Abolishing user fees for children and pregnant women trebled uptake of malaria-related interventions in Kangaba, Mali.

Malaria is the most common cause of morbidity and mortality in children under 5 in Mali. Health centres provide primary care, including malaria treatment, under a system of cost recovery. In 2005, Médecins sans Frontieres (MSF) started supporting health centres in Kangaba with the provision of rapid malaria diagnostic tests and artemisinin-based combination therapy. Initially MSF subsidized malaria tests and drugs to reduce the overall cost for patients. In a second phase, MSF abolished fees for all children under 5 irrespective of their illness and for pregnant women with fever. This second phase was associated with a trebling of both primary health care utilization and malaria treatment coverage for these groups. MSF's experience in Mali suggests that removing user fees for vulnerable groups significantly improves utilization and coverage of essential health services, including for malaria interventions. This effect is far more marked than simply subsidizing or providing malaria drugs and diagnostic tests free of charge. Following the free care strategy, utilization of services increased significantly and under-5 mortality was reduced. Fee removal also allowed for more efficient use of existing resources, reducing average cost per patient treated. These results are particularly relevant for the context of Mali and other countries with ambitious malaria treatment coverage objectives, in accordance with the United Nations Millennium Development Goals. This article questions the effectiveness of the current national policy, and the effectiveness of reducing the cost of drugs only (i.e. partial subsidies) or providing malaria tests and drugs free for under-5s, without abolishing other related fees. National and international budgets, in particular those that target health systems strengthening, could be used to complement existing subsidies and be directed towards effective abolition of user fees. This would contribute to increasing the impact of interventions on population health and, in turn, the effectiveness of aid

The Ghana Community-based Health Planning and Services Initiative: Fostering evidence-based organizational change and development in a resource-constrained setting

Research projects demonstrating ways to improve health services often fail to have an impact on what national health programs actually do. An approach to evidence-based policy development has been launched in Ghana that bridges the gap between research and program implementation. The Community-based Health Planning and Services (CHPS) initiative employs strategies tested in the successful Navrongo experiment to guide national health reforms that mobilize volunteers, resources, and cultural institutions to support community-based primary health care. Over the 1999 to 2002 period, 100 out of the 110 districts in Ghana adopted a CHPS initiative. This paper reviews features of the initiative that explain its success and constrain future progress

Evidence-based development of health and family planning programs in Bangladesh and Ghana

This paper describes two initiatives that have used experimental studies to guide the development of community-based health and family planning programs. In Bangladesh and Ghana, factorial experiments were implemented in stages. An exploratory phase developed a service system for community-based health care; an experimental phase assessed the demographic impact of the system; a replication phase examined the transferability of the experimental program to a non-research setting; and a scaling-up phase facilitated the extension of the new system to the national health care program. All stages were guided by research, with questions, mechanisms, and outcomes shifting as the process developed. Large-scale systems development was achieved in both Bangladesh and Ghana, not because the scaling-up programs were alike, but because similar research approaches informed their strategies, allowing them to adapt to contrasting societal and institutional contexts. Success in Bangladesh and Ghana suggests ways in which evidence-based system development can overcome resource and organizational constraints and foster transitions from limited, passive clinical services to active programs for providing accessible community-based care

The Ghana essential health interventions program: a plausibility trial of the impact of health systems strengthening on maternal and child survival

