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Nyenswah TG, Skrip L, Stone M, Schue JL, Peters DH, Brieger WR. Documenting the development, adoption and pre-ebola implementation of Liberia's integrated disease surveillance and response (IDSR) strategy. BMC Public Health 2023; 23:2093. [PMID: 37880607 PMCID: PMC10601278 DOI: 10.1186/s12889-023-17006-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND In the immediate aftermath of a 14-year civil conflict that disrupted the health system, Liberia adopted the internationally recommended integrated disease surveillance and response (IDSR) strategy in 2004. Despite this, Liberia was among the three West African countries ravaged by the worst Ebola epidemic in history from 2014 to 2016. This paper describes successes, failures, strengths, and weaknesses in the development, adoption, and implementation of IDSR following the civil war and up until the outbreak of Ebola, from 2004 to early 2014. METHODS We reviewed 112 official Government documents and peer-reviewed articles and conducted 29 in-depth interviews with key informants from December 2021 to March 2022 to gain perspectives on IDSR in the post-conflict and pre-Ebola era in Liberia. We assessed the core and supportive functions of IDSR, such as notification of priority diseases, confirmation, reporting, analysis, investigation, response, feedback, monitoring, staff training, supervision, communication, and financial resources. Data were triangulated and presented via emerging themes and in-depth accounts to describe the context of IDSR introduction and implementation, and the barriers surrounding it. RESULTS Despite the adoption of the IDSR framework, Liberia failed to secure the resources-human, logistical, and financial-to support effective implementation over the 10-year period. Documents and interview reports demonstrate numerous challenges prior to Ebola: the surveillance system lacked key components of IDSR including laboratory testing capacity, disease reporting, risk communication, community engagement, and staff supervision systems. Insufficient financial support and an abundance of vertical programs further impeded progress. In-depth accounts by donors and key governmental informants demonstrate that although the system had a role in detecting Ebola in Liberia, it could not respond effectively to control the disease. CONCLUSION Our findings suggest that post-war, Liberia's health system intended to prioritize epidemic preparedness and response with the adoption of IDSR. However, insufficient investment and systems development meant IDSR was not well implemented, leaving the country vulnerable to the devastating impact of the Ebola epidemic.
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Affiliation(s)
- Tolbert G Nyenswah
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Laura Skrip
- School of Public Health, University of Liberia, Monrovia, Liberia
| | - Mardia Stone
- Division of Global Psychiatry, Boston University School of Medicine, Boston Medical Center, Boston, USA
| | - Jessica L Schue
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - William R Brieger
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Marten R, Shroff ZC, Hanson K, Davies S, Reddy S, Vega J, Peters DH, Ghaffar A. Reimagining health systems as systems for health. BMJ 2022; 379:o3025. [PMID: 36526278 DOI: 10.1136/bmj.o3025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Robert Marten
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sally Davies
- Trinity College, Cambridge University, Cambridge, UK
| | - Srinath Reddy
- Public Health Foundation of India (PHFI), New Delhi, India
| | | | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Abdul Ghaffar
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
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Meghani A, Rodríguez DC, Peters DH, Bennett S. Understanding reasons for and strategic responses to administrative health data misreporting in an Indian state. Health Policy Plan 2022; 38:150-160. [PMID: 35941075 PMCID: PMC9923373 DOI: 10.1093/heapol/czac065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/28/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
The misreporting of administrative health data creates an inequitable distribution of scarce health resources and weakens transparency and accountability within health systems. In the mid-2010s, an Indian state introduced a district ranking system to monitor the monthly performance of health programmes alongside a set of data quality initiatives. However, questions remain about the role of data manipulation in compromising the accuracy of data available for decision-making. We used qualitative approaches to examine the opportunities, pressures and rationalization of potential data manipulation. Using purposive sampling, we interviewed 48 district-level respondents from high-, middle- and low-ranked districts and 35 division- and state-level officials, all of whom had data-related or programme monitoring responsibilities. Additionally, we observed 14 district-level meetings where administrative data were reviewed. District respondents reported that the quality of administrative data was sometimes compromised to achieve top district rankings. The pressure to exaggerate progress was a symptom of the broader system for assessing health performance that was often viewed as punitive and where district- and state-level superiors were viewed as having limited ability to ensure accountability for data quality. However, district respondents described being held accountable for results despite lacking the adequate capacity to deliver on them. Many rationalized data manipulation to cope with high pressures, to safeguard their jobs and, in some cases, for personal financial gain. Moreover, because data manipulation was viewed as a socially acceptable practice, ethical arguments against it were less effective. Potential entry points to mitigate data manipulation include (1) changing the incentive structures to place equal emphasis on the quality of data informing the performance data (e.g. district rankings), (2) strengthening checks and balances to reinforce the integrity of data-related processes within districts and (3) implementing policies to make data manipulation an unacceptable anomaly rather than a norm.
