Applying a Client-centered Approach to Maternal and Neonatal Networks of Care: Case Studies from Urban and Rural Nigeria

Institutionalizing linkages between informal healthcare providers and the formal health system in Nigeria: what are the facilitating and constraining contextual influences?

With most households in rapidly urbanizing cities in low- and medium-income countries using private and informal providers for basic healthcare, the need to establish linkages with the formal sector is paramount in the drive for universal health coverage. Successful and effective linkage of informal healthcare providers to the formal health system requires an understanding of prevailing contextual factors and how they can be modulated to support the linkages. Context plays a pivotal role in shaping the nature and success of any integration efforts. This paper, based on a qualitative study, explored the facilitating and constraining contextual influences shaping the linkage of informal healthcare providers into the formal health system in governance, service delivery, and data reporting. The research was conducted in Enugu and Anambra states in southeastern Nigeria. In-depth interviews were held with 12 senior healthcare managers, 16 primary healthcare facility managers, 32 informal providers, and 16 community leaders. Eight sex-disaggregated focus group discussions were held with health service users. Transcripts were coded in NVivo using a pre-defined coding framework comprising facilitators and constraints at the individual, organisational, and environmental levels. Individual factors that influence linkage of informal providers into the formal health system include personal attitudes towards linkage, capacity of informal providers to deliver quality services, nature of existing relationships between formal and informal providers, and trust in the formal health system. Organizational factors include leadership structure, coordination and accountability mechanisms, functional management capacity of the formal health system, and multiple regulatory frameworks. External factors include supportive health policies on integration, sustainable funding for continuous training and supportive supervision, and global agenda/support for integration. This study has provided valuable insights for decision makers and practitioners for harnessing the contextual factors to link informal healthcare providers successfully and effectively to the formal health system in order to improve access to quality health services in urban slums.

Collaboration between local authorities and civil society organisations for improving health: a scoping review

OBJECTIVES

Cross-sector collaboration has been encouraged to improve population health. Both local authorities and civil society organisations impact population health, but less is known about how the actual process of collaboration is done. This scoping review aims to explore how local authorities and civil society organisations collaborate with the ambition to improve population health.

DESIGN

This scoping review was informed by the guidance of the Joanna Briggs Institute, and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

DATA SOURCES

Medline, Web of Science, CINAHL and Sociological Abstracts were searched from inception to September 2022.

ELIGIBILITY CRITERIA

We included peer-reviewed empirical studies that describe the initiation, execution or sustainment of collaboration for health between local authorities and civil society organisations.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data, which was summarised and analysed using inductive content analysis.

RESULTS

In the 79 included articles, collaborations between local authorities and civil society organisations entailed many different aspects, from exchanging knowledge, allocating resources, providing different types of support or human resources, training, forming different working groups, agreements and working plans to gathering data for needs analysis or evaluation. Few articles described how the collaboration had been initiated or sustained. Initiation was done through advocacy, needs assessments, making a request, creating a workgroup and conducting a pilot study. Sustainment efforts were continuous meetings, documents and tools, funding, and different plans and work structures. There were often additional actors involved in the collaborations. Information about study design was often not described in a clear and comparative manner.

CONCLUSIONS

There is a need for more research on the details of initiating, executing and sustaining collaborations for health between local authorities and civil society organisations. Knowledge from this scoping review can be used to inform the planning of future collaborations between local authorities and civil society organisations.

Approaches to implementing and financing primary health care in Kenya: a case of seven counties

Background

Kenya has prioritized Primary Health Care as an indispensable foundation to realize UHC by 2022. Integral to this approach's operationalization is the adoption of the primary health care networks (PCNs) model to strengthen service delivery efficiency and coordination. The PCNs are coordinated by a Multidisciplinary Team (MDT). The MDT is dynamic and should comprise a care and support team that matches patient health needs and the catchment population. This scholarly article delineates the outcomes of an investigative assessment reviewing the current state and trajectory of PHC implementation, focusing on the PCN implementation, and analyzing PHC financing modalities in 7 counties in Kenya.

Methods

This study employed a mixed-methodological approach to gather data from seven counties; Garissa, Nyeri, Makueni, Vihiga, Kisumu, Nakuru, and Mombasa. Key informant interviews were conducted with county health officials and partners. Additionally, counties were supplied with templates for qualitative data. Data was subsequently analyzed using thematic analysis and descriptive statistics.

