Health systems and MNCH outcomes in West Africa : a study of conducive and limiting health systems factors to improving mother, new born and child health in West Africa

The presentation provides demographic information/graphs regarding child mortality rates over time (1990-2013) in sub-Sharan African countries, and specifically focuses on countries involved in the West African Health Organization (WAHO) Innovating for Maternal and Child Health in Africa (IMCHA) project: Benin, Burkina Faso, Ghana, Mali, Nigeria, and Senegal. It reviews significant factors within the project regarding motivation, barriers, competencies and conducive and limiting health system factors

“Wood already touched by fire is not hard to set alight” Comment on “Constraints to applying systems thinking concepts in health systems: A regional perspective from surveying stakeholders in Eastern Mediterranean countries”

A major constraint to the application of any form of knowledge and principles is the awareness, understanding and acceptance of the knowledge and principles. Systems Thinking (ST) is a way of understanding and thinking about the nature of health systems and how to make and implement decisions within health systems to maximize desired and minimize undesired effects. A major constraint to applying ST within health systems in Low- and Middle-Income Countries (LMICs) would appear to be an awareness and understanding of ST and how to apply it. This is a fundamental constraint and in the increasing desire to enable the application of ST concepts in health systems in LMIC and understand and evaluate the effects; an essential first step is going to be enabling of a wide spread as well as deeper understanding of ST and how to apply this understandin

Why district assemblies disburse resources to district health systems for service delivery at district level in the context of decentralization: a comparative study of two districts in the Volta Region of Ghana

ObjectivesTo explore why the District Assembly disburses financial and other resources to the District Health System.DesignMultiple case study with a single unit of analysis (holistic) using quantitative and qualitative methods of data collection involving a desk review, analysis of routine health management information system data and key informant interviews.SettingTwo districts in the Volta Region of Ghana.ParticipantsTwelve key officials of each district assembly and the district health system (24 total) who had worked in the district at least a year or more.InterventionsNone.ResultsBoth District Assemblies had moderate decision space which was influenced by their capacity, power and contextual factors like politics, economics, legal and situational factors. Disbursement of financial and other resources to the District Health Systems was influenced by financial capacity, use of power by stakeholders, context and the decision space of the District Assembly. Political actors appeared to have more power in resource disbursement decision making than community members and technocrats in a context of resource constraints and inadequate funding. The funding available was used predominantly for capital investments, mainly construction of Community Based Health Planning and Services (CHPS) compounds.ConclusionIt is important to make policies that will regulate the relative power among the political appointees like the District Chief Executives (DCEs), public and civil servants in decentralized departments and agencies and Community members to make resource disbursement more sensitive to communities and decentralized departments

Strengthening health system leadership for better governance: what does it take?

This editorial provides an overview of the six papers included in this special supplement on health leadership in Africa. Together the papers provide evidence of leadership in public hospital settings and of initiatives to strengthen leadership development. On the one hand, they demonstrate both that current leadership practices often impact negatively on staff motivation and patient care, and that contextual factors underpin poor leadership. On the other hand, they provide some evidence of the positive potential of new forms of participatory leadership, together with ideas about what forms of leadership development intervention can nurture new forms of leadership. Finally, the papers prompt reflection on the research needed to support the implementation of such interventions

When ‘solutions of yesterday become problems of today': crisis-ridden decision making in a complex adaptive system (CAS)—the Additional Duty Hours Allowance in Ghana

Implementation of policies (decisions) in the health sector is sometimes defeated by the system's response to the policy itself. This can lead to counter-intuitive, unanticipated, or more modest effects than expected by those who designed the policy. The health sector fits the characteristics of complex adaptive systems (CAS) and complexity is at the heart of this phenomenon. Anticipating both positive and negative effects of policy decisions, understanding the interests, power and interaction between multiple actors; and planning for the delayed and distal impact of policy decisions are essential for effective decision making in CAS. Failure to appreciate these elements often leads to a series of reductionist approach interventions or ‘fixes'. This in turn can initiate a series of negative feedback loops that further complicates the situation over time. In this paper we use a case study of the Additional Duty Hours Allowance (ADHA) policy in Ghana to illustrate these points. Using causal loop diagrams, we unpack the intended and unintended effects of the policy and how these effects evolved over time. The overall goal is to advance our understanding of decision making in complex adaptive systems; and through this process identify some essential elements in formulating, updating and implementing health policy that can help to improve attainment of desired outcomes and minimize negative unintended effect

Boundary-spanning: reflections on the practices and principles of Global Health.

