be related to availability of decision-space in these areas. Other planning considerations such as link between problem and strategy, inclusion of gender and use of indicators were evident in the design of the workplans.

CONCLUSIONS

The study has demonstrated that, with appropriate support using an action research approach, DHMTs are able to design workplans which include integrated HR strategies. This process will help districts to address workforce and other service delivery problems as well as improving 'health workforce literacy' of DHMT members which will benefit the country more broadly if and when any of the team members is promoted.

Community participation in the health system: analyzing the implementation of community health committee policies in Kenya

BACKGROUND

Community health committees (CHCs) are a mechanism for communities to voluntarily participate in making decisions and providing oversight of the delivery of community health services. For CHCs to succeed, governments need to implement policies that promote community participation. Our research aimed to analyze factors influencing the implementation of CHC-related policies in Kenya.

METHODS

Using a qualitative study design, we extracted data from policy documents and conducted 12 key informant interviews with health workers and health managers in two counties (rural and urban) and the national Ministry of Health. We applied content analysis for both the policy documents and interview transcripts and summarized the factors that influenced the implementation of CHC-related policies.

FINDINGS

Since the inception of the community health strategy, the roles of CHCs in community participation have been consistently vague. Primary health workers found the policy content related to CHCs challenging to translate into practice. They also had an inadequate understanding of the roles of CHCs, partly because policy content was not adequately disseminated at the primary healthcare level. It emerged that actors involved in organizing and providing community health services did not perceive CHCs as valuable mechanisms for community participation. County governments did not allocate funds to support CHC activities, and policies focused more on incentivizing community health volunteers (CHVs) who, unlike CHCs, provide health services at the household level. CHVs are incorporated in CHCs.

CONCLUSION

Kenya's community health policy inadvertently created role conflict and competition for resources and recognition between community health workers involved in service delivery and those involved in overseeing community health services. Community health policies and related bills need to clearly define the roles of CHCs. County governments can promote the implementation of CHC policies by including CHCs in the agenda during the annual review of performance in the health sector.

How context influences the functionality of community-level health governance structures: A case study of community health committees in Kenya

Community Health Committees (CHCs) are mechanisms through which communities participate in the governance and oversight of community health services. While there is renewed interest in strengthening community participation in the governance of community health services, there is limited evidence on how context influences community-level structures of governance and oversight. The objective of this study was to examine how contextual factors influence the functionality of CHCs in Kajiado, Migori, and Nairobi Counties in Kenya. Using a case study design, we explored the influence of context on CHCs using 18 focus group discussions with 110 community members (clients, CHC members, and community health volunteers [CHVs]) and interviews with 33 health professionals. Essential CHC functions such as 'leadership' and 'management' were weak, partly because Health professionals did not involve CHCs in developing health plans. Community Health Committees were active in the supervision of CHVs, reviewing their household reports, although they did not utilise these data for making decisions. Resource mobilisation and evaluation of health programs were affected by the lack of administrative and operational support, such as training. Despite having influential membership, CHCs could not provide leadership and management functions. Health system actors perceived the roles of CHCs as service providers rather than structures for governance and oversight. Insufficient awareness of CHC roles among health professionals, lack of training and operational support for community-based activities constrained CHCs' functionality and thus their role in community participation. While there are efforts to institutionalise community-level governance structures for health at sub-national level, there is a need to scale-up these efforts countrywide. We recommend that community-level governance structures be empowered, mandated, and provided with resources to take on the responsibility of overseeing community health services and exacting accountability from health providers.

How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda

BACKGROUND

The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda.

METHODS

The study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention.

RESULTS

A shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up.

CONCLUSIONS

Despite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.

Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda - lessons from the PERFORM2Scale consortium

Background

Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale’s theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature.

Methods

The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations. The reflections were captured in detailed annual reports, on which this article is based.

Results

The PERFORM2Scale ToC describes how the management strengthening intervention, which targets district health management teams, was expected to improve health workforce performance and service delivery at scale, and which assumptions were instrumental to track over time. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did (and did not) happen. This helped in strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the annual reflections, these actions and adaptations related to: assessing the scalability of the intervention, documentation and dissemination of evidence about the effects of the intervention, understanding power relationships between key stakeholders, the importance of developing and monitoring a scale-up strategy and identification of opportunities to integrate (parts of) the intervention into existing structures and strategies.

Conclusions

PERFORM2Scale’s experience provides lessons for using ToCs to monitor and evaluate the scale-up of health system strengthening interventions. ToCs can help in establishing a common vision on intervention scale-up. ToC-based approaches should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up.

Assessing the scalability of a health management-strengthening intervention at the district level: a qualitative study in Ghana, Malawi and Uganda

Background

The scale-up of successfully tested public health interventions is critical to achieving universal health coverage. To ensure optimal use of resources, assessment of the scalability of an intervention is recognized as a crucial step in the scale-up process. This study assessed the scalability of a tested health management-strengthening intervention (MSI) at the district level in Ghana, Malawi and Uganda.

Methods

Qualitative interviews were conducted with intervention users (district health management teams, DHMTs) and implementers of the scale-up of the intervention (national-level actors) in Ghana, Malawi and Uganda, before and 1 year after the scale-up had started. To assess the scalability of the intervention, the CORRECT criteria from WHO/ExpandNet were used during analysis.

Results

The MSI was seen as credible, as regional- and national-level Ministry of Health officials were championing the intervention. While documented evidence on intervention effectiveness was limited, district- and national-level stakeholders seemed to be convinced of the value of the intervention. This was based on its observed positive results regarding management competencies, teamwork and specific aspects of health workforce performance and service delivery. The perceived need for strengthening of management capacity and service delivery showed the relevance of the intervention, and relative advantages of the intervention were its participatory and sustainable nature. Turnover within the DHMTs and limited (initial) management capacity were factors complicating implementation. The intervention was not contested and was seen as compatible with (policy) priorities at the national level.

Conclusion

We conclude that the MSI is scalable. However, to enhance its scalability, certain aspects should be adapted to better fit the context in which the intervention is being scaled up. Greater involvement of regional and national actors alongside improved documentation of results of the intervention can facilitate scale-up. Continuous assessment of the scalability of the intervention with all stakeholders involved is necessary, as context, stakeholders and priorities may change. Therefore, adaptations of the intervention might be required. The assessment of scalability, preferably as part of the monitoring of a scale-up strategy, enables critical reflections on next steps to make the intervention more scalable and the scale-up more successful.

Participation in primary health care through community-level health committees in Sub-Saharan Africa: a qualitative synthesis

Background

Health committees are key mechanisms for enabling participation of community members in decision-making on matters related to their health. This paper aims to establish an in-depth understanding of how community members participate in primary health care through health committees in sub-Saharan Africa (SSA).

Methods

We searched peer-reviewed English articles published between 2010 and 2019 in MEDLINE, Popline and CINAHL databases. Articles were eligible if they involved health committees in SSA. Our search yielded 279 articles and 7 duplicates were removed. We further excluded 255 articles following a review of titles and abstracts by two authors. Seventeen abstracts were eligible for full text review. After reviewing the full-text, we further excluded two articles that did not explicitly describe the role of health committees in community participation. We therefore included 15 articles in this review. Two authors extracted data on how health committees contributed to community participation in SSA using a conceptual framework for assessing community participation in health. We derived our themes from five process indicators in this framework, namely, leadership, management and planning, resource mobilization from external sources, monitoring and evaluation and women involvement.

Findings

We found that health committees work well in voicing communities’ concerns about the quality of care provided by health facility staff, day-to-day management of health facilities and mobilizing financial and non-financial resources for health activities and projects. Health committees held health workers accountable by monitoring absenteeism, quality of services and expenditures in health facilities. Health committees lacked legitimacy because selection procedures were often not transparent and participatory. Committee members were left out in planning and budgeting processes by health workers, who perceived them as insufficiently educated and trained to take part in planning. Most health committees were male-dominated, thus limiting participation by women.

Conclusion

Health committees contribute to community participation through holding primary health workers accountable, voicing their communities’ concern and mobilizing resources for health activities and projects. Decision makers, health managers and advocates need to fundamentally rethink how health committees are selected, empowered and supported to implement their roles and responsibilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12730-y.

