Global health initiatives in Africa - governance, priorities, harmonisation and alignment

Donor coordination to support universal health coverage in Malawi

Development assistance is a major source of financing for health in least developed countries. However, persistent aid fragmentation has led to inefficiencies and health inequities and constrained progress towards Universal Health Coverage (UHC). Malawi is a case study for this global challenge, with 55% of total health expenditure funded by donors and fragmentation across 166 financing sources and 265 implementing partners. This often leads to poor coordination and misalignment between government priorities and donor projects. To address these challenges, the Malawi Ministry of Health (MoH) has developed and implemented an architecture of aid coordination tools and processes. Using a case study approach, we documented the iterative development, implementation and institutionalization of these tools, which was led by the MoH with technical assistance from the Clinton Health Access Initiative. We reviewed the grey literature, including relevant policy documents, planning tools and databases of government/partner funding commitments, and drew upon the authors' experiences in designing, implementing and scaling up these tools. Overall, the iterative use and revision of these tools by the Government of Malawi across the national and subnational levels, including integration with the government's public financial management system, was critical to successful uptake. The tools are used to inform government and partner resource allocation decisions, assess financing and gaps for national and district plans and inform donor grant applications. As Malawi has launched the Health Sector Strategic Plan 2023-2030, these tools are being adapted for the 'One Plan, One Budget and One Report' approach. However, while the tools are an incremental mechanism to strengthen aid alignment, success has been constrained by the larger context of power imbalances and misaligned incentives between the donor community and the Government of Malawi. Reform of the aid architecture is therefore critical to ensure that these tools achieve maximum impact in Malawi's journey towards UHC.

Challenges in international health financing and implications for the new pandemic fund

BACKGROUND

The failures of the international COVID-19 response highlighted key gaps in pandemic preparedness and response (PPR). The G20 and WHO have called for additional funding of $10.5 billion per year to adequately strengthen the global PPR architecture. In response to these calls, in 2022 the World Bank announced the launch of a new Financial Intermediary Fund (The Pandemic Fund) to catalyse this additional funding. However, there is considerable unclarity regarding the governance makeup and financial modalities of the Pandemic Fund, and divergence of opinion about whether the Fund has been successfully designed to respond to key challenges in global health financing.

METHODS/RESULTS

The article outlines eight challenges associated with global health financing instruments and development aid for health within the global health literature. These include misaligned aid allocation; accountability; multistakeholder representation and participation; country ownership; donor coherency and fragmentation; transparency; power dynamics, and; anti-corruption. Using available information about the Pandemic Fund, the article positions the Pandemic Fund against these challenges to determine in what ways the financing instrument recognizes, addresses, partially addresses, or ignores them. The assessment argues that although the Pandemic Fund has adopted a few measures to recognise and address some of the challenges, overall, the Pandemic Fund has unclear policies in response to most of the challenges while leaving many unaddressed.

CONCLUSION

It remains unclear how the Pandemic Fund is explicitly addressing challenges widely recognized in the global health financing literature. Moreover, there is evidence that the Pandemic Fund might be exacerbating these global financing challenges, thus raising questions about its potential efficacy, suitability, and chances of success. In response, this article offers four sets of policy recommendations for how the Pandemic Fund and the PPR financing architecture might respond more effectively to the identified challenges.

mRNA vaccines: The future of prevention of viral infections?

Messenger RNA (mRNA) vaccines against COVID-19 are the first authorized biological preparations developed using this platform. During the pandemic, their administration has been proven to be a life-saving intervention. Here, we review the main advantages of using mRNA vaccines, identify further technological challenges to be met during the development of the mRNA platform, and provide an update on the clinical progress on leading mRNA vaccine candidates against different viruses that include influenza viruses, human immunodeficiency virus 1, respiratory syncytial virus, Nipah virus, Zika virus, human cytomegalovirus, and Epstein-Barr virus. The prospects and challenges of manufacturing mRNA vaccines in low-income countries are also discussed. The ongoing interest and research in mRNA technology are likely to overcome some existing challenges for this technology (e.g., related to storage conditions and immunogenicity of some components of lipid nanoparticles) and enhance the portfolio of vaccines against diseases for which classical formulations are already authorized. It may also open novel pathways of protection against infections and their consequences for which no safe and efficient immunization methods are currently available.

Medical Dominance in Global Health Institutions as an Obstacle to Equity and Effectiveness Comment on "Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process"

Medical professionals exercised structural and productive power in the Global Fund's Country Coordinating Mechanism (CCM) in Nigeria, directly impacting the selection of approaches to HIV/AIDS care, as described in a case study by Lassa and colleagues. This research contributes to a robust scholarship on how biomedical power inhibits a holistic understanding of health and prevents the adoption of solutions that are socially grounded, multi-disciplinary, and co-created with communities. We highlight Lassa and colleagues' findings demonstrating the 'long arm' of global health institutions in country-level health policy choices, and reflect on how medical dominance within global institutions serves as a tool of control in ways that pervert incentives and undermine equity and effectiveness. We call for increased research and advocacy to surface these conduits of power and begin to loosen their hold in the global health policy agenda.

Impact of COVID-19 Lock-Downs on Nature Connection in Southern and Eastern Africa

The response of African countries immediately after the COVID-19 pandemic declaration was rapid and appropriate, with low infections and mortality rates until June 2020. Severe lock-down measures were effective in Africa; however, the reduction in the amount of natural experience influences the quality of life in modern society. This study is conducted as an international comparative study in five African countries on changes in the perception of health recovery and outdoor activities in urban forests during the COVID-19 pandemic. An online survey was conducted with 430 respondents to investigate the relationships between COVID-19 stress, indoor activity, appreciation of greenspaces, perception of health recovery, and use of greenspaces. A structural equation model was used for analysis. The visit frequency and staying time in urban forests after lock-down dramatically decreased, raising concerns about nature-deficit disorder across the target countries after the end of the pandemic. This study confirmed urban dwellers’ desire for natural experiences and health recovery during the pandemic and predicts an explosive increase in urban forest utilization after the pandemic has ended.

