Disclosure, transparency, and accountability: a qualitative survey of public sector pharmaceutical committee conflict of interest policies in the World Health Organization South-East Asia Region.

BACKGROUND: Weak governance over public sector pharmaceutical policy and practice limits access to essential medicines, inflates pharmaceutical prices, and wastes scarce health system resources. Pharmaceutical systems are technically complex and involve extensive interactions between the private and public sectors. For members of public sector pharmaceutical committees, relationships with the private sector can result in conflicts of interest, which may introduce commercial biases into decision-making, potentially compromising public health objectives and health system sustainability. We conducted a descriptive, qualitative study of conflict of interest policies and practices in the public pharmaceutical sector in ten countries in the World Health Organization (WHO) South-East Asia Region (SEAR) (Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste) between September 2020 and March 2021. RESULTS: We identified 45 policy and regulatory documents and triangulated documentary data with 21 expert interviews. Key informants articulated very different governance priorities and conflict of interest concerns depending on the features of their country's pharmaceutical industry, market size, and national economic objectives related to the domestic pharmaceutical industry. Public sector pharmaceutical policies and regulations consistently contained provisions for pharmaceutical committee members to disclose relevant interests, but contained little detail about what should be declared, when, and how often, nor whether disclosures are evaluated and by whom. Processes for preventing or managing conflicts of interest were less well developed than those for disclosure except for a few key procurement processes. Where processes for managing conflicts of interest were specified, the dominant strategy was to recuse committee members with a conflict of interest from relevant work. Policies rarely specified that committee members should divest or otherwise be free from conflicts of interest. CONCLUSIONS: Robust processes for conflict of interest prevention and management could ensure the integrity of decision-making and build public trust in pharmaceutical processes to achieve public health objectives. Upstream approaches including supportive legislative frameworks, the creation of oversight bodies, and strengthening regulatory institutions can also contribute to building cultures of transparency, accountability, and trust.

Evaluating implementation effectiveness and sustainability of a maternity waiting homes intervention to improve access to safe delivery in rural Zambia: a mixed-methods protocol.

BACKGROUND: In low-income countries such as Zambia, where maternal mortality rates are persistently high, maternity waiting homes (MWHs) represent one potential strategy to improve access to safe delivery, especially for women living in remote areas. The Maternity Homes Access in Zambia project (MAHMAZ) is evaluating the impact of a MWH model on women's access to safe delivery in rural Zambia. There is a growing need to understand not only the effectiveness of interventions but also the effectiveness of their implementation in order to appropriately interpret outcomes. There is little evidence to guide effective implementation of MWH for both immediate uptake and to promote sustainability in this context. This protocol describes a study that aims to investigate the effectiveness of the implementation of MAHMAZ by not only documenting fidelity but also identifying factors that influence implementation success and affect longer-term sustainability. METHODS: This study will use mixed methods to evaluate the implementation effectiveness and sustainability of the MAHMAZ intervention. In our study, "implementation effectiveness" means to expand beyond measuring fidelity to the MWH model and includes assessing both the adoption and uptake of the model and identifying those factors that facilitate or inhibit uptake. Sustainability is defined as the routine implementation of an intervention after external support has ended. Quantitative methods include extracting data from existing records at the MWHs and health facilities to analyze patterns of utilization, and conducting a routine health facility assessment to determine facility-level factors that may influence MWH implementation and woman-level outcomes. We will also conduct an experience survey with MWH users and apply a checklist to assess fidelity to the MWH model. Qualitative methods include in-depth interviews and focus group discussions with MWH users, community members and other stakeholders. Qualitative data will be analyzed using an integrated framework drawing constructs from the Consolidated Framework for Implementation Research and the Conceptual Framework for Sustainability. DISCUSSION: The findings from this evaluation will be shared with policymakers formulating policy affecting the implementation of MWH and may be used as evidence for programmatic decisions by the government and supporting agencies in deciding to take this model to scale. TRIAL REGISTRATION: NCT02620436, Registered 3 December 2015, Prospectively registered (clinicaltrials.gov; for the overarching quasi-experimental impact study).

Building financial management capacity for community ownership of development initiatives in rural Zambia.