As Global Health evolves, not merely as a metaphor for international collaboration, but as a distinct field of practice, it warrants greater consideration of how it is practiced, by whom, and for what goals. We believe that, to become more relevant for the health systems and communities that are their intended beneficiaries, Global Health practices must actively span and disrupt boundaries of geography, geopolitics and constituency, some of which are rooted in imbalances of power and resources. In this process, fostering cross-country learning networks and communities of practice, and building local and national institutions with a global outlook in low and middle-income countries, are critically important. Crucially, boundary-spanning practices in Global Health require a mindset of inclusiveness, awareness of and respect for different coexisting realities

Spanning maternal, newborn and child health (MNCH) and health systems research boundaries : conducive and limiting health systems factors to improving MNCH outcomes in West Africa

Canadian Institutes of Health Research (CIHR)Global Affairs Canada (GAC)Economic Community of West African States (ECOWA

A Narrative Synthesis Review of Out-of-Pocket Payments for Health Services Under Insurance Regimes: A Policy Implementation Gap Hindering Universal Health Coverage in Sub-Saharan Africa.

BACKGROUND: "Achieve universal health coverage (UHC), including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all" is the Sustainable Development Goal (SDG) 3.8 target. Although most high-income countries have achieved or are very close to this target, low- and middle-income countries (LMICs) especially those in sub-Saharan Africa (SSA) are still struggling with its achievement. One of the observed challenges in SSA is that even where services are supposed to be "free" at point-of-use because they are covered by a health insurance scheme, out-of-pocket fees are sometimes being made by clients. This represents a policy implementation gap. This study sought to synthesise the known evidence from the published literature on the 'what' and 'why' of this policy implementation gap in SSA. METHODS: The study drew on Lipsky's street level bureaucracy (SLB) theory, the concept of practical norms, and Taryn Vian's framework of corruption in the health sector to explore this policy implementation gap through a narrative synthesis review. The data from selected literature were extracted and synthesized iteratively using a thematic content analysis approach. RESULTS: Insured clients paid out-of-pocket for a wide range of services covered by insurance policies. They made formal and informal cash and in-kind payments. The reasons for the payments were complex and multifactorial, potentially explained in many but not all instances, by coping strategies of street level bureaucrats to conflicting health sector policy objectives and resource constraints. In other instances, these payments appeared to be related to structural violence and the 'corruption complex' governed by practical norms. CONCLUSION: A continued top-down approach to health financing reforms and UHC policy is likely to face implementation gaps. It is important to explore bottom-up approaches - recognizing issues related to coping behaviour and practical norms in the face of unrealistic, conflicting policy dictates

Health systems and MNCH outcomes in West Africa : a study of conducive and limiting health systems : factors to improving maternal, newborn and child health (MNCH) in West Africa

This study explored health system factors conducive to, or that limit maternal, newborn and child health (MNCH) policy, program implementation and outcomes in West Africa, and how and why they work in some contexts. Findings relate to the health system and how it affects interventions and outcomes. There is little research in the sub-region related to such values as responsiveness, equity, fairness, justice, and rights and responsibilities, which may be explicitly or implicitly held within the health system, and more specifically, how they apply to MNCH and other programs

“We have nice policies but…”: implementation gaps in the Ghana adolescent health service policy and strategy (2016–2020)

Introduction Although policies for adolescent health exist in Ghana, their implementation is challenging. Availability of services for adolescent sexual and reproductive health and adolescent mental health remains less than desired, with adolescent mental health being particularly neglected despite being an important contributor to poor health outcomes. This study presents an analysis of gaps in the implementation of the Ghana Adolescent Health Service Policy and Strategy (2016–2020), including how and why the context influenced the observed implementation gaps. Methods Data for this study is drawn from 17 in-depth interviews with purposefully identified key stakeholders in adolescent mental, sexual, and reproductive health across the national and subnational levels; four focus group discussions (FGDs) with district health management teams; and 11 FGDs with adolescents in and out of schools in four selected districts in the Greater Accra region. Data were analyzed using both inductive and deductive approaches. The deductive analysis drew on Leichter’s conceptualization of context as structural, cultural, situational, and environmental factors. Results Of the 23 planned strategies and programs for implementing the policy, 13 (57%) were partially implemented, 6 (26%) were not implemented at all, and only 4 (17%) were fully implemented. Multiple contextual factors constrained the policy implementation and contributed to the majority of strategies not being implemented or partially implemented. These factors included a lack of financial resources for implementation at all levels of the health system and the related high dependence on external funding for policy implementation. Service delivery for adolescent mental health, and adolescent sexual and reproductive health, appeared to be disconnected from the delivery of other health services, which resulted in weak or low cohesion with other interventions within the health system. Discussion Bottom-up approaches that engage closely with adolescent perspectives and consider structural and cultural contexts are essential for effective policy implementation. It is also important to apply systemic and multi-sectoral approaches that avoid fragmentation and synergistically integrate policy interventions