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Affiliation(s)
- Ankita Meghani
- *Corresponding author. Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA. E-mail:
| | - Daniela C Rodríguez
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - Sara Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
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Schleiff MJ, Rangnekar A, Oviedo Gomez F, Teddy G, Peters DH, Balabanova D. Towards Core Competencies for Health Policy and Systems Research (HPSR) Training: Results From a Global Mapping and Consensus-Building Process. Int J Health Policy Manag 2022; 11:1058-1068. [PMID: 33590742 PMCID: PMC9808165 DOI: 10.34172/ijhpm.2020.258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/14/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND As the field of health policy and systems research (HPSR) continues to grow, there is a recognition of the need for training in HPSR. This aspiration has translated into a multitude of teaching programmes of variable scope and quality, reflecting a lack of consensus on the skills and practices required for rigorous HPSR. The purpose of this paper is to identify an agreed set of core competencies for HPSR researchers, building on the previous work by the Health Systems Global (HSG) Thematic Working Group on Teaching & Learning. METHODS Our methods involved an iterative approach of four phases including a literature review, key informant interviews and group discussions with HPSR educators, and webinars with pre-post surveys capturing views among the global HPSR community. The phased discussions and consensus-building contributed to the evolution of the HPSR competency domains and competencies framework. RESULTS Emerging domains included understanding health systems complexity, assessing policies and programs, appraising data and evidence, ethical reasoning and practice, leading and mentoring, building partnerships, and translating and utilizing knowledge and HPSR evidence. The development of competencies and their application were often seen as a continuous process spanning evidence generation, partnering, communicating and helping to identify new critical health systems questions. CONCLUSION The HPSR competency set can be seen as a useful reference point in the teaching and practice of high-quality HPSR and can be adapted based on national priorities, the particularities of local contexts, and the needs of stakeholders (HPSR researchers and educators), as well as practitioners and policy-makers. Further research is needed in using the core competency set to design national training programmes, develop locally relevant benchmarks and assessment methods, and evaluate their use in different settings.
