The politics and practice of initiating a public health postgraduate programme in three universities in sub-Saharan Africa: the challenges of alignment and coherence.

BACKGROUND: In-country postgraduate training programme in low and middle income countries are widely considered to strengthen institutional and national capacity. There exists dearth of research about how new training initiatives in public health training institutions come about. This paper examines a south-south collaborative initiative wherein three universities based in Ethiopia, Rwanda and Mozambique set out to develop a local based postgraduate programme on health workforce development/management through partnership with a university in South Africa. METHODS: We used a qualitative case study design. We conducted semi-structured interviews with 36 key informants, who were purposively recruited based on their association or proximity to the programme, and their involvement in the development, review, approval and implementation of the programme. We gathered supplementary data through document reviews and observation. Thematic analysis was used and themes were generated inductively from the data and deductively from literature on capacity development. RESULTS: University A successfully initiated a postgraduate training programme in health workforce development/management. University B and C faced multiple challenges to embed the programme. It was evident that multiple actors underpin programme introduction across institutions, characterized by contestations over issues of programme feasibility, relevance, or need. A daunting challenge in this regard is establishing coherence between health ministries' expectation to roll out training programmes that meet national health priorities and ensure sustainability, and universities and academics' expectations for investment or financial incentive. Programme champions, located in the universities, can be key actors in building such coherence, if they are committed and received sustained support. The south-south initiative also suffers from lack of long term and adequate support. CONCLUSIONS: Against the background of very limited human capacity and competition for this capacity, initiating the postgraduate programme on health workforce development/management proved to be a political as much as a technical undertaking influenced by multiple actors vying for recognition or benefits, and influence over issues of programme feasibility, relevance or need. Critical in the success of the initiative was alignment and coherence among actors, health ministries and universities in particular, and how well programme champions are able to garner support for and ownership of programme locally. The paper argues that coherence and alignment are crucial to embed programmes, yet hard to achieve when capacity and resources are limited and contested.

Determinants of effective organisational capacity training: lessons from a training programme on health workforce development with participants from three African countries.

BACKGROUND: Health systems in sub-Saharan Africa face multifaceted capacity challenges to fulfil their mandates of service provision and governance of their resources. Four academic institutions in Africa implemented a World Health Organisation-funded collaborative project encompassing training, curriculum development, and partnership to strengthen national leadership and training capacity for health workforce development. This paper looks into the training component of the project, a blended Masters programme in public health that sought to improve the capacity of personnel involved in teaching or management/development of human resources for health. The paper aims to explore factors influencing contribution of training to organisational capacity development. METHODS: We chose a case study design. Semi-structured interviews were held with 18 trainees that were enrolled in the training programme, and who were affiliated to health ministries or public health training institutions. We gathered additional data through document reviews, observation, and interviews with 14 key informants associated with the programme and/or working in the collaborating institutions. The evidence gathered were analysed thematically. RESULTS: Thirteen of the 18 training participants stayed in the target institutions and contributed to improved capacity of their institutions in the fields of management, policy, planning, research, training, or curriculum development. Five left for private and international agencies due to dissatisfaction with payment, work conditions, or career prospect. Factors that were associated with the training, trainees, and the institutional and broader context, determine contribution of training to organisational capacity development. These include relevance of newly acquired knowledge and skills set of trainees to the role/position they assume in the organisation; recognition of trainees by employing organisations in terms of promotion or assignment of challenging tasks; and motivation and retention of trained staff. CONCLUSION: Training, even if relevant and applicable, makes no more than a 'latent' contribution, one which is activated and realised through alignment of clusters of interacting contextual and relational factors related to the target institutions and trained personnel. While not predictable, implementers need to focus more deliberately on the likely interaction and best possible alignments between training relevance, student selection for potential to contribute, recognition and career advancement potential.

Health needs, health care seeking behaviour, and utilization of health services among lesbians, gays and bisexuals in Addis Ababa, Ethiopia.

