Availability of published evidence on coverage, cost components, and funding support for digitalisation of infectious disease surveillance in Africa, 2003-2022: a systematic review.

BACKGROUND: The implementation of digital disease surveillance systems at national levels in Africa have been challenged by many factors. These include user applicability, utility of IT features but also stable financial support. Funding closely intertwines with implementations in terms of geographical reach, disease focus, and sustainability. However, the practice of evidence sharing on geographical and disease coverage, costs, and funding sources for improving the implementation of these systems on the continent is unclear. OBJECTIVES: To analyse the key characteristics and availability of evidence for implementing digital infectious disease surveillance systems in Africa namely their disease focus, geographical reach, cost reporting, and external funding support. METHODS: We conducted a systematic review of peer-reviewed and grey literature for the period 2003 to 2022 (PROSPERO registration number: CRD42022300849). We searched five databases (PubMed, MEDLINE over Ovid, EMBASE, Web of Science, and Google Scholar) and websites of WHO, Africa CDC, and public health institutes of African countries. We mapped the distribution of projects by country; identified reported implementation cost components; categorised the availability of data on cost components; and identified supporting funding institutions outside Africa. RESULTS: A total of 29 reports from 2,033 search results were eligible for analysis. We identified 27 projects implemented in 13 countries, across 32 sites. Of these, 24 (75%) were pilot projects with a median duration of 16 months, (IQR: 5-40). Of the 27 projects, 5 (19%) were implemented for HIV/AIDs and tuberculosis, 4 (15%) for malaria, 4 (15%) for all notifiable diseases, and 4 (15%) for One Health. We identified 17 cost components across the 29 reports. Of these, 11 (38%) reported quantified costs for start-up capital, 10 (34%) for health personnel compensation, 9 (31%) for training and capacity building, 8 (28%) for software maintenance, and 7(24%) for surveillance data transmission. Of 65 counts of external funding sources, 35 (54%) were governmental agencies, 15 (23%) foundations, and 7 (11%) UN agencies. CONCLUSIONS: The evidence on costing data for the digitalisation of surveillance and outbreak response in the published literature is sparse in quantity, limited in detail, and without a standardised reporting format. Most initial direct project costs are substantially donor dependent, short lived, and thus unsustainable.

Introduction and acceptability of the Surveillance Outbreak Response Management and Analysis System (SORMAS) during the COVID-19 pandemic in Côte d'Ivoire.

BACKGROUND: The Surveillance Outbreak Response Management and Analysis System (SORMAS) has been implemented for various infectious diseases since 2015. 2020, at the beginning of the COVID-19 pandemic, SORMAS was adapted to SARS-CoV2. METHODS: We assessed the acceptability and usability of SORMAS and accompanied its implementation in two pilot regions of Côte d'Ivoire (Abidjan 2 and Gbêkê) from July/August 2021 to March 2022. We conducted 136 semi-structured interviews to cover knowledge on COVID-19, information on conventional surveillance systems for disease monitoring including COVID-19, acceptability of SORMAS, and impact of SORMAS on epidemic preparedness and surveillance. Scores before and 6-8 months after implementation were compared. RESULTS: SORMAS was implemented in two pilot regions in Côte d'Ivoire. The conventional software for the surveillance of the COVID-19 pandemic by the company MAGPI was maintained in parallel; the additional time needs to enter and manage the data in SORMAS were the main concern. SORMAS acceptance and satisfaction scores were high after the user training, which was prior to implementation, and after 6-8 months of use. The ability of SORMAS to improve COVID-19 preparedness and early detection of cases and contacts was widely acknowledged. To keep the understanding and skills of users up-to-date, regular refresher trainings were requested. The expectation to be able to make decisions based on data produced by SORMAS was high at baseline and the perceived experience after several months of use of the software was very positive. Unfortunately, the link with the laboratories could not be established in the pilot regions, but it is an existing feature of SORMAS that many users were asking for. Following the positive experience using SORMAS for COVID-19, the pilot regions expanded its use for monitoring and management of measles, yellow fever, meningitis, and cholera. CONCLUSION: SORMAS was very well accepted by users and decision makers in the two pilot regions of Côte d'Ivoire and its ability to improve epidemic preparedness and surveillance was acknowledged. If the hurdles of maintenance (tablets, server, and maintaining user skills) are handled sustainably, it can serve as a valid tool to identify, surveil and manage future outbreaks of various infectious diseases in Côte d'Ivoire.