Results

Successful implementation of PCNs was positively correlated with robust county-level leadership, prioritization of PHC funding, intersectoral collaboration, and joint planning initiatives. Counties which had achieved high levels of community health unit (CHU) establishment and functionality were more adept at successfully mapping and operationalizing PCNs. All participating counties adopted Sub-County Health Management Teams (SCHMTs) as the MDTs due to staffing limitations at primary care facilities consequently inhibiting the capacity for effective MDT engagement. Fiscal commitments at the county level were imperative for facilitating the mobility of MDTs and orchestrating community outreach initiatives. Reimbursements from the National Hospital Insurance Fund (NHIF) served as a pivotal financial conduit for the sustenance of primary care facilities.

Conclusion

The study finds that robust leadership, funding, collaboration, and planning were crucial for the effective operationalization and financial structuring of PCNs. The study recommends that the county governments should invest more in PHC infrastructure, equipment, and supplies, as well as in strengthening the capacity and mobility of MDTs. The study also suggests that uptake of NHIF will enhance the sustainability of PCNs.

Improving complex health systems and lived environments for maternal and perinatal well-being in urban sub-Saharan Africa: the UrbanBirth Collective

While maternal mortality decreased during the Millennium Development Goals era, it remains unacceptably high, with stagnation in reductions possible due to shocks such as COVID-19. Most women in low- and middle-income countries already receive antenatal care and over half give birth in health facilities. In cities, use of health facilities for childbirth is near universal (>90%). Cities present complex challenges in ensuring pregnant women receive equitable, high-quality care. The UrbanBirth Collective is a portfolio of projects in sub-Saharan African cities seeking to address an important knowledge gap: how to adapt urban healthcare systems and lived environments to improve maternal and perinatal well-being? Its key focus is care during labour, childbirth, and the early postnatal period, when most poor maternal and perinatal outcomes occur. Our starting projects focus on harnessing open source data to examine and compare cities on the continent, including in-depth case studies of three cities: Grand Conakry (Guinea), Grand Nokoué metropolitan area (Benin), and Lubumbashi (Democratic Republic of the Congo), where we will capture and analyse three main dimensions of the dynamics: maternal health service provision; maternal healthcare use by women; and the complex, nonlinear interactions between the provision and use of care within the spatial, social, and political ecosystem of a city. By comparing these three cities, we shall propose a generalisable model which can be validated and applied in other cities in sub-Saharan Africa. The growth of cities demands increasing attention on future-proofing them with the capacity to develop, implement, and continuously adapt a coherent strategy for the provision of equitable maternal and newborn care. Our ambition is to contribute to reaching zero preventable maternal deaths in cities. To achieve these goals through understanding specific contexts and facilitating the adoption and application of research findings and recommendations, we will collaborate closely with local stakeholders, including healthcare workers, community leaders, and policymakers.

Networks of care for optimizing Primary Health Care Service Delivery in Ethiopia: Enhancing relational linkages and care coordination

INTRODUCTION

Ethiopia has made notable progress in reducing maternal and perinatal mortality, yet challenges remain in meeting the 2030 Sustainable Development Goals. Persistent issues such as low service utilization, coupled with poor quality, fragmented care, and ineffective referral systems hinder progress. The "Improve Primary Health Care Service Delivery (IPHCSD)" project, implemented by JSI and Amref Health Africa since April 2022, seeks to address these gaps through a Networks of Care (NoCs) approach. This paper describes the lessons learned from implementing the NoCs approach to optimize primary health care in Ethiopia.

METHODS

The project incorporates embedded implementation science, guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Key implementation strategies co-designed included strengthening community engagement, establishing NoCs, and introducing quality improvement initiatives using the Model for Improvement. Routine program monitoring data, NoCs process evaluation, and facility service statistics were utilized for this study. Service statistics were analyzed using Student's t-test and interrupted time-series analysis to compare maternal and child care outcomes before and after the NoCs intervention, with counterfactual estimates generated to assess the intervention's impact. Qualitative data from key informant interviews were transcribed, coded, and analyzed to identify themes and patterns using Atlas.ti.

RESULTS

The NoCs approach has significantly enhanced relational linkages between primary health care facilities and health care providers, fostering stronger collaboration and communication. This has fostered trust, improved care coordination, optimized primary health care performance, and increased health service utilization within woreda health systems. The interrupted time series analysis indicated that the rate of ANC 8+ visits was 29.8% per month higher than expected without the NoCs strategy (Coef: 2.39; p-value < 0.01) and an 18.4% increase in obstetric complications managed (Coef: 1.71; p-value = 0.050), with a 43% overall increase. Perinatal mortality decreased by 34%, from 31.3 to 20.1 per 1,000 births [t-test: 2.12; p-value: 0.040)].

