Assessing changes in adolescent girls' and young women's sexual and reproductive health service utilisation following a COVID-19 lockdown in eSwatini.

The effects of COVID-19-associated restrictions on youth sexual and reproductive health (SRH) care during the pandemic remain unclear, particularly in sub-Saharan Africa. This study uses interrupted time series analyses to assess changes in SRH care utilisation (including visits for HIV testing and treatment, family planning, and antenatal care) adolescent girls' and young women's (AGYW; aged 15-24 years old) in eSwatini following COVID-19 lockdown beginning in March 2020. SRH utilisation data from 32 clinics in the Manzini region that remained open throughout the 2020 COVID-19 period were extracted from eSwatini's electronic health record system. We tabulated and graphed monthly visits (both overall and by visit type) by AGYW during the two-year period between January 2019 and December 2020. Despite the March to September 2020 lockdown, we did not detect significant changes in monthly visit trends from 2019 to 2020. Our findings suggest little change to AGYW's SRH utilisation in eSwatini during the 2020 COVID-19 lockdown period.

Strengthening Public Health Scholarship in Sudan: The Role of Leadership and Mentorship Development.

A robust public health workforce in Sudan is essential for accelerating progress toward the Sustainable Development Goals, and strengthening public health education is a priority for the Ministries of Health and Higher Education. Faculty at public health training institutions are a critical resource. Globally, development programs for junior to midlevel public health faculty have been well documented. However, most involved direct partnership between a university from the Global North and only one or two universities from the Global South, only one included an explicit focus on creation of a leadership network, and none were launched as fully virtual collaborations. Therefore, we conducted a mixed-method evaluation of the fully virtual Yale-Sudan Program for Research Leadership in Public Health. We used program records, participant feedback, competency assessment, and network analysis to evaluate 1) participant engagement, 2) change in skill, and 3) change in collaboration. The program achieved a 93% graduation rate. All participants would "definitely" recommend the program and described the live virtual sessions as engaging, effective, and accessible. We observed progress toward learning objectives and significant increases in 13 of 14 leadership and mentorship competency domains. Collaboration across Sudanese institutions increased, including an almost doubling in the number of pairs reporting scholarly collaboration. Eight authorship teams are actively working toward peer-reviewed publications. The program engaged scholars and policymakers from across Sudan and the Sudanese diaspora achieved high levels of co-creation and continues despite significant political unrest in the country, serving as a promising model for strengthening of public health education in Sudan.

Improving management of vaccine supply chains: A multi-methods evaluation of vSTEP in Zambia.

BACKGROUND: Equipping supply chain professionals at all levels of the health care systems with essential leadership and management skills is essential to achieving global immunization targets. Numerous and diverse professional development initiatives have been established to support vaccine supply chain managers in Gavi-eligible countries. However, COVID-19 catalyzed rapid innovation in approaches to support leadership development in times of rapid change, and systematic evaluation of these approaches can inform future workforce development strategies to ensure resilient health systems. Therefore, we sought to evaluate outcomes and short-term impact of the fully virtual Strategic Training Executive Program 2.0 (vSTEP 2.0) program in Zambia on participant engagement, skill development, and application of new skills to improve supply chain performance. METHODS: We used a multi-method design to describe the outcomes and short-term impact of vSTEP 2.0 at three levels: (1) delegate response to the training experience (including participation, completion, and satisfaction); (2) delegate change in leadership skill (including achievement of learning objectives and change in competencies); and (3) application of new skills to impact supply chain performance. RESULTS: The program achieved high levels of engagement and an 83% graduation rate despite the length and rigor of the program. High satisfaction was evidenced by positive feedback from delegates on the quality and relevance of the program, especially in the context of COVID response (100% would "definitely" recommend). Delegates demonstrated significant growth in all domains of leadership competencies and applied their learnings to address a complex challenge in supply chain performance in their home organization. DISCUSSION: These findings demonstrate a strong appetite for leadership development support among vaccine supply chain professionals, especially in times of rapid change such as during the COVID response. These results also demonstrate the feasibility and impact of a fully virtual model for leadership development, with implications well beyond the COVID-19 pandemic.

Measuring Organizational Culture in Ethiopia's Primary Care System: Validation of a Practical Survey Tool for Managers.

