Performance-based financing as a health system reform : mapping the key dimensions for monitoring and evaluation

Peer reviewedPublisher PD

Why we should rethink ‘adoption’ in agricultural innovation: Empirical insights from Malawi

The challenges of land degradation, climate change and food insecurity have led to the introduction of conservation agriculture (CA) aimed at enhancing yield and soil quality. Despite positive biophysical results, low adoption rates have been the focus of studies identifying constraints to wider uptake. While the adoption framework is popular for measuring agricultural innovation, objective adoption measurements remain problematic and do not recognize the contextual and dynamic decision‐making process. This study uses a technographic and participatory approach to move beyond the adoption framework and understand: (a) how agricultural decision‐making takes place including the knowledge construction, (b) how agriculture is performed in a context of project intervention and (c) how practice adaptation plays out in the context of interacting knowledge. Findings confirm that farmer decision‐making is dynamic, multidimensional and contextual. The common innovation diffusion model uses a theory of change, showcasing benefits through training lead farmers as community advocates and demonstration trials. Our study shows that the assumed model of technology transfer with reference to climate‐smart agriculture interventions is not as linear and effective as assumed previously. We introduce four lenses that contribute to better understanding complex innovation dynamics: (a) social dynamics and information transfer, (b) contextual costs and benefits, (c) experience and risk aversion, and (d) practice adaptation. Investments should build on existing knowledge and farming systems including a focus on the dynamic decision process to support the 'scaling up, scaling out and scaling deep' agenda for sustainable agricultural innovations

Impact of Community-Based Larviciding on the Prevalence of Malaria Infection in Dar es Salaam, Tanzania.

The use of larval source management is not prioritized by contemporary malaria control programs in sub-Saharan Africa despite historical success. Larviciding, in particular, could be effective in urban areas where transmission is focal and accessibility to Anopheles breeding habitats is generally easier than in rural settings. The objective of this study is to assess the effectiveness of a community-based microbial larviciding intervention to reduce the prevalence of malaria infection in Dar es Salaam, United Republic of Tanzania. Larviciding was implemented in 3 out of 15 targeted wards of Dar es Salaam in 2006 after two years of baseline data collection. This intervention was subsequently scaled up to 9 wards a year later, and to all 15 targeted wards in 2008. Continuous randomized cluster sampling of malaria prevalence and socio-demographic characteristics was carried out during 6 survey rounds (2004-2008), which included both cross-sectional and longitudinal data (N = 64,537). Bayesian random effects logistic regression models were used to quantify the effect of the intervention on malaria prevalence at the individual level. Effect size estimates suggest a significant protective effect of the larviciding intervention. After adjustment for confounders, the odds of individuals living in areas treated with larviciding being infected with malaria were 21% lower (Odds Ratio = 0.79; 95% Credible Intervals: 0.66-0.93) than those who lived in areas not treated. The larviciding intervention was most effective during dry seasons and had synergistic effects with other protective measures such as use of insecticide-treated bed nets and house proofing (i.e., complete ceiling or window screens). A large-scale community-based larviciding intervention significantly reduced the prevalence of malaria infection in urban Dar es Salaam

HIV prevalence in severely malnourished children admitted to nutrition rehabilitation units in Malawi: Geographical & seasonal variations a cross-sectional study