Contributing to collaborative health governance in Africa: a realist evaluation of the Universal Health Coverage Partnership

Background

Policy dialogue, a collaborative governance mechanism, has raised interest among international stakeholders. They see it as a means to strengthen health systems governance and to participate in the development of health policies that support universal health coverage. In this context, WHO has set up the Universal Health Coverage Partnership. This Partnership aims to support health ministries in establishing inclusive, participatory, and evidence-informed policy dialogue. The general purpose of our study is to understand how and in what contexts the Partnership may support policy dialogue and with what outcomes. More specifically, our study aims to answer two questions: 1) How and in what contexts may the Partnership initiate and nurture policy dialogue? 2) How do collaboration dynamics unfold within policy dialogue supported by the Partnership? 

Methods

We conducted a multiple-case study realist evaluation based on Emerson’s integrative framework for collaborative governance to investigate the role of the Partnership in policy dialogue on three policy issues in six sub-Saharan African countries: health financing (Burkina Faso and Democratic Republic of Congo), health planning (Cabo Verde, Niger, and Togo), and aid coordination for health (Liberia). We interviewed 121 key informants, analyzed policy documents, and observed policy dialogue events.

Results

The Partnership may facilitate the initiation of policy dialogue when: 1) stakeholders feel uncertain about health sector issues and acknowledge their interdependence in responding to such issues, and 2) policy dialogue coincides with their needs and interests. In this context, policy dialogue enables stakeholders to build a shared understanding of issues and of the need for action and encourages collective leadership. However, ministries’ weak ownership of policy dialogue and stakeholders’ lack of confidence in their capacity for joint action hinder their engagement and curb the institutionalization of policy dialogue.

Conclusions

Development aid actors wishing to support policy dialogue must do so over the long term so that collaborative governance becomes routine and a culture of collaboration has time to grow. Public administrations should develop collaborative governance mechanisms that are transparent and intelligible in order to facilitate stakeholder engagement.

The Role of African Nurse Diaspora in Addressing Public Health Priorities in Africa

African countries experience many complex public health challenges that, to tackle, require coordinated, multi-stakeholder, collaborative partnerships at local and global levels. The African nurse diaspora is a strategic stakeholder, contributor, and liaison to public health interventions, given their roots in the continent, their professional connections in the west, and their ability to build an extensive network of global partners. Using a descriptive qualitative approach that amplifies the voices of the Africa nurse diaspora, this study provides an insider view of the continent’s public health priorities and what roles the diaspora can play to improve health and population outcomes. Findings show that Africa’s high disease burden is generally preventable but compounded by enduring socioeconomic challenges. Against this situation, African-born nurses in the diaspora are uniquely positioned to mobilize both local and global stakeholders in coordinated global health policy interventions and actively engage communities in preventive care while earning their trust.

Data and information needs of policymakers for palliative cancer care: a multi-country qualitative study

Background

Despite regional efforts to address concerns regarding the burden of advanced cancer in Africa, urgent attention is still required. Widespread issues include late symptom presentation, inaccessibility of palliative care services, limited resources, poor data quality, disparity in data availability, and lack of stakeholder engagement. One way of helping to address these issues is by understanding and meeting the data and information needs of policymakers in palliative cancer care.

Aims

To explore the views of policymakers regarding data availability, data gaps and preferred data formats to support policy and decision making for palliative cancer care in Nigeria, Uganda and Zimbabwe.

Methods

A secondary analysis of interview data collected as part of a cross-sectional qualitative study that aimed to explore the data and information needs of patients, policymakers and caregivers in Nigeria, Uganda and Zimbabwe. Framework analysis, guided by the MEASURE evaluation framework, was used to qualitatively analyse the data.

Results

Twenty-six policymakers were recruited. The policymakers data and information concerns are aligned to the MEASURE evaluation framework of data and information use and include; assessing and improving data use (e.g. low prioritisation of cancer); identifying and engaging the data user (e.g. data processes); improving data quality (e.g. manual data collection processes); improving data availability (e.g. the accessibility of data); identifying information needs (e.g. what is ‘need to know’?); capacity building in core competencies (e.g. skills gaps); strengthening organisational data demand and use (e.g. policy frameworks); monitoring, evaluating and communicating of data demand and use (e.g. trustworthiness of data).

Conclusions

We present evidence of data sources, challenges to their access and use, guidance on data needs for policymakers, and opportunities for better engagement between data producers, brokers and users. This framework of evidence should inform the development of strategies to improve data access and use for policy and decision making to improve palliative cancer services in participating countries with relevance to the wider region.

Barriers and facilitators of facility-based kangaroo mother care in sub-Saharan Africa: a systematic review

Background

Hospital-based kangaroo mother care can help reduce preventable newborn deaths and has been recommended by the World Health Organization in the care of low birthweight babies weighing 2000 g or less. However, implementation has been limited. The objective of this review is to understand the barriers and facilitators of kangaroo mother care implementation in health facilities in sub-Saharan Africa, where there are the highest rates of neonatal mortality in the world.