BACKGROUND: Organizational culture has been widely recognized as predictive of health system performance and improved outcomes across various healthcare settings. Research on organizational culture in healthcare has been largely conducted in high-income settings, and validated scales to measure this concept in primary healthcare systems in low- and middle-income country (LMIC) settings are lacking. Our study aimed to validate a tool to measure organizational culture in the context of the Ethiopian Primary Healthcare Transformation Initiative (PTI), a collaborative of the Federal Ministry of Health (FMoH) and the Yale Global Health Leadership Initiative to strengthen primary healthcare system performance in Ethiopia. METHODS: Following established survey development and adaptation guidelines, we adapted a 31-item US-based organizational culture scale using (1) cognitive interviewing, (2) testing with 1176 district and zonal health officials from four regions in Ethiopia, and (3) exploratory factor analysis (EFA). RESULTS: Based on the results of cognitive interviewing, an adapted 30-item survey was piloted. The factor analyses of 1034 complete surveys (88% complete responses) identified five constructs of the scale which demonstrated strong validity and internal consistency: learning and problem solving, psychological safety, resistance to change, time for improvement, and commitment to the organization. Of the 30 a priori items, 26 items loaded well on the five constructs (loading values 0.40-0.86), and 4 items failed to load. Cronbach alpha coefficients were 0.86 for the scale as a whole and ranged from 0.65 to 0.90 for the subscales. The five-factor solution accounted for 62% of total variance in culture scores across respondents. CONCLUSION: Through validation and factor analyses, we generated a 26-item scale for measuring organizational culture in public primary healthcare systems in LMIC settings. This validated tool can be useful for managers, implementers, policy-makers, and researchers to assess and improve organizational culture in support of improved primary healthcare system performance.

Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study.

BACKGROUND: Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention. METHODS: Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis. DISCUSSION: This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

Building leadership and management competencies of national immunization teams in 16 Gavi-eligible countries through the EPI leadership and management programme.

BACKGROUND: Strengthening leadership and management competencies among national Expanded Programme on Immunization (EPI) teams will be critical to achieving global immunization targets and other sustainable developmental goals. However, there is little empirical evidence of the effectiveness of investments in leadership and management capacity in the context of national EPI programs. Therefore, we sought to evaluate the EPI Leadership and Management Programme (EPI LAMP), a nine-month certificate program for EPI teams in national Ministries of Health from Gavi priority countries in Anglophone and Francophone Africa and Asia. METHODS: We used a mixed-methods longitudinal evaluation to describe EPI LAMP at four levels: (1) participant response to the training experience based on program administration records and satisfaction surveys; (2) change in management and leadership skill based on competency surveys and exit interviews; (3) change in behavior in the workplace based on exit interviews; and (4) impact of the training on EPI program performance based on the results of each delegate's leadership project. RESULTS: In the first three cohorts, the programme engaged 16 countries (63 participants) and achieved an 86% graduation rate (54 alumni). Participants demonstrated significant improvement in management and leadership competencies across eight domains with the largest improvement observed in the domain of governance and leadership. Women showed greater increases than men, especially in the domains of Operations Management and Political Advocacy and Dialogue. We observed no difference in the gains made by French-speaking delegates compared to English-speaking participants. Breakthrough projects developed by each team improved EPI program performance, as measured by metrics specific to each project. DISCUSSION: Our results show that team-based leadership programs can foster improvements in management practice, collaboration, and problem-solving, and that engagement the broader policy and organizational context is needed to foster the systems thinking capacity required to address complex challenges and improve system performance.

The role of leadership in times of systems disruption: a qualitative study of health and social care integration.

OBJECTIVES: To understand whether and how effective integration of health and social care might occur in the context of major system disruption (the COVID-19 pandemic), with a focus on how the initiative may overcome past barriers to integration. DESIGN: Rapid, descriptive case study approach with deviant case sampling to gather and analyse key informant interviews and relevant archival documents. SETTING: The innovation ('COVID-19 Protect') took place in Norfolk and Waveney, UK, and aimed to foster integration across highly diverse organisations, capitalising on existing digital technology to proactively identify and support individuals most at risk of severe illness from COVID-19. PARTICIPANTS: Twenty-six key informants directly involved with project conceptualisation and early implementation. Participants included clinicians, executives, digital/information technology leads, and others. Final sample size was determined by theoretical saturation. RESULTS: Four primary recurrent themes characterised the experiences of diverse team members in the project: (1) ways of working that supported rapid collaboration, (2) leveraging diversity and clinician input for systems change, (3) allowing for both central control and local adaptation and (4) balancing risk taking and accountability. CONCLUSIONS: This rapid case study underscores the role of leadership in large systems change efforts, particularly in times of major disruption. Project leadership overcame barriers to integration highlighted by prior studies, including engaging with aversion to clinical/safety risk, fostering distributed leadership and developing shared organisational practices for data sharing and service delivery. These insights offer considerations for future efforts to support strategic integration of health and social care.

