District Health Managers' Perceptions of Supervision in Malawi and Tanzania.

Mid-level cadres are being used to address human resource shortages in many African contexts, but insufficient and ineffective human resource management is compromising their performance. Supervision plays a key role in performance and motivation, but is frequently characterised by periodic inspection and control, rather than support and feedback to improve performance. This paper explores the perceptions of district health management teams in Tanzania and Malawi on their role as supervisors and on the challenges to effective supervision at the district level. This qualitative study took place as part of a broader project, "Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers". Semi-structured interviews were conducted with 20 district health management team personnel in Malawi and 37 council health team members in Tanzania. The interviews covered a range of human resource management issues, including supervision and performance assessment, staff job descriptions and roles, motivation and working conditions. Participants displayed varying attitudes to the nature and purpose of the supervision process. Much of the discourse in Malawi centred on inspection and control, while interviewees in Tanzania were more likely to articulate a paradigm characterised by support and improvement. In both countries, facility level performance metrics dominated. The lack of competency-based indicators or clear standards to assess individual health worker performance were considered problematic. Shortages of staff, at both district and facility level, were described as a major impediment to carrying out regular supervisory visits. Other challenges included conflicting and multiple responsibilities of district health team staff and financial constraints. Supervision is a central component of effective human resource management. Policy level attention is crucial to ensure a systematic, structured process that is based on common understandings of the role and purpose of supervision. This is particularly important in a context where the majority of staff are mid-level cadres for whom regulation and guidelines may not be as formalised or well-developed as for traditional cadres, such as registered nurses and medical doctors. Supervision needs to be adequately resourced and supported in order to improve performance and retention at the district level

Process evaluation in the field: global learnings from seven implementation research hypertension projects in low-and middle-income countries

Background Process evaluation is increasingly recognized as an important component of effective implementation research and yet, there has been surprisingly little work to understand what constitutes best practice. Researchers use different methodologies describing causal pathways and understanding barriers and facilitators to implementation of interventions in diverse contexts and settings. We report on challenges and lessons learned from undertaking process evaluation of seven hypertension intervention trials funded through the Global Alliance of Chronic Diseases (GACD). Methods Preliminary data collected from the GACD hypertension teams in 2015 were used to inform a template for data collection. Case study themes included: (1) description of the intervention, (2) objectives of the process evaluation, (3) methods including theoretical basis, (4) main findings of the study and the process evaluation, (5) implications for the project, policy and research practice and (6) lessons for future process evaluations. The information was summarized and reported descriptively and narratively and key lessons were identified. Results The case studies were from low- and middle-income countries and Indigenous communities in Canada. They were implementation research projects with intervention arm. Six theoretical approaches were used but most comprised of mixed-methods approaches. Each of the process evaluations generated findings on whether interventions were implemented with fidelity, the extent of capacity building, contextual factors and the extent to which relationships between researchers and community impacted on intervention implementation. The most important learning was that although process evaluation is time consuming, it enhances understanding of factors affecting implementation of complex interventions. The research highlighted the need to initiate process evaluations early on in the project, to help guide design of the intervention; and the importance of effective communication between researchers responsible for trial implementation, process evaluation and outcome evaluation. Conclusion This research demonstrates the important role of process evaluation in understanding implementation process of complex interventions. This can help to highlight a broad range of system requirements such as new policies and capacity building to support implementation. Process evaluation is crucial in understanding contextual factors that may impact intervention implementation which is important in considering whether or not the intervention can be translated to other contexts

Tobacco industry globalization and global health governance: : towards an interdisciplinary research agenda