Methods

A systematic search was performed on MEDLINE, Web of Science, Cumulative Index to Nursing and Allied Health, African Journals Online, African Index Medicus as well as the references of relevant articles. Inclusion criteria included primary research, facility-based kangaroo mother care in sub-Saharan Africa. Studies were assessed by the Critical Appraisal Skills Programme Qualitative Checklist and the National Institutes of Health quality assessment tools and underwent narrative synthesis.

Results

Thirty studies were included in the review. This review examined barriers and facilitators to kangaroo mother care practice at health systems level, health worker experiences and perspectives of mothers and their families. Strong local leadership was essential to overcome barriers of inadequate space, limited budget for supplies, inadequate staffing, lack of guidelines and policies and insufficient supportive supervision. Workload burdens, knowledge gaps and staff attitudes were highlighted as challenges at health workers’ level, which could be supported by sharing of best practices and success stories. Support for mothers and their families was also identified as a gap.

Conclusion

Building momentum for kangaroo mother care in health facilities in sub-Saharan Africa continues to be a challenge. Strengthening health systems and communication, prioritizing preterm infant care in public health strategies and supporting health workers and mothers and their families as partners in care are important to scale up. This will support sustainable kangaroo mother care implementation as well as strengthen quality of newborn care overall. PROSPERO registration: CRD42020166742.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03646-3.

Does the gap between health workers' expectations and the realities of implementing a performance-based financing project in Mali create frustration?

Background

Performance-Based Financing (PBF), an innovative health financing initiative, was recently implemented in Mali. PBF aims to improve quality of care by motivating health workers. The purpose of this research was to identify and understand how health workers’ expectations related to their experiences of the first cycle of payment of PBF subsidies, and how this experience affected their motivation and sentiments towards the intervention. We pose the research question, “how does the process of PBF subsidies impact the motivation of health workers in Mali?”

Methods

We adopted a qualitative approach using multiple case studies. We chose three district hospitals (DH 1, 2 and 3) in three health districts (district 1, 2 and 3) among the ten in the Koulikoro region. Our cases correspond to the three DHs. We followed the principle of data source triangulation; we used 53 semi-directive interviews conducted with health workers (to follow the principle of saturuation), field notes, and documents relating to the distribution grids of subsidies for each DH. We analyzed data in a mixed deductive and inductive manner.

Results

The results show that the PBF subsidies led to health workers feeling more motivated to perform their tasks overall. Beyond financial motivation, this was primarily due to PBF allowing them to work more efficiently. However, respondents perceived a discrepancy between the efforts made and the subsidies received. The fact that their expectations were not met led to a sense of frustration and disappointment. Similarly, the way in which the subsidies were distributed and the lack of transparency in the distribution process led to feelings of unfairness among the vast majority of respondents. The results show that frustrations can build up in the early days of the intervention.

Conclusion

The PBF implementation in Mali left health workers frustrated. The short overall implementation period did not allow actors to adjust their initial expectations and motivational responses, neither positive nor negative. This underlines how short-term interventions might not just lack impact, but instil negative sentiments likely to carry on into the future.

Addressing Africa's pandemic puzzle: Perspectives on COVID-19 transmission and mortality in sub-Saharan Africa

To date, SARS-CoV-2 (the virus that causes COVID-19) has spread to almost every region of the world, infecting millions and resulting in the deaths of hundreds of thousands of people. Although it was predicted that Africa would suffer a massive loss of life due to this pandemic, the number of COVID-19 cases has been relatively low across the continent. Researchers have speculated that several factors may be responsible for this outcome in Africa, including the extensive experience that countries have with infectious diseases and the young median age of their populations. However, it is still important for African countries to adopt aggressive and bold approaches against COVID-19, in case the nature of the pandemic changes. This short review will summarize the status of the outbreak in Africa and propose possible reasons for current trends, as well as discuss interventions aimed at preventing a rapid increase in the number of COVID-19 cases in the future.

Planning universal accessibility to public health care in sub-Saharan Africa

Achieving universal health care coverage-a key target of the United Nations Sustainable Development Goal number 3-requires accessibility to health care services for all. Currently, in sub-Saharan Africa, at least one-sixth of the population lives more than 2 h away from a public hospital, and one in eight people is no less than 1 h away from the nearest health center. We combine high-resolution data on the location of different typologies of public health care facilities [J. Maina et al., Sci. Data 6, 134 (2019)] with population distribution maps and terrain-specific accessibility algorithms to develop a multiobjective geographic information system framework for assessing the optimal allocation of new health care facilities and assessing hospitals expansion requirements. The proposed methodology ensures universal accessibility to public health care services within prespecified travel times while guaranteeing sufficient available hospital beds. Our analysis suggests that to meet commonly accepted universal health care accessibility targets, sub-Saharan African countries will need to build ∼6,200 new facilities by 2030. We also estimate that about 2.5 million new hospital beds need to be allocated between new facilities and ∼1,100 existing structures that require expansion or densification. Optimized location, type, and capacity of each facility can be explored in an interactive dashboard. Our methodology and the results of our analysis can inform local policy makers in their assessment and prioritization of health care infrastructure. This is particularly relevant to tackle health care accessibility inequality, which is not only prominent within and between countries of sub-Saharan Africa but also, relative to the level of service provided by health care facilities.

Challenges to effective governance in a low income healthcare system: a qualitative study of stakeholder perceptions in Malawi

Background

All countries face challenging decisions about healthcare coverage. Malawi has committed to achieving Universal Health Coverage (UHC) by 2030, the timeframe set out by the Sustainable Development Goals (SDGs). As in other low income countries, scarce resources stand in the way of more equitable health access and quality in Malawi. Its health sector is highly dependent on donor contributions, and recent poor governance of government-funded healthcare saw donors withdraw funding, limiting services and resources. The 2017 National Health Plan II and accompanying Health Strategic Plan II identify the importance of improved governance and strategies to achieve more effective cooperation with stakeholders. This study explores health sector stakeholders’ perceptions of the challenges to improving governance in Malawi’s national health system within the post-2017 context of government attempts to articulate a way forward.