Creativity in problem solving to improve complex health outcomes: Insights from hospitals seeking to improve cardiovascular care.

Introduction: Improving performance often requires health care teams to employ creativity in problem solving, a key attribute of learning health systems. Despite increasing interest in the role of creativity in health care, empirical evidence documenting how this concept manifests in real-world contexts remains limited. Methods: We conducted a qualitative study to understand how creativity was fostered during problem solving in 10 hospitals that took part in a 2-year collaborative to improve cardiovascular care outcomes. We analyzed interviews with 197 hospital team members involved in the collaborative, focusing on work processes or outcomes that participants self-identified as creative or promoting creativity. We sought to identify recurrent patterns across instances of creativity in problem solving. Results: Participants reported examples of creativity at both stages typically identified in problem solving research and practice: uncovering non-obvious problems and finding novel solutions. Creativity generally involved the assembly of an "ecological view" of the care process, which reflected a more complete understanding of relationships between individual care providers, organizational sub-units, and their environment. Teams used three prominent behaviors to construct the ecological view: (a) collecting new and diverse information, (b) accepting (rather than dismissing) disruptive information, and (c) employing empathy to understand and share feelings of others. Conclusions: We anticipate that findings will be useful to researchers and practitioners who wish to understand how creativity can be fostered in problem solving to improve clinical outcomes and foster learning health systems.

An Analysis of Zonal Health Management Capacity and Health System Performance: Ethiopia Primary Healthcare Transformation Initiative.

BACKGROUND: District management is emerging as a lynchpin for primary healthcare system performance. However, delivery of district-level interventions at scale is challenging, and overlooks the potential role of management at other subnational levels. From 2015-2019, Ethiopia's Primary Healthcare Transformation Initiative (PTI), aimed to build a culture of performance management and accountability at the zonal level. This paper aims to evaluate the longitudinal change in management practice and performance in the 19 zones participating in PTI, which included 315 districts and 1617 health centers. METHODS: Using data from PTI intervention (2018 to 2019), we employed quantitative measures of management capacity at health center, district, and zonal levels, and quantified primary healthcare service performance using a summary score based on antenatal care coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. We used multiple generalized linear regression models accounting for clustering of health centers within zones to quantify (1) change in management and performance during the two-year intervention, (2) associations between the changes in management capacity at the zonal, district, and health facility level. RESULTS: Adherence to management standards at the zonal, district, and health facility level improved significantly over two years (37%, P<.001; 18%, P<.001; 18%, P<.001; respectively), as did the performance summary score (14%, P<.001). Adherence at the zonal level in year one was associated with district level adherence in year one (P=.04), and, over the two-year period (P=.002), and district management mediated the relationship between management practice at zonal and health center levels (P<.001). CONCLUSION: Improvements in zonal-level management practice were associated with significant improvements in district-level management and performance in PTI sites. Investments in managerial practices at the zonal level may provide an immediate way to energize primary healthcare system performance at scale in low-income country settings.

District-Level Health Management and Health System Performance: The Ethiopia Primary Healthcare Transformation Initiative.

BACKGROUND: Despite a wide range of interventions to improve district health management capacity in low-income settings, evidence of the impact of these investments on system-wide management capacity and primary healthcare systems performance is limited. To address this gap, we conducted a longitudinal study of the 36 rural districts (woredas), including 229 health centers, participating in the Primary Healthcare Transformation Initiative (PTI) in Ethiopia. METHODS: Between 2015 and 2017, we collected quantitative measures of management capacity at the district and health center levels and a primary healthcare key performance indicator (KPI) summary score based on antenatal care (ANC) coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. We conducted repeated measures analysis of variance (ANOVA) to assess (1) changes in management capacities at the district health office level and health center level, (2) changes in health systems performance, and (3) the differential effects of more vs less intensive intervention models. RESULTS: Adherence to management standards at both district and health center levels improved during the intervention, and the most prominent improvement was achieved during district managers' exposure to intensive mentorship and education. We did not observe similar patterns of change in KPI summary score. CONCLUSION: The district health office is a valuable entry point for primary healthcare reform, and district- and facility-level management capacity can be measured and improved in a relatively short period of time. A combination of intensive mentorship and structured team-based education can serve as both an accelerator for change and a mechanism to inform broader reform efforts.

