Barriers in Cleft Service Access in Sub-Saharan Africa: A Thematic Analysis of Practical Needs of Rural Families.

OBJECTIVE: To explore the experiences and perceptions of barriers of parents and family members of patients with cleft lip and palate in accessing cleft services in remote northwest Nigeria. DESIGN: Face-to-face semi-structured audio recorded interviews were used to obtained qualitative textual data. Thematic analysis using interpretative descriptive techniques was employed to understand the participants' lived experiences with barriers and accessibility to cleft services. SETTING: Participants were from Sokoto, Kebbi and Zamfara states in remote northwest, Nigeria. PARTICIPANTS: Consisted of 22 caregivers (17 parents and 5 extended family members) were purposively sampled between 2017 and 2020. MAIN OUTCOME MEASURES: Barriers experienced while accessing cleft services were identified during thematic analysis. RESULT: Over three quarter of the respondents had patients with both cleft lip and palate and without any previous family history (n = 20). About two-thirds of the participants (n = 15) were females. Most of the interviews were conducted before the surgeries (n = 15). FIVE THEMES EMERGED: lack of information, financial difficulty, misrepresentation from health workers, multiple transportation and previous disappointment. CONCLUSIONS: Areas of poor awareness, misinformation from primary health care workers, financial hurdles, multiple transportation logistics and others were identified. Aggressive broadcasting of information through radio, timely treatment and collaboration with influential religious leaders were emphasized. Support, grants and subsidies from government and voluntary agencies are encouraged to mitigate the huge out of pocket cost of cleft care in the region.

Mapping and analysing community health worker programmes in the Eastern Mediterranean region.

BACKGROUND: Community health worker (CHW) programmes are increasingly being recognized as an important strategy that can help to strengthen comprehensive primary health care (PHC), as the foundation of work towards achieving universal health care (UHC) and meeting the Sustainable Development Goals (SDGs). The WHO Regional Office for the Eastern Mediterranean undertook a situational analysis of CHW programmes in the Region to better understand the current situation and the issues involved. METHODS: A two-step process was employed: a review of available literature on CHWs in the Region was conducted, followed by a survey of CHW programmes in the region, focussing on programmes that were country-led and country-wide. RESULTS: Thirteen countries were found to have community health worker programmes with varying governance and programmatic structures. Broadly, two categories can be distinguished: (a) several countries have well established and mature national CHW programmes that are in most cases supported by external donors but driven and coordinated by national governments; (b) a greater number of countries that have smaller, emerging government or partner led projects and programmes. A few countries have deliberately opted for other models to strengthen primary care and community outreach, for example, through community nursing. CONCLUSION: CHW programmes play an increasingly important role in primary health care in the Eastern Mediterranean Region, providing promotive, preventive, and emergency services. This bodes well for efforts to strengthen and embed comprehensive primary health care as the foundation of national health systems, to improve health emergency preparedness, achieve UHC and meet the SDGs. Nonetheless, all but a few programmes face challenges of weak governance, fragmentation and unreliable support, similar to those in other countries. However, the main finding of the analysis was that the role of CHWs in countries' health service delivery is woefully under-researched in almost all countries in the region, and more research to better understand and support programmes in the context of local health system contexts is urgently needed.

Aspirations and realities of intergovernmental collaboration in national- level interventions: insights from maternal, neonatal and child health policy processes in Nigeria, 2009-2019.

In Nigeria's federal government system, national policies assign concurrent healthcare responsibilities across constitutionally arranged government levels. Hence, national policies, formulated for adoption by states for implementation, require collaboration. This study examines collaboration across government levels, tracing implementation of three maternal, neonatal and child health (MNCH) programmes, developed from a parent integrated MNCH strategy, with intergovernmental collaborative designs, to identify transferable principles to other multilevel governance contexts, especially low-income countries.National-level setting was Abuja, where policymaking is domiciled, while two subnational implementation settings (Anambra and Ebonyi states) were selected based on their MNCH contexts. A qualitative case study triangulated information from 69 documents and 44 in-depth interviews with national and subnational policymakers, technocrats, academics and implementers. Emerson's integrated collaborative governance framework was applied thematically to examine how governance arrangements across the national and subnational levels impacted policy processes.The results showed that misaligned governance structures constrained implementation. Specific governance characteristics (subnational executive powers, fiscal centralisation, nationally designed policies, among others) did not adequately generate collaboration dynamics for collaborative actions. Collaborative signing of memoranda of understanding happened passively, but the contents were not implemented. Neither state adhered to programme goals, despite contextual variations, because of an underlying disconnect in the national governance structure.Collaboration across government levels could be better facilitated via full devolution of responsibilities by national authorities to subnational governments, with the national level providing independent evaluation and guidance only. Given the existing fiscal structure, innovative reforms which hold government levels accountable should be linked to fiscal transfers. Sustained advocacy and context-specific models of achieving distributed leadership across government levels are required across similar resource-limited countries. Stakeholders should be aware of what drivers are available to them for collaboration and what needs to be built within the system context.

