Learning health systems in low-income and middle-income countries: exploring evidence and expert insights.

INTRODUCTION: Learning health systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of LHS, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterise LHS in low/middle-income country (LMIC) settings. METHODS: We adopted an exploratory approach to the literature review, recognising there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge. RESULTS: The findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels.We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with 'best fit' solutions. CONCLUSION: Health systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge.

Status of Compassionate, Respectful, and Caring Health Service Delivery: Scoping Review.

BACKGROUND: A compassionate, respectful, and caring (CRC) health professional is very important for human-centered care, serving clients ethically and with respect, adhering to the professional oath, and serving as a model for young professionals. As countries try to achieve universal health coverage (UHC), quality delivery of health services is crucial. CRC health care is an initiative around the need to provide quality care services to clients and patients. However, there is an evidence gap on the status of CRC health care service delivery. OBJECTIVE: This scoping review aimed to map global evidence on the status of CRC health service delivery practice. METHODS: An exhaustive literature review and Delphi technique were used to answer the 2 research questions: "What is the current status of CRC health care practices among health workers?" and "Is it possible for health professionals, health managers, administrators, and policy makers to incorporate it into their activity while designing strategies that could improve the humanistic and holistic approach to health care provision?" The studies were searched from the year 2014 to September 2020 using electronic databases such as MEDLINE (PubMed), Cochrane Library, Web of Science, Hinari, and the World Health Organization (WHO) library. Additionally, grey literature such as Google, Google Scholar, and WorldWideScience were scrutinized. Studies that applied any study design and data collection and analysis methods related to CRC care were included. Two authors extracted the data and compared the results. Discrepancies were resolved by discussion, or the third reviewer made the decision. Findings from the existing literature were presented using thematic analysis. RESULTS: A total of 1193 potentially relevant studies were generated from the initial search, and 20 studies were included in the final review. From this review, we identified 5 thematic areas: the status of CRC implementation, facilitators for CRC health care service delivery, barriers to CRC health care delivery, disrespectful and abusive care encountered by patients, and perspectives on CRC. The findings of this review indicated that improving the mechanisms for monitoring health facilities, improving accountability, and becoming aware of the consequences of maltreatment within facilities are critical steps to improving health care delivery practices. CONCLUSIONS: This scoping review identified that there is limited CRC service provision. Lack of training, patient flow volume, and bed shortages were found to be the main contributors of CRC health care delivery. Therefore, the health care system should consider the components of CRC in health care delivery during in-service training, pre-service training, monitoring and evaluation, community engagement, workload division, and performance appraisal.

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."

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.

Modified scoping review of the enablers and barriers to implementing primary health care in the COVID-19 context.

Since the Alma Ata Declaration of 1978, countries have varied in their progress towards establishing and sustaining comprehensive primary health care (PHC) and realizing its associated vision of 'Health for All'. International health emergencies such as the coronavirus-19 (COVID-19) pandemic underscore the importance of PHC in underpinning health equity, including via access to routine essential services and emergency responsiveness. This review synthesizes the current state of knowledge about PHC impacts, implementation enablers and barriers, and knowledge gaps across the three main PHC components as conceptualized in the 2018 Astana Framework. A scoping review design was adopted to summarize evidence from a diverse body of literature with a modification to accommodate four discrete phases of searching, screening and eligibility assessment: a database search in PubMed for PHC-related literature reviews and multi-country analyses (Phase 1); a website search for key global PHC synthesis reports (Phase 2); targeted searches for peer-reviewed literature relating to specific components of PHC (Phase 3) and searches for emerging insights relating to PHC in the COVID-19 context (Phase 4). Evidence from 96 included papers were analysed across deductive themes corresponding to the three main components of PHC. Findings affirm that investments in PHC improve equity and access, healthcare performance, accountability of health systems and health outcomes. Key enablers of PHC implementation include equity-informed financing models, health system and governance frameworks that differentiate multi-sectoral PHC from more discrete service-focussed primary care, and governance mechanisms that strengthen linkages between policymakers, civil society, non-governmental organizations, community-based organizations and private sector entities. Although knowledge about, and experience in, PHC implementation continues to grow, critical knowledge gaps are evident, particularly relating to country-level, context-specific governance, financing, workforce, accountability and service coordination mechanisms. An agenda to guide future country-specific PHC research is outlined.

PRIMASYS: a health policy and systems research approach for the assessment of country primary health care systems.

