Teamwork in community health committees: a case study in two urban informal settlements.

BACKGROUND: Community health committees (CHCs) are mechanisms for community participation in decision-making and overseeing health services in several low-and middle-income countries (LMICs). There is little research that examines teamwork and internal team relationships between members of these committees in LMICs. We aimed to assess teamwork and factors that affected teamwork of CHCs in an urban slum setting in Nairobi, Kenya. METHODS: Using a qualitative case-study design, we explored teamwork of two CHCs based in two urban informal settlements in Nairobi. We used semi-structured interviews (n = 16) to explore the factors that influenced teamwork and triangulated responses using three group discussions (n = 14). We assessed the interpersonal and contextual factors that influenced teamwork using a framework for assessing teamwork of teams involved in delivering community health services. RESULTS: Committee members perceived the relationships with each other as trusting and respectful. They had regular interaction with each other as friends, neighbors and lay health workers. CHC members looked to the Community Health Assistants (CHAs) as their supervisor and "boss", despite CHAs being CHC members themselves. The lay-community members in both CHCs expressed different goals for the committee. Some viewed the committee as informal savings group and community-based organization, while others viewed the committee as a structure for supervising Community Health Promoters (CHPs). Some members doubled up as both CHPs and CHC members. Complaints of favoritism arose from CHC members who were not CHPs whenever CHC members who were CHPs received stipends after being assigned health promotion tasks in the community. Underlying factors such as influence by elites, power imbalances and capacity strengthening had an influence on teamwork in CHCs. CONCLUSION: In the absence of direction and support from the health system, CHCs morph into groups that prioritize the interests of the members. This redirects the teamwork that would have benefited community health services to other common interests of the team. Teamwork can be harnessed by strengthening the capacity of CHC members, CHAs, and health managers in team building and incorporating content on teamwork in the curriculum for training CHCs.

Master's degree in sexual and reproductive health: enhancing career development opportunities for midwives in Mali.

BACKGROUND: Midwives' contribution to improving outcomes for women and newborns depends on factors such as quality of pre-service training, access to continuing professional development, and the presence of an enabling work environment. The absence of opportunities for career development increases the likelihood that health professionals, including midwives, will consider leaving the profession due to a lack of incentives to sustain and increase motivation to remain in the field. It also limits the opportunities to better contribute to policy, training, and research. This study aimed to assess the influence of a Master in Sexual and Reproductive Health (SRH) at the INFSS on midwives' career progression in Mali. METHODS: This mixed methods study was conducted using an online questionnaire, semi-structured interviews, and a document review. The study participants included graduates from two cohorts (N = 22) as well as employers, managers, and teachers of the graduates (N = 20). Data were analysed according to research questions, comparing, and contrasting answers between different groups of respondents. RESULTS: The study revealed that graduates enrolled in the programme primarily to improve their knowledge and skills in management and public health. The graduates' expected roles are those of programme and health project manager and participation in planning and monitoring activities at national or sub-national level. The managers expected the programme to reflect the needs of the health system and equip midwives with skills in management and planning. The Master enhanced opportunities for graduates to advance their career in fields they are not usually working in such as management, research, and supervision. However, the recognition of the master's degree and of the graduates' profile is not yet fully effective. CONCLUSION: The master's degree in SRH is a capacity building programme. Graduates developed skills and acquired advanced knowledge in research and management, as well as a postgraduate degree. However, the master programme needs to be better aligned with health system needs to increase the recognition of graduates' skills and have a more positive impact on graduates' careers.

Using the integration of human resource management strategies at district level to improve workforce performance: analysis of workplan designs in three African countries.