BACKGROUND: Building financial management capacity is increasingly important in low- and middle-income countries to help communities take ownership of development activities. Yet, many community members lack financial knowledge and skills. METHODS: We designed and conducted financial management trainings for 83 members from 10 community groups in rural Zambia. We conducted pre-training and post-training tests and elicited participant feedback. We conducted 28 in-depth interviews over 18 months and reviewed financial records to assess practical application of skills. RESULTS: The training significantly improved knowledge of financial concepts, especially among participants with secondary education. Participants appreciated exercises to contextualize financial concepts within daily life and liked opportunities to learn from peers in small groups. Language barriers were a particular challenge. After trainings, sites successfully adhered to the principles of financial management, discussing the benefits they experienced from practicing accountability, transparency, and accurate recordkeeping. CONCLUSION: Financial management trainings need to be tailored to the background and education level of participants. Trainings should relate financial concepts to more tangible applications and provide time for active learning. On-site mentorship should be considered for a considerable time. This training approach could be used in similar settings to improve community oversight of resources intended to strengthen developmental initiatives.

Effectiveness of community outreach HIV prevention programs in Vietnam: a mixed methods evaluation.

BACKGROUND: In 2014, Vietnam was the first Southeast Asian country to commit to achieving the World Health Organization's 90-90-90 global HIV targets (90% know their HIV status, 90% on sustained treatment, and 90% virally suppressed) by 2020. This pledge represented further confirmation of Vietnam's efforts to respond to the HIV epidemic, one feature of which has been close collaboration with the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Starting in 2004, PEPFAR supported community outreach programs targeting high-risk populations (people who inject drugs, men who have sex with men, and sex workers). To provide early evidence on program impact, in 2007-2008 we conducted a nationwide evaluation of PEPFAR-supported outreach programs in Vietnam. The evaluation focused on assessing program effect on HIV knowledge, high-risk behaviors, and HIV testing among high-risk populations-results relevant to Vietnam's push to meet global HIV goals. METHODS: We used a mixed-methods cross-sectional evaluation design. Data collection encompassed a quantitative survey of 2199 individuals, supplemented by 125 in-depth interviews. Participants were members of high-risk populations who reported recent contact with an outreach worker (intervention group) or no recent contact (comparison group). We assessed differences in HIV knowledge, risky behaviors, and HIV testing between groups, and between high-risk populations. RESULTS: Intervention participants knew significantly more about transmission, prevention, and treatment than comparison participants. We found low levels of injection drug-use-related risk behaviors and little evidence of program impact on such behaviors. In contrast, a significantly smaller proportion of intervention than comparison participants reported risky sexual behaviors generally and within each high-risk population. Intervention participants were also more likely to have undergone HIV testing (76.1% vs. 47.0%, p < 0.0001) and to have received pre-test (78.0% vs. 33.7%, p < 0.0001) and post-test counseling (80.9% vs. 60.5%, p < 0.0001). Interviews supported evidence of high impact of outreach among all high-risk populations. CONCLUSIONS: Outreach programs appear to have reduced risky sexual behaviors and increased use of HIV testing services among high-risk populations in Vietnam. These programs can play a key role in reducing gaps in the HIV care cascade, achieving the global 90-90-90 goals, and creating an AIDS-free generation.

The sustainable development goals as a framework to combat health-sector corruption.

Corruption is diverse in its forms and embedded in health systems worldwide. Health-sector corruption directly impedes progress towards universal health coverage by inhibiting people's access to quality health services and to safe and effective medicines, and undermining systems for financial risk protection. Corruption is also a cross-cutting theme in the United Nations' sustainable development goals (SDGs) which aim to improve population health, promote justice and strong institutions and advance sustainable human development. To address health-sector corruption, we need to identify how it happens, collect evidence on its impact and develop frameworks to assess the potential risks and put in place protective measures. We propose that the SDGs can be leveraged to develop a new approach to anti-corruption governance in the health sector. The aim will be to address coordination across the jurisdictions of different countries and foster partnerships among stakeholders to adopt coherent policies and anti-corruption best practices at all levels. Combating corruption requires a focused and invigorated political will, better advocacy and stronger institutions. There is no single solution to the problem. Nevertheless, a commitment to controlling corruption via the SDGs will better ensure the integrity of global health and human development now and beyond 2030.

La corruption revêt diverses formes et mine les systèmes de santé du monde entier. La corruption dans le secteur de santé entrave directement les progrès en faveur de la couverture sanitaire universelle en empêchant l'accès de la population à des services de santé de qualité et à des médicaments sûrs et efficaces, et en ébranlant les systèmes de protection contre le risque financier. La corruption est également une thématique transversale des objectifs de développement durable (ODD) des Nations Unies, qui visent à améliorer la santé de la population, à promouvoir la justice et des institutions efficaces, et à favoriser le développement humain durable. Pour combattre la corruption dans le secteur de la santé, il est nécessaire de déterminer comment elle se produit, de collecter des données sur son impact et d'élaborer des cadres pour évaluer les risques potentiels et mettre en place des mesures de protection. Nous suggérons de tirer parti des ODD pour développer un nouveau système de gouvernance anticorruption dans le secteur de la santé. L'objectif sera d'assurer la coordination entre les systèmes juridiques des différents pays et d'encourager les partenariats entre les parties prenantes en vue de l'adoption de politiques cohérentes et de pratiques anticorruption exemplaires à tous les niveaux. La lutte contre la corruption exige une volonté politique ciblée et dynamisée, une prise de position renforcée et des institutions plus efficaces. Il n'existe pas de solution unique à ce problème. Néanmoins, un engagement en faveur de la lutte contre la corruption par le biais des ODD permettra de mieux assurer l'intégrité de la santé mondiale et du développement humain jusqu'à 2030 et au-delà.

