Improving health worker motivation and performance to deliver adolescent sexual and reproductive health services in the Democratic Republic of Congo: study design of implementation research to assess the feasibility, acceptability, and effectiveness of a package of interventions.

During its last funding cycle from 2018-2020, the Global Fund in collaboration with the Ministry of Health, World Health Organization, and implementing partners Cordaid and Santé Rural (SANRU), implemented a multi-sectoral, contextualized approach to improve the sexual and reproductive health of adolescent girls and young women in two regions in the Democratic Republic of the Congo, which included community-based, school-based and health facility-based actions. This implementation research focuses on the health-facility component. The objective of this research is to evaluate the feasibility, acceptability, and effectiveness of a package of interventions to improve health workers' knowledge, skills, and attitudes in providing sexual and reproductive health services to adolescents, whilst concomitantly creating an enabling work environment for building health workers' motivation. The package includes a combination of job descriptions, training and refresher training, desk reference tools, and collaborative learning. The package did not focus on improving amenities, providing or repairing equipment, or providing medicines and supplies. The underlying theoretical framework informing the project and the implementation research draws from Social Network Theory, Diffusion of Innovations and Normalization Process Theory. Qualitative and quantitative process and outcome data from in-depth interviews and focus group discussions with health workers and health managers, field notes, monitoring reports, costing sheets, and health worker surveys, adolescent mystery client assessments, and exit interviews with adolescents will be collected as part of a time-series study. The findings from this implementation research will be utilized to inform future adaptations and/or scale-up of the package of interventions to improve health worker motivation and performance in the Democratic Republic of the Congo and elsewhere. The findings will also contribute to advancing the use of theoretical approaches within the field of implementation research.

A collaborative learning approach to improving health worker performance in adolescent sexual and reproductive health service provision: a descriptive feasibility study in six health zones in the Democratic Republic of the Congo.

Poor performance among health service providers is a key barrier to high quality, adolescent-responsive health services. Collaborative learning has been shown to strengthen health service provider performance, but few studies have examined its implementation in adolescent health services. In this paper, we describe a collaborative learning approach for adolescent health service providers implemented as part of a project aiming to prevent HIV in adolescent girls and young women in the Democratic Republic of the Congo (DRC) and explore its feasibility, acceptability, benefits and challenges. To do so, we reviewed plans, budgets and progress reports, as well as nested implementation research related to the project. We also carried out a quantitative analysis of the number, location, participants and topics of collaborative learning sessions conducted as part of this initiative, and thematic analysis to synthesise findings on perceived benefits and challenges. Under the project, 32 collaborative learning sessions of approximately two-hour duration were held with up to 15 participants, most of whom were nurses, between June 2018 and May 2019. The project cost was approximately USD 135,000 over three years. Reported benefits included improving health service provider attitudes, knowledge and skills; ensuring delivery of non-judgemental, empathic and confidential health services; and improving communication and collaboration between health services and adolescents together with their parents. While the novelty of the approach in this context presented challenges, our results suggest that collaborative learning in adolescent health services is feasible, acceptable, and inexpensive. It may help strengthen the knowledge and skills of health service providers, build positive attitudes and motivation, and improve their performance and thereby the adolescent-responsiveness of health services. Further research is needed to confirm these results in other settings and to examine the impact of collaborative learning on the acceptability and uptake of health services.

Leveraging Global Fund investments for health systems strengthening: a qualitative case study on Morocco's Concept Note development.

BACKGROUND: In 2014, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) introduced a new funding model. Following notice of their 2014-2016 allocation, Morocco took the bold decision to reallocate its entire allocated investment (US$ 8 029 632) for health systems strengthening (HSS) and submitted a comprehensive request for funding solely for interventions to strengthen the health system. AIMS: To explore the specific barriers and facilitators to Morocco's novel development and submission of a cross-cutting HSS funding request to the Global Fund and to document lessons learned and recommendations for policy and programme leaders interested in leveraging Global Fund investments for health systems. METHODS: A thorough desk review of key documents and 15 in-depth qualitative interviews were conducted with key stakeholders in Morocco in 2017. RESULTS: In preparation for the funding request, Morocco carried out a comprehensive assessment of the health system, which included extensive dialogue with stakeholders and partners. This action was critical to developing a shared understanding and support for adopting a cross-cutting HSS approach. Despite concerns about potential negative effects of diverting funding from disease-specific programmes, visionary leadership advocated effectively for investing in HSS, and this paved the way for the development of a clear Concept Note requesting Global Fund financial support for the health system more broadly. CONCLUSION: Morocco was the first country in the Global Fund's Middle/East North Africa region to invest its entire Global Fund allocation in strengthening the health system. Many important lessons have been learned from this novel experience and these are presented for shared learning. This opportunity for learning is timely as countries begin preparations for the upcoming funding cycle.

Determinants of uptake of intermittent preventive treatment during pregnancy: a review.

Malaria in pregnancy (MiP) contributes to devastating maternal and neonatal outcomes. Coverage of intermittent preventive treatment during pregnancy (IPTp) remains alarmingly low. Data was compiled from MiP programme reviews and performed a literature search on access to and determinants of IPTp. National malaria control and reproductive health (RH) policies may be discordant. Integration may improve coverage. Medication stock-outs are a persistent problem. Quality improvement programmes are often not standardized. Capacity building varies across countries. Community engagement efforts primarily focus on promotion of services. The majority of challenges can be addressed at country level to improve IPTp coverage.

Depression in primary care: part 1-screening and diagnosis.

Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. In this first of two reviews, we outline an approach to screening and diagnosing depression in primary care that evaluates current evidence based guidelines and applies the recommendations to clinical practice. The second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.

Depression in primary care: part 2-management.

Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. The first review outlined an approach to screening and diagnosing depression in primary care. This second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.

Measuring Efficiency at the Interface of Behavioral and Physical Health Care.

BACKGROUND: Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both). AIMS OF THE STUDY: To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development. METHODS: We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included. RESULTS: 85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31). DISCUSSION: Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes. LIMITATIONS: We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified. IMPLICATION FOR HEALTH CARE PROVISION AND USE: Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care. IMPLICATIONS FOR HEALTH POLICIES: Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts. IMPLICATIONS FOR FURTHER RESEARCH: There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

A renewed focus on preventing malaria in pregnancy.

While much progress has been achieved globally in the fight against malaria, the significant financial investments made to date have not translated into scaled-up malaria in pregnancy (MiP) prevention efforts. Mothers and newborns remain at risk, and now is the time to refocus efforts. Against the backdrop of a new global health architecture embodied by the principles of Every Women, Every Child and driven by the work of the H6 Partnership, Global Financing Facility, strong bilaterals and key financiers, there is a new and timely juncture to advocate for MiP. Recent updates in the WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience present an opportunity to strengthen MiP as a core maternal and child health issue and position MiP prevention as a priority.

Prioritizing quality measure concepts at the interface of behavioral and physical healthcare.

OBJECTIVE: Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care. DESIGN: We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures. SETTING: United States. PARTICIPANTS: Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates. MAIN OUTCOME MEASURES: Panelists rated measure concepts on importance, validity and feasibility. RESULTS: The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were 'ready for further development' ('General medical screening and follow-up in behavioral health settings' and 'Mental health screening at general medical healthcare settings'). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible. CONCLUSIONS: This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.