Exploring Politics and Contestation in the Policy Process: The Case of Zambia's Contested Community Health Strategy.

There have been increased calls for low- and middle-income countries to develop community health systems (CHS) policies or strategies. However, emerging global guidance brackets the inherent complexity and contestation of policy development at the country level. This is explored through the case of Zambia's 5-year Community Health Strategy (CH Strategy), formulated in 2017 and then summarily withdrawn and reissued two years later, with largely similar content. This paper examines the events, actors, and contexts behind this abrupt change in the Strategy, through an analysis of documentary sources and interviews with 21 stakeholders involved in the policy process. We describe an environment of contestation, characterised by numerous international partners weighing in on the CH Strategy, interfacing with shifting loci of responsibility for the CHS in the Ministry of Health (MoH). Despite the rhetoric of participation, providers and communities played no part in the policy process. These dynamics created the conditions for the abrupt change in strategy, illustrating the inherently fraught and political nature of policy development on the CHS in many countries. Going forward, we conclude that paying attention to processes of CHS policy development, and in particular the interaction between events, actors, and contexts, is as important as ensuring meaningful policy content.

Health policy and systems research capacity development to support maternal, new-born, child and adolescent health in West and Central Africa.

Objectives: To examine how and why a South-South capacity development and networking program for leadership, research, practice and advocacy on maternal new-born, child and adolescent health and health policy and systems strengthening in West Africa and Cameroon worked and identify lessons for low- and middle-income countries. Design: Single qualitative case study drawing on data from document review, observations, key informant interviews and a deliberative workshop. Ethics approval for primary data collection was obtained from the Ghana Health Service Ethical Review Committee (GHS-ERC 012/10/18). Setting: West Africa and Cameroon. Participants: Researchers, policy and programme managers and frontline health workers. Interventions: Networking and capacity development. Results: The programme made good progress in implementing many but not all planned capacity development and networking activities. The opportunity to network with other organisations and individuals and across countries, disciplines, and languages as well as to learn, to develop skills, and obtain mentorship support, were considered valuable benefits of the partnership. Human and financial resource constraints meant that not all planned interventions could be implemented. Conclusions: Lessons for health policy and systems research capacity building in LMIC include the potential of South-South partnerships, the need for dedicated resources, the potential of Sub-regional health organizations to support capacity building and recognition that each effort builds on preceding efforts of others, and that it is important to explore and understand where the energy and momentum for change lies. Funding: The work described here has been funded by IDRC Canada under research grant # 108237 "West and Central African partnership for maternal, new-born, child and adolescent health research."

Historical and contemporary factors that influenced the emergence and continuity of WANEL: Lessons for sustainable HPSR network formation in LMICs.

Objectives: To explore historical and contemporary factors and processes that influenced the emergence of WANEL and analyse how the formation process has influenced the network's continued existence and sustainability and lesson for sub-regional health policy and systems research (HPSR) networking in Low -and -Middle -Income Countries (LMICs). Design: Qualitative explanatory case study which used process tracing to chart the formation and development of WANEL. Methods: Data was obtained through document reviews, semi-structured interviews, group discussions, and participant observation. Data was analysed using thematic content analysis. Results: The emergence of WANEL was made possible by several factors, including support from a network of senior HPSR champions and institutions across West Africa; sustained funding from IDRC Canada, a reputable funder with a track record in supporting research capacity development in LMICs; learning and networking opportunities provided by CHEPSAA Emerging Leaders and the Institute of Tropical Medicine Antwerp Emerging Voices for Global Health initiative. Its formation followed a mix of emergent and engineered processes. Conclusion: WANEL is the first and currently the only sub-regional network for early and mid-career health policy and systems researchers and practitioners in West Africa. To ensure its long-term sustainability, the network needs to put in place mechanisms to constantly attract and develop the next generation of early and mid-career researchers, maintain links with senior researchers, strengthen its capacity for coordination and facilitation, and develop a plan for its long-term financial sustainability. Funding: The study is funded by IDRC Canada Project 108237-001: Popularly known as the Consortium for Mothers, Newborn, Children, Adolescents and Health Policy and Systems strengthening in West and Central Africa. (COM-CAHPSS).