For the renewed global impetus on primary health care (PHC) to translate into action at a country level, it will be important to strengthen existing ways of understanding and assessing country PHC systems. The architecture and performance of primary care systems are widely acknowledged to be crucial determinants of the health of populations in high-income countries as well as in low- and middle-income countries. There is no one-size-fits-all model of a country-level PHC system, and countries have implemented diverse models, adapted to and conditioned by their respective social, economic and political contexts. This paper applies advances in the field of health policy and systems research (HPSR) to propose an approach to the assessment of country PHC systems, using a compendium of 70 elements of enquiry requiring mixed quantitative and qualitative assessment. The approach and elements of enquiry were developed based on a review of policy and guidance documents and literature on PHC and HPSR and were finalized as part of a consultation of experts on PHC. Key features of the approach include sensitivity to context, flexibility in allowing for in-depth enquiry where necessary, systems thinking, a learning emphasis, and complementarity with existing frameworks and efforts. Implemented in 20 countries to date, the approach is anticipated to have further utility in a single country as well as in comparative assessments of PHC systems.

Governance Roles and Capacities of Ministries of Health: A Multidimensional Framework.

The lack of capacity for governance of Ministries of Health (MoHs) is frequently advanced as an explanation for health systems failures in low- and middle-income countries (LMICs). But do we understand what governance capacities MoHs should have? Existing frameworks have not fully captured the dynamic and contextually determined role of MoHs, and there are few frameworks that specifically define capacities for governance. We propose a multidimensional framework of capacities for governance by MoHs that encompasses both the "hard" (de jure, explicit and functional) and "soft" (de facto, tacit, and relational) dimensions of governance, and reflects the diversification of their mandates in the context of the Sustainable Development Goals (SDGs). Four case studies illustrate different aspects of the framework. We hope that the framework will have multiple potential benefits including benchmarking MoH governance capacities, identifying and helping analyze capacity gaps, and guiding strategies to strengthen capacity.

What we know and don't know about the immunization program of Ethiopia: a scoping review of the literature.

BACKGROUND: There has been significant recent prioritization and investment in the immunization program in Ethiopia. However, coverage rates have stagnated and remained low for many years, suggesting the presence of systemic barriers to implementation. Hence, there is a need to consolidate the existing knowledge, in order to address them and consequently improve program effectiveness. METHODS: A thorough literature review and Delphi method were used. In this review, we searched Pubmed/Medline, WHO library, Science direct, Cochrane library, Google scholar and Google using different combinations of search strategies. Studies that applied any study design, data collection and analysis methods related to immunization program were included. In the Delphi method, a panel of 28 national and international experts were participated to identify current evidence gaps and set research priorities under the immunization program. RESULTS: In this review, a total of 55 studies and national documents were included. The review showed that the vaccination coverage ranged from 20.6% in Afar to 91.7% in Amhara region with large inequities related to socio-economic, health service access and knowledge about vaccination across different settings. Only one study reported evidence on timeliness of immunization as 60%. The review revealed that 80% of health facilities provide immunization service nationally while service availability was only 2% in private health facilities. This review indicated that poor vaccine storage, vaccine shortage, service interruptions, poor defaulter tracing, low community engagement and poor documentation were the main barriers for the Expanded Program on Immunization with variations across different regions. Through expert panel of discussion using Delphi method, 10 priority research areas were identified across different domains of the immunization program at national level. CONCLUSION: We found out that there is substantial knowledge on vaccination coverage, however, there is little evidence on timeliness of vaccination. The existing barriers that affect full immunization coverage also varied from context to context which indicates there is a need to design and implement evidence based locally tailored interventions. This review also indicated evidence gaps with more focus on health system related implementation barriers at lower level and identified further research priorities in the immunization program of Ethiopia.

Superficial brachioulnar artery and its clinical significance.

The authors report a rare variation of the vasculature in the upper limbs of an 84-year-old male cadaver. A high bifurcation of the brachial artery occurred bilaterally at the proximal one-third of each arm. The radial arteries were larger than the ulnar arteries and gave origin to the common interosseous arteries. At the cubital fossa, the ulnar arteries traversed medial to the median nerves, continuing superficial to all forearm muscles except the palmaris longus tendon, characteristic of superficial brachioulnar arteries. The aforementioned variations have rarely been reported in previous literature and demonstrate important clinical significance in relation to accidental intra-arterial injections, errors in blood pressure readings, as well as orthopedic, plastic, and vascular surgeries of the upper limbs.