Shifting patterns of tobacco production and consumption, and the resultant disease burden worldwide since the late twentieth century prompted efforts to strengthen global health governance through adoption of the Framework Convention on Tobacco Control. While the treaty is rightfully considered an important achievement, to address a neglected public health issue through collective action, evidence suggests that tobacco industry globalization continues apace. In this article we provide a systematic review of the public health literature and reveal definitional and measurement imprecision, ahistorical timeframes, transnational tobacco companies and the state as the primary units and levels of analysis, and a strong emphasis on agency as opposed to structural power. Drawing on the study of globalization in international political economy and business studies, we identify opportunities to expand analysis along each of these dimensions. We conclude that this expanded and interdisciplinary research agenda provides the potential for fuller understanding of the dual and dynamic relationship between the tobacco industry and globalization. Deeper analysis of how the industry has adapted to globalization over time, as well as how the industry has influenced the nature and trajectory of globalization, is essential for building effective global governance responses

Reducing the role of the food, tobacco, and alcohol industries in non-communicable disease risk in South Africa

Noncommunicable diseases (NCDs) impose a growing burden on the health, economy, and development of South Africa. According to the World Health Organization, four risk factors, tobacco use, alcohol consumption, unhealthy diets, and physical inactivity, account for a significant proportion of major NCDs. We analyze the role of tobacco, alcohol, and food corporations in promoting NCD risk and unhealthy lifestyles in South Africa and in exacerbating inequities in NCD distribution among populations. Through their business practices such as product design, marketing, retail distribution, and pricing and their business practices such as lobbying, public relations, philanthropy, and sponsored research, national and transnational corporations in South Africa shape the social and physical environments that structure opportunities for NCD risk behavior. Since the election of a democratic government in 1994, the South African government and civil society groups have used regulation, public education, health services, and community mobilization to modify corporate practices that increase NCD risk. By expanding the practice of health education to include activities that seek to modify the practices of corporations as well as individuals, South Africa can reduce the growing burden of NCDs

Microwave sinter forging of alumina powder

International audienceMicrowave sintering under load is expected to be a promising technique to process ceramics with fine microstructure. This paper presents a new setup allowing sinter forging ceramic compacts in a 2.45 GHz single-mode microwave cavity. This setup has the following features: maximum temperature of 1600 degrees C, heating rate between 1 and 250 degrees C min(-1), maximum stress of 50 MPa applied upon an 8 mm diameter sample. A specific protocol has been defined to calibrate the pyrometer used to measure the sample temperature. Alpha-alumina compacts have been microwave sinter forged under various stresses in the range 0-30 MPa. The results are compared to those obtained in a conventional furnace under 0, 4 and 8 MPa. Final axial and radial shrinkages are identical with the two techniques. The final relative density of the material is not affected by load and is equal to 0.94 and 0.96 in microwave sinter forging and conventional sinter forging, respectively. Two assumptions are proposed to explain this difference: a microwave effect and a temperature discrepancy. Finally the load does not significantly affect grain growth

A CMOS compatible ultrasonic transducer fabricated with deep reactive ion etching

International audienceThis paper describes design, fabrication, and test of an integrated micromachined ultrasound transducer (MUT). This MUT can work as an emitter and a receiver of ultrasonic signals in air and is intended to be used in applications requiring both acoustic signal generation and sensing. Among these applications there can be detection or distance measurements of different objects where the nature either of these objects or of their surroundings does not allow the use of light-based methods. The device has been fabricated in a 0.8 mum CMOS process combined with deep reactive ion etching, integrating in the same chip a suspended membrane (plate) and the associated interface electronics. The plate is thermally actuated at its resonance frequency (40 kHz) during emission. During reception, a piezoresistive bridge placed on the membrane is used for monitoring its deflections. The main advantage of the design using an actuator and a sensor integrated in one multilayer structure is its simplicity. Comparing with capacitive transducers where two-electrode structure is used, considerations in terms of mechanical stability and membrane damping as well as the fabrication process are not critical. The integrated solution allows the use of an amplifier at the output of the piezoresistive Wheatstone bridge which results in the sensitivity of 35 mV/Pa; the maximum acoustic pressure generated by the transducer at 10 mm is 5 mP