La corrupción es diversa en sus formas y está incrustada en los sistemas de salud de todo el mundo. La corrupción en el sector de la salud impide directamente el progreso hacia la cobertura universal de la salud al cohibir el acceso de las personas a servicios de salud de calidad y a medicamentos seguros y eficaces, y debilitar los sistemas de protección contra los riesgos financieros. La corrupción es también un tema transversal en los objetivos de desarrollo sostenible (ODS) de las Naciones Unidas, cuyo objetivo es mejorar la salud de la población, promover la justicia y el fortalecimiento de las instituciones y promover el desarrollo humano sostenible. Para hacer frente a la corrupción en el sector de la salud, es necesario identificar cómo se produce, recopilar pruebas de su impacto y desarrollar marcos para evaluar los riesgos potenciales y establecer medidas de protección. Se propone aprovechar los ODS para desarrollar un nuevo enfoque de la gobernanza anticorrupción en el sector de la salud. El objetivo será coordinar las distintas jurisdicciones de los distintos países y fomentar las asociaciones entre las partes interesadas para adoptar políticas coherentes y prácticas óptimas de lucha contra la corrupción a todos los niveles. La lucha contra la corrupción requiere una voluntad política centrada y fortalecida, una mejor promoción y el fortalecimiento de las instituciones. No existe una única solución al problema. Sin embargo, el compromiso de controlar la corrupción a través de los ODS garantizará mejor la integridad de la salud mundial y el desarrollo humano actual y después de 2030.

Increasing transparency and accountability in national pharmaceutical systems.

Access to safe, effective, good-quality medicines can be compromised by poor pharmaceutical system governance. This system is particularly vulnerable to inefficiencies and to losses from corruption, because it involves a complex mix of actors with diverse responsibilities. A high level of transparency and accountability is critical for minimizing opportunities for fraud and leakage. In the past decade, the Good Governance for Medicines programme and the Medicines Transparency Alliance focused on improving accountability in the pharmaceutical system and on reducing its vulnerability to corruption by increasing transparency and encouraging participation by a range of stakeholders. Experience with these two programmes revealed that stakeholders interpreted transparency and accountability in a range of different ways. Moreover, programme implementation and progress assessments were complicated by a lack of clarity about what information should be disclosed by governments and about how greater transparency can strengthen accountability for access to medicines. This article provides a conceptual understanding of how transparency can facilitate accountability for better access to medicines. We identified three categories of information as prerequisites for accountability: (i) standards and commitments; (ii) decisions and results; and (iii) consequences and responsive actions. Examples are provided for each. Conceptual clarity and practical examples of the information needed to ensure accountability can help policy-makers identify the actions required to increase transparency and accountability in their pharmaceutical systems. We also discuss factors that can hinder or facilitate the use of information to hold to account those responsible for improving access to medicines.

L'accès à des médicaments sûrs, efficaces et de bonne qualité peut être compromis par la mauvaise gouvernance du secteur pharmaceutique. Celui-ci est particulièrement exposé aux inefficacités et aux pertes dues à la corruption, du fait qu'il implique un ensemble complexe d'acteurs aux différentes responsabilités. Une grande transparence et l'obligation de rendre des comptes sont indispensables pour minimiser les possibilités de fraude et de fuite. Durant la dernière décennie, le programme de Bonne gouvernance dans le secteur pharmaceutique et l'initiative Medicines Transparency Alliance se sont attachés à améliorer la reddition de comptes dans le secteur pharmaceutique et à réduire la vulnérabilité de ce dernier face à la corruption, en augmentant la transparence et en encourageant la participation de nombreuses parties prenantes. L'expérience de ces deux programmes a révélé que les parties prenantes interprétaient la transparence et la reddition de comptes de différentes manières. En outre, la mise en œuvre des programmes et l'évaluation des progrès ont été compliquées par un manque de clarté quant aux informations que les gouvernements devaient communiquer et à la manière dont une plus grande transparence pouvait renforcer la reddition de comptes et l'accès aux médicaments. Cet article entend expliquer en quoi la transparence peut faciliter la reddition de comptes et améliorer l'accès aux médicaments. Nous avons identifié trois catégories d'informations nécessaires à la reddition de comptes: (i) normes et engagements; (ii) décisions et résultats; (iii) conséquences et mesures réactives. Des exemples sont présentés pour chaque catégorie. Un cadre théorique clair et des exemples pratiques d'informations nécessaires pour assurer la reddition de comptes peuvent aider les responsables politiques à déterminer les actions requises pour augmenter la transparence et la reddition de comptes dans leurs systèmes pharmaceutiques. Nous évoquons aussi les facteurs qui peuvent entraver ou faciliter l'utilisation des informations et engager la responsabilité des personnes chargées d'améliorer l'accès aux médicaments.