Background: During the 1990s, researchers at the Navrongo Health Research Centre in northern Ghana developed a highly successful community health program. The keystone of the Navrongo approach was the deployment of nurses termed community health officers to village locations. A trial showed that, compared to areas relying on existing services alone, the approach reduced child mortality by half, maternal mortality by 40%, and fertility by nearly a birth — from a total fertility rate of 5.5 in only five years. In 2000, the government of Ghana launched a national program called Community-based Health Planning and Services (CHPS) to scale up the Navrongo model. However, CHPS scale-up has been slow in districts located outside of the Upper East Region, where the “Navrongo Experiment” was first carried out. This paper describes the Ghana Essential Health Intervention Project (GEHIP), a plausibility trial of strategies for strengthening CHPS, especially in the areas of maternal and newborn health, and generating the political will to scale up the program with strategies that are faithful to the original design. Description of the intervention: GEHIP improves the CHPS model by 1) extending the range and quality of services for newborns; 2) training community volunteers to conduct the World Health Organization service regimen known as integrated management of childhood illness (IMCI); 3) simplifying the collection of health management information and ensuring its use for decision making; 4) enabling community health nurses to manage emergencies, particularly obstetric complications and refer cases without delay; 5) adding $0.85 per capita annually to district budgets and marshalling grassroots political commitment to financing CHPS implementation; and 6) strengthening CHPS leadership at all levels of the system. Evaluation design: GEHIP impact is assessed by conducting baseline and endline survey research and computing the Heckman “difference in difference” test for under-5 mortality in three intervention districts relative to four comparison districts for core indicators of health status and survival rates. To elucidate results, hierarchical child survival hazard models will be estimated that incorporate measures of health system strength as survival determinants, adjusting for the potentially confounding effects of parental and household characteristics. Qualitative systems appraisal procedures will be used to monitor and explain GEHIP implementation innovations, constraints, and progress. Discussion: By demonstrating practical means of strengthening a real-world health system while monitoring costs and assessing maternal and child survival impact, GEHIP is expected to contribute to national health policy, planning, and resource allocation that will be needed to accelerate progress with the Millennium Development Goals

Bridging the gap between evidence-based innovation and national health-sector reform in Ghana

Although experimental trials often identify optimal strategies for improving community health, transferring operational innovation from well-funded research programs to resource-constrained settings often languishes. Because research initiatives are based in institutions equipped with unique resources and staff capabilities, results are often dismissed by decisionmakers as irrelevant to large-scale operations and national health policy. This article describes an initiative undertaken in Nkwanta District, Ghana, focusing on this problem. The Nkwanta District initiative is a critical link between the experimental study conducted in Navrongo, Ghana, and a national effort to scale up the innovations developed in that study. A 2002 Nkwanta district-level survey provides the basis for assessing the likelihood that the Navrongo model is replicable elsewhere in Ghana. The effect of community-based health planning and services exposure on family planning and safe-motherhood indicators supports the hypothesis that the Navrongo model is transferable to impoverished rural settings elsewhere. This finding confirms the need for strategies to bridge the gap between Navrongo evidence-based innovation and national health-sector reform

Factors influencing uptake of voluntary counselling and testing services for HIV/AIDS in the Lower Manya Krobo Municipality (LMKM) in the Eastern Region of Ghana: a cross-sectional household survey

Background Voluntary counselling and testing (VCT) is one of the nine strategies recommended for prevention and control of HIV globally. In this study, we assessed the awareness and utilisation of VCT services among residents of the Lower Manya Krobo Municipality (LMKM) in the Eastern Region of Ghana. Methods A population-based descriptive cross-sectional survey was conducted with 200 participants, aged between 18 and 55 years. Participants were recruited using cluster and simple random techniques to take part in the survey. Data was analysed descriptively, as well as using regression analysis approach. Results Ninety-one percent of the respondents surveyed were aware of VCT services for HIV/AIDS. Seventy percent (70 %) have used VCT service in the last 12 months prior to the survey. Of this proportion, 97 % were satisfied with the quality of VCT services offered and indicated their willingness to recommend the service to others. Participants desire to know their HIV status (40 %), referral by health workers (25 %), and participants who wanted to get married (11 %) were the main reasons for increased uptake. Participants who had formal education, primary (OR = 1.8 (95 % CI 1.25–2.84)), junior high school (OR = 2.3 (95 % CI 1.54–3.37)), senior high school (OR = 2.8 (95 % CI 1.73–4.78)), and tertiary (OR = 3.4 (95 % CI 1.98–8.42)), had increased chance of using VCT service compared with participants who had no education (p < 0.001). Reasons for non-utilisation of VCT service were lack of awareness of the VCT service in the area (32 %), fear of being stigmatised (53 %), and the belief that HIV/AIDS cannot be cured and therefore the lack of need (5 %). Conclusions Although awareness and utilisation of VCT service rates were reportedly high, more efforts need to be done in order to increase awareness and promote utilisation. HIV/AIDS educational campaign programmes need to be strongly pursued, with emphasis on the benefits of VCT services. This has the potential of reducing stigma and increase utilisation

