Measuring governance at health facility level: developing and validation of simple governance tool in Zambia.

BACKGROUND: Governance has been cited as a key determinant of economic growth, social advancement and overall development. Achievement of millennium development goals is partly dependant on governance practices. In 2007, Health Systems 20/20 conducted an Internet-based survey on the practice of good governance. The survey posed a set of good practices related to health governance and asked respondents to indicate whether their experience confirmed or disconfirmed those practices. We applied the 17 governance statements in rural health facilities of Zambia. The aim was to establish whether the statements were reliable and valid for assessing governance practices at primary care level. METHODS: Both quantitative and qualitative methods were used. We first applied the governance statements developed by the health system 20/20 and then conducted focus group discussion and In-depth interviews to explore some elements of governance including accountability and community participation. The target respondents were the health facility management team and community members. The sample size include 42 health facilities. Data was analyzed using SPSS version 17 and Nvivo version 9. RESULTS: The 95% one-sided confidence interval for Cronbach's alpha was between 0.69 and 0.74 for the 16 items.The mean score for most of the items was above 3. Factor analysis yielded five principle components: Transparency, community participation, Intelligence & vision, Accountability and Regulation & oversight. Most of the items (6) clustered around the transparency latent factor. Chongwe district performed poorly in overall mean governance score and across the five domains of governance. The overall scores in Chongwe ranged between 51 and 94% with the mean of 80%. Kafue and Luangwa districts had similar overall mean governance scores (88%). Community participation was generally low. Generally, it was noted that community members lacked capacity to hold health workers accountable for drugs and medical supplies. CONCLUSIONS: The study successfully validated and applied the new tool for evaluating health system governance at health facility level. The results have shown that it is feasible to measure governance practices at health facility level and that the adapted tool is fairly reliable with the 95% one-sided confidence interval for Cronbach's alpha laying between 0.69 and 0.74 for the 16 items. Caution should be taken when interpreting overall scores as they tended to mask domain specific variations

Model parameterization to simulate and compare the PAR absorption potential of two competing plant species

Mountain pastures dominated by the pasture grass Setaria sphacelata in the Andes of southern Ecuador are heavily infested by southern bracken (Pteridium arachnoideum), a major problem for pasture management. Field observations suggest that bracken might outcompete the grass due to its competitive strength with regard to the absorption of photosynthetically active radiation (PAR). To understand the PAR absorption potential of both species, the aims of the current paper are to (1) parameterize a radiation scheme of a two-big-leaf model by deriving structural (LAI, leaf angle parameter) and optical (leaf albedo, transmittance) plant traits for average individuals from field surveys, (2) to initialize the properly parameterized radiation scheme with realistic global irradiation conditions of the Rio San Francisco Valley in the Andes of southern Ecuador, and (3) to compare the PAR absorption capabilities of both species under typical local weather conditions. Field data show that bracken reveals a slightly higher average leaf area index (LAI) and more horizontally oriented leaves in comparison to Setaria. Spectrometer measurements reveal that bracken and Setaria are characterized by a similar average leaf absorptance. Simulations with the average diurnal course of incoming solar radiation (1998–2005) and the mean leaf–sun geometry reveal that PAR absorption is fairly equal for both species. However, the comparison of typical clear and overcast days show that two parameters, (1) the relation of incoming diffuse and direct irradiance, and (2) the leaf–sun geometry play a major role for PAR absorption in the two-big-leaf approach: Under cloudy sky conditions (mainly diffuse irradiance), PAR absorption is slightly higher for Setaria while under clear sky conditions (mainly direct irradiance), the average bracken individual is characterized by a higher PAR absorption potential. (∼74 MJ m−2 year−1). The latter situation which occurs if the maximum daily irradiance exceeds 615 W m−2 is mainly due to the nearly orthogonal incidence of the direct solar beam onto the horizontally oriented frond area which implies a high amount of direct PAR absorption during the noon maximum of direct irradiance. Such situations of solar irradiance favoring a higher PAR absorptance of bracken occur in ∼36% of the observation period (1998–2005). By considering the annual course of PAR irradiance in the San Francisco Valley, the clear advantage of bracken on clear days (36% of all days) is completely compensated by the slight but more frequent advantage of Setaria under overcast conditions (64% of all days). This means that neither bracken nor Setaria show a distinct advantage in PAR absorption capability under the current climatic conditions of the study area

Measuring health system strengthening: application of the balanced scorecard approach to rank the baseline performance of three rural districts in Zambia.

INTRODUCTION: There is growing interest in health system performance and recently WHO launched a report on health systems strengthening emphasising the need for close monitoring using system-wide approaches. One recent method is the balanced scorecard system. There is limited application of this method in middle- and low-income countries. This paper applies the concept of balanced scorecard to describe the baseline status of three intervention districts in Zambia. METHODOLOGY: The Better Health Outcome through Mentoring and Assessment (BHOMA) project is a randomised step-wedged community intervention that aims to strengthen the health system in three districts in the Republic of Zambia. To assess the baseline status of the participating districts we used a modified balanced scorecard approach following the domains highlighted in the MOH 2011 Strategic Plan. RESULTS: Differences in performance were noted by district and residence. Finance and service delivery domains performed poorly in all study districts. The proportion of the health workers receiving training in the past 12 months was lowest in Kafue (58%) and highest in Luangwa district (77%). Under service capacity, basic equipment and laboratory capacity scores showed major variation, with Kafue and Luangwa having lower scores when compared to Chongwe. The finance domain showed that Kafue and Chongwe had lower scores (44% and 47% respectively). Regression model showed that children's clinical observation scores were negatively correlated with drug availability (coeff -0.40, p = 0.02). Adult clinical observation scores were positively association with adult service satisfaction score (coeff 0.82, p = 0.04) and service readiness (coeff 0.54, p = 0.03). CONCLUSION: The study applied the balanced scorecard to describe the baseline status of 42 health facilities in three districts of Zambia. Differences in performance were noted by district and residence in most domains with finance and service delivery performing poorly in all study districts. This tool could be valuable in monitoring and evaluation of health systems