Health policy and systems research capacity development to support maternal, newborn, child and adolescent health in West and Central Africa

Objectives: To examine how and why a South-South capacity development and networking program for leadership, research, practice and advocacy on maternal new-born, child and adolescent health and health policy and systems strengthening in West Africa and Cameroon worked and identify lessons for low- and middle-income countries. Design: Single qualitative case study drawing on data from document review, observations, key informant interviews and a deliberative workshop. Ethics approval for primary data collection was obtained from the Ghana Health Service Ethical Review Committee (GHS-ERC 012/10/18). Setting: West Africa and Cameroon Participants: Researchers, policy and programme managers and frontline health workers Interventions: Networking and capacity development Results: The programme made good progress in implementing many but not all planned capacity development and networking activities. The opportunity to network with other organisations and individuals and across countries, disciplines, and languages as well as to learn, to develop skills, and obtain mentorship support, were considered valuable benefits of the partnership. Human and financial resource constraints meant that not all planned interventions could be implemented. Conclusions: Lessons for health policy and systems research capacity building in LMIC include the potential of South-South partnerships, the need for dedicated resources, the potential of Sub-regional health organizations to support capacity building and recognition that each effort builds on preceding efforts of others, and that it is important to explore and understand where the energy and momentum for change lies.

Community health workers at the dawn of a new era: 3. Programme governance.

BACKGROUND: Community health workers (CHWs) can play a critical role in primary healthcare and are seen widely as important to achieving the health-related Sustainable Development Goals (SDGs). The COVID-19 pandemic has emphasized the key role of CHWs. Improving how CHW programmes are governed is increasingly recognized as important for achieving universal access to healthcare and other health-related goals. This paper, the third in a series on "Community Health Workers at the Dawn of a New Era", aims to raise critical questions that decision-makers need to consider for governing CHW programmes, illustrate the options for governance using examples of national CHW programmes, and set out a research agenda for understanding how CHW programmes are governed and how this can be improved. METHODS: We draw from a review of the literature as well as from the knowledge and experience of those involved in the planning and management of CHW programmes. RESULTS: Governing comprises the processes and structures through which individuals, groups, programmes, and organizations exercise rights, resolve differences, and express interests. Because CHW programmes are located between the formal health system and communities, and because they involve a wide range of stakeholders, their governance is complex. In addition, these programmes frequently fall outside of the governance structures of the formal health system or are poorly integrated with it, making governing these programmes more challenging. We discuss the following important questions that decision-makers need to consider in relation to governing CHW programmes: (1) How and where within political structures are policies made for CHW programmes? (2) Who implements decisions regarding CHW programmes and at what levels of government? (3) What laws and regulations are needed to support the programme? (4) How should the programme be adapted across different settings or groups within the country or region? CONCLUSION: The most appropriate and acceptable models for governing CHW programmes depend on communities, on local health systems, and on the political system in which the programme is located. Stakeholders in each setting need to consider what systems are currently in place and how they might be adapted to local needs and systems.

Prioritizing people and rapid learning in times of crisis: A virtual learning initiative to support health workers during the COVID-19 pandemic.

