Exploring system drivers of gender inequity in development assistance for health and opportunities for action.

Background : Deep-rooted and widespread gender-based bias and discrimination threaten achievement of the Sustainable Development Goals. Despite evidence that addressing gender inequities contributes to better health and development outcomes, the resources for, and effectiveness of, such efforts in development assistance for health (DAH) have been insufficient. This paper explores systemic challenges in DAH that perpetuate or contribute to gender inequities, with a particular focus on the role of external donors and funders. Methods: We applied a co-creation system design process to map and analyze interactions between donors and recipient countries, and articulate drivers of gender inequities within the landscape of DAH. We conducted qualitative primary data collection and analysis in 2021 via virtual facilitated discussions and visual mapping exercises among a diverse set of 41 stakeholders, including representatives from donor institutions, country governments, academia, and civil society. Results: Six systemic challenges emerged as perpetuating or contributing to gender inequities in DAH: 1) insufficient input and leadership from groups affected by gender bias and discrimination; 2) decision-maker blind spots inhibit capacity to address gender inequities; 3) imbalanced power dynamics contribute to insufficient resources and attention to gender priorities; 4) donor funding structures limit efforts to effectively address gender inequities; 5) fragmented programming impedes coordinated attention to the root causes of gender inequities; and 6) data bias contributes to insufficient understanding of and attention to gender inequities. Conclusions : Many of the drivers impeding progress on gender equity in DAH are embedded in power dynamics that distance and disempower people affected by gender inequities. Overcoming these dynamics will require more than technical solutions. Groups affected by gender inequities must be centered in leadership and decision-making at micro and macro levels, with practices and structures that enable co-creation and mutual accountability in the design, implementation, and evaluation of health programs.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance.

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

Integrating Human-Centered Design to Advance Global Health: Lessons From 3 Programs.

BACKGROUND: Human-centered design (HCD) is increasingly being used as a complementary approach to traditional global health methods due to its ability to bring new ideas to entrenched problems, integrate multiple stakeholder perspectives, and bring in a strong human lens among other advantages. To reap these benefits, public health and design practitioners in global health programs can learn from the early experiences of integrating HCD to advance these efforts. OBJECTIVE: This article distills lessons gathered from 3 programs leveraging HCD to advance global health programming: (1) the "V" program which used an HCD approach to reframe the once-a-day HIV prevention pill from a potentially stigmatizing medicine into empowering self-care; (2) the Adolescents 360 program which integrated HCD to create a service for adolescent girls to access contraception in Ethiopia and to scale this offering nationwide; and (3) Reimagining TA which used HCD to help shift perceptions around traditional technical assistance models to one of co-creation, defining a new approach for non-financial support for health systems strengthening. FINDINGS: To inform global health programs that are considering employing an HCD approach, lessons learned are distilled into 3 categories: (1) planning: considerations for problem definition and project scoping to allow for flexibility and selection of appropriate methods; (2) engaging: reflections on the means to productively engage different stakeholder groups to build alignment, understanding, and buy-in; (3) applying: adoption of new ways of working during implementation to best take advantage of the benefits of HCD while promoting long-term program sustainability and learning. CONCLUSION: These lessons represent an important step on the pathway to demonstrate the contributions of HCD to improving the effectiveness of health programs at a time when the global health community needs the most robust set of tools possible to meet the demands of our current pandemic context and beyond.

Country perspectives on improving technical assistance in the health sector.

Background: This paper presents learnings from the Re-Imagining Technical Assistance for Maternal, Neonatal, and Child Health and Health Systems Strengthening (RTA) project implemented in the Democratic Republic of the Congo and Nigeria from April 2018 to September 2020 by JSI Research & Training Institute, Inc. and Sonder Collective and managed by the Child Health Task Force. The first of RTA's two phases involved multiple design research activities, such as human-centered design and co-creation, while the second phase focused on secondary analysis of interviews and reports from the design research. This paper explores the limitations of current technical assistance (TA) approaches and maps opportunities to improve how TA is planned and delivered in the health sector. Methods: We analyzed project reports and 68 interviews with TA funders, providers, and consumers to explore in greater detail their perspectives on TA, its characteristics and drawbacks as well as opportunities for improvement. We used qualitative content analysis techniques for this study.   Results: The issues surrounding TA included the focus on donor-driven agendas over country priorities, poor accountability between and within TA actors, inadequate skill transfer from TA providers to government TA consumers, an emphasis on quick fixes and short-term thinking, and inadequate governance mechanisms to oversee and manage TA. Consequently, health systems do not achieve the highest levels of resilience and autonomy. Conclusions: Participants in project workshops and interviews called for a transformation in TA centered on a redistribution of power enabling governments to establish their health agendas in keeping with the issues that are of greatest importance to them, followed by collaboration with donors to develop TA interventions. Recommended improvements to the TA landscape in this paper include nine critical shifts, four domains of change, and 20 new guiding principles.