Methods

A qualitative study design was used. Interviews were conducted with 22 representatives of major international and faith-based non-government organisations, civil society organisations, local government and government-funded organisations, and governance bodies operating in Malawi. Open questions were asked about experiences and perceptions of the functioning of the health system and healthcare decision-making. Content relating to healthcare governance was identified in the transcripts and field notes and analysed using inductive content analysis.

Results

Stakeholders view governance challenges as a significant barrier to achieving a more effective and equitable health system. Three categories were identified: accountability (enforceability; answerability; stakeholder-led initiatives); health resource management (healthcare financing; drug supply); influence in decision-making (unequal power; stakeholder engagement).

Conclusions

Health sector stakeholders see serious political, structural, and financial challenges to improving governance in the national health system in Malawi which will impact the government’s goal of achieving UHC by 2030. Stakeholders identify the need for improved oversight, implementation, service delivery and social accountability of government-funded service providers to communities. Eighteen months after the introduction of the policy documents, they see little evidence of improved governance and have little or no confidence in the government’s ability to deliver UHC. The difficulties stakeholders perceive in relation to building equitable and effective healthcare governance in Malawi have relevance for other resource-limited countries which have also committed to the goal of UHC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06002-x.

Expansion of HIV testing in Eswatini: stakeholder perspectives on reaching the first 90

Achieving the United Nations' 90-90-90 goals has proven challenging in most settings and the ambitious 95-95-95 goals seem even more elusive. However, in Eswatini - a lower-middle-income country in sub-Saharan Africa with the highest HIV prevalence in the world - an estimated 92% of people living with HIV know their status. We conducted 26 in-depth interviews with stakeholders from policy, implementation, donor, local advocacy and academic sectors to elicit the facilitators and inhibitors to HIV testing uptake in Eswatini. Background data and related reports and policy documents (n = 57) were also reviewed. Essential facilitators included good governance via institutional and national budgetary commitments, which often led to swift adoption of globally recommended programs and standards. The integration of HIV testing into all points of care fostered a sense that testing was part of routine care, which reduced stigma. Challenges, however, centred on social norms that disadvantage certain groups with high ongoing HIV risk (such as key populations, adolescent girls and young women), a heavy reliance on external donor funding, and stigma that had subsided but nevertheless persisted. Amid concerns about whether the 90-90-90 targets could be achieved by 2020, the experience of Eswatini provides tangible insights into factors that have successfully influenced HIV testing uptake and may thus prove informative for other countries.

The network approach to laboratory procurement and supply chain management: Addressing the system issues to enhance HIV viral load scale-up

Investment in viral load scale-up in order to control the HIV epidemic and meet the Joint United Nations Programme on HIV and AIDS (UNAIDS) '90-90-90' goals has prompted the President's Emergency Plan for AIDS Relief and countries to increase their investment in viral load and infant virological testing. This has resulted in the increased procurement of molecular-based instruments, with many countries having challenges to effectively procure and place these products. In response to these challenges, the global laboratory stakeholder community has developed an informed 'network approach' to guide placement strategies. This article defines and describes the 'network approach' for laboratory procurement and supply chain management to assist countries in developing a strategic instrument procurement and placement strategy. The four key pillars of the approach should be performed in a stepwise fashion, with regular reviews. The approach is comprised of (1) laboratory network optimisation, (2) forecasting and supply planning, (3) the development of effective procurement and strategic sourcing to develop 'all-inclusive' contracts that provide transparent pricing, and the establishment of clear service and maintenance expectations and key performance indicators and (4) performance management to increase communication and planning, and promote issue resolution. Investments in the network approach will enable countries to strengthen laboratory systems and ready them for future laboratory needs. These disease-agnostic networks will be poised to improve overall national disease surveillance and assist countries in responding to disease outbreaks and other chronic diseases.

Management of mothers and neonates in low resources setting during covid-19 pandemia

The coronavirus disease (COVID-19) epidemic started in the Hubei province of China, but is rapidly spreading all over the world. Much of the information and literature have been centered on the adult population while a few reports pertaining to COVID-19 and neonates have been published so far. Actual guidelines are based on expert opinion and show significant differences among the official neonatal societies around the world. Recommendations for the care of neonates born to suspected or confirmed COVD-19 positive mothers in low-resource settings are very limited. This perspective aims to provide practical support for the planning of delivery, resuscitating, stabilizing, and providing postnatal care to an infant born to a mother with suspected or confirmed COVID-19 in low-resource settings where resources for managing emergency situations are limited.

Integrating pharmaceutical systems strengthening in the current global health scenario: three 'uncomfortable truths'

The response to emergency public health challenges such as HIV, TB, and malaria has been successful in mobilising resources and scaling up treatment for communicable diseases. However, many of the remaining challenges in improving access to and appropriate use of medicines and services require pharmaceutical systems strengthening. Incorporating pharmaceutical systems strengthening into global health programmes requires recognition of a few ‘truths’. Systems strengthening is a lengthy and resource-intensive process that requires sustained engagement, which may not align with the short time frame for achieving targets in vertical-oriented programmes. Further, there is a lack of clarity on what key metrics associated with population and patient level outcomes should be tracked for systems strengthening interventions. This can hinder advocacy and communication with decision makers regarding health systems investments. Moving forward, it is important to find ways to balance the inherent tensions between the short-term focus on the efficiency of vertical programmes and broader, longer-term health and development objectives. Global health programme design should also shift away from a narrow view of medicines primarily as an input commodity to a more comprehensive view that recognizes the various structures and processes and their interactions within the broader health system that help ensure access to and appropriate use of medicines and related services.