BACKGROUND: There is a worldwide shortage of health workers against WHO recommended staffing levels to achieve Universal Health Coverage. To improve the performance of the existing health workforce a set of integrated human resources (HR) strategies are needed to address the root causes of these shortages. The PERFORM2Scale project uses an action research approach to support district level management teams to develop appropriate workplans to address service delivery and workforce-related problems using a set of integrated human resources strategies. This paper provides evidence of the feasibility of supporting managers at district level to design appropriate integrated workplans to address these problems. METHODS: The study used content analysis of documents including problem trees and 43 workplans developed by 28 district health management teams (DHMT) across three countries between 2018 and 2021 to identify how appropriate basic planning principles and the use of integrated human resource and health systems strategies were used in the design of the workplans developed. Four categories of HR strategies were used for the analysis (availability, direction, competencies, rewards and sanctions) and the relationship between HR and wider health systems strategies was also examined. RESULTS: About half (49%) of the DHMTs selected service-delivery problems while others selected workforce performance (46%) or general management (5%) problems, yet all workplans addressed health workforce-related causes through integrated workplans. Most DHMTs used a combination of strategies for improving direction and competencies. The use of strategies to improve availability and the use of rewards and sanctions was more common amongst DHMTs in Ghana; this may be related to availability of decision-space in these areas. Other planning considerations such as link between problem and strategy, inclusion of gender and use of indicators were evident in the design of the workplans. CONCLUSIONS: The study has demonstrated that, with appropriate support using an action research approach, DHMTs are able to design workplans which include integrated HR strategies. This process will help districts to address workforce and other service delivery problems as well as improving 'health workforce literacy' of DHMT members which will benefit the country more broadly if and when any of the team members is promoted.

Community participation in the health system: analyzing the implementation of community health committee policies in Kenya.

BACKGROUND: Community health committees (CHCs) are a mechanism for communities to voluntarily participate in making decisions and providing oversight of the delivery of community health services. For CHCs to succeed, governments need to implement policies that promote community participation. Our research aimed to analyze factors influencing the implementation of CHC-related policies in Kenya. METHODS: Using a qualitative study design, we extracted data from policy documents and conducted 12 key informant interviews with health workers and health managers in two counties (rural and urban) and the national Ministry of Health. We applied content analysis for both the policy documents and interview transcripts and summarized the factors that influenced the implementation of CHC-related policies. FINDINGS: Since the inception of the community health strategy, the roles of CHCs in community participation have been consistently vague. Primary health workers found the policy content related to CHCs challenging to translate into practice. They also had an inadequate understanding of the roles of CHCs, partly because policy content was not adequately disseminated at the primary healthcare level. It emerged that actors involved in organizing and providing community health services did not perceive CHCs as valuable mechanisms for community participation. County governments did not allocate funds to support CHC activities, and policies focused more on incentivizing community health volunteers (CHVs) who, unlike CHCs, provide health services at the household level. CHVs are incorporated in CHCs. CONCLUSION: Kenya's community health policy inadvertently created role conflict and competition for resources and recognition between community health workers involved in service delivery and those involved in overseeing community health services. Community health policies and related bills need to clearly define the roles of CHCs. County governments can promote the implementation of CHC policies by including CHCs in the agenda during the annual review of performance in the health sector.

How context influences the functionality of community-level health governance structures: A case study of community health committees in Kenya.

Community Health Committees (CHCs) are mechanisms through which communities participate in the governance and oversight of community health services. While there is renewed interest in strengthening community participation in the governance of community health services, there is limited evidence on how context influences community-level structures of governance and oversight. The objective of this study was to examine how contextual factors influence the functionality of CHCs in Kajiado, Migori, and Nairobi Counties in Kenya. Using a case study design, we explored the influence of context on CHCs using 18 focus group discussions with 110 community members (clients, CHC members, and community health volunteers [CHVs]) and interviews with 33 health professionals. Essential CHC functions such as 'leadership' and 'management' were weak, partly because Health professionals did not involve CHCs in developing health plans. Community Health Committees were active in the supervision of CHVs, reviewing their household reports, although they did not utilise these data for making decisions. Resource mobilisation and evaluation of health programs were affected by the lack of administrative and operational support, such as training. Despite having influential membership, CHCs could not provide leadership and management functions. Health system actors perceived the roles of CHCs as service providers rather than structures for governance and oversight. Insufficient awareness of CHC roles among health professionals, lack of training and operational support for community-based activities constrained CHCs' functionality and thus their role in community participation. While there are efforts to institutionalise community-level governance structures for health at sub-national level, there is a need to scale-up these efforts countrywide. We recommend that community-level governance structures be empowered, mandated, and provided with resources to take on the responsibility of overseeing community health services and exacting accountability from health providers.

Scaling up task-sharing psychological interventions for refugees in Jordan: a qualitative study on the potential barriers and facilitators.