The Evolution of Trust Within a Global Health Partnership With the Private Sector: An Inductive Framework.

BACKGROUND: Public-private partnerships (PPPs) in global health are increasingly common to support sustainable development and strengthen health systems in low- and middle-income countries. Since the release of the Sustainable Development Goals (SDGs) in 2015 culminating in a discrete goal "to revitalize the global partnership for sustainable development," public health scholars have sought to understand what makes PPPs successful in different contexts. While trust has long been identified as a key component of successful strategic alliances in the private sector, less is known about how trust emerges between public- and private- sector partners, particularly in global health. Therefore, we investigated how trust between partners evolved in the context of Project Last Mile (PLM), a global health partnership that translates the business acumen of The Coca-Cola Company to strengthen public health systems across Africa. METHODS: This study draws upon secondary analysis of qualitative data generated as part of the longitudinal, mixed-methods evaluation of PLM across country settings. Seventy-seven interviews with a purposeful sample of key stakeholders were conducted in Mozambique, South Africa and eSwatini between August 2016 and July 2018. Trained qualitative interviewers followed a standard discussion guide, and audio-recorded interviews with participants' consent. In this secondary analysis, we analyzed qualitative data to understand how trust between partners was cultivated across settings. RESULTS: We drew upon stakeholder experiences to inform an inductive framework for how trust develops over time. Our analysis revealed five domains that were foundational to building trust: (1) reputational context, (2) team composition, (3) tangible outputs, (4) shared values, and (5) effective communication. CONCLUSION: The framework may be useful for private and public sector entities seeking to establish and sustain trust within their global health partnerships.

Girl Champ in eSwatini: A Strategic Marketing Campaign to Promote Demand for Sexual and Reproductive Health Services Among Young Women.

Efforts to engage adolescent girls and young women (AGYW) in HIV services have struggled, in part, due to limited awareness of services and stigma. Strategic marketing is a promising approach, but the impact on youth behavior change is unclear. We report findings from a mixed methods evaluation of the Girl Champ campaign, designed to generate demand for sexual and reproductive services among AGYW, and piloted in three clinics in the Manzini region of eSwatini. We analyzed and integrated data from longitudinal, clinic-level databases on health service utilization among AGYW before and after the pilot, qualitative interviews with stakeholders responsible for the implementation of the pilot, and participant feedback surveys from attendees of Girl Champ events. Girl Champ was well received by most stakeholders based on event attendance and participant feedback, and associated with longitudinal improvements in demand for HIV services. Findings can inform future HIV demand creation interventions for youth.

Strengthening the Mentorship and Leadership Capacity of HIV/AIDS and Tuberculosis Researchers in South Africa.

Programs to increase emerging and established HIV and tuberculosis (TB) researchers' capacity to be more effective leaders and mentors are urgently needed in low- and middle-income countries (LMICs). Although conceptual frameworks of mentoring and mentoring toolkits have been developed by and for researchers in LMIC settings, few mentor training programs have been implemented and evaluated in these settings. We created, implemented, and evaluated a 9-month, certificate-level mentorship training program to strengthen the pipeline of HIV and TB researchers in South Africa. Differentiating features of the program included careful contextualization of mentorship tools and approaches, inclusion of a leadership curriculum to improve participant ability to work effectively in teams and organizations, and attention to processes that promote interinstitutional collaboration in mentorship. Twelve mid-career researchers graduated from the first cohort of the program. Among participants, we observed significant longitudinal improvement in mentorship competencies, increased numbers of network connections in multiple domains of collaboration, and high levels of satisfaction. We anticipate that the program description and results will be useful to researchers, research institutions, and funders seeking to build research mentorship and leadership capacity in LMIC settings.

Title: Expansion of a national differentiated service delivery model to support people living with HIV and other chronic conditions in South Africa: a descriptive analysis.