Adoption of harmonisation policy for the midwives' training programme in Mali: A policy analysis

West Africa is engaged in a process of harmonising health workers' training programmes as a means to regulate regional training standards and thus improve their quality. There is currently a lack of documented information regarding the adoption of these revised training programmes. In 2012 a harmonised programme, the WAHO competency-based curriculum, was introduced in Mali for training midwives. The present study explores the barriers and facilitators of the adoption of this programme and how the content, context, process, and actor-related factors influenced this. We used a qualitative research design consisting of document analysis (n = 25) and semi-structured interviews (n = 21) with policymakers, students, and those in charge of implementing the training programme. Information was collected on education and training policies, the context and process of the harmonised curriculum development, its adoption, and the actors involved in the adoption strategy, along with their role. The study shows that the adoption of the harmonised curriculum in Mali offered midwives an opportunity to attain a higher standard of training and level of qualification than before. It also displayed both the government's and the public school's willingness and commitment to improve maternal and child health through enhancing midwives' training standards. The most salient factors that influenced adoption were the lack of available resources, and the lack of involvement of, and coordination with, relevant actors for successful policy adoption. Mali's experience of adopting the harmonisation policy of training curricula demonstrates the need for the authorities to collaborate with relevant actors for information dissemination and in the adoption process. It also demonstrates the need for finding innovative ways to secure and diversify funding opportunities, as well as establish a supervisory body for health worker training.

Preferences and Experiences Regarding the Use of the Self-Sampling Device in hrHPV Screening for Cervical Cancer

BACKGROUND

To improve participation in the Dutch cervical cancer screening, a self-sampling device (SSD) was introduced in 2017 into the Dutch population-based screening programme (PBS) for the early detection of cervical cancer. The aim of this study was to gather potential preferences and experiences that might influence a woman's decision to use the SSD in the Dutch PBS.

METHODS

A scoping review was performed in the PubMed database. Studies that assessed preferences and experiences of women regarding the SSD were included, and preferences and experiences were extracted. In addition, in a qualitative study, the list of potential preferences and experiences specific for the Dutch PBS was extended based on semi-structured interviews with SSD users as well as non-SSD users who recently participated in the PBS, analysed in a structured manner by translating full sentences to key words.

RESULTS

Ninety-eight studies were included in the scoping review and 16 interviews were performed. Frequently mentioned reasons for using the SSD, in both the interviews and the literature, were practicality and comfort. Frequently mentioned reasons for not using the SSD were fear of not performing the SSD procedure correctly and doubts on whether the results of the high-risk human papillomavirus (hrHPV) test will be reliable. A new positive experience elicited in the interviews was accessibility. Negative preferences and experiences were not being aware the SSD was an option, and the inconvenience that after an hrHPV-positive test result of the SSD, an additional smear test at the GP is necessary.

CONCLUSION

Several preferences and experiences play a role in the choice whether or not to use the SSD. Based on the currently found preferences and experiences, an app will be developed in order to assess which of these are the most important for women participating in the Dutch population-based cervical screening programme.

Syndemic contexts: findings from a review of research on non-communicable diseases and interviews with experts

Background

Syndemics are characterized by the clustering of two or more health conditions, their adverse interaction, and contextual factors that create the conditions for clustering and/or interaction that worsens health outcomes. Studying syndemics entails drawing on diverse disciplines, including epidemiology and anthropology. This often means collaboration between researchers with different scholarly backgrounds, who share and – ideally – integrate their findings.

Objective

This article examines how context within syndemics has been defined and studied.

Methods

A literature review of empirical studies focusing on syndemics involving non-communicable diseases (NCDs) and mental health conditions was conducted and the full text of 13 articles was analyzed. The review was followed-up with semi-structured interviews with 11 expert researchers working in the field.

Results

The review and interviews highlighted a relatively consistent definition of syndemics. The reviewed studies of NCD-related syndemics tended to focus on micro-level context, suggesting a need to analyze further underlying structural factors. In their syndemics research, respondents described working with other disciplines and, although there were some challenges, welcomed greater disciplinary diversity. Methodological gaps, including a lack of mixed methods and longitudinal studies, were identified, for which further interdisciplinary collaborations would be beneficial.

Conclusions

NCD-related syndemics research would benefit from further analysis of structural factors and the interconnections between syndemic components across multiple levels, together with more ambitious research designs integrating quantitative and qualitative methods. Research on the COVID-19 pandemic can benefit from a syndemics approach, particularly to understand vulnerability and the unequal impacts of this public health crisis.

The COVID-19 pandemic presents an opportunity to develop more sustainable health workforces

This commentary addresses the critically important role of health workers in their countries' more immediate responses to COVID-19 outbreaks and provides policy recommendations for more sustainable health workforces. Paradoxically, pandemic response plans in country after country, often fail to explicitly address health workforce requirements and considerations. We recommend that policy and decision-makers at the facility, regional and country-levels need to: integrate explicit health workforce requirements in pandemic response plans, appropriate to its differentiated levels of care, for the short, medium and longer term; ensure safe working conditions with personal protective equipment (PPE) for all deployed health workers including sufficient training to ensure high hygienic and safety standards; recognise the importance of protecting and promoting the psychological health and safety of all health professionals, with a special focus on workers at the point of care; take an explicit gender and social equity lens, when addressing physical and psychological health and safety, recognising that the health workforce is largely made up of women, and that limited resources lead to priority setting and unequitable access to protection; take a whole of the health workforce approach-using the full skill sets of all health workers-across public health and clinical care roles-including those along the training and retirement pipeline-and ensure adequate supervisory structures and operating procedures are in place to ensure inclusive care of high quality; react with solidarity to support regions and countries requiring more surge capacity, especially those with weak health systems and more severe HRH shortages; and acknowledge the need for transparent, flexible and situational leadership styles building on a different set of management skills.

Social determinants of maternal health: a scoping review of factors influencing maternal mortality and maternal health service use in India

BACKGROUND

Maternal health remains a major public health problem in India, with large inter- and intra-state inequities in maternal health service use and maternal deaths. The Commission on Social Determinants of Health provides a framework to identify structural and intermediary factors of health inequities, including maternal health, and understand their mechanism of influence, which might be important in addressing maternal health inequities in India. Our review aims to map and summarize the evidence on social determinants influencing maternal health in India and understand their mechanisms of influence by using a maternal health-specific social determinants framework.

METHODS

A scoping review was conducted of peer-reviewed journal articles in two databases (PubMed and Science Direct) on quantitative and qualitative studies conducted in India after 2000. We also searched for articles in a search engine (Google Scholar). Forty-one studies that met the study objectives were included: 25 identified through databases and search engines and 16 through reference check.

RESULTS

Economic status, caste/ethnicity, education, gender, religion, and culture were the most important structural factors of maternal health service use and maternal mortality in India. Place of residence, maternal age at childbirth, parity and women's exposure to mass media, and maternal health messages were the major intermediary factors. The structural factors influenced the intermediary factors (either independently or in association with other factors) that contributed to the use of maternal health service or caused maternal deaths. The health system emerged as a crucial and independent intermediary factor of influence on maternal health in India. Issues of power were observed in broader social contexts and in the relationships of health workers which led to differential access to maternal healthcare for women from different socioeconomic groups.

CONCLUSION

The model integrates existing information from quantitative and qualitative studies and provides a more comprehensive picture of structural and intermediary factors of maternal health service use and maternal mortality in India and their mechanisms of influence. Given the limitations of this study, we indicate the areas for further research pertaining to the framework and maternal health.

Career mobility of maternal care providers in Mali: a mixed method study on midwives and obstetric nurses

BACKGROUND

An important strategy to reduce maternal and child mortality in Mali is to increase the number of deliveries assisted by qualified personnel in primary care facilities, especially in rural areas. However, placements and retention of healthcare professionals in rural areas are a major problem, not only in Mali but worldwide, and are a challenge to the health sector. The purpose of this study was to map the mobility of midwives and obstetric nurses during their work lives, in order to better understand their career paths and the role that working in rural areas plays. This article contributes to the understanding of career mobility as a determinant of the retention of rural health professionals.