Insights for the future of health system partnerships in low- and middle-income countries: a systematic literature review

BACKGROUND

Despite growing support for the private sector involvement in the provision of public health services in Low- and Middle-Income Countries (LMICs), a lack of clear information on the future of the provision of such services restricts the ability of managers and policy-makers to assess how feasible integration between public and private actors may be in these countries. This paper presents a systematic literature review which traces the dynamics and boundaries of public-private partnerships for the healthcare sector in LMICs.

METHODS

A total of 723 articles indexed in Scopus were initially submitted to bibliometric analysis. Finally, 148 articles published in several academic journals were selected for independent full-text review by two researchers. Content analysis was made in order to minimise mistakes in interpreting the findings of studies in the sample.

RESULTS

Public-private partnerships identified through the content analysis were categorised into four research areas: 1) Transfer of resources; 2) Co-production of health goods and services; 3) Governance networks; 4) Criteria for successful partnership development.

CONCLUSIONS

The four main research areas supply suggestions for a future research agenda, and managerial and policy implications for partnerships in LMICs.

Health systems strengthening to optimise scale-up in global mental health in low- and middle-income countries: lessons from the frontlines. A re-appraisal

Against the backdrop of mounting calls for the global scaling-up of mental health services - including quality care and prevention services - there is very little guidance internationally on strategies for scaling-up such services. Drawing on lessons from scale-up attempts in six low- and middle-income countries, and using exemplars from the front-lines in South Africa, we illustrate how health reforms towards people-centred chronic disease management provide enabling policy window opportunities for embedding mental health scale-up strategies into these reforms. Rather than going down the oft-trodden road of vertical funding for scale-up of mental health services, we suggest using the policy window that stresses global policy shifts towards strengthening of comprehensive integrated primary health care systems that are responsive to multimorbid chronic conditions. This is indeed a substantial opportunity to firmly locate mental health within these horizontal health systems strengthening funding agendas. Although this approach will promote systems more enabling of scaling-up of mental health services, implications for donor funders and researchers alike is the need for increased time commitments, resources and investment in local control.

Pharmacotherapy for hypertension in Sub-Saharan Africa: a systematic review and network meta-analysis

BACKGROUND

The highest burden of hypertension is found in Sub-Saharan Africa (SSA) with a threefold greater mortality from stroke and other associated diseases. Ethnicity is known to influence the response to antihypertensives, especially in black populations living in North America and Europe. We sought to outline the impact of all commonly used pharmacological agents on both blood pressure reduction and cardiovascular morbidity and mortality in SSA.

METHODS

We used similar criteria to previous large meta-analyses of blood pressure agents but restricted results to populations in SSA. Quality of evidence was assessed using a risk of bias tool. Network meta-analysis with random effects was used to compare the effects across interventions and meta-regression to explore participant heterogeneity.

RESULTS

Thirty-two studies of 2860 participants were identified. Most were small studies from single, urban centres. Compared with placebo, any pharmacotherapy lowered SBP/DBP by 8.51/8.04 mmHg, and calcium channel blockers (CCBs) were the most efficacious first-line agent with 18.46/11.6 mmHg reduction. Fewer studies assessing combination therapy were available, but there was a trend towards superiority for CCBs plus ACE inhibitors or diuretics compared to other combinations. No studies examined the effect of antihypertensive therapy on morbidity or mortality outcomes.

CONCLUSION

Evidence broadly supports current guidelines and provides a clear rationale for promoting CCBs as first-line agents and early initiation of combination therapy. However, there is a clear requirement for more evidence to provide a nuanced understanding of stroke and other cardiovascular disease prevention amongst diverse populations on the continent.

TRIAL REGISTRATION

PROSPERO, CRD42019122490. This review was registered in January 2019.

Health systems strengthening to optimise scale-up in global mental health in low- and middle-income countries: lessons from the frontlines

Against the backdrop of mounting calls for the global scaling-up of mental health services - including quality care and prevention services - there is very little guidance internationally on strategies for scaling-up such services. Drawing on lessons from scale-up attempts in six low- and middle-income countries (LMICs), and using exemplars from the front-lines in South Africa; we illustrate how health reforms towards people-centred chronic disease management provide enabling policy window opportunities for embedding mental health scale-up strategies into these reforms. Rather than going down the oft-trodden road of vertical funding for scale-up of mental health services, we suggest using the policy window that stresses global policy shifts towards strengthening of comprehensive integrated primary health care systems that are responsive to multimorbid chronic conditions. This is indeed a substantial opportunity to firmly locate mental health within these horizontal health systems strengthening funding agendas. While this approach will promote systems more enabling of scaling up of mental health services, implications for donor funders and researchers alike is the need for increased time commitments, resources and investment in local control.

HIV pre-exposure prophylaxis for female sex workers: ensuring women's family planning needs are not left behind

INTRODUCTION

Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs.

DISCUSSION

FSWs have high unmet need for effective contraception and unintended pregnancy is common in low- and middle-income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk-taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single-focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real-life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two-fold increase in condomless sex among FSWs on PrEP, which, given low use of non-barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW-focused community-based HIV services is likely to be the most effective model for improving access to non-barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed.

CONCLUSIONS

As PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women's rights.