The Western Cape province was the early epicentre of the coronavirus disease 2019 pandemic in South Africa and on the African continent. In this short article we report on an initiative set up within the provincial Department of Health early in the pandemic to facilitate collective learning and support for health workers and managers across the health system, emphasising the importance of leadership, systems resilience, nonhierarchical learning and connectedness. These strategies included regular and systematic engagement with organised labour, different ways of gauging and responding to staff morale, and daily 'huddles' for raid learning and responsive action. We propose three transformational actions that could deliver health systems that protect staff during good times and in times of system shocks. (a) Continuously invest in building the foundations of system resilience in good times, to draw on in an acute crisis situation. (b) Provide consistent leadership for an explicit commitment to supporting health workers through decisive action across the system. (c) Optimise available resources and partners, act on improvement ideas and obstacles. Build trusting relationships amongst and across actors.

Evidence of past and current collaborations between traditional health practitioners and biomedical health practitioners: a scoping review protocol.

INTRODUCTION: Healthcare seekers around the globe use more than one healthcare system, with most using the traditional and the Western approaches concurrently. To date, little collaboration between the two systems has taken place within the mental health space compared with other areas of medicine. In order to inform integrating plans for traditional health practitioners and biomedical health practitioners in the South African mental health system, it is important to know which models of collaboration are used in other medical settings and contexts. This study aims to document global evidence on collaboration practices between traditional health practitioners and biomedical professionals when working with various health conditions. METHODS AND ANALYSIS: This scoping review will be guided by an improved Arksey and O'Malley framework, the 2010 Levac et al methodological framework and the 2017 Joanna Briggs Institute guidelines. A systematic literature search will be carried out using seven different databases, EMBASE, PubMed, LILACS MEDLINE, APA PsycArticles, CINAHL Plus, Academic Search Complete and Scopus, in addition to the WHO repository, bibliographical search engines, and Open Access Theses and Dissertations. Moreover, the references of relevant publications between January 1978 and March 2020 will be scanned. Two reviewers will independently screen articles for eligibility based on the predetermined inclusion and exclusion criteria. Thematic analysis and descriptive numerical analysis will be performed using ATLAS.ti V.8 and Excel software, respectively. The results for this review will be presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review. ETHICS AND DISSEMINATION: This study will not require ethics approval because publicly available material will be used. Study findings will be published in an open-access journal and be presented to other key health system stakeholders and academic research gatherings.

Policy Adoption and the Implementation Woes of the Intersectoral First 1000 Days of Childhood Initiative, In the Western Cape Province of South Africa.

BACKGROUND: There is a growing interest in implementing intersectoral approaches to address social determinants especially within the Sustainable Development Goals (SDGs) era. However, there is limited research that uses policy analysis approaches to understand the barriers to adoption and implementation of intersectoral approaches. In this paper we apply a policy analysis lens in examining implementation of the first thousand days (FTD) of childhood initiative in the Western Cape province of South Africa. This initiative aims to improve child outcomes through a holistic intersectoral approach, referred to as nurturing care. METHODS: The case of the FTD initiative was constructed through a triangulated analysis of document reviews (34), in depth interviews (22) and observations. The analysis drew on Hall's 'ideas, interests and institutions' framework to understand the shift from political agendas to the implementation of the FTD. RESULTS: In the Western Cape province, the FTD agenda setting process was catalysed by the increasing global evidence on the life-long impacts of brain development during the early childhood years. This created a window of opportunity for active lobbying by policy entrepreneurs and a favourable provincial context for a holistic focus on children. However, during implementation, the intersectoral goal of the FTD got lost, with limited bureaucratic support from service-delivery actors and minimal cross-sector involvement. Challenges facing the health sector, such as overburdened facilities, competing policies and the limited consideration of implementation realities (such as health providers' capacity), were perceived by implementing actors as the key constraints to intersectoral action. As a result, FTD actors, whose decision-making power largely resided in health services, reformulated FTD as a traditional maternal-child health mandate. Ambiguity and contestation between key actors regarding FTD interventions contributed to this narrowing of focus. CONCLUSION: This study highlights conditions that should be considered for the effective implementation of intersectoral action - including engaging cross-sector players in agenda setting processes and creating spaces that allow the consideration of actors' interests especially those at service-delivery level. Networks that prioritise relationship building and trust can be valuable in allowing the emergence of common goals that further embrace collective interests.

Looking back to look forward: a review of human resources for health governance in South Africa from 1994 to 2018.