El acceso a medicamentos seguros, eficaces y de buena calidad puede verse comprometido por una mala gestión del sistema farmacéutico. Este sistema es particularmente vulnerable a las ineficiencias y a las pérdidas derivadas de la corrupción porque implica una compleja mezcla de distintos participantes con diversas responsabilidades. Un alto nivel de transparencia y responsabilidad es fundamental para minimizar las oportunidades de fraude y filtraciones. En la última década, el programa de Buena Gestión de los Medicamentos y la Alianza para la Transparencia de los Medicamentos se han centrado en mejorar la responsabilidad del sistema farmacéutico y en reducir su vulnerabilidad a la corrupción mediante el aumento de la transparencia y el fomento de la participación de una serie de partes interesadas. La experiencia con estos dos programas reveló que las partes interesadas interpretaban la transparencia y la responsabilidad de diversas maneras. Además, la implementación de los programas y las evaluaciones de progreso se complicaron debido a la falta de claridad sobre la información que deben divulgar los gobiernos y sobre cómo una mayor transparencia puede fortalecer la responsabilidad en el acceso a los medicamentos. Este artículo ofrece una explicación conceptual de cómo la transparencia puede facilitar la responsabilidad para un mejor acceso a los medicamentos. Se han identificado tres categorías de información como requisitos previos a la responsabilidad: (i) normas y compromisos; (ii) decisiones y resultados; y (iii) consecuencias y medidas de respuesta. Se ofrecen ejemplos de todas. La claridad de conceptos y los ejemplos prácticos de la información necesaria para garantizar la responsabilidad pueden ayudar a los responsables políticos a identificar las medidas necesarias para aumentar la transparencia y la responsabilidad en sus sistemas farmacéuticos. También se analizan los factores que dificultan o facilitan el uso de la información para responsabilizar a las personas responsables de mejorar el acceso a los medicamentos.

The influence of quality maternity waiting homes on utilization of facilities for delivery in rural Zambia.

BACKGROUND: Residential accommodation for expectant mothers adjacent to health facilities, known as maternity waiting homes (MWH), is an intervention designed to improve access to skilled deliveries in low-income countries like Zambia where the maternal mortality ratio is estimated at 398 deaths per 100,000 live births. Our study aimed to assess the relationship between MWH quality and the likelihood of facility delivery in Kalomo and Choma Districts in Southern Province, Zambia. METHODS: We systematically assessed and inventoried the functional capacity of all existing MWH using a quantitative facility survey and photographs of the structures. We calculated a composite score and used multivariate regression to quantify MWH quality and its association with the likelihood of facility delivery using household survey data collected on delivery location in Kalomo and Choma Districts from 2011-2013. RESULTS: MWH were generally in poor condition and composite scores varied widely, with a median score of 28.0 and ranging from 12 to 66 out of a possible 75 points. Of the 17,200 total deliveries captured from 2011-2013 in 40 study catchment area facilities, a higher proportion occurred in facilities where there was either a MWH or the health facility provided space for pregnant waiting mothers compared to those with no accommodations (60.7% versus 55.9%, p <0.001). After controlling for confounders including implementation of Saving Mothers Giving Life, a large-scale maternal health systems strengthening program, among women whose catchment area facilities had an MWH, those women with MWHs in their catchment area that were rated medium or high quality had a 95% increase in the odds of facility delivery than those whose catchment area MWHs were of poor quality (OR: 1.95, 95% CI 1.76, 2.16). CONCLUSIONS: Improving both the availability and the quality of MWH represents a potentially useful strategy to increasing facility delivery in rural Zambia. TRIAL REGISTRATION: The Zambia Chlorhexidine Application Trial is registered at Clinical Trials.gov (identifier: NCT01241318).

The disease of corruption: views on how to fight corruption to advance 21st century global health goals.