CONCLUSION

The NoCs approach in Ethiopia has proven effective in enhancing the relational elements, care coordination, and quality of primary health care services, leading to better maternal and child health outcomes. The findings expand the existing body of research on NoCs implementation best practices and further confirm that it provides a scalable model for strengthening health services in low-resource settings.

Operational demonstration and process evaluation of non-pneumatic anti-shock garment (NASG) introduction to the public health system of Northern Province, Zambia

BACKGROUND

A disproportionate burden of maternal deaths occurs in low- and middle-income countries (LMICs), and obstetric hemorrhage (OH) is a leading cause of excess mortality. In Zambia, most of maternal deaths are directly caused by OH. The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that uses compression to the abdomen and lower body to stop and reverse hypovolemic shock secondary to OH. We describe the process and experiences introducing the NASG into the Zambia public health system to encourage the development of national policies, clinical guidelines, and implementation plans that feature the NASG.

METHODS

We conducted an observational study of NASG introduction to 143 public health facilities in Northern Province, Zambia, organizing observations into the five dimensions of the RE-AIM evaluation framework: reach, effectiveness, adoption, implementation, and maintenance. The NASG was introduced in August 2019, and the introduction was evaluated for 18 months. Data on healthcare worker training and mentorship, cases where NASG was used, and NASG availability and use during the study period were collected and analyzed.

RESULTS

The NASG was successfully introduced and integrated into the Zambia public health system, and appropriately used by healthcare workers when responding to cases of OH. Sixteen months after NASG introduction, NASGs were available and functional at 99% of study sites and 88% reported ever using a NASG. Of the 68 cases of recorded OH where a NASG was applied, 66 were confirmed as clinically appropriate, and among cases where shock index (SI) could be calculated, 59% had SI ≥ 0.9. Feedback from healthcare providers revealed that 97% thought introducing the NASG was a good decision, and 92% felt confident in their ability to apply the NASG after initial training. The RE-AIM average for this study was 0.65, suggesting a public health impact that is not equivocal, and that NASG introduction had a positive population-based effect.

CONCLUSIONS

A successful NASG demonstration took place over the course of 18 months in the existing health system of Northern Province, Zambia, suggesting that incorporation of NASG into the standard of care for obstetric emergency in the Zambia public sector is feasible and can be maintained without external support.

Developing an understanding of networks with a focus on LMIC health systems: How and why clinical and programmatic networks form and function to be able to change practices: A realist review

Networks are an increasingly employed approach to improve quality of care, service delivery, and health systems performance, particularly in low-and-middle income country (LMIC) health systems. The literature shows that networks can improve the provision and quality of services and health system functioning but there is limited evidence explaining how and why networks are established and work to achieve their reported results. We undertook a realist review to explore this. The objective of this realist review was to develop a programme theory outlining the underlying mechanisms and interactions of contexts that explain how and why a network's set-up and function enable high-quality care and services and improved clinical outcomes in LMIC health systems. We followed Pawson's five steps for realist reviews. The search strategy was based on a previously published scoping review with additional searches. Literature was selected based on its relevance to the programme theory and rigour. Context-mechanism-outcome configurations were developed from the extracted data to refine the initial programme theory with causal explanations. Theories on social movements and organisations supported the identification of mechanism and brought additional explanatory power to the programme theory. The programme theory explains how networks are initiated, formed, and function in a way that sets them up for network leadership and committed, engaged, and motivated network members to emerge and to change practices, which may lead to improved quality of care, service delivery, and clinical outcomes through the following phases: identify a problem, developing a collective vision, taking action to solve the problem, forming purposeful relationships, linkages, and partnerships, building a network identity and culture, and the creation of a psychological safe space. This deeper understanding of networks formation and functioning can lead to a more considered planning and implementation of networks, thereby improving health system functioning and performance.