While South Africa has had a fairly consistent record of producing national-level strategic plans for human resources for health in the past 25 years, the country continues to face major problems of affordability, availability, distribution and management of its health workforce. There are several factors contributing to the state of health human resources in the country, but problems with governance stand out as one area requiring further research, analysis and critique. This paper presents a retrospective analysis of the historical patterns in national health human resources governance in South Africa, based on a desktop policy review spanning 25 years after democracy. The authors took a multi-pronged, iterative approach, reviewing policy documents alongside grey and published literature. This led to a timeline showing key legislation, relevant health system and human resource policies, interventions, reviews and evaluations from 1994 to 2018. The review identified three distinct periods that help to characterise the terrain of human resources for health governance over the concerned 25 years. Firstly, a foundational period, in which much of the constitutional and legislative groundwork was laid. Secondly, the HIV epidemic period, which presented a major disruption to the development of system wide governance interventions and improvements. Thirdly, the launch of National Health Insurance discussions and policy processes, which signalled a gradual return to a comprehensive systems focus in line with the founding principles of the first period. Using this periodisation, as well as a conceptual framework of health human resources governance functions based on international literature, the authors argue that South Africa has experienced both progress and challenges in human resources for health governance. This has affected the successful implementation of its policy and strategic planning over the past 25 years. Good governance for human resources for health requires capable stewardship, underpinned by an appropriate mix of technical and administrative skills and explicit political support. The review findings suggest that strengthening human resources for health governance roles, including fostering purposeful stewardship by the National Department of Health, may be key to shifting the terrain in the availability and performance of South Africa's health workforce going forwards.

Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa.

This paper reports a study from Cape Town, South Africa, that tested an existing framework of everyday health system resilience (EHSR) in examining how a local health system responded to the chronic stress of large-scale organizational change. Over two years (2017-18), through cycles of action-learning involving local managers and researchers, the authorial team tracked the stress experienced, the response strategies implemented and their consequences. The paper considers how a set of micro-governance interventions and mid-level leadership practices supported responses to stress whilst nurturing organizational resilience capacities. Data collection involved observation, in-depth interviews and analysis of meeting minutes and secondary data. Data analysis included iterative synthesis and validation processes. The paper offers five sets of insights that add to the limited empirical health system resilience literature: 1) resilience is a process not an end-state; 2) resilience strategies are deployed in combination rather than linearly, after each other; 3) three sets of organizational resilience capacities work together to support collective problem-solving and action entailed in EHSR; 4) these capacities can be nurtured by mid-level managers' leadership practices and simple adaptations of routine organizational processes, such as meetings; 5) central level actions must nurture EHSR by enabling the leadership practices and micro-governance processes entailed in everyday decision-making.

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.

The impact of differing frames on early stages of intersectoral collaboration: the case of the First 1000 Days Initiative in the Western Cape Province.

BACKGROUND: While intersectoral collaboration is considered valuable and important for achieving health outcomes, there are few examples of successes. The literature on intersectoral collaboration suggests that success relies on a shared understanding of what can be achieved collectively and whether stakeholders can agree on mutual goals or acceptable trade-offs. When health systems are faced with negotiating intersectoral responses to complex issues, achieving consensus across sectors can be a challenging and uncertain process. Stakeholders may present divergent framings of the problem based on their disciplinary background, interests and institutional mandates. This raises an important question about how different frames of problems and solutions affect the potential to work across sectors during the initiating phases of the policy process. METHODS: In this paper, this question was addressed through an analysis of the case of the First 1000 Days (FTD) Initiative, an intersectoral approach targeting early childhood in the Western Cape Province of South Africa. We conducted a documentary analysis of 34 policy and other documents on FTD (spanning global, national and subnational spheres) using Schmidt's conceptualisation of policy ideas in order to elicit framings of the policy problem and solutions. RESULTS: We identified three main frames, associated with different sectoral positionings - a biomedical frame, a nurturing care frame and a socioeconomic frame. Anchored in these different frames, ideas of the problem (definition) and appropriate policy solutions engaged with FTD and the task of intersectoral collaboration at different levels, with a variety of (sometimes cross) purposes. CONCLUSIONS: The paper concludes on the importance of principled engagement processes at the beginning of collaborative processes to ensure that different framings are revealed, reflected upon and negotiated in order to arrive at a joint determination of common goals.

Towards universal health coverage: what are the system requirements for effective large-scale community health worker programmes?