METHODS

A mixed method study was conducted on 2005, 2010, and 2015 cohorts of midwives and obstetric nurses. The cohorts have been defined by their year of graduation. Quantitative data were collected from 268 midwives and obstetric nurses through questionnaires. Qualitative data had been gathered through semi-structured interviews from 25 midwives and stakeholders. A content analysis was conducted for the qualitative data.

RESULTS

Unemployment rate was high among the respondents: 39.4% for midwives and 59.4% for obstetric nurses. Most of these unemployed nurses and midwives are working, but unpaid. About 80% of the employed midwives were working in urban facilities compared to 64.52% for obstetric nurses. Midwives were employed in community health centers (CSCom) (43%), referral health centers (CSRef) (20%), and private clinics and non-governmental organizations (NGO) (15%). The majority of midwives and obstetric nurses were working in the public sector (75.35%) and as civil servants (65.5%). The employment status of midwives and obstetric nurses evolved from private to public sector, from rural to urban areas, and from volunteer/unpaid to civil servants through recruitment competitions. Qualitative data supported the finding that midwives and obstetric nurses prefer to work as civil servant and preferably in urban areas and CSRef.

CONCLUSION

The current mobility pattern of midwives and obstetric nurses that brings them from rural to urban areas and towards a civil servant status in CSRef shows that it is not likely to increase their numbers in the short term in places where qualified midwives are most needed.

Rural pipeline and willingness to work in rural areas: Mixed method study on students in midwifery and obstetric nursing in Mali

The availability and retention of healthcare professionals in rural areas and remote areas is a challenge to the health sector worldwide. Attracting people who are most likely to be interested in rural practice can be conducive to the sustainable availability of health services in rural areas where health facilities are typically understaffed and existing professionals often underqualified. This article aims to contribute to the rural pipeline evidence, and reports on the findings of a study that investigated the career choices of midwifery and obstetric nurse students in Mali. The article enquires into the relationship between their intention to practice in rural areas and the different components of the rural pipeline. A mixed method study using a survey, semi-structured interviews, and document analysis was conducted from October to December 2017 on third-year midwifery and obstetric nurse students and school-managers. Descriptive statistics and bivariate analysis were performed for quantitative data, and content analysis was carried out for the qualitative data. Key findings suggest that students prefer urban locations for living and for work. The intention to work in rural areas seems to be influenced by the current living situation (currently living in a rural area) or having attended secondary school or professional training in rural areas.

'You have a child who will call you "mama" ': understanding adolescent pregnancy in South Sudan

BACKGROUND

Pregnancy amongst adolescent girls is common in many parts of the world. The dominant discourse in public health unquestioningly paints this as a problem; it does not pay sufficient attention to girls' views.

OBJECTIVES

This paper presents a critical account of adolescent South Sudanese girls' reasons for and explanations of childbearing. It discusses their experiences and views on childbearing and attempts to explain their reproductive choices and actions, in context.

METHODS

The study draws upon 24 interviews with adolescent boys, girls and parents from Wau, South Sudan. Data was analysed using the framework analysis approach.

RESULTS

Three interacting themes within which adolescent girls framed their views and decisions about childbearing are identified. The local society places high value on motherhood - adolescent girls' desires to become mothers is a reproduction of this social norm. Girls linked having a child to the possibility of making one's 'own home'; in the difficult and uncertain context they lived in, for many girls, having a child (and making a home) appeared as one of the few means to be happy. In making the decision to bear a child, the girls navigated multiple dilemmas and trade-offs between an unpromising present and an uncertain future. Bearing a child and making one's 'own home' was seen as a way to exit into the world of adults, and as a strategy towards achieving security and stability.

CONCLUSIONS

Instead of simplistically problematizing adolescent pregnancy in South Sudan, it is important to take into account the experiences and standpoints of adolescent girls, and to recognize that in choosing to become mothers, they are in many ways exercising agency despite being severely constrained by complex, insecure and unfair social circumstances. We argue that such an approach will allow the development of more appropriate, realistic and inclusive health and social policies and programs.

"It's like these CHCs don't exist, are they featured anywhere?": Social network analysis of community health committees in a rural and urban setting in Kenya

BACKGROUND

In Kenya, Community Health Committees (CHC) were established to enhance community participation in health services. Their role is to provide leadership, oversight in delivery of community health services, promote social accountability and mobilize resources for community health. CHCs form social networks with other actors, with whom they exchange health information for decision-making and accountability. This case study aimed to explore the structure of a rural and an urban CHC network and to analyze how health-related information flowed in these networks. Understanding the pathways of information in community settings may provide recommendations for strategies to improve the role and functioning of CHCs.

METHODS

In 2017, we conducted 4 focus group discussions with 27 community discussants and 10 semi-structured interviews with health professionals in a rural area and an urban slum. Using social network analysis, we determined the structure of their social networks and how health related information flowed in these networks.

RESULTS

Both CHCs were composed of respected persons nominated by their communities. Each social network had 12 actors that represented both community and government institutions. CHCs were not central actors in the exchange of health-related information. Health workers, community health volunteers and local Chiefs in the urban slum often passed information between the different groups of actors, while CHCs hardly did this. Therefore, CHCs had little control over the flow of health-related information. Although CHC members were respected persons who served in multiple roles within their communities, this did not enhance their centrality. It emerged that CHCs were often left out in the flow of health-related information and decision-making, which led to demotivation. Community health volunteers were more involved by other actors such as health managers and non-governmental organizations as a conduit for health-related information.

CONCLUSION

Social network analysis demonstrated how CHCs played a peripheral role in the flow of health-related information. Their perception of being left out of the information flow led to demotivation, which hampered their ability to facilitate community participation in community health services; hence challenging effective participation through CHCs.

"We come as friends": approaches to social accountability by health committees in Northern Malawi

Background

In Malawi, as in many low-and middle-income countries, health facility committees (HFCs) are involved in the governance of health services. Little is known about the approaches they use and the challenges they face. This study explores how HFCs monitor the quality of health services and how they demand accountability of health workers for their performance.

Methods

Documentary analysis and key informant interviews (7) were complemented by interviews with purposefully selected HFC members (22) and health workers (40) regarding their experiences with HFCs. Data analysis was guided by a coding scheme informed by social accountability concepts complemented by inductive analysis to identify participants’ perceptions and meanings of processes of social accountability facilitated by HFCs.

Results

The results suggest that HFCs address poor health worker performance (such as absenteeism, poor treatments and informal payments), and report severe misconduct to health authorities. The informal and constructive approach that most HFCs use is shaped by formal definitions and common expectations of the role of HFCs in service delivery as well as resource constraints. The primary function of social accountability through HFCs appears to be co-production: the management of social relations around the health facility and the promotion of a minimum level of access and quality of services.

Conclusions

Policymakers and HFC support programs should take into account the broad task description of HFCs and integrate social accountability approaches in existing quality of care programs. The study also underscores the need to clarify accountability arrangements and linkages with upward accountability approaches in the system.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4069-2) contains supplementary material, which is available to authorized users.

Social Accountability in Maternal Health Services in the Far-Western Development Region in Nepal: An Exploratory Study

Background: Social accountability or citizen-led accountability has been promoted in many low- and middle-income countries to improve the quality, access to and use of maternal health services. Experiences with social accountability in maternal health services in Nepal have not yet been documented. This study identifies existing social accountability structures and activities in maternal health services in two districts of Far-Western Nepal and explores their functions, implementation and gaps/challenges.

Methods: An exploratory study was conducted that included in-depth interviews with purposively selected policy advisors (8), healthcare officials (11), healthcare providers (12) and non-governmental staff (3); and focus group discussions (FGDs) with 54 women. Data analysis was conducted using thematic content analysis based on George’s information, dialogue and negotiation framework.

Results: Social accountability in maternal health existed in terms of structures such as mothers’ groups (MGs), female community health volunteers (FCHVs) and Health Facility Operation and Management Committees (HFOMCs); and activities such as social audits and community health score board (CHSB). MGs and FCHVs were perceived as trusted intermediaries, but their functioning was limited to information. HFOMCs were not fully functional. Social audits and CHSBs were implemented in limited sites and with poor participation by women. Health-sector responses were mainly found at the local level. Factors contributing to these challenges were the absence of a mandate and limited capacity, including resources.