Corruption has been described as a disease. When corruption infiltrates global health, it can be particularly devastating, threatening hard gained improvements in human and economic development, international security, and population health. Yet, the multifaceted and complex nature of global health corruption makes it extremely difficult to tackle, despite its enormous costs, which have been estimated in the billions of dollars. In this forum article, we asked anti-corruption experts to identify key priority areas that urgently need global attention in order to advance the fight against global health corruption. The views shared by this multidisciplinary group of contributors reveal several fundamental challenges and allow us to explore potential solutions to address the unique risks posed by health-related corruption. Collectively, these perspectives also provide a roadmap that can be used in support of global health anti-corruption efforts in the post-2015 development agenda.

Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments.

BACKGROUND: Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments. METHODS: The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings. RESULTS: OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general. CONCLUSIONS: Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.

Characterizing the role of informal payments in the delivery of pathology and clinical laboratory services.

OBJECTIVES: Informal payments (IPs) are unofficial cash or in-kind payments for goods or services that should be covered by the health care system. They are a common but regressive method of financing health care in low- and lower-middle-income countries (LMICs). This study aims to characterize the prevalence and impact of IPs on pathology and laboratory medicine (PALM) services. METHODS: From September 2021 to September 2022, PALM staff were surveyed about the frequency, determinants, and impacts of IPs in their respective workplaces. RESULTS: In total, 268 responses were received, and 46.6% (125/268) reported experience with IPs. These 125 participants were more likely to work in the public sector and in LMICs. Approximately 65% reported accepting IPs to perform tests or release results. Obtaining faster results was the most commonly perceived reason for patients offering IPs. Overall, participants reported that IPs had more negative than positive impacts on their workplace. CONCLUSIONS: This represents a first step in characterizing IPs within PALM and how this practice may affect access to these services in LMICs. Specifically, the fact that faster turnaround time was the most frequently perceived reason for offering IPs uncovers a potential barrier to improving PALM capacity in these regions.

Learning from the End of the Public-Private Partnership for Lesotho's National Referral Hospital Network.

Background: Public-private partnerships (PPP) are one strategy to finance and deliver healthcare in lower-resourced settings. Lesotho's Queen 'Mamohato Memorial Hospital Integrated Network (QMMH-IN) was sub-Saharan Africa's first and largest integrated healthcare PPP. Objective: We assessed successes and challenges to performance of the QMMH-IN PPP. Methods: We conducted 26 semi-structured interviews among QMMH-IN executive leadership and staff in early 2020. Questions were guided by the WHO Health System Building Blocks Framework. We conducted a thematic analysis. Findings: Facilitators of performance included: 1) PPP leadership commitment to quality improvement supported by protocols, monitoring, and actions; 2) high levels of accountability and discipline; and 3) well-functioning infrastructure, core systems, workflows, and internal referral network. Barriers to performance included: 1) human resource management challenges and 2) broader health system and referral network limitations. Respondents anticipated the collapse of the PPP and suggested better investing in training incoming managerial staff, improving staffing, and expanding QMMH-IN's role as a training facility. Conclusions: The PPP contract was terminated approximately five years before its anticipated end date; in mid-2021 the government of Lesotho assumed management of QMMH-IN. Going forward, the Lesotho government and others making strategic planning decisions should consider fostering a culture of quality improvement and accountability; ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening. Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP. Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system.

Strengthening capacity for AIDS vaccine research: analysis of the Pfizer Global Health Fellows program and the International AIDS Vaccine Initiative.

BACKGROUND: Industry partnerships can help leverage resources to advance HIV/AIDS vaccine research, service delivery, and policy advocacy goals. This often involves capacity building for international and local non-governmental organizations (NGOs). International volunteering is increasingly being used as a capacity building strategy, yet little is known about how corporate volunteers help to improve performance of NGOs in the fight against HIV/AIDS. METHODS: This case study helps to extend our understanding by analyzing how the Pfizer Global Health Fellows (GHF) program helped develop capacity of the International AIDS Vaccine Initiative (IAVI), looking specifically at Fellowship activities in South Africa, Kenya, and Uganda. From 2005-2009, 8 Pfizer GHF worked with IAVI and local research centers to strengthen capacity to conduct and monitor vaccine trials to meet international standards and expand trial activities. Data collection for the case study included review of Fellow job descriptions, online journals, evaluation reports, and interviews with Fellows and IAVI staff. Qualitative methods were used to analyze factors which influenced the process and outcomes of capacity strengthening. RESULTS: Fellows filled critical short-term expert staffing needs at IAVI as well as providing technical assistance and staff development activities. Capacity building included assistance in establishing operating procedures for the start-up period of research centers; training staff in Good Clinical Practice (GCP); developing monitoring capacity (staff and systems) to assure that centers are audit-ready at all times; and strategic planning for data management systems. Factors key to the success of volunteering partnerships included similarities in mission between the corporate and NGO partners, expertise and experience of Fellows, and attitudes of partner organization staff. CONCLUSION: By developing standard operating procedures, ensuring that monitoring and regulatory compliance systems were in place, training African investigators and community members, and engaging in other systems strengthening activities, the GHF program helped IAVI to accelerate vaccine development activities in the field, and to develop the organization's capacity to manage change in the future. Our study suggests that a program of sustained corporate volunteering over several years may increase organizational learning and trust, leading to stronger capacity to advance and achieve NGO goals.