What makes health systems resilient? A qualitative analysis of the perspectives of Swiss NGOs.

BACKGROUND: Resilience has become relevant than ever before with the advent of increasing and intensifying shocks on the health system and its amplified effects due to globalization. Using the example of non-state actors based in Switzerland, the aim of this study is to explore how and to what extent NGOs with an interest in global health have dealt with unexpected shocks on the health systems of their partner countries and to reflect on the practical implications of resilience for the multiple actors involved. Consequently, this paper analyses the key attributes of resilience that targeted investments may influence, and the different roles key stakeholders may assume to build resilience. METHODS: This is a descriptive and exploratory qualitative study analysing the perspectives on health system resilience of Swiss-based NGOs through 20 in-depth interviews. Analysis proceeded using a data-driven thematic analysis closely following the framework method. An analytical framework was developed and applied systematically resulting in a complete framework matrix. The results are categorised into the expected role of the governments, the role of the NGOs, and practical future steps for building health system resilience. RESULTS: The following four key 'foundations of resilience' were found to be dominant for unleashing greater resilience attributes regardless of the nature of shocks: 'realigned relationships,' 'foresight,' 'motivation,' and 'emergency preparedness.' The attribute to 'integrate' was shown to be one of the most crucial characteristics of resilience expected of the national governments from the NGOs, which points to the heightened role of governance. Meanwhile, as a key stakeholder group that is becoming inevitably more powerful in international development cooperation and global health governance, non-state actors namely the NGOs saw themselves in a unique position to facilitate knowledge exchange and to support long-term adaptations of innovative solutions that are increasing in demand. The strongest determinant of resilience in the health system was the degree of investments made for building long-term infrastructures and human resource development which are well-functioning prior to any potential crisis. CONCLUSIONS: Health system resilience is a collective endeavour and a result of many stakeholders' consistent and targeted investments. These investments open up new opportunities to seek innovative solutions and to keep diverse actors in global health accountable. The experiences and perspectives of Swiss NGOs in this article highlight the vital role NGOs may play in building resilient health systems in their partner countries. Specifically, strong governance, a bi-directional knowledge exchange, and the focus on leveraging science for impact can draw greater potential of resilience in the health systems. Governments and the NGOs have unique points of contribution in this journey towards resilience and bear the responsibility to support governments to prioritise investing in the key 'foundations of resilience' in order to activate greater attributes of resilience. Resilience building will not only prepare countries for future shocks but bridge the disparate health and development agenda in order to better address the nexus between humanitarian aid and development cooperation.

Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda - lessons from the PERFORM2Scale consortium.

BACKGROUND: Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale's theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature. METHODS: The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations. The reflections were captured in detailed annual reports, on which this article is based. RESULTS: The PERFORM2Scale ToC describes how the management strengthening intervention, which targets district health management teams, was expected to improve health workforce performance and service delivery at scale, and which assumptions were instrumental to track over time. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did (and did not) happen. This helped in strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the annual reflections, these actions and adaptations related to: assessing the scalability of the intervention, documentation and dissemination of evidence about the effects of the intervention, understanding power relationships between key stakeholders, the importance of developing and monitoring a scale-up strategy and identification of opportunities to integrate (parts of) the intervention into existing structures and strategies. CONCLUSIONS: PERFORM2Scale's experience provides lessons for using ToCs to monitor and evaluate the scale-up of health system strengthening interventions. ToCs can help in establishing a common vision on intervention scale-up. ToC-based approaches should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up.

A qualitative study to investigate Swiss hospital personnel's perceived importance of and experiences with patient's mental-somatic multimorbidities.