BACKGROUND: South Africa is home to 7.7 million people living with HIV and supports the largest antiretroviral therapy (ART) program worldwide. Despite global investment in HIV service delivery and the parallel challenge of non-communicable diseases (NCDs), there are few examples of integrated programs addressing both HIV and NCDs through differentiated service delivery. In 2014, the National Department of Health (NDoH) of South Africa launched the Central Chronic Medicines Dispensing and Distribution (CCMDD) program to provide patients who have chronic diseases, including HIV, with alternative access to medications via community-based pick-up points. This study describes the expansion of CCMDD toward national scale. METHODS: Yale monitors CCMDD expansion as part of its mixed methods evaluation of Project Last Mile, a national technical support partner for CCMDD since 2016. From March 2016 through October 2019, cumulative weekly data on CCMDD uptake [patients enrolled, facilities registered, pick-up points contracted], type of medication provided [ART only; NCD only; and ART-NCD] and collection sites preferred by patients [external pick-up points; adherence/outreach clubs; or facility-based fast lanes], were extracted for descriptive, longitudinal analysis. RESULTS: As of October 2019, 3,436 health facilities were registered with CCMDD across 46 health districts (88 % of South Africa's districts), and 2,037 external pick-up points had been contracted by the NDoH. A total of 2,069,039 patients were actively serviced through CCMDD, a significant increase since 2018 (p < 0.001), including 76 % collecting ART [64 % ART only, 12 % ART plus NCD/comorbidities] and 479,120 [24 %] collecting medications for chronic diseases only. Further, 734,005 (35 %) of patients were collecting from contracted, external pick-up points, a 73 % increase in patient volume from 2018. DISCUSSION: This longitudinal description of CCMDD provides an example of growth of a national differentiated service delivery model that integrates management of HIV and noncommunicable diseases. This study demonstrates the success of the program in engaging patients irrespective of their chronic condition, which bodes well for the potential of the program to address the rising burden of both HIV and NCDs in South Africa. CONCLUSIONS: The CCMDD program expansion signals the potential for a differentiated service delivery strategy in resource-limited settings that can be agnostic of the patients chronic disease condition.

Diabetes prevention in the Caribbean using Lifestyle Intervention and Metformin Escalation (LIME): Protocol for a hybrid Type-1 effectiveness-implementation trial using a quasi-experimental study design.

BACKGROUND: Globally, several diabetes prevention interventions have been shown to be cost-effective, yet they have had limited adaptation, implementation, and evaluation in the Caribbean and among Caribbean-descent individuals, where the burden of type 2 diabetes is high. We report on the protocol for the Lifestyle Intervention with Metformin Escalation (LIME) study - an evidence-based diabetes prevention intervention to reduce the incidence of diabetes among Caribbean-descent individuals with prediabetes. METHODS: LIME is a hybrid type-I effectiveness-implementation quasi-experimental study taking place in 4 clinical sites in Barbados, Trinidad, the U.S. Virgin Islands, and Puerto Rico. LIME targets individuals who self-identify as Caribbean or Caribbean-descent and have high-risk prediabetes with a hemoglobin A1c (HbA1c) between 6 and 6.4%. Eligible participants in the intervention arm are enrolled in a six-week lifestyle modification workshop. Six months later, individuals who have not lost at least 5% of their bodyweight or continue to have an HbA1c of 6% or higher are prescribed metformin medication. In total, participants are followed for one year. The primary effectiveness outcome is proportion of individuals who lower their HbA1c below 6%. DISCUSSION: LIME is a unique diabetes prevention intervention for Caribbean and Caribbean-descent individuals. LIME utilizes a tailored lifestyle change curriculum, incorporates appropriate metformin prescribing when lifestyle change alone is insufficient, targets the highest-risk individuals with prediabetes, and is based in a clinical setting to ensure sustainability.

Project Last Mile and the development of the Girl Champ brand in eSwatini: engaging the private sector to promote uptake of health services among adolescent girls and young women.

In eSwatini and across sub-Saharan Africa, adolescent girls and young women (AGYW) are at significantly higher risk of HIV infection and poorer sexual and reproductive health (SRH) than their male counterparts. AGYW demonstrate low demand for SRH services, further contributing to poor outcomes. Strategic marketing approaches, including those used by multinational corporations, have potential to support demand creation for SRH services among AGYW, but there is limited empirical evidence on the direct application of private-sector strategic marketing approaches in this context. Therefore, we examined how Project Last Mile worked with eSwatini's Ministry of Heath to translate strategic marketing approaches from the Coca-Cola system to attract AGYW to SRH services. We present qualitative market research using the ZMET® methodology with 12 young Swazi women (ages 15-24), which informed development of a highly branded communication strategy consistent with other successful gain-framing approaches. Qualitative in-depth interviews with 19 stakeholders revealed receptivity to the market research findings, and highlighted local ownership over the strategic marketing process and brand. These results can inform similar efforts to translate strategic marketing to support demand generation in pursuit of public health goals to reduce HIV risk and improve SRH.

