Using systems thinking to understand the scale-up and sustainability of health innovation: a case study of seasonal malaria chemoprevention processes in Burkina Faso.

BACKGROUND: Scale-up and sustainability are often studied separately, with few studies examining the interdependencies between these two processes and the implementation contexts of innovations towards malaria prevention and control. Researchers and implementers offer much more attention to the content of innovations, as they focus on the technological dimensions and the conditions for expansion. Researchers have often considered innovation a linear sequence in which scaling up and sustainability represented the last stages. Using systems thinking in this manuscript, we analyze complex scaling and sustainability processes through adopting and implementing seasonal malaria chemoprevention (SMC) in Burkina Faso from 2014 to 2018. METHODS: We conducted a qualitative case study involving 141 retrospective secondary data (administrative, press, scientific, tools and registries, and verbatim) spanning from 2012 to 2018. We complemented these data with primary data collected between February and March 2018 in the form of 15 personal semi-structured interviews with SMC stakeholders and non-participant observations. Processual analysis permitted us to conceptualize scale-up and sustainability processes over time according to different vertical and horizontal levels of analysis and their interconnections. RESULTS: Our results indicated six internal and external determinants of SMC that may negatively or positively influence its scale-up and sustainability. These determinants are effectiveness, monitoring and evaluation systems, resources (financial, material, and human), leadership and governance, adaptation to the local context, and other external elements. Our results revealed that donors and implementing actors prioritized financial resources over other determinants. In contrast, our study clearly showed that the sustainability of the innovation, as well as its scaling up, depends significantly on the consideration of the interconnectedness of the determinants. Each determinant can concurrently constitute an opportunity and a challenge for the success of the innovation. CONCLUSION: Our findings highlight the usefulness of the systemic perspective to consider all contexts (international, national, subnational, and local) to achieve large-scale improvements in the quality, equity, and effectiveness of global health interventions. Thus, complex and systems thinking have made it possible to observe emergent and dynamic innovation behaviors and the dynamics particular to sustainability and scaling up processes.

A conceptualisation of scale-up and sustainability of social innovations in global health: a narrative review and integrative framework for action.

BACKGROUND: The scale-up and sustainability of social innovations for health have received increased interest in global health research in recent years; however, these ambiguous concepts are poorly defined and insufficiently theorised and studied. Researchers, policymakers, and practitioners lack conceptual clarity and integrated frameworks for the scale-up and sustainability of global health innovations. Often, the frameworks developed are conceived in a linear and deterministic or consequentialist vision of the diffusion of innovations. This approach limits the consideration of complexity in scaling up and sustaining innovations. OBJECTIVE: By using a systems theory lens and conducting a narrative review, this manuscript aims to produce an evidence-based integrative conceptual framework for the scale-up and sustainability of global health innovations. METHOD: We conducted a hermeneutic narrative review to synthetise different definitions of scale-up and sustainability to model an integrative definition of these concepts for global health. We have summarised the literature on the determinants that influence the conditions for innovation success or failure while noting the interconnections between internal and external innovation environments. RESULTS: The internal innovation environment includes innovation characteristics (effectiveness and testability, monitoring and evaluation systems, simplification processes, resource requirements) and organisational characteristics (leadership and governance, organisational change, and organisational viability). The external innovation environment refers to receptive and transformative environments; the values, cultures, norms, and practices of individuals, communities, organisations, and systems; and other contextual characteristics relevant to innovation development. CONCLUSION: From these syntheses, we proposed an interconnected framework for action to better guide innovation researchers, practitioners, and policymakers in incorporating complexity and systemic interactions between internal and external innovation environments in global health.

La pérennité d'un projet de prévention et de prise en charge de la malnutrition au Niger.

OBJECTIVE: This article is a case study of a capacity-building project to reduce malnutrition, implemented by a non-governmental organization (NGO) in Niger. It aims to generate a set of lessons learned on the processes of sustaining health interventions in vulnerable contexts. METHODS: Using a theoretical framework on sustainability, we carried out a thematic analysis on semi-structured individual interviews (n = 124) collected, between 2016 and 2017, during the evaluative research of the NGO project. RESULTS: The data analysis revealed several risks and opportunities to sustain the project activities, classified according to the characteristics of a routine identified in the theoretical framework: memory, routines, values, and rules. Our findings show a low level of sustainability of the project. Several activities were stopped at the end of the project and others may not continue in the long term. Indeed, local realities-poverty and political fragility-combined with the 'short-term' and vertical logics of the project's implementation have hindered the project activities' sustainability. CONCLUSION: In vulnerable environments, sustainability should not simply be seen as an outcome to be achieved at the end of the project. The sustainability process must be activated by key stakeholders, focusing not only on the resources stabilizing but also on the resilience of the structures and systems in which interventions are embedded.

