Can Action Research Strengthen District Health Management and Improve Health Workforce Performance? A Research Protocol.

The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome. The overall aim of the PERFORM project is to identify ways of strengthening district management in order to address health workforce inadequacies by improving health workforce performance in SSA. The study will take place in three districts each in Ghana, Tanzania and Uganda using an action research approach. With the support of the country research teams, the district health management teams (DHMTs) will lead on planning, implementation, observation, reflection and redefinition of the activities in the study. Taking into account the national and local human resource (HR) and health systems (HS) policies and practices already in place, 'bundles' of HR/HS strategies that are feasible within the context and affordable within the districts' budget will be developed by the DHMTs to strengthen priority areas of health workforce performance. A comparative analysis of the findings from the three districts in each country will add new knowledge on the effects of these HR/HS bundles on DHMT management and workforce performance and the impact of an action research approach on improving the effectiveness of the DHMTs in implementing these interventions. Different challenges were faced during the development of the methodology. These include the changing context in the study districts, competing with other projects and duties for the time of district managers, complexity of the study design, maintaining the anonymity and confidentiality of study participants as well as how to record the processes during the study. We also discuss how these challenges are being addressed. The dissemination of this research protocol is intended to generate interest in the PERFORM project and also stimulate discussion on the use of action research in complex studies such as this on strengthening district health management to improve health workforce performance

Conceptual framework for systemic capacity strengthening for health policy and systems research

Health policy and systems research (HPSR) is critical in developing health systems to better meet the health needs of their populations. The highly contextualised nature of health systems point to the value of local knowledge and the need for context-embedded HPSR. Despite such need, relatively few individuals, groups or organisations carry out HPSR, particularly in low-income and middle-income countries. Greater effort is required to strengthen capacity for, and build the field of, HPSR by capturing the multilevel and nuanced representation of HPSR across contexts. No comprehensive frameworks were found that inform systemic HPSR capacity strengthening. Existing literature on capacity strengthening for health research and development tends to focus on individual-level capacity with less attention to collective, organisational and network levels. This paper proposes a comprehensive framework for systemic capacity strengthening for HPSR, uniquely drawing attention to the blurred boundaries and amplification potential for synergistic capacity strengthening efforts across the individual, organisational and network levels. Further, it identifies guiding values and principles that consciously acknowledge and manage the power dynamics inherent to capacity strengthening work. The framework was developed drawing on available literature and was peer-reviewed by the Board and Thematic Working Groups of Health Systems Global. While the framework focuses on HPSR, it may provide a useful heuristic for systemic approaches to capacity strengthening more generally; facilitate its mainstreaming within organisations and networks and help maintain a focused approach to, and structure repositories of resources on, capacity strengthening

Reclaiming comprehensive public health

Global and national responses to the COVID-19 pandemic highlight a long-standing tension between biosecurity-focused, authoritarian and sometimes militarised approaches to public health and, in contrast, comprehensive, social determinants, participatory and rights-based approaches. Notwithstanding principles that may limit rights in the interests of public health and the role of central measures in some circumstances, effective public health in a protracted pandemic like COVID-19 requires cooperation, communication, participatory decision-making and action that safeguards the Siracusa principles, respect for people’s dignity and local-level realities and capacities. Yet there is mounting evidence of a dominant response to COVID-19 where decisions are being made and enforced in an overcentralised, non-transparent, top-down manner, often involving military coercion and abuse in communities, even while evidence shows the long-term harm to public health and human rights. In contrast, experiences of comprehensive, equity-focused, participatory public health approaches, which use diverse sources of knowledge, disciplines and capabilities, show the type of public health approach that will be more effective to meet the 21st century challenges of pandemics, climate, food and energy crises, growing social inequality, conflict and other threats to health

Systematic review of the role of social inclusion within sustainable urban developments

Rapid urbanisation presents multiple opportunities, but also poses challenges for equitable distribution of gains from socio-economic developments. This systematic review explored the role of social inclusion within the urban sustainability agenda. Sustainable urban developments were conceptualised as comprising environmental, spatial, social and economic perspectives; and social inclusion as entailing access to core services (healthcare) and resources (food). A search of five databases and grey literature returned 1,015 articles; 26 papers were included following screening using pre-determined criteria. Data was analysed thematically. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations were followed. Most included studies were from North America and few were from Africa and Asia. More empirical than conceptual studies were found, and more focused on food than healthcare. Social inclusion was generally included within the urban sustainability but was often an autonomous component, rather than mainstreamed, within urban sustainability. Social inclusion was mostly related to multiple elements of sustainability, with the greatest focus on combinations of environmental, social and economic opportunities for under privileged groups. However, less consideration was given to gender, ethnicity and other aspects of intersectionality. Multiple theories contributed to transferability of lessons. Key policy implications include prioritising the most vulnerable socially excluded populations, ensuring equal representation in urban planning, designing people-centred systems, building partnerships with communities, considering socio-cultural-political-economic contexts, and recognising both intended and unintended effects. More research is needed in low and middle-income countries (LMICs) on the role of social inclusion in achieving sustainable development, using cross-disciplinary approaches