BACKGROUND: Mental-somatic multimorbidity in general hospital settings is associated with long hospital stays, frequent rehospitalization, and a deterioration of disease course, thus, highlighting the need for treating hospital patients more holistically. However, there are several challenges to overcome to address mental health conditions in these settings. This study investigated hospital personnel's perceived importance of and experiences with mental-somatic multimorbidities of patients in hospital settings in Basel, Switzerland, with special consideration of the differences between physicians and nurses. METHODS: Eighteen semi-structured interviews were conducted with nurses (n = 10) and physicians (n = 8) in different hospitals located in Basel, Switzerland. An inductive approach of the framework analysis was used to develop the themes. RESULTS: Four themes emerged from the data analysis: 1) the relevance of mental-somatic multimorbidity within general hospitals, 2) health professionals managing their emotions towards mental health, 3) knowledge and competencies in treating patients with mental-somatic multimorbidity, and 4) interprofessional collaboration for handling mental-somatic multimorbidity in hospital settings.The mental-somatic multimorbidities in general hospital patients was found to be relevant among all hospital professionals, although the priority of mental health was higher for nurses than for physicians. This might have resulted from different working environments or in efficient interprofessional collaboration in general hospitals. Physicians and nurses both highlighted the difficulties of dealing with stigma, a lack of knowledge of mental disorders, the emphasis place on treating somatic disorders, and competing priorities and work availability, which all hindered the adequate handling of mental-somatic multimorbidity in general hospitals. CONCLUSION: To support health professionals to integrate mental health into their work, proper environments within general hospitals are needed, such as private rooms in which to communicate with patients. In addition, changes in curriculums and continuing training are needed to improve the understanding of mental-somatic multimorbidities and reduce negative stereotypes. Similarly, interprofessional collaboration between health professionals needs to be strengthened to adequately identify and treat mentally multimorbid patients. A stronger focus should be placed on physicians to improve their competencies in considering patient mental health in their daily somatic treatment care.

Insured clients out-of-pocket payments for health care under the national health insurance scheme in Ghana.

BACKGROUND: In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments (OOP) by insured clients is one of such challenges of the scheme. This study sought to examine the types of services OOP charges are made for by insured clients and how much insured clients pay out-of-pocket. METHODS: This was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and the results presented as proportions and means. RESULTS: Of all the survey respondents 49.7% reported paying out-of-pocket for out-patient care while 46.9% of the insured clients paid out-of-pocket. Forty-two percent of the insured poorest quintile also paid out-of-pocket. Insured clients paid for consultation (75%) and drugs (63.2%) while 34.9% purchased drugs outside the health facility they visited. The unavailability of drugs (67.9%) and drugs not covered by the NHIS (20.8%) at the health facility led to out-of-pocket payments. On average, patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Ashanti region, patients living in the Northern region were 74% less at odds to pay out-of-pocket for health care. CONCLUSION AND RECOMMENDATION: Insured clients of Ghana's NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities while the consultation fees are charged to meet the administrative costs of services. These charges occur in disadvantaged regions and in all health facilities. The high reliance on out-of-pocket payments can impede Ghana's progress towards achieving Universal Health Coverage and the Sustainable Development Goal 3, seeking to end poverty and reduce inequalities. In order to build trust and confidence in the NHIS there is the need to eliminate out-of-pocket payments for consultation and medicines by insured clients.

How to bring research evidence into policy? Synthesizing strategies of five research projects in low-and middle-income countries.

BACKGROUND: Addressing the uptake of research findings into policy-making is increasingly important for researchers who ultimately seek to contribute to improved health outcomes. The aims of the Swiss Programme for Research on Global Issues for Development (r4d Programme) initiated by the Swiss National Science Foundation and the Swiss Agency for Development and Cooperation are to create and disseminate knowledge that supports policy changes in the context of the 2030 Agenda for Sustainable Development. This paper reports on five r4d research projects and shows how researchers engage with various stakeholders, including policy-makers, in order to assure uptake of the research results. METHODS: Eleven in-depth interviews were conducted with principal investigators and their research partners from five r4d projects, using a semi-structured interview guide. The interviews explored the process of how stakeholders and policy-makers were engaged in the research project. RESULTS: Three key strategies were identified as fostering research uptake into policies and practices: (S1) stakeholders directly engaged with and sought evidence from researchers; (S2) stakeholders were involved in the design and throughout the implementation of the research project; and (S3) stakeholders engaged in participatory and transdisciplinary research approaches to coproduce knowledge and inform policy. In the first strategy, research evidence was directly taken up by international stakeholders as they were actively seeking new evidence on a very specific topic to up-date international guidelines. In the second strategy, examples from two r4d projects show that collaboration with stakeholders from early on in the projects increased the likelihood of translating research into policy, but that the latter was more effective in a supportive and stable policy environment. The third strategy adopted by two other r4d projects demonstrates the benefits of promoting colearning as a way to address potential power dynamics and working effectively across the local policy landscape through robust research partnerships. CONCLUSIONS: This paper provides insights into the different strategies that facilitate collaboration and communication between stakeholders, including policy-makers, and researchers. However, it remains necessary to increase our understanding of the interests and motivations of the different actors involved in the process of influencing policy, identify clear policy-influencing objectives and provide more institutional support to engage in this complex and time-intensive process.