Training nonspecialists in providing evidence-based psychological interventions (i.e. task-sharing) can effectively increase community access to psychological support. However, task-sharing interventions for this purpose are rarely used at scale. The aim of this study was to examine the factors influencing the potential for scaling up (i.e. scalability) of a task-sharing psychological intervention called Problem Management Plus (PM+) for Syrian refugees in Jordan. Semi-structured individual (n = 17) and group interviews (n = 20) were conducted with stakeholders knowledgeable about PM+ and the mental health system for Syrian refugees in Jordan. Using 'system innovation perspective', this study conceptualized the context as landscape developments, and systemic considerations were divided into culture (shared ways of thinking) and structure (ways of organizing). Political momentum was identified as a landscape trend likely facilitating scaling up, while predicted reductions in financial aid was regarded as a constraint. In terms of culture, the medicalized approach to mental health, stigma and gender were reported barriers for scaling up PM+. Using non-stigmatizing language and offering different modalities, childcare options and sessions outside of working hours were suggestions to reduce stigma, accommodate individual preferences and increase the demand for PM+. In relation to structure, the feasibility of scaling up PM+ largely depends on the ability to overcome legal barriers, limitations in human and financial resources and organizational challenges. We recommend sustainable funding to be made available for staff, training, supervision, infrastructure, coordination, expansion and evaluation of 'actual' scaling up of PM+. Future research may examine the local feasibility of various funding, training and supervision models. Lessons learned from actual scaling up of PM+ and similar task-sharing approaches need to be widely shared.

How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda.

BACKGROUND: The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. METHODS: The study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention. RESULTS: A shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up. CONCLUSIONS: Despite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.

Human Resources for Health in Conflict Affected Settings: A Scoping Review of Primary Peer Reviewed Publications 2016-2022.

BACKGROUND: Conflict has devastating effects on health systems, especially on healthcare workers (HCWs) working in under-resourced and hostile environments. However, little evidence is available on how policy-makers, often together with development partners, can optimize the organization of the health workforce and support HCWs to deliver accessible and trustworthy health services in conflict-affected settings (CAS). METHODS: A scoping review was conducted to review recent evidence (2016-2022) on human resources for health (HRH) in CAS, and critically discuss HRH challenges in these settings. Thirty-six studies were included in the review and results were presented using an adapted version of the health labour market (HLM) framework. RESULTS: Evidence from CAS highlights that conflict causes specific constraints in both the education sector and in the HLM, and deepens any existing disconnect between those sectors. Parallel and inadequate education and performance management systems, attacks on health facilities, and increased workload and stress, amongst other factors, affect HCW motivation, performance, distribution, and attrition. Short-term, narrowly focused policy-making undermines the long-term sustainability and resilience of the health workforce in CAS, and also contributes to the limited and narrow available research base. CONCLUSION: While HRH and workforce issues in CAS include those found in many other low- and middle-income countries (LMICs), an additional set of challenges for HCWs, governance dynamics and institutional constraints in CAS 'multiply' negative effects on the health workforce. HRH policies, programmes and interventions must be aligned with the political and broader societal context, including the stage, severity and other dynamics of conflict. During conflict, it is important to try to monitor in- and outflow of HCWs and provide HCWs the support they need at local level or through remote measures. The post-conflict situation may present opportunities for improvement in HRH, but a clear understanding of political economy dynamics is required to better act on any such a window of opportunity.

Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda - lessons from the PERFORM2Scale consortium.

BACKGROUND: Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale's theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature. METHODS: The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations. The reflections were captured in detailed annual reports, on which this article is based. RESULTS: The PERFORM2Scale ToC describes how the management strengthening intervention, which targets district health management teams, was expected to improve health workforce performance and service delivery at scale, and which assumptions were instrumental to track over time. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did (and did not) happen. This helped in strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the annual reflections, these actions and adaptations related to: assessing the scalability of the intervention, documentation and dissemination of evidence about the effects of the intervention, understanding power relationships between key stakeholders, the importance of developing and monitoring a scale-up strategy and identification of opportunities to integrate (parts of) the intervention into existing structures and strategies. CONCLUSIONS: PERFORM2Scale's experience provides lessons for using ToCs to monitor and evaluate the scale-up of health system strengthening interventions. ToCs can help in establishing a common vision on intervention scale-up. ToC-based approaches should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up.

Assessing the scalability of a health management-strengthening intervention at the district level: a qualitative study in Ghana, Malawi and Uganda.