Exploring networks of care in implementing midwife-led birthing centres in low- and middle-income countries: A scoping review

The evidence for the benefits of midwifery has grown over the past two decades and midwife-led birthing centres have been established in many countries. Midwife-led care can only make a sustained and large-scale contribution to improved maternal and newborn health outcomes if it is an integral part of the health care system but there are challenges to the establishment and operation of midwife-led birthing centres. A network of care (NOC) is a way of understanding the connections within a catchment area or region to ensure that service provision is effective and efficient. This review aims to evaluate whether a NOC framework-in light of the literature about midwife-led birthing centres-can be used to map the challenges, barriers and enablers with a focus on low-to-middle income countries. We searched nine academic databases and located 40 relevant studies published between January 2012 and February 2022. Information about the enablers and challenges to midwife-led birthing centres was mapped and analysed against a NOC framework. The analysis was based on the four domains of the NOC: 1) agreement and enabling environment, 2) operational standards, 3) quality, efficiency, and responsibility, 4) learning and adaptation, which together are thought to reflect the characteristics of an effective NOC.Of the 40 studies, half (n = 20) were from Brazil and South Africa. The others covered an additional 10 countries. The analysis showed that midwife-led birthing centres can provide high-quality care when the following NOC elements are in place: a positive policy environment, purposeful arrangements which ensure services are responsive to users' needs, an effective referral system to enable collaboration across different levels of health service and a competent workforce committed to a midwifery philosophy of care. Challenges to an effective NOC include lack of supportive policies, leadership, inter-facility and interprofessional collaboration and insufficient financing. The NOC framework can be a useful approach to identify the key areas of collaboration required for effective consultation and referral, to address the specific local needs of women and their families and identify areas for improvement in health services. The NOC framework could be used in the design and implementation of new midwife-led birthing centres.

Understanding networks in low-and middle-income countries' health systems: A scoping review

Networks are an often-employed approach to improve problems of poor service delivery and quality of care in sub-optimally functioning health systems. There are many types of health system networks reported in the literature and despite differences, there are identifiable common characteristics, uses, purposes, and stakeholders. This scoping review systematically searched the literature on networks in health systems to map the different types of networks to develop an understanding of what they are, when and what they are used for, and the purposes they intend to achieve. Peer-reviewed literature was systematically searched from six databases (Medline (Ovid), EMBASE (Ovid), Global Health (Ovid), the Cochrane Library, Web of Science Core Collection, Global Index Medicus's Africa Index Medicus) and grey literature was purposively searched. Data from the selected literature on network definitions, characteristics, stakeholders, uses, and purposes were charted. Drawing on existing frameworks and refining with the selected literature, a five-component framework (form and structure, governance and leadership, mode of functioning, resources, and communication), broadly characterizing a network, is proposed. The framework and mapping of uses, purposes, and stakeholders is a first step towards further understanding what networks are, when and what they are used for, and the purposes they intend to achieve in health systems.

Networks of Care: An Approach to Improving Maternal and Newborn Health

The Networks of Care approach has the potential to harmonize existing strategies and optimize health systems functions for maternal and newborn health, thereby strengthening the quality of care and ultimately improving outcomes.

Reducing maternal and neonatal mortality through integrated and sustainability-focused programming in Zambia

Reducing maternal and neonatal mortality is a critical health priority within Zambia and globally. Although evidence-based clinical interventions can prevent a majority of these deaths, scalable and sustainable delivery of interventions across low-resource settings remains uneven, particularly across rural and marginalized communities. The Zambian Ministry of Health and the Clinton Health Access Initiative implemented an integrated sexual, reproductive, maternal, and newborn health (SRMNH) program in Northern Province aimed at dramatically reducing mortality over four years. Interventions were implemented between 2018 and 2021 across 141 government-owned health facilities covering all 12 districts of Northern Province, the poorest performing province nationwide and home to over 1.4 million people, around six pillars of an integrated health system. Data on institutional delivery and antenatal and postnatal care were collected through the national Health Management Information System (HMIS). A community-based system for capturing birth outcomes was established using existing government tools and community volunteers since HMIS did not include community-based mortality. Baseline and endline population-based mortality rates were compared for program-supported areas. From the earliest period of population-based mortality reporting in 2019 to program end in 2021, there were statistically significant decreases of 41%, 45%, and 43% in maternal, neonatal, and perinatal mortality rates respectively. Between 2017 to 2021, institutional maternal, neonatal, and perinatal mortality rates across entirety of Northern Province reduced by 12%, 40%, and 41%, respectively. Service readiness and coverage for SRMNH services improved dramatically, supporting increased numbers of patients. Significant mortality reductions were achieved over a relatively short period, reinforced through an emphasis on sustainability and strengthening existing government systems. These results were attained through a consciously cost-efficient approach backed by substantially lower levels of external investment relative to prior programs, allowing many of the interventions to be successfully adopted by government within public sector budgets.