Partnering to proceed: scaling up adolescent sexual reproductive health programmes in Tanzania. Operational research into the factors that influenced local government uptake and implementation

BACKGROUND: Little is known about how to implement promising small-scale projects to reduce reproductive ill health and HIV vulnerability in young people on a large scale. This evaluation documents and explains how a partnership between a non-governmental organization (NGO) and local government authorities (LGAs) influenced the LGA-led scale-up of an innovative NGO programme in the wider context of a new national multisectoral AIDS strategy. METHODS: Four rounds of semi-structured interviews with 82 key informants, 8 group discussions with 49 district trainers and supervisors (DTS), 8 participatory workshops involving 52 DTS, and participant observations of 80% of LGA-led and 100% of NGO-led meetings were conducted, to ascertain views on project components, flow of communication and decision-making and amount of time DTS utilized undertaking project activities. RESULTS: Despite a successful ten-fold scale-up of intervention activities in three years, full integration into LGA systems did not materialize. LGAs contributed significant human resources but limited finances; the NGO retained control over finances and decision-making and LGAs largely continued to view activities as NGO driven. Embedding of technical assistants (TAs) in the LGAs contributed to capacity building among district implementers, but may paradoxically have hindered project integration, because TAs were unable to effectively transition from an implementing to a facilitating role. Operation of NGO administration and financial mechanisms also hindered integration into district systems. CONCLUSIONS: Sustainable intervention scale-up requires operational, financial and psychological integration into local government mechanisms. This must include substantial time for district systems to try out implementation with only minimal NGO support and modest output targets. It must therefore go beyond the typical three- to four-year project cycles. Scale-up of NGO pilot projects of this nature also need NGOs to be flexible enough to adapt to local government planning cycles and ongoing evaluation is needed to ensure strategies employed to do so really do achieve full intervention integration

Health personnel retention strategies in a peri-urban community: an exploratory study on Epworth, Zimbabwe

BACKGROUND : The need to retain health personnel is a policy challenge undermining health system reform of the 21st century. The need to resolve this global health workforce crisis resulted in the First Global Forum on Human Resources for Health in 2008 from which the Kampala Declaration and Agenda for Global Action was formulated. However, whilst there have been several studies exploring the retention of health personnel towards this end, available literature does not provide a detailed narrative on strategies used in peri-urban communities. The aim of this study was to explore retention strategies implemented in a Zimbabwean peri-urban community between 2009 and 2014 and implications for peri-urban communities towards the health system reform agenda. METHODS : The study was carried out in Epworth, a peri-urban community in Harare, Zimbabwe. The research design was a cross-sectional survey, in which qualitative methods were used in sampling, data collection, reporting and analysis. Qualitative tools were used to collect data through in-depth interviews with purposively selected health personnel managers at 10 local clinics and sample interviews with purposively selected healthcare workers who included registered general nurses, state-certified nurses, midwives, environmental health technicians, nurse aids and community health volunteers at each clinic. Two focus group discussions were carried out with community health volunteers. Qualitative data was subjected to thematic analysis, with coding being performed manually. RESULTS : A programme-specific strategic partnership between the government and donor community contributed towards the mobilisation of more health personnel, health facilities, worker development and remuneration. To complement this, the Ministry of Health intervened through the review and payment of salaries, support towards post-basic training and development, and protection. The local board, mission and donors contributed through the payment of top-up allowances and provision of non-monetary incentives. CONCLUSIONS : The review of salaries, engagement of international strategic partners, payment of top-up allowances, support towards post-basic training and development, mobilisation of more health personnel, non-monetary incentives and healthcare worker protection were critical towards the retention of health personnel in the Epworth peri-urban community between 2009 and 2014.We are most grateful to the African Doctoral Dissertation Research Fellowship Award (ADDRF 2015-2017 ADF 002) offered by the African Population and Health Research Centre in partnership with the International Development Research Centre which made this research possible. We are also grateful to the University of Pretoria Postgraduate Research Bursary (10443925) which also made this study possible.http://www.human-resources-health.comam2016School of Health Systems and Public Health (SHSPH