BACKGROUND: The scale-up of successfully tested public health interventions is critical to achieving universal health coverage. To ensure optimal use of resources, assessment of the scalability of an intervention is recognized as a crucial step in the scale-up process. This study assessed the scalability of a tested health management-strengthening intervention (MSI) at the district level in Ghana, Malawi and Uganda. METHODS: Qualitative interviews were conducted with intervention users (district health management teams, DHMTs) and implementers of the scale-up of the intervention (national-level actors) in Ghana, Malawi and Uganda, before and 1 year after the scale-up had started. To assess the scalability of the intervention, the CORRECT criteria from WHO/ExpandNet were used during analysis. RESULTS: The MSI was seen as credible, as regional- and national-level Ministry of Health officials were championing the intervention. While documented evidence on intervention effectiveness was limited, district- and national-level stakeholders seemed to be convinced of the value of the intervention. This was based on its observed positive results regarding management competencies, teamwork and specific aspects of health workforce performance and service delivery. The perceived need for strengthening of management capacity and service delivery showed the relevance of the intervention, and relative advantages of the intervention were its participatory and sustainable nature. Turnover within the DHMTs and limited (initial) management capacity were factors complicating implementation. The intervention was not contested and was seen as compatible with (policy) priorities at the national level. CONCLUSION: We conclude that the MSI is scalable. However, to enhance its scalability, certain aspects should be adapted to better fit the context in which the intervention is being scaled up. Greater involvement of regional and national actors alongside improved documentation of results of the intervention can facilitate scale-up. Continuous assessment of the scalability of the intervention with all stakeholders involved is necessary, as context, stakeholders and priorities may change. Therefore, adaptations of the intervention might be required. The assessment of scalability, preferably as part of the monitoring of a scale-up strategy, enables critical reflections on next steps to make the intervention more scalable and the scale-up more successful.

Inclusion strategies in multi-stakeholder dialogues: The case of a community-based participatory research on immunization in Nigeria.

BACKGROUND: Community-Based Participatory Research (CBPR) has been used to address health disparities within several contexts by actively engaging communities. Though dialogues are recognized as a medium by which community members and other actors can make their voices heard through processes that support shared-decision making, power asymmetries often impede the achievement of this objective. Traditionally such relationship asymmetries exist between communities, health workers, and other professionals resulting in the exclusion of communities from decision making in participatory practices and dialogues. This study aimed to explore the experiences in the dialogues between different groups within communities, health workers and local government officials in a CBPR project on immunization in Nigeria. We adapted the framework by Elberse et al. (2011) to structure the possible exclusion mechanisms that could exist in dialogues between the three groups and we set up inclusion strategies to diminish the inequalities as much as possible. METHODS AND FINDINGS: This is an exploratory and descriptive case study, using qualitative methods. Data was collected through observation and semi-structured interviews (SSI) with dialogue participants. All 24 participants in the multi-stakeholder dialogues were interviewed. Inclusion strategies involved creating enabling circumstances; influencing behaviour; and influencing use of language. Verbal and circumstantial strategies were of limited value in reducing exclusion. Behavioural inclusion strategies created more awareness of the importance of inclusion; and enabled different community stakeholders to direct their influences towards achieving the collective goals of the collaboration. An important learning is that if evidence is used in the dialogues, even when exclusion of certain individuals occurs, the outcomes could still favour them. A key issue is the difference between participation and representation and the need for more efficient ways of carrying out such interactive processes to ensure that the participation of the vulnerable groups is not merely symbolic. The study makes a case for the use of 'boundary spanners' in this dynamic-these are 'elite' individuals (or community champions) who can be a voice for the minorities and who could have the opportunity to influence decision making. CONCLUSION: CBPR can enable local governments to develop effective partnerships with health workers and communities to achieve health-related goals even in the presence of asymmetries in relationships. Inclusion strategies in dialogues can improve participation and enable shared decision making, however exclusion of vulnerable groups may still occur. Intra-community dynamics and socio-cultural contexts can drive exclusion and less privileged community members require proper representation to enable their issues to be captured effectively.

Participation in primary health care through community-level health committees in Sub-Saharan Africa: a qualitative synthesis.