Incorporating operational research in programmes funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria in four sub-Saharan African countries.

BACKGROUND: The current study builds upon a previous situation analysis of the extent to which grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) are being utilized to support operational research and implementation research (OR/IR) activities in recipient countries. The objective of this follow-up study was to identify approaches and pathways to implement an OR component into grants to the Global Fund, in four sub-Saharan African countries. Special focus was given to the Structured Operational Research and Training IniTiative (SORT IT). METHODS: The conceptual framework was based on an analysis to identify elements supporting and blocking the integration of OR, called force field analysis, and a behavioural change assessment covering aspects such as opportunity, motivation, capability and triggers to do the integration. Data were collected through online surveys and stakeholder interviews both via telephone/online conference tools and in person in four countries with a high burden of malaria and tuberculosis. These countries were Ghana, Sierra Leone, the United Republic of Tanzania and Zimbabwe. The stakeholders included programme managers, implementation partners, representatives from international organisations, academic and governmental research institutions and other individuals involved in the countries' needs assessment and National Strategic Plan development. RESULTS: We identified opportunities to integrate OR into the countries' programmes during the funding process, the country's needs assessment being the most important one, including the need of OR-related capacity. Both the force field analysis and the behavioural change assessment showed that the necessary elements to integrate OR were present in the countries. Motivation, capability and efficiency were found to be a managerial value omnipresent across stakeholders. However, those elements were influenced by the tendency to favour tangible assets over any abstract ones, such as increasing organisational capacity in OR. CONCLUSIONS: In each of the countries assessed, there is potential to integrating OR into the programmes supported by the Global Fund. However, given the relative lack of OR-related capacity and skills encountered, a capacity strengthening tool, such as SORT IT, would be of benefit helping to identify and carry forward OR activities sustainably.

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system.

BACKGROUND: The Philippines decentralized government health services through devolution to local governments in 1992. Over the years, opinions varied on the impact of devolved governance to decision-making for local health services. The objective of this study was to analyze decision-makers' perspectives on who should be making decisions for local health services and on their preferred structure of health service governance should they be able to change the situation. METHODS: We employed a mixed methods approach that included an online survey in one region and in-depth interviews with purposively-selected decision-makers in the Philippine health system. Study participants were asked about their perspectives on decision-making in the functions of planning, health financing, resource management, human resources for health, health service delivery, and data management and monitoring. Analysis of survey results through visualization of data on charts was complemented by the themes that emerged from the qualitative analysis of in-depth interviews based on the Framework Method. RESULTS: We received 24 online survey responses and interviewed 27 other decision-makers. Survey respondents expressed a preference to shift decision-making away from the local politician in favor of the local health officer in five functions. Most survey participants also preferred re-centralization. Analysis of the interviews suggested that the preferences expressed were likely driven by an expectation that re-centralization would provide a solution to the perceived politicization in decision-making and the reliance of local governments on central support. CONCLUSIONS: Rather than re-centralize the health system, one policy option for consideration for the Philippines would be to maintain devolution but with a revitalized role for the central level to maintain oversight over local governments and regulate their decision-making for the functions. Decentralization, whether in the Philippines or elsewhere, must not only transfer decision-making responsibility to local levels but also ensure that those granted with the decision space could perform decision-making with adequate capacities and could grasp the importance of health services.

Policy levers and priority-setting in universal health coverage: a qualitative analysis of healthcare financing agenda setting in Kenya.

BACKGROUND: Competing priorities in health systems necessitate difficult choices on which health actions and investments to fund: decisions that are complex, value-based, and highly political. In light of the centrality of universal health coverage (UHC) in driving current health policy, we sought to examine the value interests that influence agenda setting in the country's health financing space. Given the plurality of Kenya's health policy levers, we aimed to examine how the perspectives of stakeholders involved in policy decision-making and implementation shape discussions on health financing within the UHC framework. METHODS: A series of in-depth key informant interviews were conducted at national and county level (n = 13) between April and May 2018. Final thematic analysis using the Framework Method was conducted to identify similarities and differences amongst stakeholders on the challenges hindering Kenya's achievement of UHC in terms of its the optimisation of health service coverage; expansion of the population that benefits from essential healthcare services; and the minimisation of out-of-pocket costs associated with health-seeking behaviour. RESULTS: Our findings indicate that the perceived lack of strategic leadership from Kenya's national government has led to a lack of agreement on stakeholders' interpretation of what is to be understood by UHC, its contextual values and priorities. We observe material differences between and within policy networks on the country's priorities for population coverage, healthcare service provision, and cost-sharing under the UHC dispensation. In spite of this, we note that progressive universalism is considered as the preferred approach towards UHC in Kenya, with most interviewees prioritising an equity-based approach that prioritises better access to healthcare services and financial risk protection. However, the conflicting priorities of key stakeholders risk derailing progress towards the expansion of access to health services and financial risk protection. CONCLUSIONS: This study adds to existing knowledge of UHC in Kenya by contextualising the competing and evolving priorities that should be taken into consideration as the country strategises over its UHC process. We suggest that clear policy action is required from national government and county governments in order to develop a logical and consistent approach towards UHC in Kenya.