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Affiliation(s)
- Meike J. Schleiff
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Francisco Oviedo Gomez
- Ministry of Health, San José, Costa Rica
- School of Public Health, University of Costa Rica, San José, Costa Rica
| | - Gina Teddy
- Center for Health Systems and Policy Research at GIMPA, Accra, Ghana
| | - David H. Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Varallyay NI, Kennedy C, Bennett SC, Peters DH. Strategies to promote evidence use for health programme improvement: learning from the experiences of embedded implementation research teams in Latin America and the Caribbean. Health Res Policy Syst 2022; 20:38. [PMID: 35392931 PMCID: PMC8991468 DOI: 10.1186/s12961-022-00834-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background To achieve global health targets, innovative approaches are needed to strengthen the implementation of efficacious interventions. New approaches in implementation research that bring together health system decision-makers alongside researchers to collaboratively design, produce and apply research evidence are gaining traction. Embedded implementation research (EIR) approaches led by decision-maker principal investigators (DM PIs) appear promising in this regard. Our aim is to describe the strategies study teams employ in the post-research phase of EIR to promote evidence-informed programme or policy improvement. Methods We conducted a prospective, comparative case study of an EIR initiative in Bolivia, Colombia and Dominican Republic. Guided by a conceptual framework on EIR, we used semi-structured key informant interviews (n = 51) and document reviews (n = 20) to examine three decision-maker-led study teams (“cases”). Focusing on three processes (communication/dissemination, stakeholder engagement with evidence, integrating evidence in decision-making) and the main outcome (enacting improvements), we used thematic analysis to identify associated strategies and enabling or hindering factors. Results Across cases, we observed diverse strategies, shaped substantially by whether the DM PI was positioned to lead the response to study findings within their sphere of work. We found two primary change pathways: (1) DM PIs implement remedial measures directly, and (2) DM PIs seek to influence other stakeholders to respond to study findings. Throughout the post-research phase, EIR teams adapted research use strategies based on the evolving context. Conclusions EIR led by well-positioned DM PIs can facilitate impactful research translation efforts. We draw lessons around the importance of (1) understanding DM PI positionality, (2) ongoing assessment of the evolving context and stakeholders and (3) iterative adaptation to dynamic, uncertain circumstances. Findings may guide EIR practitioners in planning and conducting fit-for-purpose and context-sensitive strategies to advance the use of evidence for programme improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-022-00834-1.
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Affiliation(s)
- N Ilona Varallyay
- Health Systems Program, Department of International Health, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States of America.
| | - Caitlin Kennedy
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States of America
| | - Sara C Bennett
- Health Systems Program, Department of International Health, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States of America
| | - David H Peters
- Department of International Health, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States of America
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Arsenault C, Rowe SY, Ross-Degnan D, Peters DH, Roder-DeWan S, Kruk ME, Rowe AK. How does the effectiveness of strategies to improve healthcare provider practices in low-income and middle-income countries change after implementation? Secondary analysis of a systematic review. BMJ Qual Saf 2022; 31:123-133. [PMID: 34006598 PMCID: PMC8784997 DOI: 10.1136/bmjqs-2020-011717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 03/22/2021] [Accepted: 04/29/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND A recent systematic review evaluated the effectiveness of strategies to improve healthcare provider (HCP) performance in low-income and middle-income countries. The review identified strategies with varying effects, including in-service training, supervision and group problem-solving. However, whether their effectiveness changed over time remained unclear. In particular, understanding whether effects decay over time is crucial to improve sustainability. METHODS We conducted a secondary analysis of data from the aforementioned review to explore associations between time and effectiveness. We calculated effect sizes (defined as percentage-point (%-point) changes) for HCP practice outcomes (eg, percentage of patients correctly treated) at each follow-up time point after the strategy was implemented. We estimated the association between time and effectiveness using random-intercept linear regression models with time-specific effect sizes clustered within studies and adjusted for baseline performance. RESULTS The primary analysis included 37 studies, and a sensitivity analysis included 77 additional studies. For training, every additional month of follow-up was associated with a 0.19 %-point decrease in effectiveness (95% CI: -0.36 to -0.03). For training combined with supervision, every additional month was associated with a 0.40 %-point decrease in effectiveness (95% CI: -0.68 to -0.12). Time trend results for supervision were inconclusive. For group problem-solving alone, time was positively associated with effectiveness, with a 0.50 %-point increase in effect per month (95% CI: 0.37 to 0.64). Group problem-solving combined with training was associated with large improvements, and its effect was not associated with time. CONCLUSIONS Time trends in the effectiveness of different strategies to improve HCP practices vary among strategies. Programmes relying solely on in-service training might need periodical refresher training or, better still, consider combining training with group problem-solving. Although more high-quality research is needed, these results, which are important for decision-makers as they choose which strategies to use, underscore the utility of studies with multiple post-implementation measurements so sustainability of the impact on HCP practices can be assessed.