Coaching Community Health Volunteers in Integrated Community Case Management Improves the Care of Sick Children Under-5: Experience from Bondo, Kenya.

BACKGROUND: Shortages of healthcare workers is detrimental to the health of communities, especially children. This paper describes the process of capacity building Community Health Volunteers (CHVs) to deliver integrated preventive and curative package of care of services to manage common childhood illness in hard-to-reach communities in Bondo Subcounty, Kenya. METHODS: A pre-test/post-test single-group design was used to assess changes in knowledge and skills related to integrated community case management (iCCM) among 58 Community Health Volunteers who received a six-day iCCM clinical training and an additional 3-week clinical coaching at health facilities. Thereafter, community health extension workers and health managers provided supportive supervision over a six-month period. Skills were assessed before the six-day training, during coaching, and after six months of iCCM implementation. RESULTS: CHVs knowledge assessment scores improved from 54.5% to 72.9% after the six-day training (p < 0.001). All 58 CHVs could assess and classify fever and diarrhoea correctly after 3-6 weeks of facility-based clinical coaching; 97% could correctly identify malnutrition and 80%, suspected pneumonia. The majority correctly performed four of the six steps in malaria rapid diagnostic testing. However, only 58% could draw blood correctly and 67% dispose of waste correctly after the testing. The proportion of CHV exhibiting appropriate skills to examine for signs of illness improved from 4% at baseline to 74% after 6 months of iCCM implementation, p < 0.05. The proportion of caregivers in intervention community units who first sought treatment from a CHV increased from 2 to 31 percent (p < 0.001). CONCLUSIONS: Training and clinical coaching built CHV's skills to manage common childhood illnesses. The CHVs demonstrated ability to follow the Kenya iCCM algorithm for decision-making on whether to treat or refer a sick child. The communities' confidence in CHVs' ability to deliver integrated case management resulted in modification of care-seeking behaviour.

Monitoring iCCM: a feasibility study of the indicator guide for monitoring and evaluating integrated community case management.

Most countries in sub-Saharan Africa have now adopted integrated community case management (iCCM) of common childhood illnesses as a strategy to improve child health. In March 2014, the iCCM Task Force published an Indicator Guide for Monitoring and Evaluating iCCM: a 'menu' of recommended indicators with globally agreed definitions and methodology, to guide countries in developing robust iCCM monitoring systems. The Indicator Guide was conceived as an evolving document that would incorporate collective experience and learning as iCCM programmes themselves evolve. This article presents findings from two studies that examined the feasibility of collecting the Indicator Guide's 18 routine monitoring indicators with the iCCM monitoring systems that countries currently have in place. We reviewed iCCM monitoring tools, protocols and reports from a purposive sample of 10 countries in sub-Saharan Africa. We developed a scorecard system to assess which of the Indicator Guide's 18 routine monitoring indicators could be calculated with the given monitoring tools, and at which level of the health system the relevant information would be available. We found that the data needed to calculate many of the Indicator Guide's routine monitoring indicators are already being collected through existing monitoring systems, although much of these data are only available at health facility level and not aggregated to district or national levels. Our results highlight challenge of using supervision checklists as a data source, and the need for countries to maintain accurate deployment data for CHWs and CHW supervisors. We suggest that some of the recommended indicators need revising. Routine monitoring will be more feasible, effective and efficient if iCCM programmes focus on a smaller set of high-value indicators that are easy to measure, reliably interpreted and useful both for global and national stakeholders and for frontline health workers themselves.