Conclusion: Formal structures and activities existed for social accountability in maternal health services in the Far-Western Development Region of Nepal, but there were limitations pertaining to their implementation. The main recommendations are: for clear policy mandates on the social accountability roles of MGs and FCHVs; wider implementation of social audits and CHSBs, with emphasis on the participation of women from disadvantaged groups; improved capacity of HFOMCs; and improved engagement of the health sector at all levels to listen and respond to women’s concerns.

[Midwives’ intention to leave primary level care services in Mali]

BACKGROUND

Mali is a country with a high rate of maternal and neonatal deaths and a low density of human resources for health. The health system faces understaffing and inequitable distribution of available resources. Health staff are reluctant to take positions and stay in first level care services. This study examines midwives and obstetric nurses' intention to leave their current positions in first level structures and management factors that influence this intention.

METHODS

A cross-sectional mixed method study was conducted with 220 midwives and obstetric nurses in 46 primary healthcare services of three health regions. Questionnaires and interview guide were used. Descriptive statistics and bi-varied analyses tested the links between managerial practices, demographic characteristics and intention to leave. A thematic analysis of the qualitative data examined the factors underlying the intention to leave.

RESULTS

Nearly half of midwives and obstetric nurses in primary healthcare services had the intention to leave their current positions. This intention to leave is more marked among midwives who have very little attraction for first-level service. Age, type of structure and area of assignment are strongly associated with the intention to leave. Managerial practices that differ according to locations and type of structures seem to influence the intention to leave.

CONCLUSION

There is a high intention to leave their position among midwives and obstetric nurses in first level services. Managerial practices seem to have more influences on the intention to leave in rural areas and among obstetric nurses.

Coming Full Circle: How Health Worker Motivation and Performance in Results-Based Financing Arrangements Hinges on Strong and Adaptive Health Systems

BACKGROUND

This paper presents findings from a study which sought to understand why health workers working under the results-based financing (RBF) arrangements in Zimbabwe reported being satisfied with the improvements in working conditions and compensation, but paradoxically reported lower motivation levels compared to those not working under RBF arrangements.

METHODS

A qualitative study was conducted amongst health workers and managers working in health facilities that were implementing the RBF arrangements and those that were not. Through purposeful sampling, 4 facilities in RBF implementing districts that reported poor motivation and satisfaction, were included as study sites. Four facilities located in non-RBF districts which reported high motivation and satisfaction were also included. Data was collected through in-depth interviews and analyzed using the framework approach.

RESULTS

Results based financing arrangements introduce a wide range of new institutional arrangements, roles, tasks, and ways of doing things, for facility staff, facility managers and, district and provincial health management teams. Findings reveal that insufficient preparedness of people and processes for this change, constrained managers and workers performance. Results based financing arrangements introduce explicit and tacit changes, including but not limited to, incentive logics, in the system. Findings show that unless systematic efforts are made to enable the absorption of these changes in the system: eg, through reconfiguring the decision space available at various levels, through clarification of accountability relationships, through building personnel and process capacities, before instituting changes, the full potential of the RBF arrangements cannot be realised.

CONCLUSION

Our study demonstrates the importance of analysing existing institutional, management and governance arrangements and capabilities and taking these into account when designing and implementing RBF interventions. Introducing RBF arrangements cannot alone overcome chronic systemic weaknesses. For a system wide change, as RBF arguably is, to be effected, explicit organisational change management processes need to be put in place, across the system. Carefully designed processes, which take into account the interest and willingness of various actors to change, and which are cognizant of and constructively engage with potential bottlenecks and points of resistance, should accompany any health system change initiative.

Gendered norms of responsibility: reflections on accountability politics in maternal health care in Malawi

Background

This paper aims to provide insights into the role of traditional authorities in two maternal health programmes in Northern Malawi. Among strategies to improve maternal health, these authorities issue by-laws: local rules to increase the uptake of antenatal and delivery care. The study uses a framework of gendered institutions to critically assess the by-law content, process and effects and to understand how responsibilities and accountabilities are constructed, negotiated and reversed.

Methods

Findings are based on a qualitative study in five health centre catchment areas in Northern Malawi. Data were collected using meeting observations and document search, 36 semi-structured individual interviews and 19 focus group discussions with female maternal health service users, male community members, health workers, traditional leaders, local officials and health committee members. A gender and power sensitive thematic analysis was performed focusing on the formulation, interpretation and implementation process of the by-laws as well as its effects on women and men.

Results

In the study district, traditional leaders introduced three by-laws that oblige pregnant women to attend antenatal care; bring their husbands along and; and to give birth in a health centre. If women fail to comply with these rules, they risk being fined or denied access to maternal health services. The findings show that responsibilities and accountabilities are negotiated and that by-laws are not uniformly applied. Whereas local officials support the by-laws, lower level health cadres’ and some community members contest them, in particular, the principles of individual responsibility and universality.

Conclusions

The study adds new evidence on the understudied phenomenon of by-laws. From a gender perspective, the by-laws are problematic as they individualise the responsibility for maternal health care and discriminate against women in the definition and application of sanctions. Through the by-laws, supported by national policies and international institutions, women bear the full responsibility for failures in maternal health care, suggesting a form of ‘reversed accountability’ of women towards global maternal health goals. This can negatively impact on women’s reproductive health rights and obstruct ambitions to achieve gender inequality and health equity. Contextualised gender and power analysis in health policymaking and programming as well as in accountability reforms could help to identify these challenges and potential unintended effects.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0848-3) contains supplementary material, which is available to authorized users.

How does social accountability contribute to better maternal health outcomes? A qualitative study on perceived changes with government and civil society actors in Gujarat, India

BACKGROUND

Social accountability mechanisms have been highlighted as making a contribution to improving maternal health outcomes and reducing inequities. But there is a lack of evidence on how they contribute to such improvements. This study aims to explore social accountability mechanisms in selected districts of the Indian state of Gujarat in relation to maternal health, the factors they address and how the results of these mechanisms are perceived.

METHODS

We conducted qualitative research through in-depth interviews and focus group discussions with actors of civil society and government health system. Data were analyzed using a framework of social determinants of maternal health in terms of structural and intermediary determinants.

RESULTS

There are social accountability mechanisms in the government and civil society in terms of structure and activities. But those that were perceived to influence maternal health were mainly from civil society, particularly women's groups, community monitoring and a maternal death review. The social accountability mechanisms influenced structural determinants - governance, policy, health beliefs, women's status, and intermediary determinants - social capital, maternal healthcare behavior, and availability, accessibility and the quality of the health service delivery system. These further positively influenced the increased use of maternal health services. The social accountability mechanisms, through the process of information, dialogue and negotiation, particularly empowered women to make collective demands of the health system and brought about changed perceptions of women among actors in the system. It ultimately improved relations between women and the health system in terms of trust and collaboration, and generated appropriate responses from the health system to meeting women's groups' demands.

CONCLUSION

Social accountability mechanisms in Gujarat were perceived to improve interaction between communities and the health system and contribute to improvements in access to and use of maternal health services. The influence of social accountability appeared to be limited to the local/district level and there was lack of capacity and ownership of the government structures.

Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review

Introduction

Maternal health and the performance of health workers is a key concern in low- and middle-income countries. Mobile health technologies are reportedly able to improve workers' performance. However, how this has been achieved for maternal health workers in low-resource settings is not fully substantiated. To address this gap by building theoretical explanations, two questions were posed: How does mobile health influence the performance of maternal health care workers in low- and middle-income countries? What mechanisms and contextual factors are associated with mobile health use for maternal health service delivery in low- and middle-income countries?

Methods

Guided by established guidelines, a realist review was conducted. Five databases were searched for relevant English language articles published between 2009 and 2016. A three-stage framework was developed and populated with explanatory configurations of Intervention-Context-Actors-Mechanism-Outcome. Articles were analyzed retroductively, with identified factors grouped into meaningful clusters.