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Affiliation(s)
- Catherine Arsenault
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Dennis Ross-Degnan
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - David H Peters
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sanam Roder-DeWan
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Rowe SY, Ross-Degnan D, Peters DH, Holloway KA, Rowe AK. The effectiveness of supervision strategies to improve health care provider practices in low- and middle-income countries: secondary analysis of a systematic review. Hum Resour Health 2022; 20:1. [PMID: 34991608 PMCID: PMC8734232 DOI: 10.1186/s12960-021-00683-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/31/2021] [Indexed: 06/03/2023]
Abstract
BACKGROUND Although supervision is a ubiquitous approach to support health programs and improve health care provider (HCP) performance in low- and middle-income countries (LMICs), quantitative evidence of its effects is unclear. The objectives of this study are to describe the effect of supervision strategies on HCP practices in LMICs and to identify attributes associated with greater effectiveness of routine supervision. METHODS We performed a secondary analysis of data on HCP practice outcomes (e.g., percentage of patients correctly treated) from a systematic review on improving HCP performance. The review included controlled trials and interrupted time series studies. We described distributions of effect sizes (defined as percentage-point [%-point] changes) for each supervision strategy. To identify attributes associated with supervision effectiveness, we performed random-effects linear regression modeling and examined studies that directly compared different approaches of routine supervision. RESULTS We analyzed data from 81 studies from 36 countries. For professional HCPs, such as nurses and physicians, primarily working at health facilities, routine supervision (median improvement when compared to controls: 10.7%-points; IQR: 9.9, 27.9) had similar effects on HCP practices as audit with feedback (median improvement: 10.1%-points; IQR: 6.2, 23.7). Two attributes were associated with greater mean effectiveness of routine supervision (p < 0.10): supervisors received supervision (by 8.8-11.5%-points), and supervisors participated in problem-solving with HCPs (by 14.2-20.8%-points). Training for supervisors and use of a checklist during supervision visits were not associated with effectiveness. The effects of supervision frequency (i.e., number of visits per year) and dose (i.e., the number of supervision visits during a study) were unclear. For lay HCPs, the effect of routine supervision was difficult to characterize because few studies existed, and effectiveness in those studies varied considerably. Evidence quality for all findings was low primarily because many studies had a high risk of bias. CONCLUSIONS Although evidence is limited, to promote more effective supervision, our study supports supervising supervisors and having supervisors engage in problem-solving with HCPs. Supervision's integral role in health systems in LMICs justifies a more deliberate research agenda to identify how to deliver supervision to optimize its effect on HCP practices.
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Affiliation(s)
| | - Dennis Ross-Degnan
- Harvard Medical School, Boston, USA
- Harvard Pilgrim Health Care Institute, Boston, USA
| | - David H. Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Kathleen A. Holloway
- World Health Organization, Southeast Asia Regional Office, Delhi, India
- International Institute of Health Management Research, Jaipur, India
- Institute of Development Studies, University of Sussex, Brighton, UK
| | - Alexander K. Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA
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Stierman EK, Kalbarczyk A, Oo HNL, Koller TS, Peters DH. Assessing Barriers to Effective Coverage of Health Services for Adolescents in Low- and Middle-Income Countries: A Scoping Review. J Adolesc Health 2021; 69:541-548. [PMID: 33712382 PMCID: PMC8442758 DOI: 10.1016/j.jadohealth.2020.12.135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/15/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Understanding barriers to health services, as experienced by adolescents, is important to expand effective and equitable coverage; however, there is limited discussion on methods for conducting barrier assessments and translating findings into action. METHODS We conducted a scoping review of literature published between 2005 and 2019 on barriers to health services for adolescents in low- and middle-income countries. The review was guided by a framework that conceptualized barriers across multiple dimensions of access (availability, geographic accessibility, affordability, and acceptability), utilization, and effective coverage. RESULTS We identified 339 studies that assessed barriers related to at least one dimension of the operational framework. Acceptability (93%) and availability (88%) of health services were the most frequently studied access dimensions; affordability (45%) and geographic access (32%) were studied less frequently. Less than half (40%) of the studies evaluated utilization, and none of the 339 studies assessed effective coverage. Attention to equity stratifiers (e.g., income, disability) was limited. Topics studied reflected only a subset of the major causes of adolescent death and disability. CONCLUSIONS Holistic, equity-oriented approaches are needed to better understand barriers across multiple dimensions that together determine whether health services are accessible, used, and effectively meet the needs of different adolescent groups.