Out of pocket expenditures of patients with a chronic condition consulting a primary care provider in Tajikistan: a cross-sectional household survey.

BACKGROUND: Within its reform efforts, the Government of Tajikistan is embracing the essential role of primary health care (PHC) in decreasing out of pocket (OOP) expenditures and increasing equity in access to health services. In the light of the increasing burden of disease relating to chronic conditions, we investigated OOP expenditures of patients with chronic conditions within a PHC setting; and if and how those expenditures are impacted by several interventions currently being implemented within Tajikistan. METHODS: A cross-sectional survey among 1600 adult patients who had visited a PHC facility was conducted. The data obtained through interviews were descriptively analysed, and logistic regressions and gamma generalized linear models were performed. RESULTS: The total OOP expenditures related to a patient's last visit to the PHC facility were 17.2 USD for those with chronic conditions and 13.9 USD for those visiting due to an acute condition. Adjustment for potential confounders reduced the discrepancy from 3.3 USD to 0.5 USD. This convergence of costs was only observed in districts covered by the Basic Benefit Package (BBP), a governmental pilot project, aiming to standardise exemptions for payment and formal co-payments for health care services. Hence, we found the BBP to have a protective impact for patients with chronic conditions. However, considering the demographics of these patients (older in age, with greater dependency on pensions and social aid, and lower socio-economic status) in combination with the 40% higher utilisation rate of PHC and the high rate of onward referrals to specialists; it is clear that patients with chronic conditions continue to face substantial long-term costs and disadvantages. CONCLUSIONS: After accounting for confounders, patients with chronic and acute conditions faced similar costs related to a single visit to a PHC facility in districts covered by the BBP. However, greater efforts are required to ensure that citizens are well informed about their rights to health care, the BBP and the services that should be provided at no cost at the point of delivery. Moreover, the needs of patients with chronic conditions warrant a more integrative approach that takes long-term expenditures and services beyond the level of PHC into account.

Assessing the effects of the nursing education reform on the educational environment in Tajikistan: a repeated cross-sectional analysis.

BACKGROUND: A well-functioning education system for family nurses is a priority of the primary health care reform in Tajikistan. In 2015/2016, a baseline study was carried out to measure the educational environment at two nursing colleges, in Kulob and Dushanbe. Building on the study's recommendations, the educational reform has addressed several key issues to improve the educational environment among nursing students with a focus on strengthening competency-based learning and clinical skills. A follow-up study was carried out in late 2018 to comparatively analyse progress in the educational environment against the baseline and assess potential impacts of tailored interventions. METHOD: A repeated cross-sectional survey involving 1239 students was applied to measure changes in the educational environment between 2015/2016 (baseline) and 2018 (endline) using the Dundee Ready Education Environment Measure (DREEM). We compared mean scores over time using Welch's two sample t-test and the Wilcoxon-Mann-Whitney test. Single items have additionally been analysed using critical threshold (flags) for mean scores, and the percentage of answers falling above or below predefined values. A multivariate non-parametric regression was applied to control for confounding factors. Internal consistency was examined using Cronbach's α. RESULTS: Cronbach's α for overall scores ranged between 0.87 and 0.89. Between 2015/2016 and 2018 the perceived educational environment improved with an increase of the mean total DREEM score from 131.8 to 146.9 in Dushanbe and from 134.9 to 151.2 in Kulob. Mean comparisons and multivariate regression revealed a significant increase of all sub-scores between 2015/2016 and 2018 with students' social self-perception exhibiting the smallest progress. Despite the general improvements observed, analysis at the level of single items revealed persistent weaknesses including a lack of competency-based learning and stress. CONCLUSIONS: The education environment has improved in several important ways between 2015/2016 and 2018 which points to a likely positive contribution of the nursing education reform. This progress notwithstanding, there is still notable room for further improvement. Targeted efforts aimed at a better organization of practical trainings, improved didactical competences of teachers, and support structures for lonely and stressed students still seem to be lacking for the achievement of a good nursing education system in Tajikistan.