RéSUMé: OBJECTIF: Cet article est une étude de cas portant sur un projet de renforcement des capacités visant à réduire la malnutrition et implanté par une organisation non gouvernementale (ONG) au Niger. Notre étude a pour but de générer un ensemble de leçons apprises sur les processus de pérennisation des interventions en santé dans des contextes vulnérables. MéTHODE: Utilisant un cadre théorique sur la pérennité, nous avons effectué une analyse thématique sur des entretiens individuels semi-structurés (n = 124) collectés, entre 2016 et 2017, durant la recherche évaluative du projet de l'ONG. RéSULTATS: L'analyse des données a révélé plusieurs risques et opportunités pour pérenniser les activités du projet qui ont été classés selon les caractéristiques d'une routine relevée dans le cadre théorique que sont : la mémoire, les routines, les valeurs et les règles. Les résultats font ressortir un faible niveau de pérennité du projet de l'ONG. Plusieurs activités ont été arrêtées à la fin du projet et d'autres risquent de ne pas continuer à long terme. En effet, les réalités locales ­ pauvreté et fragilité politique ­ combinées aux logiques 'courtermistes' et verticales de mise en œuvre du projet empêchent sa pérennisation. CONCLUSION: Dans des environnements vulnérables, la pérennité ne devrait pas simplement être considérée comme un résultat à atteindre à la fin du projet. Le processus de pérennisation doit être activé par les parties prenantes, en mettant l'accent non seulement sur la stabilisation des ressources mais également sur la résilience des structures et systèmes dans lesquels sont intégrées les interventions.

Why is repositioning public health innovation towards a social paradigm necessary? A reflection on the field of public health through the examples of Ebola and Covid-19.

Health innovations are generally oriented on a techno-economic vision. In this perspective, technologies are seen as an end in themselves, and there is no arrangement between the technical and the social values of innovation. This vision prevails in sanitary crises, in which management is carried out based on the search for punctual, reactive, and technical solutions to remedy a specific problem without a systemic/holistic, sustainable, or proactive approach. This paper attempts to contribute to the literature on the epistemological orientation of innovations in the field of public health. Taking the Covid-19 and Ebola crises as examples, the primary objective is to show how innovation in health is oriented towards a techno-economic paradigm. Second, we propose a repositioning of public health innovation towards a social paradigm that will put more emphasis on the interaction between social and health dimensions in the perspective of social change. We will conclude by highlighting the roles that public health could play in allowing innovations to have more social value, especially during sanitary crises.

What are the roles of community health workers? Looking back at the philosophies of primary health care.

This commentary discusses the different roles of community health workers (CHWs), their challenges and limitations in a historical perspective of primary health care (PHC). We first try to show that the comprehensive philosophy of PHC promulgated in Alma-Ata proposed the role of CHWs as actors who work in community development. On the other hand, in the 1980s, with the emergence of the selective philosophy of PHC, CHWs' role was more affiliated with the health system. We conclude our pitch about the balance that can exist between these different roles by suggesting that CHWs can work in continuity with the health system, but they should not be considered as affordable labor. Also, they must be supported in their activities to develop their communities, allowing them to participate effectively in programs and policies that concern them and their community.

[The non-uptake of prenatal care in Burkina Faso]. / Le non-recours aux soins prénatals au Burkina Faso.

INTRODUCTION: Despite the importance of prenatal care to decrease maternal and neonatal mortality, uptake remains suboptimal in Burkina Faso. This article documents the reasons for non-uptake of prenatal care, by focusing on women who either completely renounce or delay their access to prenatal care. METHODS: Qualitative data collection was performed in the rural town of Kokologho from October 2013 to january 2014. Different collection methods were used: participant observation, twenty-two individual semi-structured interviews with women who accessed prenatal care as a late option and eight informal interviews with key informants identified in the community. RESULTS: Thematic analysis revealed four barriers against the effective use of prenatal care by women: (1) lack of knowledge about the prenatal care schedule and purpose (2) perception of pregnancy and prenatal care (3) socioeconomic barriers: direct payment for prenatal care and the limited autonomy of women, and (4) perception of the quality of prenatal care. DISCUSSION: Based on these observations, non-uptake of prenatal care is discussed using different types of explanatory typologies adopted for this study: non-knowledge, non-claiming by choice or constraints and non-reception of care. This theoretical approach reveals that failures in healthcare services as well as the dichotomy between social representations and medical standards of pregnancy and prenatal care contribute to exclude some women from the prenatal care system.