Five minutes with Susan J. Carroll on women in politics: “There’s no question that some of the barriers are starting to come down, but others still remain”

With the seeming inevitability of Hillary Clinton’s nomination in 2016, the next presidential election may be the first in history to result in a woman president. To coincide with an recent event at the LSE,USAPP editor, Chris Gilson and Democratic Audit’s Sean Kippin, spoke to Professor Susan Carroll, author of ‘More Women Can Run: Gender and Pathways to the State Legislatures’ on the likelihood of a Clinton presidency and on the challenges faced by aspirant female politicians and established woman leaders

Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa.

Recent global crises have brought into sharp relief the absolute necessity of resilient health systems that can recognise and react to societal crises. While such crises focus the global mind, the real work lies, however, in being resilient in the face of routine, multiple challenges. But what are these challenges and what is the work of nurturing everyday resilience in health systems? This paper considers these questions, drawing on long-term, primarily qualitative research conducted in three different district health system settings in Kenya and South Africa, and adopting principles from case study research methodology and meta-synthesis in its analytic approach. The paper presents evidence of the instability and daily disruptions managed at the front lines of the district health system. These include patient complaints, unpredictable staff, compliance demands, organisational instability linked to decentralisation processes and frequently changing, and sometimes unclear, policy imperatives. The paper also identifies managerial responses to these challenges and assesses whether or not they indicate everyday resilience, using two conceptual lenses. From this analysis, we suggest that such resilience seems to arise from the leadership offered by multiple managers, through a combination of strategies that become embedded in relationships and managerial routines, drawing on wider organisational capacities and resources. While stable governance structures and adequate resources do influence everyday resilience, they are not enough to sustain it. Instead, it appears important to nurture the power of leaders across every system to reframe challenges, strengthen their routine practices in ways that encourage mindful staff engagement, and develop social networks within and outside organisations. Further research can build on these insights to deepen understanding

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

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

Implementing large-scale health system strengthening interventions: experience from the better health outcomes through mentoring and assessments (BHOMA) project in Zambia

Background Under the Doris Duke Charitable Foundation’s African Health Initiative, five Population Health Implementation and Training partnerships were established as long-term health system strengthening projects in five Sub-Saharan Countries. In Zambia, the Centre for Infectious Disease Research in Zambia began to implement the Better Health Outcomes through Mentorship and Assessments (BHOMA) in 2009. This was a combined community and health systems project involving 42 public facilities and their catchment populations. The impact of this intervention is reported elsewhere, but less attention has been paid to evaluation approaches that generate an understanding of the forces shaping the intervention. This paper is focused on understanding the implementation practices of the BHOMA intervention in Zambia. Methods Qualitative approaches were employed to understand and explain health systems intervention implementation practices between 2014 and 2016. We purposively sampled six clinics out of the 42 that participated in the BHOMA project within three districts of Lusaka province in Zambia. At the facility-level we targeted health centre in-charges, health workers, and community health workers. In-depth interviews (n = 22), focus group discussions (n = 3) and observations were also collected and synthesised. Results The major health system challenges addressed by the BHOMA project included poor infrastructure, lack of human resources, poor service delivery, long distances to health centres and inadequate health information systems. In order to implement this in the districts it was necessary to engage with the Ministry of Health and district managers, however, these partners were not actively engaged in intervention design There was great variation in perceptions about the BHOMA interventions. The implementation team considered BHOMA as a ‘proof of concept pilot project’, running parallel to the public health system, while district health officials from the Ministry of health understood it as a ‘long term partner’ and were therefore resistant to the short-term nature of the intervention. Conclusions The Normalization Process Theory provided a useful framework to understand and explain implementation processes for the BHOMA intervention in Zambia. We clearly demonstrated the applicability of all the four main components of the NPT: coherence (or sense-making); cognitive participation (or engagement); collective action and reflexive monitoring. We demonstrated how complex and dynamic the intervention played out among different actors and how implementation was affected by difference in appreciation and interpretation of the goal of the intervention. Our findings support the growing demand for process evaluations to use theory based approaches to examine how context interact with local interventions to affect outcomes intended or not. Trial registration ClinicalTrials.gov Identifier: NCT01942278 . Registered: September 13, 2013 (Retrospectively registered)

Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa.