Against the background of efforts to strengthen health systems for universal health coverage and health equity, many African countries have been relying on lay members of the community, often referred to as community health workers (CHWs), to deliver primary healthcare services. Growing demand and great variability in definitions, roles, governance and funding of CHWs have prompted the need to revisit CHW programmes and provide guidance on the implementation of successful programmes at scale. Drawing on the synthesised evidence from two extensive literature reviews, this article determines foundational elements of functioning CHW programmes, focusing in particular on the systems requirements of large-scale programmes. It makes recommendations for the effective development of large-scale CHW programmes. The key foundational elements of successful CHW programmes identified are (1) embeddedness, connectivity and integration into the larger system of healthcare service delivery; (2) cadre differentiation and role clarity in order to maintain clear scopes of work and accountability; (3) sound programme design based on local contextual factors and effective people management; and (4) ongoing monitoring, learning and adapting based on accurate and timely local data in order to ensure optimal fit to local context since one size does not fit all. We conclude that CHWs are an investment in health systems strengthening and community resilience with enormous potential for contributing to universal health coverage and the sustainable development goals if well designed and managed. While the evidence base is uneven and mixed, it provides extensive insight and knowledge to strengthen, scale up and sustain CHW programmes throughout Africa.

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.

A decade of aid coordination in post-conflict Burundi's health sector.

BACKGROUND: The launch of Global Health Initiatives in early 2000' coincided with the end of the war in Burundi. The first large amount of funding the country received was ear-marked for human immunodeficiency virus (HIV) and immunization programs. Thereafter, when at global level aid effectiveness increasingly gained attention, coordination mechanisms started to be implemented at national level. METHODS: This in-depth case study provides a description of stakeholders at national level, operating in the health sector from early 2000' onwards, and an analysis of coordination mechanisms and stakeholders perception of these mechanisms. The study was qualitative in nature, with data consisting of interviews conducted at national level in 2009, combined with document analysis over a 10 year-period. RESULTS: One main finding was that HIV epidemic awareness at global level shaped the very core of the governance in Burundi, with the establishment of two separate HIV and health sectors. This led to complex, nay impossible, inter-institutional relationships, hampering aid coordination. The stakeholder analysis showed that the meanings given to 'coordination' differed from one stakeholder to another. Coordination was strongly related to a centralization of power into the Ministry of Health's hands, and all stakeholders feared that they may experience a loss of power vis-à-vis others within the development field, in terms of access to resources. All actors agreed that the lack of coordination was partly related to the lack of leadership and vision on the part of the Ministry of Health. That being said, the Ministry of Health itself also did not consider itself as a suitable coordinator. CONCLUSIONS: During the post-conflict period in Burundi, the Ministry of Health was unable to take a central role in coordination. It was caught between the increasing involvement of donors in the policy making process in a so-called fragile state, the mistrust towards it from internal and external stakeholders, and the global pressure on Paris Declaration implementation, and this fundamentally undermined coordination in the health sector.

Health policy and system support to optimise community health worker programmes: an abridged WHO guideline.

Optimising community health worker (CHW) programmes requires evidence-based policies on their education, deployment, and management. This guideline aims to inform efforts by planners, policy makers, and managers to improve CHW programmes as part of an integrated approach to strengthen primary health care and health systems. The development of this guideline followed the standard WHO approach to developing global guidelines. We conducted one overview of reviews, 15 systematic reviews (each one on a specific policy question), and a survey of stakeholders' views on the acceptability and feasibility of the interventions under consideration. We assessed the quality of systematic reviews using the AMSTAR tool, and the certainty of the evidence using the GRADE methodology. The overview of reviews identified 122 eligible articles and the systematic reviews identified 137 eligible primary studies. The stakeholder perception survey obtained inputs from 96 respondents. Recommendations were developed in the areas of CHW selection, preservice education, certification, supervision, remuneration and career advancement, planning, community embeddedness, and health system support. These are the first evidence-based global guidelines for health policy and system support to optimise community health worker programmes. Key considerations for implementation include the need to define the role of CHWs in relation to other health workers and plan for the health workforce as a whole rather than by specific occupational groups; appropriately integrate CHW programmes into the general health system and existing community systems; and ensure internal coherence and consistency across different policies and programmes affecting CHWs.