A cost description of the setup costs of community-owned maternity waiting homes in rural Zambia.

Maternity waiting homes (MWHs) are one strategy to improve access to skilled obstetric care in low resource settings such as Zambia. The Maternity Homes Access in Zambia project built 10 MWHs at rural health centers in Zambia for women awaiting delivery and postnatal care (PNC) visits. The objective of this paper is to summarize the costs associated with setup of 10 MWHs, including infrastructure, furnishing, stakeholder engagement, and activities to build the capacity of local communities to govern MWHs. We do not present operational costs after setup was complete. We used a retrospective, top-down program costing approach. We reviewed study documentation to compile planned and actual costs by site. All costs were annuitized using a 3% discount rate and organized by cost categories: (1) Capital: infrastructure and furnishing, and (2) Installation: capacity building activities and stakeholder engagement. We assumed lifespans of 30 years for infrastructure; 5 years for furnishings; and 3 years for installation activities. Annuitized costs were used to estimate cost per night stayed and per visit for delivery and PNC-related stays. We also modeled theoretical utilization and cost scenarios. The average setup cost of one MWH was $85,284 (capital: 76%; installation: 24%). Annuitized setup cost per MWH was USD$12,516 per year. At an observed occupancy rate of 39%, setup cost per visit to the MWH was USD$70, while setup cost per night stayed was USD$6. The cost of stakeholder engagement activities was underbudgeted by half at the beginning of this project.This analysis serves as a planning resource for governments and implementers that are considering MWHs as a component of their overall maternal and child health strategy. Planning considerations should include the annuitized cost, value of capacity building and stakeholder engagement, and that cost per bed night and visit are dependent upon utilization.

Whistleblowing as an anti-corruption strategy in health and pharmaceutical organizations in low- and middle-income countries: a scoping review.

BACKGROUND: Whistleblowing can bring suspected wrongdoing to the attention of someone who is in the position to rectify the problem. Whistleblowing research can help improve effectiveness of anti-corruption efforts in the health sector. OBJECTIVE: The objective of this scoping review is to understand the extent and type of evidence on whistleblowing as an anti-corruption strategy in health and pharmaceutical organisations in low- and middle-income countries (LMICs). METHODS: This scoping review searched the PubMed, Scopus, and EMBASE databases from 2005 to 2020, limited to English language. We also searched websites of multilateral agencies or international non-governmental organisations for policy documents, guidance and reports. Titles and abstracts were screened to remove those where the focus was not on health, pharmaceuticals, whistleblowing, or LMIC context. Articles focused on research misconduct were excluded. Full-text articles were assessed for eligibility on these same criteria. Included sources were analysed thematically, based on five categories including definitions and models; evidence of reporting frequency; factors influencing whistleblowing; cultural context; and outcomes. RESULTS: The review found 22 sources including reports, policies, and guidance documents (12, 55%), news articles (4, 18%), policy analyses/reviews (3, 14%), commentaries (2, 9%), and empirical studies (1, 5%). Most sources described whistleblowing policy and system components such as how whistleblowing is defined, who can report, and how confidentiality is assured. Few articles documented types and frequencies of corruption identified through whistleblowing or factors associated with whistleblowing. Several studies mentioned cultural norms as a potential limitation to whistleblowing effectiveness. About one-third of the sources described fear of retaliation and noted the need to strengthen protection for whistleblowers. CONCLUSION: Research on whistleblowing is scarce in health and pharmaceutical organisations in LMICs. Documentation of policies, factors associated with whistleblowing, and whistleblowing outcomes is needed and could help countries to mainstream whistleblowing as a sectoral anti-corruption strategy.

Using Open Public Meetings and Elections to Promote Inward Transparency and Accountability: Lessons From Zambia.