Resource constraints, value for money debates and concerns about provider behaviour have placed accountability 'front and centre stage' in health system improvement initiatives and policy prescriptions. There are a myriad of accountability relationships within health systems, all of which can be transformed by decentralisation of health system decision-making from national to subnational level. Many potential benefits of decentralisation depend critically on the accountability processes and practices of front-line health facility providers and managers, who play a central role in policy implementation at province, county, district and facility levels. However, few studies have examined these responsibilities and practices in detail, including their implications for service delivery. In this paper we contribute to filling this gap through presenting data drawn from broader ongoing research collaborations between researchers and health managers in Kenya and South Africa. These collaborations are aimed at understanding and strengthening day-to-day micropractices of health system governance, including accountability processes. We illuminate the multiple directions and forms of accountability operating at the subnational level across three sites. Through detailed illustrative examples we highlight some of the unintended consequences of bureaucratic forms of accountability, the importance of relational elements in enabling effective bureaucratic accountability, and the ways in which front-line managers can sometimes creatively draw upon one set of accountability requirements to challenge another set to meet their goals. Overall, we argue that interpersonal interactions are key to appropriate functioning of many accountability mechanisms, and that policies and interventions supportive of positive relationships should complement target-based and/or audit-style mechanisms to achieve their intended effects. Where this is done systematically and across key elements and actors of the health system, this offers potential to build everyday health system resilience

Scaling up health policies and services in low- and middle-income settings

"Scaling up" effective health services is high on the policy agendas of many countries and international agencies. The current concern has been driven by growing recognition both of the challenges of achieving the health-related Millennium Development Goals (MDGs) in many countries, and of the need to ensure that the increased resources for health channelled through disease-specific health initiatives are able generate health gain at scale. Effective and cost-effective interventions exist to address many of the major causes of disease burden in the developing world, but coverage of many of these services remains low. There is a substantial gap between what could be achieved and what is actually being achieved in terms of health improvement in low- and middle-income countries

Provision of the progestogen-only pill by community pharmacies as bridging contraception for women receiving emergency contraception:the Bridge-it RCT

Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 27. See the NIHR Journals Library website for further project information.Peer reviewedPublisher PD

Use of effective contraception following provision of the progestogen-only pill for women presenting to community pharmacies for emergency contraception (Bridge-It):a pragmatic cluster-randomised crossover trial

BACKGROUND:Unless women start effective contraception after oral emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies. We hypothesised that pharmacist provision of the progestogen-only pill as a bridging interim method of contraception with emergency contraception plus an invitation to a sexual and reproductive health clinic, in which all methods of contraception are available, would result in increased subsequent use of effective contraception. METHODS:We did a pragmatic cluster-randomised crossover trial in 29 UK pharmacies among women receiving levonorgestrel emergency contraception. Women aged 16 years or older, not already using hormonal contraception, not on medication that could interfere with the progestogen-only pill, and willing to give contact details for follow-up were invited to participate. In the intervention group, women received a 3-month supply of the progestogen-only pill (75 μg desogestrel) plus a rapid access card to a participating sexual and reproductive health clinic. In the control group, pharmacists advised women to attend their usual contraceptive provider. The order in which each pharmacy provided the intervention or control was randomly assigned using a computer software algorithm. The primary outcome was the use of effective contraception (hormonal or intrauterine) at 4 months. This study is registered, ISRCTN70616901 (complete). FINDINGS:Between Dec 19, 2017, and June 26, 2019, 636 women were recruited to the intervention group (316 [49·6%], mean age 22·7 years [SD 5·7]) or the control group (320 [50·3%], 22·6 years [5·1]). Three women (one in the intervention group and two in the control group) were excluded after randomisation. 4-month follow-up data were available for 406 (64%) participants, 25 were lost to follow-up, and two participants no longer wanted to participate in the study. The proportion of women using effective contraception was 20·1% greater (95% CI 5·2-35·0) in the intervention group (mean 58·4%, 48·6-68·2), than in the control group (mean 40·5%, 29·7-51·3 [adjusted for recruitment period, treatment group, and centre]; p=0·011).The difference remained significant after adjusting for age, current sexual relationship, and history of effective contraception use, and was robust to the effect of missing data (assuming missingness at random). No serious adverse events occurred. INTERPRETATION:Provision of a supply of the progestogen-only pill with emergency contraception from a community pharmacist, along with an invitation to a sexual and reproductive health clinic, results in a clinically meaningful increase in subsequent use of effective contraception. Widely implemented, this practice could prevent unintended pregnancies after use of emergency contraception. FUNDING:National Institute for Health Research (Health Technology Assessment Programme project 15/113/01)

