Learning health systems in low-income and middle-income countries: exploring evidence and expert insights.

From Europe PMC via Jisc Publications RouterHistory: ppub 2022-09-01Publication status: PublishedIntroductionLearning health systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of LHS, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterise LHS in low/middle-income country (LMIC) settings.MethodsWe adopted an exploratory approach to the literature review, recognising there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge.ResultsThe findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels.We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with 'best fit' solutions.ConclusionHealth systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge

The Interface Between Communities and the Primary Care System in Rural and Low-income West Virginia: Historical and County-level Experience to Inform the Future of Community Health Workers (CHWs)

West Virginia (WV) has been working to strengthen the interface between its communities and the primary care system for many decades. The uncertain future of the Affordable Care Act (ACA) and recent evidence of continued lags and declines in health outcomes and state and federal healthcare budgets have added to the urgency for further changes to primary care system functioning and community engagement. A dialogue about how to address these challenges is underway among a number of stakeholders in WV, which includes potential uses and strategies for Community Health Workers (CHWs). This dissertation included a historical analysis to provide state-wide context of the community and primary care system interface since the New Deal Era in WV, and two county-level case studies to explore the nature of that interface at the local level. The historical analysis entailed archival document review and 12 oral histories, which were analyzed and organized into an historical argument synthesizing WV’s experience. The county case study sites were selected to represent different contexts as well as population health status across the state. These cases provided frontline perspectives from the primary care workforce and communities. Methods for the county cases included document review and 35 in-depth interviews. The interviews were transcribed and coded, and two cases were developed using a framework analysis approach. Historically, the state of WV has extensive experience with encouraging, supporting, or requiring community and primary care system interaction. This experience has been fragmented and inaccessible to current stakeholders, however, and has not led to a coherent strategy or program. Stakeholders and decision-makers can learn from historical experience about how communities have engaged with primary care in order to develop such a program; the county case studies will reinforce and spotlight such learning opportunities. Mingo County, the first of the two county cases, has a short history of bringing multiple local partners together to create a shared vision for a healthier future. These partners are implementing an integrated set of initiatives, including a CHW cadre, to engage and support the community while providing services that reflect local priorities and values. In Pendleton County, several decades of experience with engaging the community to provide input and feedback to the primary care system has resulted in high quality clinical services and enduring relationships among local individuals and agencies. This county does not have a shared vision for the future of primary care or CHWs, with many local agencies working independently. This study identified a number of recommendations for the future of CHW work in WV and beyond: 1) Develop local visions and strategies for CHWs and share these with other counties and state-level leadership in WV to help inform local and state plans and identify necessary resources. 2) Ensure that communities and the primary care system seek out, value, and support those individuals performing CHW tasks. 3) Keep CHW certification processes simple and be inclusive of diverse local models. 4) Invest time and resources in relationships among and between community members and the primary care system at local- and state-level. 5) Draw on community and primary care worker experiences in WV to identify relevant and inclusive metrics for measuring and tracking community engagement. 6) Continue to focus attention and support on primary care and community engagement, particularly when political and financial support is for these efforts is low

Health policy and systems research training: global status and recommendations for action.

OBJECTIVE: To investigate the characteristics of health policy and systems research training globally and to identify recommendations for improvement and expansion. METHODS: We identified institutions offering health policy and systems research training worldwide. In 2014, we recruited participants from identified institutions for an online survey on the characteristics of the institutions and the courses given. Survey findings were explored during in-depth interviews with selected key informants. FINDINGS: The study identified several important gaps in health policy and systems research training. There were few courses in central and eastern Europe, the Middle East, North Africa or Latin America. Most (116/152) courses were instructed in English. Institutional support for courses was often lacking and many institutions lacked the critical mass of trained individuals needed to support doctoral and postdoctoral students. There was little consistency between institutions in definitions of the competencies required for health policy and systems research. Collaboration across disciplines to provide the range of methodological perspectives the subject requires was insufficient. Moreover, the lack of alternatives to on-site teaching may preclude certain student audiences such as policy-makers. CONCLUSION: Training in health policy and systems research is important to improve local capacity to conduct quality research in this field. We provide six recommendations to improve the content, accessibility and reach of training. First, create a repository of information on courses. Second, establish networks to support training. Third, define competencies in health policy and systems research. Fourth, encourage multidisciplinary collaboration. Fifth, expand the geographical and language coverage of courses. Finally, consider alternative teaching formats

Learning health systems in low-income and middle-income countries: exploring evidence and expert insights

From BMJ via Jisc Publications RouterHistory: received 2021-11-26, accepted 2022-02-16, ppub 2022-09, epub 2022-09-20Peer reviewed: TrueAcknowledgements: We would like to acknowledge the contribution of Charity Jensen, who worked on the two background papers which supported this article.Publication status: PublishedFunder: Alliance for Health Policy and Systems Research; FundRef: http://dx.doi.org/10.13039/100007855; Grant(s): Not applicableIntroduction: Learning health systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of LHS, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterise LHS in low/middle-income country (LMIC) settings. Methods: We adopted an exploratory approach to the literature review, recognising there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge. Results: The findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels. We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with ‘best fit’ solutions. Conclusion: Health systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge

Hubris, humility and humanity: expanding evidence approaches for improving and sustaining community health programmes