Results

Of 1254 records identified, 23 articles representing 16 studies were retained. Four main mechanisms were identified: usability and empowerment explaining mobile health adoption, third-party recognition explaining mobile health utilization, and empowerment of health workers explaining improved competence. Evidence was skewed toward the adoption and utilization stage of the framework, with weak explanations for performance outcomes.

Conclusions

Findings suggest that health workers can be empowered to adopt and utilize mobile health in contexts where it is aligned to their needs, workload, training, and skills. In turn, mobile health can empower health workers with skills and confidence when it is perceived as useful and easy to use, in contexts that foster recognition from clients, peers, or supervisors.

Multistakeholder Perspectives on Maternal Text Messaging Intervention in Uganda: Qualitative Study

Background

Despite continued interest in the use of mobile health for improving maternal health outcomes, there have been limited attempts to identify relevant program theories.

Objectives

This study had two aims: first, to explicate the assumptions of program designers, which we call the program theory and second, to contrast this program theory with empirical data to gain a better understanding of mechanisms, facilitators, and barriers related to the program outcomes.

Methods

To achieve the aforementioned objectives, we conducted a retrospective qualitative study of a text messaging (short message service) platform geared at improving individual maternal health outcomes in Uganda. Through interviews with program designers (n=3), we elicited 3 main designers’ assumptions and explored these against data from qualitative interviews with primary beneficiaries (n=26; 15 women and 11 men) and health service providers (n=6), as well as 6 focus group discussions with village health team members (n=50) who were all involved in the program.

Results

Our study results highlighted that while the program designers’ assumptions were appropriate, additional mechanisms and contextual factors, such as the importance of incentives for village health team members, mobile phone ownership, and health system factors should have been considered.

Conclusions

Our results indicate that text messages could be an effective part of a more comprehensive maternal health program when context and system barriers are identified and addressed in the program theories.

Sustaining success: aligning the public health workforce in South-Eastern Europe with strategic public health priorities

OBJECTIVES

To map out the Public Health Workforce (PHW) involved in successful public health interventions.

METHODS

We did a pilot assessment of human resources involved in successful interventions addressing public health challenges in the countries of South-Eastern Europe (SEE). High-level representatives of eight countries reported about success stories through the coaching by experts. During synthesizing qualitative data, experts applied triangulation by contacting additional sources of evidence and used the framework method in data analysis.

RESULTS

SEE countries tailored public health priorities towards social determinants, health equalities, and prevention of non-communicable diseases. A variety of organizations participated in achieving public health success. The same applies to the wide array of professions involved in the delivery of Essential Public Health Operations (EPHOs). Key enablers of the successful work of PHW were staff capacities, competences, interdisciplinary networking, productivity, and funding.

CONCLUSIONS

Despite diversity across countries, successful public health interventions have similar ingredients. Although PHW is aligned with the specific public health success, a productive interface between health and other sectors is crucial for rolling-out successful interventions.

The Effect of a Community Health Worker Utilized Mobile Health Application on Maternal Health Knowledge and Behavior: A Quasi-Experimental Study

Background

Mobile technology (mHealth) is increasingly being used to achieve improved access and quality of maternal care, particularly in rural areas of low- and middle-income countries. In 2011, a mobile application—Mobile for Mothers (MfM)—was implemented in Jharkhand, India to support home visits by community health workers. The objective of this study is to assess the impact of the mHealth intervention on maternal health.

Methods

Households from three subdistricts in the Deoghar district of Jharkhand were selected using a multistage cluster sampling approach. Households from the Sarwan subdistrict received the MfM intervention, those from Devipur subdistrict received other interventions asides MfM from the implementing non-governmental organization (NGO), while households from Mohanpur subdistrict received the current standard of care. Women (n = 2,200) between the ages of 18 and 45 who had delivered a baby in the past 1 year were enrolled into the study. The primary outcomes of interest were maternal health knowledge, antenatal care (ANC) attendance, and delivery in a health facility.

Results

Post-intervention, women in the MfM group had higher maternal health knowledge, were more likely to attend four or more ANC visits, and deliver at the health facility when compared with the NGO and standard care group. After controlling for predictors, women in the intervention group significantly performed better than both the NGO and standard care groups on all three-outcome variables (all P > 0.05).

Conclusion

The results indicate that although the MfM mHealth intervention could influence adherence and practice of recommended maternal health behaviors, it could not overcome key sociocultural determinants of maternal health such as caste and educational status, which are specific to the Indian context. mHealth holds continued promise for maternal health but implementers and policy makers must additionally address health system and sociocultural factors that play a significant role in the uptake of recommended maternal health practices.

Informal social accountability in maternal health service delivery: A study in Northern Malawi

Despite the expansion of literature on social accountability in low-and middle-income countries, little is known about how health providers experience daily social pressure and citizen feedback. This study used a narrative inquiry approach to explore the function of daily social accountability relations among maternal health care workers in rural Malawi. Through semi-structured interviews with 32 nurses and 19 clinicians, we collected 155 feedback cases allowing the identification of four main strategies social actors use to express their opinion and concerns about maternal health services. We found that women who used delivery care express their appreciation for successful deliveries directly to the health worker but complaints, such as on absenteeism and poor interpersonal behaviour, follow an indirect route via intermediaries such as the health workers' spouse, co-workers or the health committee who forward some cases of misbehaviour to district authorities. The findings suggest that citizen feedback is important for the socialization, motivation and retention of maternal healthcare workers in under resourced rural settings. Practitioners and external development programmes should understand and recognize the value of already existing accountability mechanisms and foster social accountability approaches that allow communities as well as health workers to challenge the systemic obstacles to quality and respectful service delivery.

Too afraid to go: fears of dignity violations as reasons for non-use of maternal health services in South Sudan

BACKGROUND

South Sudan has one of the worst health and maternal health situations in the world. Across South Sudan, while maternal health services at the primary care level are not well developed, even where they exist, many women do not use them. Developing location specific understanding of what hinders women from using services is key to developing and implementing locally appropriate public health interventions.

METHODS

A qualitative study was conducted to gain insight into what hinders women from using maternal health services. Focus group discussions (5) and interviews (44) were conducted with purposefully selected community members and health personnel. A thematic analysis was done to identify key themes.

RESULTS

While accessibility, affordability, and perceptions (need and quality of care) related barriers to the use of maternal health services exist and are important, women's decisions to use services are also shaped by a variety of social fears. Societal interactions entailed in the process of going to a health facility, interactions with other people, particularly other women on the facility premises, and the care encounters with health workers, are moments where women are afraid of experiencing dignity violations. Women's decisions to step out of their homes to seek maternal health care are the results of a complex trade-off they make or are willing to make between potential threats to their dignity in the various social spaces they need to traverse in the process of seeking care, their views on ownership of and responsibility for the unborn, and the benefits they ascribe to the care available to them.

CONCLUSIONS

Geographical accessibility, affordability, and perceptions related barriers to the use of maternal health services in South Sudan remain; they need to be addressed. Explicit attention also needs to be paid to address social accessibility related barriers; among others, to identify, address and allay the various social fears and fears of dignity violations that may hold women back from using services. Health services should work towards transforming health facilities into social spaces where all women's and citizen's dignity is protected and upheld.

How do accountability problems lead to maternal health inequities? A review of qualitative literature from Indian public sector

Background

There are several studies from different geographical settings and levels on maternal health, but none analyzes how accountability problems may contribute to the maternal health outcomes. This study aimed to analyze how accountability problems in public health system lead to maternal deaths and inequities in India.

Methods

A conceptual framework was developed bringing together accountability process (in terms of standard setting, performance assessment, accountability (or answerability, and enforceability) —an ongoing cyclical feedback process at different levels of health system) and determinants of maternal health to analyze the influence of the process on the determinant leading to maternal health outcomes. A scoping review of qualitative and mixed-methods studies from public health sector in India was conducted. A narrative and interpretive synthesis approach was applied to analyze data.