BACKGROUND: Health committees are key mechanisms for enabling participation of community members in decision-making on matters related to their health. This paper aims to establish an in-depth understanding of how community members participate in primary health care through health committees in sub-Saharan Africa (SSA). METHODS: We searched peer-reviewed English articles published between 2010 and 2019 in MEDLINE, Popline and CINAHL databases. Articles were eligible if they involved health committees in SSA. Our search yielded 279 articles and 7 duplicates were removed. We further excluded 255 articles following a review of titles and abstracts by two authors. Seventeen abstracts were eligible for full text review. After reviewing the full-text, we further excluded two articles that did not explicitly describe the role of health committees in community participation. We therefore included 15 articles in this review. Two authors extracted data on how health committees contributed to community participation in SSA using a conceptual framework for assessing community participation in health. We derived our themes from five process indicators in this framework, namely, leadership, management and planning, resource mobilization from external sources, monitoring and evaluation and women involvement. FINDINGS: We found that health committees work well in voicing communities' concerns about the quality of care provided by health facility staff, day-to-day management of health facilities and mobilizing financial and non-financial resources for health activities and projects. Health committees held health workers accountable by monitoring absenteeism, quality of services and expenditures in health facilities. Health committees lacked legitimacy because selection procedures were often not transparent and participatory. Committee members were left out in planning and budgeting processes by health workers, who perceived them as insufficiently educated and trained to take part in planning. Most health committees were male-dominated, thus limiting participation by women. CONCLUSION: Health committees contribute to community participation through holding primary health workers accountable, voicing their communities' concern and mobilizing resources for health activities and projects. Decision makers, health managers and advocates need to fundamentally rethink how health committees are selected, empowered and supported to implement their roles and responsibilities.

Preferences and Experiences Regarding the Use of the Self-Sampling Device in hrHPV Screening for Cervical Cancer.

BACKGROUND: To improve participation in the Dutch cervical cancer screening, a self-sampling device (SSD) was introduced in 2017 into the Dutch population-based screening programme (PBS) for the early detection of cervical cancer. The aim of this study was to gather potential preferences and experiences that might influence a woman's decision to use the SSD in the Dutch PBS. METHODS: A scoping review was performed in the PubMed database. Studies that assessed preferences and experiences of women regarding the SSD were included, and preferences and experiences were extracted. In addition, in a qualitative study, the list of potential preferences and experiences specific for the Dutch PBS was extended based on semi-structured interviews with SSD users as well as non-SSD users who recently participated in the PBS, analysed in a structured manner by translating full sentences to key words. RESULTS: Ninety-eight studies were included in the scoping review and 16 interviews were performed. Frequently mentioned reasons for using the SSD, in both the interviews and the literature, were practicality and comfort. Frequently mentioned reasons for not using the SSD were fear of not performing the SSD procedure correctly and doubts on whether the results of the high-risk human papillomavirus (hrHPV) test will be reliable. A new positive experience elicited in the interviews was accessibility. Negative preferences and experiences were not being aware the SSD was an option, and the inconvenience that after an hrHPV-positive test result of the SSD, an additional smear test at the GP is necessary. CONCLUSION: Several preferences and experiences play a role in the choice whether or not to use the SSD. Based on the currently found preferences and experiences, an app will be developed in order to assess which of these are the most important for women participating in the Dutch population-based cervical screening programme.

Adoption of harmonisation policy for the midwives' training programme in Mali: A policy analysis.

West Africa is engaged in a process of harmonising health workers' training programmes as a means to regulate regional training standards and thus improve their quality. There is currently a lack of documented information regarding the adoption of these revised training programmes. In 2012 a harmonised programme, the WAHO competency-based curriculum, was introduced in Mali for training midwives. The present study explores the barriers and facilitators of the adoption of this programme and how the content, context, process, and actor-related factors influenced this. We used a qualitative research design consisting of document analysis (n = 25) and semi-structured interviews (n = 21) with policymakers, students, and those in charge of implementing the training programme. Information was collected on education and training policies, the context and process of the harmonised curriculum development, its adoption, and the actors involved in the adoption strategy, along with their role. The study shows that the adoption of the harmonised curriculum in Mali offered midwives an opportunity to attain a higher standard of training and level of qualification than before. It also displayed both the government's and the public school's willingness and commitment to improve maternal and child health through enhancing midwives' training standards. The most salient factors that influenced adoption were the lack of available resources, and the lack of involvement of, and coordination with, relevant actors for successful policy adoption. Mali's experience of adopting the harmonisation policy of training curricula demonstrates the need for the authorities to collaborate with relevant actors for information dissemination and in the adoption process. It also demonstrates the need for finding innovative ways to secure and diversify funding opportunities, as well as establish a supervisory body for health worker training.

Navigating the political and technical challenges of developing a national HRH strategy: a case study in Greece.