Changing hospital organisational culture for improved patient outcomes: developing and implementing the leadership saves lives intervention.

BACKGROUND: Leadership Saves Lives (LSL) was a prospective, mixed methods intervention to promote positive change in organisational culture across 10 diverse hospitals in the USA and reduce mortality for patients with acute myocardial infarction (AMI). Despite the potential impact of complex interventions such as LSL, descriptions in the peer-reviewed literature often lack the detail required to allow adoption and adaptation of interventions or synthesis of evidence across studies. Accordingly, here we present the underlying design principles, overall approach to intervention design and core content of the intervention. METHODS OF INTERVENTION DEVELOPMENT: Hospitals were selected for participation from the membership of the Mayo Clinic Care Network using random sampling with a purposeful component. The intervention was designed based on the Assess, Innovate, Develop, Engage, Devolve model for diffusion of innovation, with attention to pressure testing of the intervention with user groups, creation of a think tank to develop a comprehensive assessment of the landscape, and early and continued engagement with strategically identified stakeholders in multiple arenas. RESULTS: We provide in-depth descriptions of the design and delivery of the three intervention components (three annual meetings of all hospitals, four rounds of in-hospital workshops and an online community), designed to equip a guiding coalition within each site to identify and address root causes of AMI mortality and improve organisational culture. CONCLUSIONS: This detailed practical description of the intervention may be useful for healthcare practitioners seeking to promote organisational culture change in their own contexts, researchers seeking to compare the results of the intervention with other leadership development and organisational culture change efforts, and healthcare professionals committed to understanding complex interventions across healthcare settings.

Experiences of managerial accountability in Ethiopia's primary healthcare system: a qualitative study.

BACKGROUND: Despite calls for improved accountability in global health systems, and a set of clear and consistent theoretical accountability frameworks, empirical descriptions of how accountability is experienced and enacted in low- and middle- income country (LMIC) settings is limited. Therefore, we sought to characterize how managers at all levels of Ethiopia's primary healthcare system experience accountability in their daily practice. METHODS: We conducted in-depth key informant interviews with 41 key stakeholders across 4 regions (Amhara, Oromia, Southern Nations Nationalities and Peoples, and Tigray) in the context of the Primary Healthcare Transformation Initiative (PTI). Consistent with the principles of grounded theory, our team used the constant comparative method to identify emergent themes related to concrete areas that could be targeted to allow an overall culture of accountability to flourish. RESULTS: Emergent themes were: development of a shared understanding of system-wide accountability, streamlining of managerial reporting lines, strengthening of medico-legal knowledge and systems, and development of mechanisms for bottom-up accountability. CONCLUSIONS: Findings may be valuable to policymakers seeking to create more effective national accountability frameworks; practitioners and development partners seeking to strengthen implementation of evidence-based accountability systems and practices; and researchers aiming to develop meaningful, practical measures of accountability in public health.

Leadership development in complex health systems: a qualitative study.

OBJECTIVE: Leadership is associated with organisational performance in healthcare, including quality, safety and clinical outcomes for patients. Leadership development programmes have proliferated in recent years. Nevertheless, very few have examined participant experiences in depth in order to understand which programmatic aspects they regard as most valuable relative to leadership in increasingly complex systems, or whether and how learnings may sustain over time. Accordingly, we explored experiences of participants in an interdisciplinary leadership development programme using qualitative methods over an extended look-back period. SETTING: Health and social care sectors in the UK. PARTICIPANTS: Key informants from three cohorts of individuals working in leadership roles in health and social care in the UK: 2013/2014, 2015/2016 and 2017/2018. We contacted 32 participants, and 26 completed interviews (81% response rate). PRIMARY AND SECONDARY OUTCOMES: We explored (1) whether and how specific skills and competencies developed during the programme were applied and/or sustained over time, and (2) whether and how the impact of the programme changed as alumni progressed through their career. RESULTS: Three major recurrent themes emerged from participants' experiences: (1) specific features of the programme meaningfully impact professional development at multiple levels; (2) the coupling of a professional network and practical tools allowed participants to address system-wide problems in new ways and (3) participants describe a level of learning that sustained and amplified over time with increased complexity in their work. CONCLUSION: This work highlights specific design characteristics of leadership development programmes that may help promote relevance and impact. Programme learnings can be translated into practice in substantive ways, with potential for the benefits of successful leadership development efforts to amplify, not fade, over time.