Results

An overarching influence of health system-related factors over non-health system-related factors leading to maternal deaths and inequities was observed. A potential link among such factors was identified with gaps in accountability functions at all levels of health system pertaining to policy gaps or conflicting/discriminatory policies and political commitment. A large number of gaps were also observed concerning performance or implementation of existing standards. Inherent to these issues was potentially a lack of proper monitoring and accountability functions. A critical role of power was observed influencing the accountability functions.

Conclusion

The narrative and interpretive synthesis approach allowed to integrate and reframe the relevant comparable information from the limited empirical studies to identify the hot spots of systemic flaws from an accountability perspective. The framework highlighted problems in health system beyond health service delivery to wider areas such as policy or politics justifying their relevance and importance in such analysis. A crucial message from the study pertains to a need to move away from the traditional concept of viewing accountability as a blame-game approach and a concern of limited frontline health workers towards a constructive and systemic approach.

[Improve the training, recruitment and deployment of health human resources in Togo.]

INTRODUCTION

The objective of this article is to describe the results of a situational analysis of training, recruitment and deployment of health workers conducted in Togo in 2015, in order to inform the new Human Resources for Health plan.

METHODS

The research was conducted according to a mixed methods approach, using both qualitative and quantitative methods. Data concerning fourteen professional categories were collected from the Ministry of Health, health training institutions, students, employers and health workers. Data collection and analysis were based on a conceptual framework depicting the training-recruitment-deployment chain. Each step in this chain influences the efficiency and efficacy of the entire chain: each step can lead to loss of health workers, loss of time or financial resources and can consequently have an impact on the availability, accessibility and quality of health workers in Togo.

RESULTS

The study identified twelve areas of improvement that could constitute future strategies for health workers, comprising five areas related to education, five areas related to personnel recruitment and two areas related to deployment.

CONCLUSION

The study proposed a conceptual framework and indicators for regular monitoring of the training-recruitment-deployment chain to allow in-depth analysis of its dynamics. This approach supports the formulation of appropriate strategies and better follow-up of the effects of interventions by the Ministry of Health.

Targeting strategies of mHealth interventions for maternal health in low and middle-income countries: a systematic review protocol

INTRODUCTION

Recently, there has been a steady increase in mobile health (mHealth) interventions aimed at improving maternal health of women in low-income and middle-income countries. While there is evidence indicating that these interventions contribute to improvements in maternal health outcomes, other studies indicate inconclusive results. This uncertainty has raised additional questions, one of which pertains to the role of targeting strategies in implementing mHealth interventions and the focus on pregnant women and health workers as target groups. This review aims to assess who is targeted in different mHealth interventions and the importance of targeting strategies in maternal mHealth interventions.

METHODS AND ANALYSIS

We will search for peer-reviewed, English-language literature published between 1999 and July 2017 in PubMed, Web of Knowledge (Science Direct, EMBASE) and Cochrane Central Registers of Controlled Trials. The study scope is defined by the Population, Intervention, Comparison and Outcomes framework: P, community members with maternal or reproductive needs; I, electronic health or mHealth programmes geared at improving maternal or reproductive health; C, other non-electronic health or mHealth-based interventions; O, maternal health measures including family planning, antenatal care attendance, health facility delivery and postnatal care attendance.

ETHICS AND DISSEMINATION

This study is a review of already published or publicly available data and needs no ethical approval. Review results will be published in a peer-reviewed journal and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42017072280.

"Ways and channels for voice regarding perceptions of maternal health care services within the communities of the Makamba and Kayanza provinces in the Republic of Burundi: an exploratory study"

Background

Increased availability of maternal health services alone does not lead to better outcomes for maternal health.The services need to be utilized first.One way to increase service utilization is to plan responsive health care services by taking into account the community’s views or expressed needs.

Burundi has a high maternal mortality ratio, and despite improvements in health infrastructure, skilled staff and the abolition of user fees for pregnant women,utilization of maternal health services remains low. Possible reasons for this include a lack of responsive healthcare services.

An exploratory study was conducted in 2013 in two provinces of Burundi (Makamba and Kayanza), with the aim to collect the experiences of women and men with the maternal health services,their views regarding those services, channels used to express these experiences, and the providers’ reaction.

Methods

Semi-structured interviews were used to collect data from men and women and key informants, including community health workers, health committee members, health providers, local authorities, religious leaders and managers of non-governmental organizations. Data analysis was facilitated by MAXQDA 11 software.

Results

Negative experiences with maternal health services were reported and included poor staff behavior towards women and a lack of medicine. Health committees and suggestion boxes were introduced by the government to channel the community’s views. However, they are not used by the community members, who prefer to use community health workers as intermediaries. Fear of expressing oneself linked to the post-war context of Burundi, social and gender norms, and religious norms limit the expression of community members’ views, especially those of women. The limited appreciation of community health workers by the providers further hampers communication and acceptance of the community’s views by health providers.

Conclusion

In Burundi, the community voice to express views on maternal health services is encountering obstacles and needs to be strengthened,especially the women’s voice. Community mobilization in the form of a mass immunization campaign day organized by women fora, and community empowerment using participatory approaches could contribute towards community voice strengthening.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2822-y) contains supplementary material, which is available to authorized users.

Perceptions on diabetes care provision among health providers in rural Tanzania: a qualitative study

Diabetes prevalence in Tanzania was estimated at 9.1% in 2012 among adults aged 24-65 years - higher than the HIV prevalence in the general population at that time. Health systems in lower- and middle-income countries are not designed for chronic health care, yet the rising burden of non-communicable diseases such as diabetes demands chronic care services. To inform policies on diabetes care, we conducted a study on the health services in place to diagnose, treat and care for diabetes patients in rural Tanzania. The study was an exploratory and descriptive study involving qualitative methods (in-depth interviews, observations and document reviews) and was conducted in a rural district in Tanzania. Fifteen health providers in four health facilities at different levels of the health care system were interviewed. The health care organization elements of the Innovative Care for Chronic Conditions (ICCC) framework were used to guide assessment of the diabetes services in the district. We found that diabetes care in this district was centralized at the referral and district facilities, with unreliable supply of necessary commodities for diabetes care and health providers who had some knowledge of what was expected of them but felt ill-prepared for diabetes care. Facility and district level guidance was lacking and the continuity of care was broken within and between facilities. The HMIS could not produce reliable data on diabetes. Support for self-management to patients and their families was weak at all levels. In conclusion, the rural district we studied did not provide diabetes care close to the patients. Guidance on diabetes service provision and human resource management need strengthening and policies related to task-shifting need adjustment to improve quality of service provision for diabetes patients in rural settings.

Performance of community health workers: situating their intermediary position within complex adaptive health systems

Health systems are social institutions, in which health worker performance is shaped by transactional processes between different actors.This analytical assessment unravels the complex web of factors that influence the performance of community health workers (CHWs) in low- and middle-income countries. It examines their unique intermediary position between the communities they serve and actors in the health sector, and the complexity of the health systems in which they operate. The assessment combines evidence from the international literature on CHW programmes with research outcomes from the 5-year REACHOUT consortium, undertaking implementation research to improve CHW performance in six contexts (two in Asia and four in Africa). A conceptual framework on CHW performance, which explicitly conceptualizes the interface role of CHWs, is presented. Various categories of factors influencing CHW performance are distinguished in the framework: the context, the health system and intervention hardware and the health system and intervention software. Hardware elements of CHW interventions comprise the supervision systems, training, accountability and communication structures, incentives, supplies and logistics. Software elements relate to the ideas, interests, relationships, power, values and norms of the health system actors. They influence CHWs' feelings of connectedness, familiarity, self-fulfilment and serving the same goals and CHWs' perceptions of support received, respect, competence, honesty, fairness and recognition.The framework shines a spotlight on the need for programmes to pay more attention to ideas, interests, relationships, power, values and norms of CHWs, communities, health professionals and other actors in the health system, if CHW performance is to improve.