Healthcare workforce reforms to enable implementation of government health policies require government leadership, and commitment of various stakeholders, but workforce reforms often meet resistance from powerful stakeholders. We use Kingdon's Multiple Streams framework to explain how in 2017, in Greece, the interplay between problems, policy and politics led to government marshalling support from experts to develop a National HRH Strategy. A window of opportunity for healthcare workforce reforms occurred because of the Ministry of Health's acknowledgement of structural workforce problems (problem stream), the introduction of policies and decrees on Primary Health Care and Public Health, and availability of globally formulated HRH policy solutions (policy stream). Additionally, interest of the government in Universal Health Coverage combined with reform requirements from European loan providers provided political opportunities (politics stream). This experience shows 1) the opportunity for change presented by circumstances; 2) the importance of creating healthcare workforce capabilities within the government to implement a health policy agenda. However, windows of opportunity are short-lived political interest is fleeting, competing problems may arise, alternative solutions may be proposed or governments may change. We conclude with a key challenge for success: how to assure continued government commitment to HRH reforms in a changing political context.

Using participatory action research to improve immunization utilization in areas with pockets of unimmunized children in Nigeria.

BACKGROUND: In 2005, Nigeria adopted the Reaching Every Ward strategy to improve vaccination coverage for children 0-23 months of age. By 2015, Ogun state had full coverage (100%) in 12 of its 20 local government areas, but eight had pockets of unimmunized children, with the highest burden (37%) in Remo North. A participatory action research (PAR) approach was used to facilitate implementation of local solutions to contextual barriers to immunization in Remo North. This article assesses and seeks to explain the outcomes of the PAR implemented in Remo North to understand whether and possibly how it improved immunization utilization. METHODS: The PAR intervention took place from 2016 to 2017. It involved two (4-month) cycles of dialogue and action between community members, frontline health workers and local government officials in two wards of Remo North, facilitated by the research team. The PAR was assessed using a pre/post-intervention-only design with mixed methods. These included household surveys of caregivers of 215 and 213 children, respectively, 25 semi-structured interviews with stakeholders involved in immunization service delivery and 16 focus group discussions with community members. Data were analysed using the Strategic Advisory Group of Experts (SAGE) vaccine hesitancy framework. RESULTS: Collaboration among the three stakeholder groups enabled the development and implementation of solutions to identified problems related to access to and use of immunization services. At endline, assessment by card for children older than 9 months revealed a significant increase in those fully immunized, from 60.7% at baseline to 90.9% (p < .05). A significantly greater number of caregivers visited fixed government health facilities for routine immunization at endline (83.2%) than at baseline (54.2%) (p < .05). The reasons reported by caregivers for improved utilization of routine immunization services were increased community mobilization activities and improved responsiveness of the health workers. Spillover effects into maternal health services enhanced the use of immunization services by caregivers. Spontaneous scale-up of actions occurred across Remo North due to the involvement of local government officials. CONCLUSION: The PAR approach achieved contextual solutions to problems identified by communities. Collection and integration of evidence into discussions/dialogues with stakeholders can lead to change. Leveraging existing structures and resources enhanced effectiveness.

Syndemic contexts: findings from a review of research on non-communicable diseases and interviews with experts.

BACKGROUND: Syndemics are characterized by the clustering of two or more health conditions, their adverse interaction, and contextual factors that create the conditions for clustering and/or interaction that worsens health outcomes. Studying syndemics entails drawing on diverse disciplines, including epidemiology and anthropology. This often means collaboration between researchers with different scholarly backgrounds, who share and - ideally - integrate their findings. OBJECTIVE: This article examines how context within syndemics has been defined and studied. METHODS: A literature review of empirical studies focusing on syndemics involving non-communicable diseases (NCDs) and mental health conditions was conducted and the full text of 13 articles was analyzed. The review was followed-up with semi-structured interviews with 11 expert researchers working in the field. RESULTS: The review and interviews highlighted a relatively consistent definition of syndemics. The reviewed studies of NCD-related syndemics tended to focus on micro-level context, suggesting a need to analyze further underlying structural factors. In their syndemics research, respondents described working with other disciplines and, although there were some challenges, welcomed greater disciplinary diversity. Methodological gaps, including a lack of mixed methods and longitudinal studies, were identified, for which further interdisciplinary collaborations would be beneficial. CONCLUSIONS: NCD-related syndemics research would benefit from further analysis of structural factors and the interconnections between syndemic components across multiple levels, together with more ambitious research designs integrating quantitative and qualitative methods. Research on the COVID-19 pandemic can benefit from a syndemics approach, particularly to understand vulnerability and the unequal impacts of this public health crisis.