Nutritional status of Tajik children and women: Transition towards a double burden of malnutrition.

The double burden of malnutrition, an emerging concern in developing countries, can exist at various levels: individual, household, and population. Here, we explore the nutritional status of Tajik women (15-49 years) and children (5-59 months) focusing on overweight/obesity along with undernutrition (underweight, stunting, and micronutrient deficiencies). For this, nutritional markers (haemoglobin (Hb), transferrin receptor (TfR), serum ferritin (Sf), retinol binding protein (RBP), vitamin D, serum folate, and urinary iodine), height, and weight were assessed from 2,145 women and 2,149 children. Dietary intake, weaning, and breastfeeding habits were recorded using a 24-hr recall and a questionnaire. Overweight (24.5%) and obesity (13.0%) are increasing among Tajik women compared with previous national surveys (2003 and 2009). Prevalence of iron deficiency and anaemia was 38.0% and 25.8%, respectively; 64.5% of women were iodine deficient, 46.5% vitamin A deficient, and 20.5% had insufficient folate levels. Women in rural areas had significantly lower iron status and body mass index and higher iodine intake compared with urban areas; 20.9% of children were stunted, 2.8% wasted, 6.2% underweight, 52.4% iron deficient, and 25.8% anaemic; all more prominent in rural areas. Dietary diversity was higher among urban women. Intraindividual or household double burden was not seen. In summary, double burden of malnutrition constituted an increase in overweight among women, especially in urban areas, and persisting levels of undernutrition (stunting, iron, and vitamin A deficiency), predominately in rural areas. A holistic, innovative approach is needed to improve infant and young children feeding and advise mothers to maintain an adequate diet.

Optimising decentralisation for the health sector by exploring the synergy of decision space, capacity and accountability: insights from the Philippines.

BACKGROUND: Several studies on decentralisation have used the 'decision space' approach to assess the breadth of space made available to decision-makers at lower levels of the health system. However, in order to better understand how decentralisation becomes effective for the health sector, analysis should go beyond assessing decision space and include the dimensions of capacity and accountability. Building on Bossert's earlier work on the synergy of these dimensions, we analysed decision-making in the Philippines where governmental health services have been devolved to local governments since 1992. METHODS: Using a qualitative research design, we interviewed 27 key decision-makers at different levels of the Philippine health system and representing various local settings. We explored their perspectives on decision space, capacities and accountability in the health sector functions of planning, financing and budget allocation, programme implementation and service delivery, management of facilities, equipment and supplies, health workforce management, and data monitoring and utilisation. Analysis followed the Framework Method. RESULTS: Across all functions, decision space for local decision-makers was assessed to be moderate or narrow despite 25 years of devolution. To improve decision-making in these functions, adjustments in local capacities should include, at the individual level, skills for strategic planning, management, priority-setting, evidence-informed policy-making and innovation in service delivery. At institutional levels, these desired capacities should include having a multi-stakeholder approach, generating revenues from local sources, partnering with the private sector and facilitating cooperation between local health facilities. On the other hand, adjustments in accountability should focus on the various mechanisms that can be enforced by the central level, not only to build the desired capacities and augment the inadequacies at local levels, but also to incentivise success and regulate failure by the local governments in performing the functions transferred to them. CONCLUSION: To optimise decentralisation for the health sector, widening decision spaces for local decision-makers must be accompanied by the corresponding adjustments in capacities and accountability for promoting good decision-making at lower levels in the decentralised functions. Analysing the health system through the lens of this synergy is useful for exploring concrete policy adjustments in the Philippines as well as in other settings.

Informing the medical education reform in Tajikistan: evidence on the learning environment at two nursing colleges.

