Strengthening local health care management in Bolivian districts through participatory operational research

Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review

BACKGROUND

Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs.

METHODS

We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author.

RESULTS

We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change.

CONCLUSIONS

Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.

Building reproductive health research and audit capacity and activity in the Pacific Islands (BRRACAP) study: methods, rationale and baseline results

BACKGROUND

Clinical research and audit in reproductive health is essential to improve reproductive health outcomes and to address the Millennium Development Goals 4 and 5. Research training, mentoring and a supportive participatory research environment have been shown to increase research activity and capacity in low to middle income countries (LMIC). This paper details the methods, rationale and baseline findings of a research program aimed at increasing clinical research activity and audit in the six Pacific Islands of Fiji, Samoa, Tonga, Vanuatu, Cook Islands and the Solomon Islands.

METHOD

Twenty-eight clinician participants were selected by the five Ministries of Health and the Fiji National University to undergo a research capacity building program which includes a research workshop and mentoring support to perform research and audit as teams in their country. Data on the participants' characteristics, knowledge and experiences were collected from structured interviews, questionnaires, focus groups, and an online survey. The interviews and the two focus groups were audio-recorded and all replies were analysed in a thematic framework.

RESULTS

The 28 participants included 9 nurses/midwives, 17 medical doctors of whom 8 were specialists in reproductive health and 2 other health workers. Most (24, 86%) were required to perform research as part of their employment and yet 17 (61%) were not confident in writing a research proposal, 13 (46%) could not use an electronic spreadsheet and the same number had not analysed quantitative data. The limited environmental enablers contributed to poor capacity with only 11 (46%) having access to a library, 10 (42%) receiving management support and 6 (25%) having access to an experienced researcher. Barriers to research that affected more than 70% of the participants were time constraints, poor coordination, no funding and a lack of skills.

CONCLUSION

Building a research capacity program appropriate for the diversity of Pacific clinicians required research evidence and collaborative effort of key stakeholders in the Pacific Islands and the region. The participants had limited research knowledge, skills and experience and would require individualized training and continuous intensive mentorship to realize their potential as clinician researchers for their services in the Pacific.

Práticas de ensino-aprendizagem com base em cenários reais

O processo ensino-pesquisa-extensão realizado com a imersão dos sujeitos em cenários reais possibilita a integração universidade-comunidade, ampliando a inserção social. O objetivo deste trabalho foi apresentar a experiência de um projeto conduzido em cinco municípios brasileiros, com a participação de docentes, pós-graduandos e acadêmicos, em parceria com prefeituras municipais e trabalhadores de saúde como cenário de ensino-pesquisa no SUS. Foram realizadas oficinas e cursos de capacitação com as equipes de saúde, gestores e conselheiros de saúde, visitas técnicas aos municípios para avaliação situacional e supervisão das atividades, avaliação da satisfação dos usuários e formação de lideranças populares. Observou-se a melhoria na organização dos serviços e estímulo ao fortalecimento do vínculo entre os usuários e prestadores de serviços. Essa experiência serviu como laboratório de aprendizagem e pesquisa, fazendo-se ciência a partir da vivência in loco da realidade do SUS e contribuindo para uma formação professional mais humanitária baseada em cenários reais.

Perceptions of quality of reproductive care services in Bolivia: use of photo prompts and surveys as an impetus for change

Surveys are sometimes used to assess women's perceptions of the quality of reproductive health care, but less empowered women may feel uncomfortable expressing their views in this method. We demonstrate the use of a participatory approach, combining a standard survey with an innovative photonarrative method. Women in Cochabamba, Bolivia, were asked to participate in exit surveys (n = 108). A subsample did photonarratives (n = 20). The survey showed rural women had less access to care, but photonarratives revealed the cause - fear. Women asserted quality of care was high, but photonarratives contradicted survey results. Staff used photonarratives to select action items for quality improvement.

Evaluating the Fabreville Heart Health Program in Laval, Canada: a dialogue between two paradigms, positivism and constructivism

As part of the Canadian Federal-Provincial Initiative in Heart Health, the goal of the Fabreville Heart Health Program was to sensitize a district of Laval, Quebec's second most populous city, to heart-healthy behaviours. The program was planned and implemented by a committee composed of Fabreville community leaders and professionals from the Public Health Department. Between 1992 and 1994, intervention objectives were defined by the department in terms of changing individual behaviours associated with cardiovascular risk factors, namely diet, sedentariness and smoking, as well as adapting physical and social environments to facilitate these changes. However, from 1994 to its conclusion in 1997, the program was re-oriented to engage the population in mobilizing their own community and taking charge of interventions themselves. Actions then became dependent on the interests and motivation of Fabreville residents to transform their lifestyles and aspects of their physical environment. The initial evaluation process, based on the positivist paradigm, was designed to measure changes in individual behaviours and certain physical environments, such as an increase in designated non-smoking areas. However, following the re-orientation towards community mobilization, it was decided that evaluation should go beyond the professional production of data to include a process of the collective construction of knowledge. Evaluation methodology then became based on the constructivist paradigm. Yet field constraints such as lack of community involvement in both leadership and process evaluation, and the need to ensure evaluation standards and fulfil sponsor obligations, compelled the Public Health Department to return to using a certain number of positivist methods. The ensuing inter-paradigm dialogue helped broaden the scope of evaluation and contributed to gaining a more in-depth understanding of the processes and outcomes of community mobilization.