Background: Severe malnutrition in childhood associated with HIV infection presents a serious humanitarian and public health challenge in Southern Africa. The aim of this study was to collect country wide data on HIV infection patterns in severely malnourished children to guide the development of integrated care in a resource limited setting.Methods: A cross sectional survey was conducted in 12 representative rural and urban Nutrition Rehabilitation Units (NRUs), from each of Malawi's 3 regions.All children and their caretakers admitted to each NRU over a two week period were offered HIV counselling and testing. Testing was carried out using two different rapid antibody tests, with PCR testing for discordant results. Children under 15 months were excluded, to avoid difficulties with interpretation of false positive rapid test results.The survey was conducted once in the dry/post-harvest season, and repeated in the rainy/hungry season.Results: 570 children were eligible for study inclusion. Acceptability and uptake of HIV testing was high: 523(91.7%) of carers consented for their children to take part; 368(70.6%) themselves accepted testing.Overall HIV prevalence amongst children tested was 21.6%(95% confidence intervals, 18.2-25.5%). There was wide variation between individual NRUs: 2.0-50.0%.Geographical prevalence variations were significant between the three regions (p < 0.01) with the highest prevalence being in the south: Northern Region 23.1%(95%CI 14.3-34.0%), Central Region 10.9%(95%CI 7.5-15.3%), and Southern Region 36.9%(95%CI 14.3-34.0%). HIV prevalence was significantly higher in urban areas, 32.9%(95%CI 26.8-39.4%) than in rural 13.2%(95%CI 9.5-17.6%)(p < 0.01). NRU HIV prevalence rates were lower in the rainy/hungry season 18.4%(95%CI 14.7-22.7%) than in the dry/post-harvest season 30.9%(95%CI 23.2-39.4%) (p < 0.001%).Conclusion: There is a high prevalence of HIV infection in severely malnourished Malawian children attending NRUs with children in urban areas most likely to be infected. Testing for HIV is accepted by their carers in both urban and rural areas. NRUs could act as entry points to HIV treatment and support programmes for affected children and families. Recognition of wide geographical variations in childhood HIV prevalence will ensure that limited resources are initially targeted to areas of highest need.These findings may have implications for the other countries with similar patterns of childhood illness and food insecurity

Rethinking the Poverty-disease Nexus: the Case of HIV/AIDS in South Africa

While it is well-established that poverty and disease are intimately connected, the nature of this connection and the role of poverty in disease causation remains contested in scientific and social studies of disease. Using the case of HIV/AIDS in South Africa and drawing on a theoretically grounded analysis, this paper reconceptualises disease and poverty as ontologically entangled. In the context of the South African HIV epidemic, this rethinking of the poverty-disease dynamic enables an account of how social forces such as poverty become embodied in the very substance of disease to produce ontologies of HIV/AIDS unique to South Africa

The match between motivation and performance management of health sector workers in Mali

Human resources for health (HRH) play a central role in improving accessibility to services and quality of care. Their motivation influences this. In Mali, operational research was conducted to identify the match between motivation and the range and use of performance management activities. OBJECTIVES: To describe the factors motivating and demotivating health workers in Mali and match the motivators with the implementation of performance management. METHODS: First an exploratory qualitative study was conducted: 28 interviews and eight group discussions were held. This was followed by a cross-sectional survey, during which 370 health workers were interviewed. The study population consisted of health workers of eight professional groups. The following issues were investigated: • motivating and demotivating factors; • experiences with performance management, including: job descriptions, continuous education, supervision, performance appraisal and career development. FINDINGS: The study showed that the main motivators of health workers were related to responsibility, training and recognition, next to salary. These can be influenced by performance management (job descriptions, supervisions, continuous education and performance appraisal). Performance management is not optimally implemented in Mali, as job descriptions were not present or were inappropriate; only 13% of interviewees received 4× per year supervision, and training needs were not analysed. Some 48% of the interviewees knew their performance had been appraised in the last two years; the appraisals were perceived as subjective. No other methods were in place to show recognition. The results enabled the research team to propose adaptations or improvements upon existing performance management. CONCLUSION: The results showed the importance of adapting or improving upon performance management strategies to influence staff motivation. This can be done by matching performance management activities to motivators identified by operational research

Clinical Epidemiology of Malaria in the Highlands of Western Kenya

Malaria in the highlands of Kenya is traditionally regarded as unstable and limited by low temperature. Brief warm periods may facilitate malaria transmission and are therefore able to generate epidemic conditions in immunologically naive human populations living at high altitudes. The adult:child ratio (ACR) of malaria admissions is a simple tool we have used to assess the degree of functional immunity in the catchment population of a health facility. Examples of ACR are collected from inpatient admission data at facilities with a range of malaria endemicities in Kenya. Two decades of inpatient malaria admission data from three health facilities in a high-altitude area of western Kenya do not support the canonical view of unstable transmission. The malaria of the region is best described as seasonal and meso-endemic. We discuss the implications for malaria control options in the Kenyan highlands

Community health and medical provision: impact on neonates (the CHAMPION trial)