Public health system challenges in the Free State, South Africa: a situation appraisal to inform health system strengthening

Background

Since the advent of democracy, the South African government has been putting charters, policies, strategies and plans in place in an effort to strengthen public health system performance and enhance service delivery. However, public health programme performance and outcomes remained poor while the burden of disease increased. This was also the case in the Free State Province, where major public health system challenges occurred around 2012. Assessment was necessary in order to inform health system strengthening.

Methods

The study entailed a multi-method situation appraisal utilising information collated in 44 reports generated in 2013 through presentations by unit managers, subdistrict assessments by district clinical specialist teams, and group discussions with district managers, clinic supervisors, primary health care managers and chief executive and clinical officers of hospitals. These data were validated through community and provincial health indabas including non-governmental organisations, councils and academics, as well as unannounced facility visits involving discussions with a wide range of functionaries and patients. The reports were reviewed using the World Health Organization health system building blocks as a priori themes with subsequent identification of emerging subthemes. Data from the different methods employed were triangulated in a causal loop diagram showing the complex interactions between the components of an (in) effective health system.

Results

The major subthemes or challenges that emerged under each a priori theme included: firstly, under the ‘service delivery’ a priori theme, ‘fragmentation of health services’ (42 reports); secondly, under the ‘health workforce’ a priori theme, ‘staff shortages’ (39 reports); thirdly, under the ‘health financing’ a priori theme, ‘financial/cash-flow problems’ (39 reports); fourthly, under the ‘leadership and governance’ a priori theme, ‘risk to patient care’ (38 reports); fifthly, under the ‘medical products/technologies’ a priori theme, ‘dysfunctional communication technology’ (27 reports); and, sixthly, under the ‘information’ a priori theme, ‘poor information management’ (26 reports).

Conclusion

The major overall public health system challenges reported by stakeholders involved fragmentation of services, staff shortages and financial/cash-flow problems. In order to effect health systems strengthening there was particularly a need to improve integration and address human and financial deficiencies in this setting.

After the Astana declaration: is comprehensive primary health care set for success this time?

Primary health care (PHC) strengthening in order to achieve the Sustainable Development Goal has again, 40 years after the Alma-Ata declaration, been declared a priority by the global health community. Despite initial progress the Alma-Ata vision of Health for All by the year 2000 was not realised. In this analysis we (1) examine the challenges that comprehensive PHC faced after the Alma-Ata declaration, (2) provide an analysis of the current opportunities and threats to comprehensive PHC strengthening on the global, national and community level and (3) review the most important policy recommendations and related evidence to address these threats for success of the Astana declaration. Factors that are predominantly opportunities are the treasure of historical lessons from the past 40 years, the increased attention to social and environmental determinants of health, the global economic growth and new technologies, in particular digital medicine, which also have the potential to revolutionise community involvement. Factors that are currently predominantly threats are insecurity, conflicts and disease outbreaks; lack of sustained political commitment and inappropriate monitoring and evaluation structures; inappropriate and unsustainable financing models; insufficient health workforce recruitment, employment and retention; missing support of physicians and their professional organisations; inadequately addressing the needs of the community and not giving attention to gender equity. In contrast to the policy and evidence context in 1978 when Alma-Ata was passed there are today policy recommendations and a large body of evidence that can address the threats to comprehensive PHC-and turn them into opportunities.

Inclusive engagement for health and development or 'political theatre': results from case studies examining mechanisms for country ownership in Global Fund processes in Malawi, Tanzania and Zimbabwe

Background

For many countries, including Malawi, Tanzania and Zimbabwe, 2017 was a transition year for support from the Global Fund to Fight AIDS, Tuberculosis and Malaria as one funding cycle closed and another would begin in 2018. Since its inception in 2001, the Global Fund has required that countries demonstrate ownership and transparency in the development of their funding requests through specific processes for inclusive, deliberative engagement led by Country Coordinating Mechanisms (CCMs). In reporting results from case study research, the article explores whether, in the context of the three countries, such requirements continue to be fit-for-purpose given difficult choices to be made for financing and sustaining their HIV programmes.

Results

The findings show how complex, competing priorities for limited resources increasingly strain processes for inclusive deliberation, a core feature of the Global Fund model. Each country has chosen expansion of HIV treatment programmes as its main strategy for epidemic control relying almost exclusively on external funding sources for support. This step has, in effect, pre-committed HIV funding, whether available or not, well into the future. It has also largely pre-empted the results of inclusive dialogue on how to allocate Global Fund resources. As a result, such processes may be entering the realm of ‘political theatre,’ or processes for processes’ sake alone, rather than being important opportunities where critical decisions regarding priorities for national HIV programmes and how they are funded could or should be made.

Conclusion

To address this, the Global Fund has begun an initiative to shore-up the capabilities of CCMs, with specialised technical and financial support, so that they can both grasp and influence the overall financing and sustainability of HIV programmes, rather than focussing on Global Fund programmes alone. What stronger CCMs could achieve, given the growing HIV-treatment-related commitments in these three countries, remains to be seen. Starting in 2020, the three countries will discover what resources the Global Fund will have for them for the 2021–2023 period. The resource needs for expanding HIV treatment programmes for this period are already foreseeable leaving few if any options for future deliberation should funding from the Global Fund and others not grow at a similar pace.

Electronic supplementary material

The online version of this article (10.1186/s12992-019-0475-9) contains supplementary material, which is available to authorized users.

A decade of aid coordination in post-conflict Burundi's health sector

BACKGROUND

The launch of Global Health Initiatives in early 2000' coincided with the end of the war in Burundi. The first large amount of funding the country received was ear-marked for human immunodeficiency virus (HIV) and immunization programs. Thereafter, when at global level aid effectiveness increasingly gained attention, coordination mechanisms started to be implemented at national level.