Evaluation of the implementation of the reaching every district approach in routine immunisation in Lusaka District, Zambia

Background: In 2003, the Government of Zambia in collaboration with implementing partners in immunisation introduced the Reaching Every District (RED) strategy to improve immunization coverage. The aim of this study is to evaluate the implementation of the RED strategy in Lusaka district.Methods: A questionnaire was administered among health centres in charge of all governmental health clinics in Lusaka districts (N = 27). RED implementation was quantified by calculating a RED implementation score (IS) for each of the RED components on a scale of 0 (low implementation score) to 5 (high implementation score).Results: The mean overall RED implementation score was 3.5. The RED component of linking services with community and re-establishing outreach were the two weakest components.Conclusions and recommendations: This evaluation showed that there are a number of elements of the RED strategy which are well implemented; however, some elements need further improvements. There is need for more research on the implementation of the RED strategy in Zambia in order to identify bottlenecks for improving immunization coverage at larger scale and a wider participation.Keywords: RED, Immunization, training, outreach, community links, monitoring, planning, supportivesupervision

Measuring health workers' motivation in rural health facilities: baseline results from three study districts in Zambia.

INTRODUCTION: Health worker motivation can potentially affect the provision of health services. Low morale among the workforce can undermine the quality of service provision and drive workers away from the profession. While the presence of high-quality, motivated staff is a key aspect of health system performance, it is also one of the most difficult factors to measure. METHODS: We assessed health worker motivation as part of the baseline assessment for a health system strengthening intervention in three rural districts in Zambia. The intervention (Better Health Outcomes Through Mentoring and Assessment (BHOMA)) aims to increase health worker motivation through training, mentoring and support. We assessed motivation by examining underlying issues grouped around relevant outcome constructs such as job satisfaction, general motivation, burnout, organization commitment, conscientiousness and timeliness that collectively measure overall levels of motivation. The tools and the concepts have been used in high-income countries and they were recently applied in African settings to measure health worker motivation. RESULTS: Female participants had the highest motivation scores (female: mean 78.5 (SD 7.8) vs male: mean (SD 7.0)). By type of worker, nurses had the highest scores while environmental health technicians had the lowest score (77.4 (SD 7.8 vs 73.2 (SD 9.3)). Health workers who had been in post longer also had higher scores (>7 months). Health workers who had received some form of training in the preceding 12 months were more likely to have a higher score; this was also true for those older than 40 years when compared to those less than 40 years of age. The highest score values were noted in conscientiousness and timeliness, with all districts scoring above 80. CONCLUSIONS: This study evaluated motivation among rural health workers using a simple adapted tool to measure the concept of motivation. Results showed variation in motivation score by sex, type of health worker, training and time in post. Further research is needed to establish why these health worker attributes were associated with motivation and whether health system interventions targeting health workers, such as the current intervention, could influence health worker motivation

Condutância estomática em folhas de feijoeiro submetido a diferentes regimes de irrigação Stomatal conductance in leaves of bean plants submitted to different irrigation regimes

O controle estomático é importante propriedade fisiológica por meio da qual as plantas limitam a perda de água, ocasionando reduções na condutância estomática e, geralmente, reduzindo as trocas gasosas como forma de resposta das plantas a diversos fatores, incluindo o estresse hídrico. O objetivo deste trabalho foi determinar a condutância estomática em folhas de feijoeiro submetido a diferentes regimes de irrigação. O experimento foi conduzido no Departamento de Engenharia Rural da Faculdade de Ciências Agrárias e Veterinárias de Jaboticabal - SP. As irrigações nos tratamentos foram determinadas em função do esgotamento de água no solo: T1 - irrigado quando esse atingiu 40% da capacidade de água disponível (CAD); T2 - quando atingiu 60% da CAD; T3 - quando atingiu 80% da CAD, e T4 - não irrigado (irrigado somente para favorecer a emergência das plântulas). As medições de condutância estomática foram realizadas diariamente no campo, nas duas faces da folha, utilizando-se de um porômetro. Em todos os tratamentos, em diversas medições, foi observada redução da condutância estomática em resposta a baixos valores de potencial mátrico e a altos valores de déficit de pressão de vapor e vice-versa. As folhas das plantas do tratamento T4, que foram submetidas a menor disponibilidade hídrica no solo, apresentaram os menores valores de condutância estomática durante os estádios do florescimento e enchimento de grãos.<br>Stomatal control is an important physiological process for plants to reduce water loss. It causes reduction in stomatal conductance and generally in gas exchanges, as a response of several factors including water stress. The objective of this study was to determine the stomatal conductance of bean leaves submitted to different irrigation regimes. Field experiment was conducted at the São Paulo State University, in Jaboticabal, Brazil. Irrigation of the treatments occurred when available water capacity in the soil decreased to 40; 60 and 80% (respectively, treatments T1, T2 and T3), while irrigation in T4 occurred only to assure seedling emergence. Direct measurements of stomatal conductance were taken every day under field conditions in both adaxial and abaxial leaf surfaces using porometer. In all treatments, several measurements showed reduced stomatal conductance in response to low values of matric potential and high values of vapor pressure deficit (DPV) and vice-versa. The lowest values of stomatal conductance of T4 leaves, taken from plants under the most restrictive water supply regime tested in this study, were observed during the period of plant flowering and grain development