BACKGROUND: The Tajik medical education system is undergoing a complex reform to enhance the transition of the healthcare system from its soviet legacy of emphasizing secondary level care/specialisation to become more family medicine and primary health care oriented. The current study presents the first empirical evaluation of the educational environment for nursing students in Tajikistan using the Dundee Ready Educational Environment Measure (DREEM). The study results contribute to the benchmarking efforts of monitoring and positively steering the educational environment over time. METHOD: The study was based on a cross-sectional survey involving 630 nursing students at two nursing colleges in Tajikistan. Students' perception of the learning environment was measured using the DREEM. Internal consistency was examined using Cronbach's alpha. General scores were calculated and measured against international benchmarks. Data was further interpreted by comparing DREEM scores between students of different sex, at different colleges and different study years using T tests. RESULTS: Cronbach's alpha ranged from 0.30 to 0.75 with an overall alpha of 0.89. General DREEM scores were slightly above average compared to similar studies with nursing students in other countries. In particular, results showed that students' academic self-perception and teachers' technical competences were generally favourably rated. Teachers' pedagogical skills were critically perceived by the study participants and teaching was generally viewed as too teacher-centred with an over-emphasis on factual learning. CONCLUSIONS: Statistical results indicated acceptable levels of reliability of the DREEM tool when applied to the Tajik nursing educational context. Students rated the learning environment as generally satisfactory with average scores similar or slightly higher than comparable scores from similar studies involving nursing students. However, the on-going educational reform could have placed more emphasis on developing faculty pedagogical skills in nursing schools. Teaching approaches would benefit from being more competency based rather than so heavily focused on factual knowledge.

How does membership in local savings groups influence the determinants of national health insurance demand? A cross-sectional study in Kisumu, Kenya.

BACKGROUND: Rotating savings and credit associations (ROSCAs) are highly active in many sub-Saharan African countries, serving as an important gateway for coping with financial risk. In light of the Kenya's National Hospital Insurance Fund's (NHIF's) strategy of targeting ROSCAs for membership enrolment, this study sought to estimate how ROSCA membership influences the determinants of voluntary health insurance enrolment. METHODS: A cross-sectional survey of 444 households was carried out in Kisumu City between July and August 2016. A structured questionnaire was administered on health insurance membership, household attributes, headship characteristics and health-seeking behaviour. We assessed the influence of ROSCA membership on the associations between NHIF enrolment and the explanatory variables using univariate logistic regression. RESULTS: The study found that education was associated with NHIF demand regardless of ROSCA membership. Both ROSCA and non-ROSCA households with high socioeconomic status showed stronger health insurance demand compared with poorer households; there was, however, no evidence that the strength of this association was influenced by ROSCA status (p-value = 0.47). Participants who were self-employed were significantly less likely to enrol into the NHIF if they did not belong to a ROSCA (interaction test p-value = 0.03). NHIF enrolment was found to be lower among female-headed households. There was a borderline effect of ROSCA membership on this association, with a lower odds ratio amongst non-ROSCA members (p-value = 0.09): the low treatment numbers amongst the insured infers that ROSCA membership may play a role on the association between gender and NHIF demand. CONCLUSIONS: Our findings suggest that ROSCA membership may play a role in increasing health insurance demand amongst some traditionally under-represented groups such as women and the self-employed. However, the strategy of targeting ROSCAs to increase national health insurance enrolment may yield exiguous results, given that ROSCA membership is itself influenced by several non-observable factors - such as time-availability and self-selection. It is therefore important to anchor outreach to ROSCAs within a broader, multi-pronged approach that targets households within their social, economic and political realities.

Strategies to improve the medical device life cycle in Mexico.

OBJECTIVE: To analyze the role of stakeholders to three alternative strategies to improve processes and practices regarding the regulation, assessment, and management of orthopaedic medical devices in Mexico. MATERIALS AND METHODS: The study was based on document analysis and 17 structured interviews with multiple key actors within the Mexican health system to inform a stakeholder analysis aiming at assessing the political feasibility of these strategies. RESULTS: Central level government agencies, those with a relation to quality of care, were identified as most relevant stakeholders to influence the adaption and application of the strategies. Major barriers identified are financial and human resources, and organisational culture towards reform. CONCLUSIONS: Discussed strategies are political feasible. However, solving identified barriers is crucial to achieve changes directed to improve outputs and outcomes of medical device life cycle and positively influence the quality of health care and the health system's performance.

Operational and implementation research within Global Fund to Fight AIDS, Tuberculosis and Malaria grants: a situation analysis in six countries.