METHODS

This in-depth case study provides a description of stakeholders at national level, operating in the health sector from early 2000' onwards, and an analysis of coordination mechanisms and stakeholders perception of these mechanisms. The study was qualitative in nature, with data consisting of interviews conducted at national level in 2009, combined with document analysis over a 10 year-period.

RESULTS

One main finding was that HIV epidemic awareness at global level shaped the very core of the governance in Burundi, with the establishment of two separate HIV and health sectors. This led to complex, nay impossible, inter-institutional relationships, hampering aid coordination. The stakeholder analysis showed that the meanings given to 'coordination' differed from one stakeholder to another. Coordination was strongly related to a centralization of power into the Ministry of Health's hands, and all stakeholders feared that they may experience a loss of power vis-à-vis others within the development field, in terms of access to resources. All actors agreed that the lack of coordination was partly related to the lack of leadership and vision on the part of the Ministry of Health. That being said, the Ministry of Health itself also did not consider itself as a suitable coordinator.

CONCLUSIONS

During the post-conflict period in Burundi, the Ministry of Health was unable to take a central role in coordination. It was caught between the increasing involvement of donors in the policy making process in a so-called fragile state, the mistrust towards it from internal and external stakeholders, and the global pressure on Paris Declaration implementation, and this fundamentally undermined coordination in the health sector.

Understanding the persistence of vertical (stand-alone) HIV clinics in the health system in Uganda: a qualitative synthesis of patient and provider perspectives

Background

Although there is mounting evidence and policy guidance urging the integration of HIV services into general health systems in countries with a high HIV burden, vertical (stand-alone) HIV clinics are still common in Uganda. We sought to describe the specific contexts underpinning the endurance of vertical HIV clinics in Uganda.

Methods

A qualitative research design was adopted. Semi-structured interviews were conducted with the heads of HIV clinics, clinicians and facility in-charges (n = 78), coupled with eight focus group discussions (64 participants) with patients from 16 health facilities purposively selected, from a nationally-representative sample of 195 health facilities across Uganda, because they run stand-alone HIV clinics. Data were analyzed by thematic approach as guided by the theory proposed by Shediac-Rizkallah & Bone (1998) which identifies; Intervention characteristics, organizational context, and broader environment factors as potentially influential on health programme sustainability.

Results

Intervention characteristics: Provider stigma was reported to have been widespread in the integrated care experience of participating health facilities which necessitated the establishment of stand-alone HIV clinics. HIV disease management was described as highly specialized which necessitated a dedicated workforce and vertical HIV infrastructure such as counselling rooms. Organizational context: Participating health facilities reported health-system capacity constraints in implementing integrated systems of care due to a shortage of ART-proficient personnel and physical space, a lack of laboratory capacity to concurrently conduct HIV and non-HIV tests and increased workloads associated with implementing integrated care. Broader environment factors: Escalating HIV client loads and external HIV funding architectures were perceived to have perpetuated verticalized HIV programming over the past decade.

Conclusion

Our study offers in-depth, contextualized insights into the factors contributing to the endurance of vertical HIV clinics in Uganda. Our analysis suggests that there is a complex interaction in supply-side constraints (shortage of ART-proficient personnel, increased workloads, laboratory capacity deficiencies) and demand-side factors (escalating demand for HIV services, psychosocial barriers to HIV care) as well as the specialized nature of HIV disease management which pose challenges to the integrated-health services agenda.

Moving towards universal health coverage: The need for a strengthened planning process

As countries embrace the ambitious universal health coverage (UHC) agenda whose major tenents include reaching everyone with the needed good quality services, strengthening the planning process to work towards a common objective is paramount. Drawing from country experiences-Swaziland and Zanzibar, we reviewed strategic planning processes to assess the extent to which they impact on realising alignment towards a collective health sector objective. Employing qualitative approaches, we reviewed strategic plans under implementation in the health sector and using an interview guide consisting of open-ended questions, interviewed key informants at the national and district level. Results showed that strategic plans are too many with majority of program strategies not well aligned to the health sector strategic plan, are not costed, and there overlaps in objectives among the several strategies addressing the same program. Weaknesses in the development process, perceived poor quality of the strategies, limited capacity, high staff turnover, and inadequate funding were the identified challenges that abate the utility of the strategic plans. Moving towards UHC starts with a robust planning process that rallies all actors and all available resources around a common objective. The planning process should be strengthened through ensuring participatory processes, evidence informed prioritisation, MoH institutional capacity to lead the process, and consideration for implementation feasibility. Flexibility to take into consideration emerging evidence and new developments in global health needs consideration.

Measles control in Australia - threats, opportunities and future needs

Control of measles was the focus of a national workshop held in 2015 in Sydney, Australia, bringing together stakeholders in disease control and immunisation to discuss maintaining Australia's measles elimination status in the context of regional and global measles control. The global epidemiology of measles was reviewed, including outbreaks in countries that have achieved elimination, such as the Disneyland outbreak in the United States and large outbreaks in Sydney, Australia. Transmission of measles between Australia and New Zealand occurs, but has not been a focus of control measures. Risk groups, the genetic and seroepidemiology of measles as well as surveillance, modelling and waning vaccine-induced immunity were reviewed. Gaps in policy, research and practice for maintaining measles elimination status in Australia were identified and recommendations were developed. Elimination of measles globally is challenging because of the infectiousness of measles and the need for 2-dose vaccine coverage rates in excess of 95% in all countries to achieve it. Until this occurs, international travel will continue to permit measles importation from endemic countries to countries that have achieved elimination. When measles cases are imported, failure to diagnose and isolate cases places the health system at risk of measles outbreaks. Vaccine funding models can result in gaps in vaccine coverage for adults and migrants. Australia introduced a whole-of-life immunisation register in 2016 and catch-up vaccination for at-risk communities, which will improve measles control. Research on diagnosis, immunology, case management and modelling of vaccination strategies are important to ensure continued control of measles.