A qualitative study of the determinants of HIV guidelines implementation in two south-eastern districts of Tanzania

Current HIV policies in Tanzania have adopted the three long-term impact results of zero new infections, zero HIV deaths and zero stigma and discrimination. Strategies to reach these results include scaling-up HIV Testing and Counselling (HTC); Preventing Mother-To-Child Transmission (PMTCT); and strengthening Care and Treatment Clinic (CTC) services. Previous studies showed that HIV policy and guideline recommendations were not always implemented in rural South Tanzania. This study aims to identify the determinants of HIV guideline implementation. A qualitative study of 23 semi-structured interviews with facility in-charges; healthcare workers; district, regional and national HIV coordinators was conducted. Five health facilities were purposively selected by level, ownership and proximity to district headquarters. Interviews were analysed according to Fleuren's five determinants of innovation uptake related to: strategies used in guideline development and dissemination; guideline characteristics; the guideline implementing organization; guideline users; and the socio-cultural and regulatory context. None of the facilities had the HTC national guideline document. Non-involvement of providers in revisions and weak planning for guideline dissemination impeded their implementation. Lengthy guidelines and those written in English were under-used, and activities perceived to be complicated, like WHO-staging, were avoided. Availability of staff and lack of supplies like test kits and medication impeded implementation. Collaboration between facilities enhanced implementation, as did peer-support among providers. Provider characteristics including education level, knowledge of, and commitment to the guideline influenced implementation. According to providers, determinants of clients' service use included gender norms, stigma, trust and perceived benefits. The regulatory context prohibited private hospitals from buying HIV supplies. Being tools for bringing policies to practice, national guidelines are crucial in the efforts towards the three zeros. Strategies to improve providers' adherence to guidelines should include development of clearer guideline dissemination plans, strengthening of the health system, and possibly addressing of provider-perceived patient-level barriers to utilizing HIV services.

Social accountability in primary health care in West and Central Africa: exploring the role of health facility committees

BACKGROUND

Social accountability has been emphasised as an important strategy to increase the quality, equity, and responsiveness of health services. In many countries, health facility committees (HFCs) provide the accountability interface between health providers and citizens or users of health services. This article explores the social accountability practices facilitated by HFCs in Benin, Guinea and the Democratic Republic of Congo.

METHODS

The paper is based on a cross-case comparison of 11 HFCs across the three countries. The HFCs were purposefully selected based on the (past) presence of community participation support programs. The cases were derived from qualitative research involving document analysis as well as interviews and focus group discussions with health workers, citizens, committee members, and local authorities.

RESULTS

Most HFCs facilitate social accountability by engaging with health providers in person or through meetings to discuss service failures, leading to changes in the quality of services, such as improved health worker presence, the availability of night shifts, the display of drug prices and replacement of poorly functioning health workers. Social accountability practices are however often individualised and not systematic, and their success depends on HFC leadership and synergy with other community structures. The absence of remuneration for HFC members does not seem to affect HFC engagement in social accountability.

CONCLUSIONS

Most HFCs in this study offer a social accountability forum, but the informal and non-systematic character and limited community consultation leave opportunities for the exclusion of voices of marginalised groups. More inclusive, coherent and authoritative social accountability practices can be developed by making explicit the mandate of HFC in the planning, monitoring, and supervision of health services; providing instruments for organising local accountability processes; strengthening opportunities for community input and feedback; and strengthening links to formal administrative accountability mechanisms in the health system.

Gender relations and women's reproductive health in South Sudan

Background

In South Sudan, women disproportionately bear the burden of morbidity and mortality related to sexual and reproductive health, with a maternal mortality ratio of 789 deaths per 100,000 live births.

Design

A qualitative study was conducted to analyze how gendered social relations among the Fertit people affect women's ability to exercise control over their reproductive lives and thereby their sexual and reproductive health. Transcripts of 5 focus group discussions and 44 semi-structured interviews conducted with purposefully selected community members and health personnel were analyzed using Connell's relational theory of gender.

Results

Women across all age groups report that they have little choice but to meet the childbearing demands of husbands and their families. Women, both young and old, and also elders, are frustrated about how men and society are letting them down and how they are left to bear the reproductive burden. The poverty and chronic insecurity in South Sudan mean that many men have few sources of pride and achievement; conformity and complicity with the hegemonic practices accord both security and a sense of belonging and privilege to men, often at the expense of women's reproductive health.

Conclusions

Inequalities in the domestic, social, and economic spheres intersect to create social situations wherein Fertit women's agency in the reproductive realm is constrained. In South Sudan, as long as economic and social opportunities for women remain restricted, and as long as insecurity and uncertainty remain, many women will have little choice but to resort to having many children to safeguard their fragile present and future. Unless structural measures are taken to address these inequalities, there is a risk of both a widening of existing health inequalities and the emergence of new inequalities.

Social norms and family planning decisions in South Sudan

Background

With a maternal mortality ratio of 789 per 100,000 live births, and a contraceptive prevalence rate of 4.7%, South Sudan has one of the worst reproductive health situations in the world. Understanding the social norms around sexuality and reproduction, across different ethnic groups, is key to developing and implementing locally appropriate public health responses.

Methods

A qualitative study was conducted in the state of Western Bahr el Ghazal (WBeG) in South Sudan to explore the social norms shaping decisions about family planning among the Fertit community. Data were collected through five focus group discussions and 44 semi-structured interviews conducted with purposefully selected community members and health personnel.

Results

Among the Fertit community, the social norm which expects people to have as many children as possible remains well established. It is, however, under competitive pressure from the existing norm which makes spacing of pregnancies socially desirable. Young Fertit women are increasingly, either covertly or overtly, making family planning decisions themselves; with resistance from some menfolk, but also support from others. The social norm of having as many children as possible is also under competitive pressure from the emerging norm that equates taking good care of one’s children with providing them with a good education. The return of peace and stability in South Sudan, and people’s aspirations for freedom and a better life, is creating opportunities for men and women to challenge and subvert existing social norms, including but not limited to those affecting reproductive health, for the better.

Conclusions

The sexual and reproductive health programmes in WBeG should work with and leverage existing and emerging social norms on spacing in their health promotion activities. Campaigns should focus on promoting a family ideal in which children become the object of parental investment, rather than labour to till the land — instead of focusing directly or solely on reducing family size. The conditions are right in WBeG and in South Sudan for public health programmes to intervene to trigger social change on matters related to sexual and reproductive health; this window of opportunity should be leveraged to achieve sustainable change.

Measuring Change in Behavior: Burkina Faso—An Analysis of a Participatory Evaluation Method of Hygiene Education for Water and Sanitation

In Boucle du Mouhoun (Burkina Faso) 53 percent of the consultations at health centers are attributed to water and sanitation-related diseases. A reduction in incidence of these diseases may be obtained by improving hygienic behavior. Therefore, a hygiene education program has been established with the objective of promoting hygienic messages through peer education. The program has been assessed by a participatory process and effect evaluation. The effect evaluation comprised structured observations of behavioral change by community members. However, results of the effect evaluation were queried. This article analyzes the evaluation method used by the program. Positive aspects included a clearly defined and comprehensive method. Nevertheless, certain aspects required improvement—for example, a better selection of indicators of behavioral change, increased participation of community members in the effect evaluation, and a follow-up of the concept of peer education in the field.

Health provider responsiveness to social accountability initiatives in low- and middle-income countries: a realist review

Social accountability in the health sector has been promoted as a strategy to improve the quality and performance of health providers in low- and middle-income countries. Whether improvements occur, however, depends on the willingness and ability of health providers to respond to societal pressure for better care. This article uses a realist approach to review cases of collective citizen action and advocacy with the aim to identify key mechanisms of provider responsiveness. Purposeful searches for cases were combined with a systematic search in four databases. To be included in the review, the initiatives needed to describe at least one outcome at the level of frontline service provision. Some 37 social accountability initiatives in 15 countries met these criteria. Using a realist approach, retroductive analysis and triangulation of methods and sources were performed to construct Context-Mechanism-Outcome configurations that explain potential pathways to provider responsiveness. The findings suggest that health provider receptivity to citizens' demands for better health care is mediated by health providers' perceptions of the legitimacy of citizen groups and by the extent to which citizen groups provide personal and professional support to health providers. Some citizen groups activated political or formal bureaucratic accountability channels but the effect on provider responsiveness of such strategies was more mixed. Favourable contexts for health provider responsiveness comprise socio-political contexts in which providers self-identify as activists, health system contexts in which health providers depend on citizens' expertise and capacities, and health system contexts where providers have the self-perceived ability to change the system in which they operate. Rather than providing recipes for successful social accountability initiatives, the synthesis proposes a programme theory that can support reflections on the theories of change underpinning social accountability initiatives and interventions to improve the quality of primary health care in different settings.