Assessment of capacity for Health Policy and Systems Research and Analysis in seven African universities: results from the CHEPSAA project

The importance of health policy and systems research and analysis (HPSR+A) is widely recognised. Universities are central to strengthening and sustaining the HPSR+A capacity as they teach the next generation of decision-makers and health professionals. However, little is known about the capacity of universities, specifically, to develop the field. In this paper we report results of capacity self-assessments by seven universities within five African countries, conducted through the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA). The capacity assessments focused on both capacity assets and needs, and covered the wider context, as well as organisational and individual capacity levels. Six thematic areas of capacity were examined: leadership and governance, organisation’s resources, scope of HPSR+A teaching and research, communication, networking and GRIPP, demand for HPRS+A, and resource environment. The self-assessments by each university used combinations of document reviews, semi-structured interviews and staff surveys, followed by comparative analysis. A Framework Approach, guided by the six thematic areas, was used to analyse data. We found that HPSR+A is an international priority, and an existing activity in Africa, though still neglected field with challenges including its reliance on unpredictable international funding. All universities have capacity assets, such as on-going HPSR+A teaching and research. There are, however, varying levels of assets (such as differences in staff numbers, group sizes and amount of HPSR+A teaching and research), which, combined with different capacity needs at all three levels (such as individual training, improvement in systems for quality assurance and fostering demand for HPSR+A work), can shape a future agenda for HPSR+A capacity strengthening. Capacity assets and needs at different levels appear related. Possible integrated strategies for strengthening universities’ capacity include: refining HPSR+A vision, mainstreaming the subject into under- and post-graduate teaching, developing emerging leaders and aligning HPSR+A capacity strengthening within the wider organisational development

A new methodology for assessing health policy and systems research and analysis capacity in African universities.

BACKGROUND: The importance of health policy and systems research and analysis (HPSR+A) has been increasingly recognised, but it is still unclear how most effectively to strengthen the capacity of the different organisations involved in this field. Universities are particularly crucial but the expansive literature on capacity development has little to offer the unique needs of HPSR+A activity within universities, and often overlooks the pivotal contribution of capacity assessments to capacity strengthening. METHODS: The Consortium for Health Policy and Systems Analysis in Africa 2011-2015 designed and implemented a new framework for capacity assessment for HPSR+A within universities. The methodology is reported in detail. RESULTS: Our reflections on developing and conducting the assessment generated four lessons for colleagues in the field. Notably, there are currently no published capacity assessment methodologies for HPSR+A that focus solely on universities - we report a first for the field to initiate the dialogue and exchange of experiences with others. Second, in HPSR+A, the unit of assessment can be a challenge, because HPSR+A groups within universities tend to overlap between academic departments and are embedded in different networks. Third, capacity assessment experience can itself be capacity strengthening, even when taking into account that doing such assessments require capacity. CONCLUSIONS: From our experience, we propose that future systematic assessments of HPSR+A capacity need to focus on both capacity assets and needs and assess capacity at individual, organisational, and systems levels, whilst taking into account the networked nature of HPSR+A activity. A genuine partnership process between evaluators and those participating in an assessment can improve the quality of assessment and uptake of results in capacity strengthening

Costs of a successful public-private partnership for TB control in an urban setting in Nepal

<p>Abstract</p> <p>Background</p> <p>In South Asia a large number of patients seek treatment for TB from private practitioners (PPs), and there is increasing international interest in involving PPs in TB control. To evaluate the feasibility, effectiveness and costs of public-private partnerships (PPPs) for TB control, a PPP was developed in Lalitpur municipality, Nepal, where it is estimated that 50% of patients with TB are managed in the private sector. From the clinical perspective the PPP was shown to be effective. The aim of this paper is to assess and report on the costs involved in the PPP scheme.</p> <p>Methods</p> <p>The approach to costing took a comprehensive view, with inclusion of costs not only incurred by health facilities but also social costs borne by patients and their escorts. Semi-structured questionnaires and guided interviews were used to collect start-up and recurrent costs for the scheme.</p> <p>Results</p> <p>Overall costs for treating a TB patient under the PPP scheme averaged US$89.60. Start-up costs per patient represented 12% of the total budget. Half of recurrent costs were incurred by patients and their escorts, with institutional costs representing most of the rest. Female patients tended to spend more and patients referred from the private sector had the highest reported costs.</p> <p>Conclusion</p> <p>Treating TB patients in the PPP scheme had a low additional cost, while doubling the case notification rate and maintaining a high success rate. Costs incurred by patients and their escorts were the largest contributors to the overall total. This suggests a focus for follow-up studies and for cost-minimisation strategies.</p