"What the mind does not know, the eyes do not see". Placing food allergy risk in sub-Saharan Africa

Policy makers and health geographers are increasingly intrigued by the global rise of chronic disease. While current engagement coalesce around cardiovascular disease, cancers, chronic respiratory disease, and diabetes, very little attention has been given to other important chronic conditions: e.g., allergic disease. Concerns about how health is shaped by context and experienced in place can provide important insights to understand the trajectory of allergic disease and inform policy especially in developing countries experiencing an epidemiologic transition. Using Ghana as a case study. this paper draw on theories of political ecology of health to enhance our understanding of how individual (e.g. care seeking behaviours), sociocultural (e.g. lack of education and awareness), health system (e.g. absence of logistics) and policy environments (e.g. absence of policy) influence the ways in which food allergy is perceived, diagnosed and managed. These findings highlight the need for decision makers to target structural factors that impede access to and utilization of healthcare, diagnostic practices, as well as food allergy coping and management strategies. Moreover, the findings highlight the need for a global health agenda that pays critical attention to place-based factors in the construction of emerging health risks.

The Global Fund's paradigm of oversight, monitoring, and results in Mozambique

Background

The Global Fund is one of the largest actors in global health. In 2015 the Global Fund was credited with disbursing close to 10 % of all development assistance for health. In 2011 it began a reform process in response to internal reviews following allegations of recipients’ misuse of funds. Reforms have focused on grant application processes thus far while the core structures and paradigm have remained intact. We report results of discussions with key stakeholders on the Global Fund, its paradigm of oversight, monitoring, and results in Mozambique.

Methods

We conducted 38 semi-structured in-depth interviews in Maputo, Mozambique and members of the Global Fund Board and Secretariat in Switzerland. In-country stakeholders were representatives from Global Fund country structures (eg. Principle Recipient), the Ministry of Health, health or development attachés bilateral and multilateral agencies, consultants, and the NGO coordinating body. Thematic coding revealed concerns about the combination of weak country oversight with stringent and cumbersome requirements for monitoring and evaluation linked to performance-based financing.

Results

Analysis revealed that despite the changes associated with the New Funding Model, respondents in both Maputo and Geneva firmly believe challenges remain in Global Fund’s structure and paradigm. The lack of a country office has many negative downstream effects including reliance on in-country partners and ineffective coordination. Due to weak managerial and absorptive capacity, more oversight is required than is afforded by country team visits. In-country partners provide much needed support for Global Fund recipients, but roles, responsibilities, and accountability must be clearly defined for a successful long-term partnership. Furthermore, decision-makers in Geneva recognize in-country coordination as vital to successful implementation, and partners welcome increased Global Fund engagement.

Conclusions

To date, there are no institutional requirements for formalized coordination, and the Global Fund has no consistent representation in Mozambique’s in-country coordination groups. The Global Fund should adapt grant implementation and monitoring procedures to the specific local realities that would be illuminated by more formalized coordination.

Electronic supplementary material

The online version of this article (10.1186/s12992-017-0308-7) contains supplementary material, which is available to authorized users.

Endoscopic Third Ventriculostomy to address hydrocephalus in Africa: A call for education and community-based rehabilitation

PURPOSE

Endoscopic Third Ventriculostomy (ETV) and Choroid Plexus Cautery (CPC) are low-cost, safe, and promising interventions for spina bifida-associated hydrocephalus (SBHCP). The purpose of this review was to explore and describe these efforts in Africa in order to upscale surgical training and rehabilitation services.

METHODS

A PubMed search for articles on ETV and CPC as management of SBHCP in Africa was performed. Two authors appraised the results for key themes in content: indications, technique, outcomes, complications, education, and rehabilitation.

RESULTS

Twenty of 47 articles identified were included for appraisal. Twelve described indications, ten and seven outlined technique and complications, respectively, and four described predictors of operative success. Fourteen studies describe outcomes, including operative and neurodevelopmental outcomes. Only two outlined educational efforts. Half of the literature stems from a single site in Uganda; in total, only six countries were represented. No articles described significant post-operative rehabilitation services or related training.

CONCLUSION

The experience of ETV and CPC in Africa is promising, however, efforts to train and empower local staff in surgical technique and methods to upscale post-operative community-based rehabilitation services remain as a key to long-term success.

Improving laboratory efficiencies to scale-up HIV viral load testing

PURPOSE OF REVIEW

Viral load measurement is a key indicator that determines patients' response to treatment and risk for disease progression. Efforts are ongoing in different countries to scale-up access to viral load testing to meet the Joint United Nations Programme on HIV and AIDS target of achieving 90% viral suppression among HIV-infected patients receiving antiretroviral therapy. However, the impact of these initiatives may be challenged by increased inefficiencies along the viral load testing spectrum. This will translate to increased costs and ineffectiveness of scale-up approaches. This review describes different parameters that could be addressed across the viral load testing spectrum aimed at improving efficiencies and utilizing test results for patient management.

RECENT FINDINGS

Though progress is being made in some countries to scale-up viral load, many others still face numerous challenges that may affect scale-up efficiencies: weak demand creation, ineffective supply chain management systems; poor specimen referral systems; inadequate data and quality management systems; and weak laboratory-clinical interface leading to diminished uptake of test results.

SUMMARY

In scaling up access to viral load testing, there should be a renewed focus to address efficiencies across the entire spectrum, including factors related to access, uptake, and impact of test results.