BACKGROUND: Community-led governance can ensure that leaders are accountable to the populations they serve and strengthen health systems for maternal care. A key aspect of democratic accountability is electing respective governance bodies, in this case community boards, and holding public meetings to inform community members about actions taken on their behalf. After helping build and open 10 maternity waiting homes (MWHs) in rural Zambia as part of a randomized controlled trial, we assisted community governance committees to plan and execute annual meetings to present performance results and, where needed, to elect new board members. METHODS: We applied a principally qualitative design using observation and analysis of written documentation of public meetings to answer our research question: how do governance committees enact inward transparency and demonstrate accountability to their communities. The analysis measured participation and stakeholder representation at public meetings, the types and purposes of accountability sought by community members as evidenced by questions asked of the governance committee, and responsiveness of the governance committee to issues raised at public meetings. RESULTS: Public meetings were attended by 6 out of 7 possible stakeholder groups, and reports were generally transparent. Stakeholders asked probing questions focused mainly on financial performance. Governance committee members were responsive to questions raised by participants, with 59% of answers rated as fully or mostly responsive (showing understanding of and answering the question). Six of the 10 sites held elections to re-elect or replace governance committee members. Only 2 sites reached the target set by local stakeholder committees of 50% female membership, down from 3 at formation. To further improve transparency and accountability, community governance committees need to engage in advance preparation of reports, and should consult with stakeholders on broader measures for performance assessment. Despite receiving training, community-level governance committees lacked understanding of the strategic purpose of open public meetings and elections, and how these relate to democratic accountability. They were therefore not motivated to engage in tactics to manage stakeholders effectively. CONCLUSION: While open meetings and elections have potential to enhance good governance at the community level, continuous training and mentoring are needed to build capacity and enhance sustainability.

Observational study of the clinical performance of a public-private partnership national referral hospital network in Lesotho: Do improvements last over time?

Public-private partnerships (PPP) may increase healthcare quality but lack longitudinal evidence for success. The Queen 'Mamohato Memorial Hospital (QMMH) in Lesotho is one of Africa's first healthcare PPPs. We compare data from 2012 and 2018 on capacity, utilization, quality, and outcomes to understand if early documented successes have been sustained using the same measures over time. In this observational study using administrative and clinical data, we assessed beds, admissions, average length of stay (ALOS), outpatient visits, and patient outcomes. We measured triage time and crash cart stock through direct observation in 2013 and 2020. Operational hospital beds increased from 390 to 410. Admissions decreased (-5.3%) while outpatient visits increased (3.8%). ALOS increased from 5.1 to 6.5 days. Occupancy increased from 82% to 99%; half of the wards had occupancy rates ≥90%, and Neonatal ward occupancy was 209%. The proportion of crash cart stock present (82.9% to 73.8%) and timely triage (84.0% to 27.6%) decreased. While overall mortality decreased (8.0% to 6.5%) and neonatal mortality overall decreased (18.0% to 16.3%), mortality among very low birth weight neonates increased (30.2% to 36.8%). Declines in overall hospital mortality are promising. Yet, continued high occupancy could compromise infection control and impede response to infections, such as COVID-19. High occupancy in the Neonatal ward suggests that the population need for neonatal care outpaces QMMH capacity; improvements should be addressed at the hospital and systemic levels. The increase in ALOS is acceptable for a hospital meant to take the most critical cases. The decline in crash cart stock completeness and timely triage may affect access to emergency treatment. While the partnership itself ended earlier than anticipated, our evaluation suggests that generally the hospital under the PPP was operational, providing high-level, critically needed services, and continued to improve patient outcomes. Quality at QMMH remained substantially higher than at the former Queen Elizabeth II hospital.

Planning for Maternity Waiting Home Bed Capacity: Lessons from Rural Zambia.

Background: Maternity waiting homes (MWH) allow pregnant women to stay in a residential facility close to a health center while awaiting delivery. This approach can improve health outcomes for women and children. Health planners need to consider many factors in deciding the number of beds needed for an MWH. Objective: The objective of the study is to review experience in Zambia in planning and implementing MWHs, and consider lessons learned in determining optimal capacity. Methods: We conducted a study of 10 newly built MWH in Zambia over 12 months. For this case study analysis, data on beds, service volume, and catchment area population were examined, including women staying at the homes, bed occupancy, and average length of stay. We analyzed bed occupancy by location and health facility catchment area size, and categorized occupancy by month from very low to very high. Findings: Most study sites were rural, with 3 of the 10 study sites rural-remote. Four sites served small catchment areas (<9 000), 3 had medium (9 000-11 000), and 3 had large (>11 000) size populations. Annual occupancy was variable among the sites, ranging from 13% (a medium rural site) to 151% (a large rural-remote site). Occupancy higher than 100% was accommodated by repurposing the MWH postnatal beds and using extra mattresses. Most sites had between 26-69% annual occupancy, but monthly occupancy was highly variable for reasons that seem unrelated to catchment area size, rural or rural-remote location. Conclusion: Planning for MWH capacity is difficult due to high variability. Our analysis suggests planners should try to gather actual recent monthly birth data and estimate capacity using the highest expected utilization months, anticipating that facility-based deliveries may increase with introduction of a MWH. Further research is needed to document and share data on MWH operations, including utilization statistics like number of beds, mattresses, occupancy rates and average length of stay.