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Affiliation(s)
- Elizabeth K. Stierman
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland,Address correspondence to: Elizabeth K. Stierman, M.P.H., Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205.
| | - Anna Kalbarczyk
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Htet Nay Lin Oo
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Theadora Swift Koller
- Gender, Equity and Human Rights Team, World Health Organization, Geneva, Switzerland
| | - David H. Peters
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Meghani A, Rodríguez DC, Bilal H, Tripathi AB, Namasivayam V, Prakash R, Peters DH, Bennett S. Examining policy intentions and actual implementation practices: How organizational factors influence health management information systems in Uttar Pradesh, India. Soc Sci Med 2021; 286:114291. [PMID: 34418584 DOI: 10.1016/j.socscimed.2021.114291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/11/2021] [Accepted: 07/31/2021] [Indexed: 11/24/2022]
Abstract
This study investigates the implementation of a recent health management information systems (HMIS) policy reform in Uttar Pradesh, India, which aims to improve the quality and use of HMIS data in decision-making. Through in-depth interviews, meeting observations and a policy document review, this study sought to capture the experiences of district-level staff (street-level bureaucrats) who were responsible for HMIS policy implementation. Findings revealed that issues of weak HMIS implementation were partly due to human resources shortages both in number and technical skill. Delays in recruitment and the presence of inactive staff overburdened existing staff and weakened the implementation of HMIS activities at the block- and district-levels. District staff also explained how inadequate computer literacy and limited technical understanding further contributed to low HMIS data quality. The organizational culture was even more constraining: working within a very rigid and hierarchical organization was challenging for district data staff, who were expected to manage day-to-day HMIS activities, but lacked the discretion and authority to do so effectively. Consequently, they had to escalate minor issues to district leadership for action and were expected to follow their supervisors' directives- even if they contradicted HMIS policy guidelines. High performance pressures associated with achieving top district rankings deviated focus away from HMIS data quality issues. Many district-level respondents described their superiors' "fixation" with becoming a top-ranking district often resulted in disregard for the quality of data informing district rankings. Furthermore, the review of district rankings only partially encouraged district-level leadership to investigate reasons for low-performing indicators. Instead, low district rankings often resulted in punitive action. The study recommends the importance of incorporating the perspectives of district staff, and recognizing their discretion, and authority when designing policy implementation processes, and finally concludes with potential strategies for strengthening the current HMIS policy reform.