Cultural Transformation in Healthcare: How Well Does the Veterans Health Administration Vision for Whole Person Care Fit the Needs of Patients at an Academic Rehabilitation Center?

Background The Veterans Health Administration is undergoing a cultural transformation toward person-driven care referred to as the Whole Health System of Care. Objective This pilot study evaluated whether the Whole Health model resonates with patients of a large public university rehabilitation clinic. Methods Thirty participants completed the Veterans Health Administration's Personal Health Inventory (PHI), and six attended the course "Taking Charge of My Life and Health." Researchers analyzed PHI responses and post-course focus group transcripts. A short post-PHI survey and post-course evaluation were collected. Results Participants agreed the PHI is a simple, useful tool. The course, while well attended, did not meet participants' expectations. Participants wanted access to integrative therapies and opportunities to contribute to healthcare transformation. Conclusion Rehabilitation patients resonated with the Whole Health vision. They expressed enthusiasm for the cultural transformation represented by the model along with frustration that standard healthcare experiences fall short of this vision

Pragmatic cluster randomised cohort cross-over trial to determine the effectiveness of bridging from emergency to regular contraception:the Bridge-It study protocol

Introduction Oral emergency contraception (EC) can prevent unintended pregnancy but it is important to start a regular method of contraception. Women in the UK usually access EC from a pharmacy but then need a subsequent appointment with a general practitioner or a sexual and reproductive health (SRH) service to access regular contraception. Unintended pregnancies can occur during this time. Methods and analysis Bridge-It is a pragmatic cluster randomised cohort cross-over trial designed to determine whether pharmacist provision of a bridging supply of a progestogen-only pill (POP) plus rapid access to a local SRH clinic, results in increased uptake of effective contraception and prevents more unintended pregnancies than provision of EC alone. Bridge-It involves 31 pharmacies in three UK regions (London, Lothian and Tayside) aiming to recruit 626–737 women. Pharmacies will give EC (levonorgestrel) according to normal practice and recruit women to both intervention and the control phases of the study. In the intervention phase, pharmacists will provide the POP (desogestrel) and offer rapid access to an SRH clinic. In the control phase, pharmacists will advise women to attend a contraceptive provider for contraception (standard care). Women will be asked 4 months later about contraceptive use. Data linkage to abortion registries will provide abortion rates over 12 months. The sample size is calculated on the primary outcome of effective contraception use at 4 months (yes/no) with 90% power and a 5% level of significance. Abortion rates will be an exploratory secondary analysis. Process evaluation includes interviews with pharmacists, SRH clinicians and women. Cost-effectiveness analysis will use a healthcare system perspective and be expressed as incremental cost-effectiveness ratio. Ethics and dissemination Ethical approval was received from South East Scotland REC June 2017. Results will be published in peer-reviewed journals and conference presentations. Trial registration number ISRCTN70616901