Out-of-Pocket Expenditures for Delivery for Maternity Waiting Home Users and Non-users in Rural Zambia.

BACKGROUND: Utilizing maternity waiting homes (MWHs) is a strategy to improve access to skilled obstetric care in rural Zambia. However, out-of-pocket (OOP) expenses remain a barrier for many women. We assessed delivery-related expenditure for women who used MWHs and those who did not who delivered at a rural health facility. METHODS: During the endline of an impact evaluation for an MWH intervention, household surveys (n = 826) were conducted with women who delivered a baby in the previous 13 months at a rural health facility and lived >10 km from a health facility in seven districts of rural Zambia. We captured the amount women reported spending on delivery. We compared OOP spending between women who used MWHs and those who did not. Amounts were converted from Zambian kwacha (ZMW) to US dollar (USD). RESULTS: After controlling for confounders, there was no significant difference in delivery-related expenditure between women who used MWHs (US$40.01) and those who did not (US$36.66) (P=.06). Both groups reported baby clothes as the largest expenditure. MWH users reported spending slightly more on accommodation compared to those did not use MWHs, but this difference represents only a fraction of total costs associated with delivery. CONCLUSION: Findings suggest that for women coming from far away, utilizing MWHs while awaiting delivery is not costlier overall than for women who deliver at a health facility but do not utilize a MWH.

Barriers and facilitators to facility-based delivery in rural Zambia: a qualitative study of women's perceptions after implementation of an improved maternity waiting homes intervention.

OBJECTIVES: Women in sub-Saharan Africa face well-documented barriers to facility-based deliveries. An improved maternity waiting homes (MWH) model was implemented in rural Zambia to bring pregnant women closer to facilities for delivery. We qualitatively assessed whether MWHs changed perceived barriers to facility delivery among remote-living women. DESIGN: We administered in-depth interviews (IDIs) to a randomly selected subsample of women in intervention (n=78) and control (n=80) groups who participated in the primary quasi-experimental evaluation of an improved MWH model. The IDIs explored perceptions and preferences of delivery location. We conducted content analysis to understand perceived barriers and facilitators to facility delivery. SETTING AND PARTICIPANTS: Participants lived in villages 10+ km from the health facility and had delivered a baby in the previous 12 months. INTERVENTION: The improved MWH model was implemented at 20 rural health facilities. RESULTS: Over 96% of participants in the intervention arm and 90% in the control arm delivered their last baby at a health facility. Key barriers to facility delivery were distance and transportation, and costs associated with delivery. Facilitators included no user fees, penalties for home delivery, desire for safe delivery and availability of MWHs. Most themes were similar between study arms. Both discussed the role MWHs have in improving access to facility-based delivery. Intervention arm participants expressed that the improved MWH model encourages use and helps overcome the distance barrier. Control arm participants either expressed a desire for an improved MWH model or did not consider it in their decision making. CONCLUSIONS: Even in areas with high facility-based delivery rates in rural Zambia, barriers to access persist. MWHs may be useful to address the distance challenge, but no single intervention is likely to address all barriers experienced by rural, low-resourced populations. MWHs should be considered in a broader systems approach to improving access in remote areas. TRIAL REGISTRATION NUMBER: NCT02620436.

Corruption: An Impediment to Delivering Pathology and Laboratory Services in Resource-Limited Settings.

OBJECTIVES: Corruption is a widely acknowledged problem in the health sector of low- and middle-income countries (LMICs). Yet, little is known about the types of corruption that affect the delivery of pathology and laboratory medicine (PALM) services. This review is a first step at examining corruption risks in PALM. METHODS: We performed a critical review of medical literature focused on health sector corruption in LMICs. To provide context, we categorized cases of laboratory-related fraud and abuse in the United States. RESULTS: Forms of corruption in LMICs that may affect the provision of PALM services include informal payments, absenteeism, theft and diversion, kickbacks, self-referral, and fraudulent billing. CONCLUSIONS: Corruption represents a functional reality in many LMICs and hinders the delivery of services and distribution of resources to which individuals and entities are legally entitled. Further study is needed to estimate the extent of corruption in PALM and develop appropriate anticorruption strategies.