BACKGROUND: The trial aims to evaluate whether neonatal mortality can be reduced through systemic changes to the provision and promotion of healthcare. Neonatal mortality rates in India are high compared to other low income countries, and there is a wide variation of rates across regions. There is evidence that relatively inexpensive interventions may be able to prevent up to 75% of these deaths. One area with a particularly high rate is Mahabubnagar District in Andhra Pradesh, where neonatal mortality is estimated to be in the region of 4-9%. The area suffers from a vicious cycle of both poor supply of and small demand for health care services. The trial will assess whether a package of interventions to facilitate systemic changes to the provision and promotion of healthcare may be able to substantially reduce neonatal mortality in this area and be cost-effective. If successful, the trial is designed so that it should be possible to substantially scale up the project in regions with similarly high neonatal mortality throughout Andhra Pradesh and elsewhere. METHODS/DESIGN: This trial will be a cluster-randomised controlled trial involving 464 villages in Mahabubnagar District. The package of interventions will first be introduced in half of the villages with the others serving as controls. The trial will run for a period of three years. The intervention in the trial has two key elements: a community health promotion campaign and a system to contract out healthcare to non-public institutions. The health promotion campaign will include a health education campaign, participatory discussion groups, training of village health workers and midwives, and improved coordination of antenatal services. The intervention group will also have subsidized access to pregnancy-related healthcare services at non-public lth centres (NPHCs). The primary outcome of the trial will be neonatal mortality. Secondary outcomes will include age at and cause of neonatal death, neonatal morbidity, maternal mortality and morbidity, health service usage, costs and several process and knowledge outcomes. DISCUSSION: The trial will be run by independent research and service delivery arms and supervised by a trial steering committee. A data monitoring committee will be put in place to monitor the trial and recommend stopping/continuation according to a Peto-Haybittle rule. The primary publication for the trial will follow CONSORT guidelines for cluster randomised controlled trials. Criteria for authorship of all papers, presentations and reports resulting from the study will conform to ICMJE standards

Improving Access to Mental Health Care and Psychosocial Support within a Fragile Context: A Case Study from Afghanistan

As one article in a series on Global Mental Health Practice, Peter Ventevogel and colleagues provide a case study of their efforts to integrate brief, practice-oriented mental health training into the Afghanistan health care system at a time when the system was being rebuilt from scratch

The role of supportive supervision on immunization program outcome - a randomized field trial from Georgia

<p>Abstract</p> <p>Background</p> <p>One of the most common barriers to improving immunization coverage rates is human resources and its management. In the Republic of Georgia, a country where widespread health care reforms have taken place over the last decade, an intervention was recently implemented to strengthen performance of immunization programs. A range of measures were taken to ensure that immunization managers carry out their activities effectively through direct, personal contact on a regular basis to guide, support and assist designated health care facility staff to become more competent in their immunization work. The aim of this study was to document the effects of "supportive" supervision on the performance of the immunization program at the district(s) level in Georgia.</p> <p>Methods</p> <p>A pre-post experimental research design is used for the quantitative evaluation. Data come from baseline and follow-up surveys of health care providers and immunization managers in 15 intervention and 15 control districts. These data were supplemented by focus group discussions amongst Centre of Public Health and health facility staff.</p> <p>Results</p> <p>The results of the study suggest that the intervention package resulted in a number of expected improvements. Among immunization managers, the intervention independently contributed to improved knowledge of supportive supervision, and helped remove self-perceived barriers to supportive supervision such as availability of resources to supervisors, lack of a clear format for providing supportive supervision, and lack of recognition among providers of the importance of supportive supervision. The intervention independently contributed to relative improvements in district-level service delivery outcomes such as vaccine wastage factors and the DPT-3 immunization coverage rate. The clear positive improvement in all service delivery outcomes across both the intervention and control districts can be attributed to an overall improvement in the Georgian population's access to health care.</p> <p>Conclusion</p> <p>Provider-based interventions such as supportive supervision can have independent positive effects on immunization program indicators. Thus, it is recommended to implement supportive supervision within the framework of national immunization programs in Georgia and other countries in transition with similar institutional arrangements for health services organization.</p> <p>Abstract in Russian</p> <p>See the full article online for a translation of this abstract in Russian.</p