Health surveillance assistants as intermediates between the community and health sector in Malawi: exploring how relationships influence performance

Background

There is increasing global interest in how best to support the role of community health workers (CHWs) in building bridges between communities and the health sector. CHWs’ intermediary position means that interpersonal relationships are an important factor shaping CHW performance. This study aimed to obtain in-depth insight into the facilitators of and barriers to interpersonal relationships between health surveillance assistants (HSAs) and actors in the community and health sector in hard-to-reach settings in two districts in Malawi, in order to inform policy and practice on optimizing HSA performance.

Methods

The study followed a qualitative design. Forty-four semi-structured interviews and 16 focus group discussions were conducted with HSAs, different community members and managers in Mchinji and Salima districts. Data were recorded, transcribed, translated, coded and thematically analysed.

Results

HSAs had relatively strong interpersonal relationships with traditional leaders and volunteers, who were generally supportive of their work. From the health sector side, HSAs linked to health professionals and managers, but found them less supportive. Accountability structures at the community level were not well-established and those within the health sector were executed irregularly. Mistrust from the community, volunteers or HSAs regarding incentives and expectations that could not be met by “higher levels” undermined support structures and led to demotivation and hampered performance. Supervision and training were sometimes a source of mistrust and demotivation for HSAs, because of the perceived disinterest of supervisors, uncoordinated supervision and favouritism in selection of training participants. Rural HSAs were seen as more disadvantaged than HSAs in urban areas.

Conclusions

HSAs’ intermediary position necessitates trusting relationships between them and all actors within the community and the health sector. There is a need to improve support and accountability structures that facilitate communication and dialogue, increase trust and manage expectations and thereby improve interpersonal relationships between HSAs and actors in the community and health sector. This would maximize the value of HSAs’ unique intermediary position and support them to deliver equitable health services. This is particularly important in rural areas, where HSAs often constitute the only point of contact with health services, yet report limited support from the health system.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1402-x) contains supplementary material, which is available to authorized users.

Optimising the benefits of community health workers' unique position between communities and the health sector: A comparative analysis of factors shaping relationships in four countries

Community health workers (CHWs) have a unique position between communities and the health sector. The strength of CHWs' relationships with both sides influences their motivation and performance. This qualitative comparative study aimed at understanding similarities and differences in how relationships between CHWs, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and CHWs' relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between CHWs and the health sector resulted in weaker relationships between CHWs and communities. The broader context (such as the socio-economic situation) and programme context (related to, for example, task-shifting, volunteering and supervision) in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust CHW programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling CHWs to perform well and responding to the opportunities offered by their unique intermediary position.

"I don't have options but to persevere." Experiences and practices of care for HIV and diabetes in rural Tanzania: a qualitative study of patients and family caregivers

Background

The high prevalence of chronic diseases in Tanzania is putting a strain on the already stretched health care services, patients and their families. This study sought to find out how health care for diabetes and HIV is perceived, practiced and experienced by patients and family caregivers, to inform strategies to improve continuity of care.

Methods

Thirty two in-depth interviews were conducted among 19 patients (10 HIV, 9 diabetes) and 13 family caregivers (6 HIV, 7 diabetes). Diabetes patients and caregivers were accessed through one referral facility. HIV patients and caregivers were accessed through HIV clinics at the district hospital, one health centre and one dispensary respectively. The innovative care for chronic conditions framework informed the study design. Data was analysed with the help of Nvivo 10.

Results

Three major themes emerged; preparedness and practices in care, health care at health facilities and community support in care for HIV and diabetes. In preparedness and practices, HIV patients and caregivers knew more about aspects of HIV than did diabetes patients and caregivers on diabetes aspects. Continued education on care for the conditions was better structured for HIV than diabetes. On care at facilities, HIV and diabetes patients reported that they appreciated familiarity with providers, warm reception, gentle correction of mistakes and privacy during care. HIV services were free of charge at all levels. Costs involved in seeking services resulted in some diabetes patients to not keep appointments. There was limited community support for care of diabetes patients. Community support for HIV care was through community health workers, patient groups, and village leaders.

Conclusion

Diabetes and HIV have socio-cultural and economic implications for patients and their families. The HIV programme is successfully using decentralization of health services, task shifting and CHWs to address these implications. For diabetes and NCDs, decentralization and task shifting are also important and, strengthening of community involvement is warranted for continuity of care and patient centeredness in care. While considering differences between HIV and diabetes, we have shown that Tanzania’s rich experiences in community involvement in health can be leveraged for care and treatment of diabetes and other NCDs.

A qualitative assessment of health extension workers' relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance

BACKGROUND

Health extension workers (HEWs) in Ethiopia have a unique position, connecting communities to the health sector. This intermediary position requires strong interpersonal relationships with actors in both the community and health sector, in order to enhance HEW performance. This study aimed to understand how relationships between HEWs, the community and health sector were shaped, in order to inform policy on optimizing HEW performance in providing maternal health services.

METHODS

We conducted a qualitative study in six districts in the Sidama zone, which included focus group discussions (FGDs) with HEWs, women and men from the community and semi-structured interviews with HEWs; key informants working in programme management, health service delivery and supervision of HEWs; mothers; and traditional birth attendants. Respondents were asked about facilitators and barriers regarding HEWs' relationships with the community and health sector. Interviews and FGDs were recorded, transcribed, translated, coded and thematically analysed.

RESULTS

HEWs were selected by their communities, which enhanced trust and engagement between them. Relationships were facilitated by programme design elements related to support, referral, supervision, training, monitoring and accountability. Trust, communication and dialogue and expectations influenced the strength of relationships. From the community side, the health development army supported HEWs in liaising with community members. From the health sector side, top-down supervision and inadequate training possibilities hampered relationships and demotivated HEWs. Health professionals, administrators, HEWs and communities occasionally met to monitor HEW and programme performance. Expectations from the community and health sector regarding HEWs' tasks sometimes differed, negatively affecting motivation and satisfaction of HEWs.

CONCLUSION

HEWs' relationships with the community and health sector can be constrained as a result of inadequate support systems, lack of trust, communication and dialogue and differing expectations. Clearly defined roles at all levels and standardized support, monitoring and accountability, referral, supervision and training, which are executed regularly with clear communication lines, could improve dialogue and trust between HEWs and actors from the community and health sector. This is important to increase HEW performance and maximize the value of HEWs' unique position.

Costs and cost-effectiveness of community health workers: evidence from a literature review

OBJECTIVE

This study sought to synthesize and critically review evidence on costs and cost-effectiveness of community health worker (CHW) programmes in low- and middle-income countries (LMICs) to inform policy dialogue around their role in health systems.

METHODS

From a larger systematic review on effectiveness and factors influencing performance of close-to-community providers, complemented by a supplementary search in PubMed, we did an exploratory review of a subset of papers (32 published primary studies and 4 reviews from the period January 2003-July 2015) about the costs and cost-effectiveness of CHWs. Studies were assessed using a data extraction matrix including methodological approach and findings.

RESULTS

Existing evidence suggests that, compared with standard care, using CHWs in health programmes can be a cost-effective intervention in LMICs, particularly for tuberculosis, but also - although evidence is weaker - in other areas such as reproductive, maternal, newborn and child health (RMNCH) and malaria.

CONCLUSION

Notwithstanding important caveats about the heterogeneity of the studies and their methodological limitations, findings reinforce the hypothesis that CHWs may represent, in some settings, a cost-effective approach for the delivery of essential health services. The less conclusive evidence about the cost-effectiveness of CHWs in other areas may reflect that these areas have been evaluated less (and less rigorously) than others, rather than an actual difference in cost-effectiveness in the various service delivery areas or interventions. Methodologically, areas for further development include how to properly assess costs from a societal perspective rather than just through the lens of the cost to government and accounting for non-tangible costs and non-health benefits commonly associated with CHWs.