BACKGROUND: Studies show that sexual and gender minorities have unique health care needs and encounter complicated problems to access health services. Drawing on the intersectionality approach, this paper examines the intersecting factors that determine health care seeking behaviour and utilization of health care services among Lesbians, Gays and Bisexuals (LGB) in Ethiopia including the diversity in experiences of these determinants and differences in the coping mechanisms to navigate these challenges within the LGB group. Despite the importance, there remains a paucity of evidence on the topic in Ethiopia. METHODS: A concurrent mixed method design was used including survey of 100 LGB, and in-depth interviews and an FGD with 10 and 8 participants, each respectively. The quantitative data was analysed using descriptive statistics. Qualitative data was analysed thematically and triangulated with quantitative data. RESULTS: The results show that heteronormativity intersects with LGB's social position (sexual identity, social network and class) to influence health care need, health seeking behaviour or access to health services. Sexual health and mental health problems are main concerns of LGB, who reported to live under acute anxiety and fear of being exposed, or bringing shame and humiliation to themselves or their families. One of the main emerging themes from the research is the link between mental health and risky sexual practices. Risk perception to HIV was high among LGB, with two-thirds reporting high risk. Only 37.5% (33/88) stated being always motivated to seek care when sick and the rest cited the following barriers that stifled their health seeking behaviour and utilization of health care services: Stigma and discrimination (83%), shame and embarrassment (83%), fear of being discovered (78%), lack of LGB friendly services (45%), affordability (18%), distance (17%), and health care professional refusal (10%). CONCLUSION: Homophobia and criminalization of homosexuality, and heteronormativity of health care services intersect with LGB's social position resulting in heterogeneity of risk, diversity of sexual and mental health needs, and difference in coping mechanisms (disadvantages and privilege). The main implication of the study is the need to recognize the existence of LGB and their diverse sexual and mental health needs, and link them to appropriate health care and pyscho-social services including HIV/AIDS prevention and treatment.

Exploring multiple job holding practices of academics in public health training institutions from three sub-Saharan Africa countries: drivers, impact, and regulation.

BACKGROUND: The paper examines external multiple job holding practices in public health training institutions based in prominent public universities in three sub-Saharan Africa countries (Rwanda, Ethiopia, Mozambique). OBJECTIVE: The study aims to contribute to broadening understanding about multiple job holding (nature and scale, drivers and reasons, impact, and efforts to regulate) in public health training schools in public universities. METHODS: A qualitative multiple case study approach was used. Data were collected through document reviews and in-depth interviews with 18 key informants. Data were then triangulated and analyzed thematically. RESULTS: External multiple job holding practices among faculty of the three public health training institutions were widely prevalent. Different factors at individual, institutional, and national levels were reported to underlie and mediate the practice. While it evidently contributes to increasing income of academics, which many described as enabling their continuing employment in the public sector, many pointed to the negative effects as well. Similarities were found regarding the nature and drivers of the practice across the institutions, but differences exist with respect to mechanisms for and extent of regulation. Regulatory mechanisms were often not clear or enforced, and academics are often left to self-regulate their engagement. Lack of regulation has been cited as allowing excessive engagement in multiple job holding practice among academics at the expense of their core institutional responsibility. This could further weaken institutional capacity and performance, and quality of training and support to students. CONCLUSION: The research describes the complexity of external multiple job holding practice, which is characterized by a cluster of drivers, multiple processes and actors, and lack of consensus about its implication for individual and institutional capacity. In the absence of a strong accountability mechanism, the practice could perpetuate and aggravate the fledgling capacity of public health training institutions.

Building capacity to develop an African teaching platform on health workforce development: a collaborative initiative of universities from four sub Saharan countries.

INTRODUCTION: Health systems in many low-income countries remain fragile, and the record of human resource planning and management in Ministries of Health very uneven. Public health training institutions face the dual challenge of building human resources capacity in ministries and health services while alleviating and improving their own capacity constraints. This paper reports on an initiative aimed at addressing this dual challenge through the development and implementation of a joint Masters in Public Health (MPH) programme with a focus on health workforce development by four academic institutions from East and Southern Africa and the building of a joint teaching platform. METHODS: Data were obtained through interviews and group discussions with stakeholders, direct and participant observations, and reviews of publications and project documents. Data were analysed using thematic analysis. CASE DESCRIPTION: The institutions developed and collaboratively implemented a 'Masters Degree programme with a focus on health workforce development'. It was geared towards strengthening the leadership capacity of Health ministries to develop expertise in health human resources (HRH) planning and management, and simultaneously build capacity of faculty in curriculum development and innovative educational practices to teach health workforce development. The initiative was configured to facilitate sharing of experience and resources. DISCUSSION: The implementation of this initiative has been complex, straddling multiple and changing contexts, actors and agendas. Some of these are common to postgraduate programmes with working learners, while others are unique to this particular partnership, such as weak institutional capacity to champion and embed new programmes and approaches to teaching. CONCLUSIONS: The partnership, despite significant inherent challenges, has potential for providing real opportunities for building the field and community of practice, and strengthening the staff and organizational capacity of participant institutions. Key learning points of the paper are:• the need for long-term strategies and engagement;• the need for more investment and attention to developing the capacity of academic institutions;• the need to invest specifically in educational/teaching expertise for innovative approaches to teaching and capacity development more broadly; and• the importance of increasing access and support for students who are working adults in public health institutions throughout Africa.