Community-based approaches are a critical foundation for many health outcomes, including reproductive, maternal, newborn and child health (RMNCH). Evidence is a vital part of strengthening that foundation, but largely focuses on the technical content of what must be done, rather than on how disparate community actors continuously interpret, implement and adapt interventions in dynamic and varied community health systems. We argue that efforts to strengthen evidence for community programmes must guard against the hubris of relying on a single approach or hierarchy of evidence for the range of research questions that arise when sustaining community programmes at scale. Moving forward we need a broader evidence agenda that better addresses the implementation realities influencing the scale and sustainability of community programmes and the partnerships underpinning them if future gains in community RMNCH are to be realised

Hubris, humility and humanity: expanding evidence approaches for improving and sustaining community health programmes

Community-based approaches are a critical foundation for many health outcomes, including reproductive, maternal, newborn and child health (RMNCH). Evidence is a vital part of strengthening that foundation, but largely focuses on the technical content of what must be done, rather than on how disparate community actors continuously interpret, implement and adapt interventions in dynamic and varied community health systems. We argue that efforts to strengthen evidence for community programmes must guard against the hubris of relying on a single approach or hierarchy of evidence for the range of research questions that arise when sustaining community programmes at scale. Moving forward we need a broader evidence agenda that better addresses the implementation realities influencing the scale and sustainability of community programmes and the partnerships underpinning them if future gains in community RMNCH are to be realised. This will require humility in understanding communities as social systems, the complexity of the interventions they engage with and the heterogeneity of evidence needs that address the implementation challenges faced. It also entails building common ground across epistemological word views to strengthen the robustness of implementation research by improving the use of conceptual frameworks, addressing uncertainty and fostering collaboration. Given the complexity of scaling up and sustaining community RMNCH, ensuring that evidence translates into action will require the ongoing brokering of relationships to support the human creativity, scepticism and scaffolding that together build layers of evidence, critical thinking and collaborative learning to effect change

Towards Core Competencies for Health Policy and Systems Research (HPSR) Training: Results From a Global Mapping and Consensus-Building Process.

BACKGROUND: As the field of health policy and systems research (HPSR) continues to grow, there is a recognition of the need for training in HPSR. This aspiration has translated into a multitude of teaching programmes of variable scope and quality, reflecting a lack of consensus on the skills and practices required for rigorous HPSR. The purpose of this paper is to identify an agreed set of core competencies for HPSR researchers, building on the previous work by the Health Systems Global (HSG) Thematic Working Group on Teaching & Learning. METHODS: Our methods involved an iterative approach of four phases including a literature review, key informant interviews and group discussions with HPSR educators, and webinars with pre-post surveys capturing views among the global HPSR community. The phased discussions and consensus-building contributed to the evolution of the HPSR competency domains and competencies framework. RESULTS: Emerging domains included understanding health systems complexity, assessing policies and programs, appraising data and evidence, ethical reasoning and practice, leading and mentoring, building partnerships, and translating and utilizing knowledge and HPSR evidence. The development of competencies and their application were often seen as a continuous process spanning evidence generation, partnering, communicating and helping to identify new critical health systems questions. CONCLUSION: The HPSR competency set can be seen as a useful reference point in the teaching and practice of high-quality HPSR and can be adapted based on national priorities, the particularities of local contexts, and the needs of stakeholders (HPSR researchers and educators), as well as practitioners and policy-makers. Further research is needed in using the core competency set to design national training programmes, develop locally relevant benchmarks and assessment methods, and evaluate their use in different settings

Learning health systems in low and middle income countries: Exploring evidence and expert insights

Sophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Introduction Learning Health Systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of learning health systems, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterize learning health systems in low- and middle-income country (LMIC) settings.Methods We adopted an exploratory approach to the literature review, recognizing there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge.Results The findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels. We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with ‘best fit’ solutions.Conclusion Health systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge.https://gh.bmj.com/inpressinpres

Global perspectives of determinants influencing HPV vaccine introduction and scale-up in low- and middle-income countries.

Achieving WHO cervical cancer elimination goals will necessitate efforts to increase HPV vaccine access and coverage in low-and-middle-income countries (LMICs). Although LMICs account for the majority of cervical cancer cases globally, scale-up of HPV vaccine programs and progress toward coverage targets in LMICs has been largely insufficient. Understanding the barriers and facilitators that stakeholders face in the introduction and scale-up of HPV vaccination programs will be pivotal in ensuring that LMICs are equipped to optimize the implementation of HPV vaccination programs. This qualitative study interviewed 13 global stakeholders categorized as either academic partners or global immunization partners to ascertain perspectives regarding factors affecting the introduction and scale-up of HPV vaccination programs in LMICs. Global stakeholders were selected as their perspectives have not been as readily highlighted within the literature despite their key role in HPV vaccination programming. The results of this investigation identified upstream (e.g., financial considerations, vaccine prioritization, global supply, capacity and delivery, and vaccine accessibility, equity, and ethics) and downstream (e.g., vaccine acceptability and hesitancy, communications, advocacy, and social mobilization) determinants that impact program introduction and scale-up and confirmed that strong political commitment and governance are significant in garnering support for HPV vaccines. As LMICs introduce HPV vaccines into their national immunization programs and develop plans for scaling up vaccination efforts, strategic approaches to communications and advocacy will also be needed to successfully meet coverage targets