BACKGROUND: Operational/implementation research (OR/IR) is a key activity to improve disease control programme performance. We assessed the extent to which malaria and tuberculosis (TB) grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria ("Global Fund") include support for OR/IR, and discuss the implications of the current Global Fund operating mechanisms for OR/IR support. METHODS: The situation analysis focussed on malaria and TB, while HIV was excluded. Stakeholder interviews were conducted at the Global Fund secretariat and in six purposefully selected high disease burden countries, namely the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Myanmar and Zimbabwe. Interviewed in-country stakeholders included the relevant disease control programme managers, project implementation partners, representatives from international organisations with a stake in global health, academic and governmental research institutions, and other relevant individuals such as members of the country coordination mechanism. Additionally, documentation of grants and OR/IR obtained from the Global Fund was reviewed. RESULTS: The Global Fund provides substantial resources for malaria and TB surveys, and supports OR/IR if such support is requested and the application is well justified. We observed considerable variations from one country to another and between programmes with regards to need, demand, absorption capacity and funding for OR/IR related to malaria and TB. Important determinants for the extent of such funding are the involvement of national research coordination bodies, established research agendas and priorities, human and technical research capacity, and involvement of relevant stakeholders in concept note development. Efforts to disseminate OR/IR findings were generally weak, and the Global Fund does not maintain a central OR/IR database. When faced with a need to choose between procurement of commodities for disease control and supporting research, countries tend to seek research funding from other donors. The Global Fund is expected to issue more specific guidance on the conditions under which it supports OR/IR, and to adapt administrative procedures to facilitate research. CONCLUSIONS: The importance of OR/IR for optimising disease control programmes is generally accepted but countries vary in their capacity to demand and implement studies. Countries expect guidance on OR/IR from the Global Fund. Administrative procedures specifically related to the budget planning should be modified to facilitate ad-hoc OR/IR funding. More generally, several countries expressed a need to strengthen capacity for planning, negotiating and implementing research.

ATTITUDES OF ORTHOPEDIC SPECIALISTS TOWARD EFFECTS OF MEDICAL DEVICE PURCHASING.

OBJECTIVES: The aim of this study was to assess viewpoints of end-users concerning the purchasing process of high-risk medical devices and to discuss the relevance of health technology assessments (HTAs) at the hospital level and other potential areas for improvement of purchasing processes. METHODS: We used a cross-sectional study and assessed the attitudes and thoughts of orthopedic specialists. The study took place between June and October 2015 in Mexico. RESULTS: We collected data from 187 orthopedic surgeons. Involvement of orthopedic specialists in purchasing was reported by 86 percent. However, clinical practice was perceived as negatively influenced by purchasing outcomes by 92 percent. The problems were described as: material failure; effectiveness of medical devices; obsolete medical device technology; incomplete provision of implant / instrument sets; delayed provision of implants and instruments. CONCLUSIONS: To prevent sub-standard outcomes of purchasing decisions, this study and the current literature suggest that technologies should be assessed during the purchasing process, end-users should be adequately involved, and decisions should be based on multiple criteria including clinical impact in the short-term (e.g., primary stability of implant) and long-term (e.g., survival of implant). The focus on Mexico is particularly novel and provides insights into a health system where HTA is mainly present at the macro level and can be used for the listing of medical device technologies in the standard list. This study concludes that Mexican stakeholders of the purchasing process underestimate the contribution of HTAs at the level of purchasing decisions. HTA in Mexico has improved over the past years but still requires more advancement.

Factors influencing the work efficiency of district health managers in low-resource settings: a qualitative study in Ghana.

BACKGROUND: There is increasing evidence that good district management practices can improve health system performance and conversely, that poor and inefficient management practices have detrimental effects. The aim of the present study was to identify factors contributing to inefficient management practices of district health managers and ways to improve their overall efficiency. METHODS: Nineteen semi-structured interviews were conducted with district health managers in three districts of the Eastern Region in Ghana. The 19 interviews conducted comprised 90% of the managerial workforce in these districts in 2013. A thematic analysis was carried out using the WHO's leadership and management strengthening framework to structure the results. RESULTS: Key factors for inefficient district health management practices were identified to be: human resource shortages, inadequate planning and communication skills, financial constraints, and a narrow decision space that constrains the authority of district health managers and their ability to influence decision-making. Strategies that may improve managerial efficiency at both an individual and organizational level included improvements to planning, communication, and time management skills, and ensuring the timely release of district funds. CONCLUSIONS: Filling District Health Management Team vacancies, developing leadership and management skills of district health managers, ensuring a better flow of district funds, and delegating more authority to the districts seems to be a promising intervention package, which may result in better and more efficient management practices and stronger health system performance.