How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana.

District Health Management Teams (DHMTs) are often entry points for the implementation of health interventions. Insight into decision-making and power relationships at district level could assist DHMTs to make better use of their decision space. This study explored how district-level health system decision-making is shaped by power dynamics in different decentralised contexts in Ghana, Malawi and Uganda. In-depth interviews took place with national- and district-level stakeholders. To unravel how power dynamics influence decision-making, the Arts and Van Tatenhove (2004) framework was applied. In Ghana and Malawi, the national-level Ministry of Health substantially influenced district-level decision-making, because of dispositional power based on financial resources and hierarchy. In Uganda and Malawi, devolution led to decision-making being strongly influenced by relational power, in the form of politics, particularly by district-level political bodies. Structural power based on societal structures was less visible, however, the origin, ethnicity or gender of decision-makers could make them more or less credible, thereby influencing distribution of power. As a result of these different power dynamics, DHMTs experienced a narrow decision space and expressed feelings of disempowerment. DHMTs' decision-making power can be expanded through using their unique insights into the health realities of their districts and through joint collaborations with political bodies.

The COVID-19 pandemic presents an opportunity to develop more sustainable health workforces.

This commentary addresses the critically important role of health workers in their countries' more immediate responses to COVID-19 outbreaks and provides policy recommendations for more sustainable health workforces. Paradoxically, pandemic response plans in country after country, often fail to explicitly address health workforce requirements and considerations. We recommend that policy and decision-makers at the facility, regional and country-levels need to: integrate explicit health workforce requirements in pandemic response plans, appropriate to its differentiated levels of care, for the short, medium and longer term; ensure safe working conditions with personal protective equipment (PPE) for all deployed health workers including sufficient training to ensure high hygienic and safety standards; recognise the importance of protecting and promoting the psychological health and safety of all health professionals, with a special focus on workers at the point of care; take an explicit gender and social equity lens, when addressing physical and psychological health and safety, recognising that the health workforce is largely made up of women, and that limited resources lead to priority setting and unequitable access to protection; take a whole of the health workforce approach-using the full skill sets of all health workers-across public health and clinical care roles-including those along the training and retirement pipeline-and ensure adequate supervisory structures and operating procedures are in place to ensure inclusive care of high quality; react with solidarity to support regions and countries requiring more surge capacity, especially those with weak health systems and more severe HRH shortages; and acknowledge the need for transparent, flexible and situational leadership styles building on a different set of management skills.

Social determinants of maternal health: a scoping review of factors influencing maternal mortality and maternal health service use in India.

BACKGROUND: Maternal health remains a major public health problem in India, with large inter- and intra-state inequities in maternal health service use and maternal deaths. The Commission on Social Determinants of Health provides a framework to identify structural and intermediary factors of health inequities, including maternal health, and understand their mechanism of influence, which might be important in addressing maternal health inequities in India. Our review aims to map and summarize the evidence on social determinants influencing maternal health in India and understand their mechanisms of influence by using a maternal health-specific social determinants framework. METHODS: A scoping review was conducted of peer-reviewed journal articles in two databases (PubMed and Science Direct) on quantitative and qualitative studies conducted in India after 2000. We also searched for articles in a search engine (Google Scholar). Forty-one studies that met the study objectives were included: 25 identified through databases and search engines and 16 through reference check. RESULTS: Economic status, caste/ethnicity, education, gender, religion, and culture were the most important structural factors of maternal health service use and maternal mortality in India. Place of residence, maternal age at childbirth, parity and women's exposure to mass media, and maternal health messages were the major intermediary factors. The structural factors influenced the intermediary factors (either independently or in association with other factors) that contributed to the use of maternal health service or caused maternal deaths. The health system emerged as a crucial and independent intermediary factor of influence on maternal health in India. Issues of power were observed in broader social contexts and in the relationships of health workers which led to differential access to maternal healthcare for women from different socioeconomic groups. CONCLUSION: The model integrates existing information from quantitative and qualitative studies and provides a more comprehensive picture of structural and intermediary factors of maternal health service use and maternal mortality in India and their mechanisms of influence. Given the limitations of this study, we indicate the areas for further research pertaining to the framework and maternal health.