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Affiliation(s)
- Ankita Meghani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
| | - Daniela C Rodríguez
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Huzaifa Bilal
- Uttar Pradesh Technical Support Unit, India Health Action Trust, Lucknow, Uttar Pradesh, India
| | - Anand B Tripathi
- Uttar Pradesh Technical Support Unit, India Health Action Trust, Lucknow, Uttar Pradesh, India
| | - Vasanthakumar Namasivayam
- Uttar Pradesh Technical Support Unit, India Health Action Trust, Lucknow, Uttar Pradesh, India; University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ravi Prakash
- Uttar Pradesh Technical Support Unit, India Health Action Trust, Lucknow, Uttar Pradesh, India; University of Manitoba, Winnipeg, Manitoba, Canada
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Sara Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Varallyay NI, Bennett SC, Kennedy C, Ghaffar A, Peters DH. How does embedded implementation research work? Examining core features through qualitative case studies in Latin America and the Caribbean. Health Policy Plan 2021; 35:ii98-ii111. [PMID: 33156937 PMCID: PMC7646734 DOI: 10.1093/heapol/czaa126] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 01/04/2023] Open
Abstract
Innovative strategies are needed to improve the delivery of evidence-informed health interventions. Embedded implementation research (EIR) seeks to enhance the generation and use of evidence for programme improvement through four core features: (1) central involvement of programme/policy decision-makers in the research cycle; (2) collaborative research partnerships; (3) positioning research within programme processes and (4) research focused on implementation. This paper examines how these features influence evidence-to-action processes and explores how they are operationalized, their effects and supporting conditions needed. We used a qualitative, comparative case study approach, drawing on document analysis and semi-structured interviews across multiple informant groups, to examine three EIR projects in Bolivia, Colombia and the Dominican Republic. Our findings are presented according to the four core EIR features. The central involvement of decision-makers in EIR was enhanced by decision-maker authority over the programme studied, professional networks and critical reflection. Strong research-practice partnerships were facilitated by commitment, a clear and shared purpose and representation of diverse perspectives. Evidence around positioning research within programme processes was less conclusive; however, as all three cases made significant advances in research use and programme improvement, this feature of EIR may be less critical than others, depending on specific circumstances. Finally, a research focus on implementation demanded proactive engagement by decision-makers in conceptualizing the research and identifying opportunities for direct action by decision-makers. As the EIR approach is a novel approach in these low-resource settings, key supports are needed to build capacity of health sector stakeholders and create an enabling environment through system-level strategies. Key implications for such supports include: promoting EIR and creating incentives for decision-makers to engage in it, establishing structures or mechanisms to facilitate decision-maker involvement, allocating funds for EIR, and developing guidance for EIR practitioners.
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Affiliation(s)
- N Ilona Varallyay
- Department of International Health, Johns Hopkins School
of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
- Corresponding author. Malabia 1970, Buenos Aires CABA 1414,
Argentina. E-mail:
| | - Sara C Bennett
- Department of International Health, Johns Hopkins School
of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
| | - Caitlin Kennedy
- Social and Behavioral Interventions Program, Department of
International Health, Johns Hopkins School of Public Health, 615 N Wolfe St,
Baltimore, MD 21205, United States
| | - Abdul Ghaffar
- The Alliance for Health Policy and Systems Research at the
World Health Organization, 20 avenue Appia, 1211 Geneva, Switzerland
| | - David H Peters
- Department of International Health, Johns Hopkins School
of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
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Yazbeck AS, Peters DH, Lindelow M, Bredenkamp C. A Special Issue Honoring the Legacy of Adam Wagstaff. Health Syst Reform 2021; 7:e1968326. [PMID: 34554037 DOI: 10.1080/23288604.2021.1968326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Abdo S Yazbeck
- International Health Department, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - David H Peters
- International Health Department, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Magnus Lindelow
- Health, Nutrition and Population Global Practice, The World Bank Group, Washington, DC, USA
| | - Caryn Bredenkamp
- Human Development Practice Group, World Bank, Washington, DC, USA.,Department of Economics, Stellenbosch University, Stellenbosch, South Africa
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Patenaude B, Rao KD, Peters DH. An Empirical Examination of the Inequality of Forgone Care in India. Health Syst Reform 2021; 7:e1894761. [PMID: 34464230 DOI: 10.1080/23288604.2021.1894761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Understanding how well a health system is meeting the needs of the population is critical to achieving the policy aspirations of universal health coverage. This study focuses on assessing the inequity of forgone care for priority maternal and child health services across India. We utilize data from the 4th round of the Indian National Family Health Survey (NFHS-4) to examine inequality of forgone care. Our outcomes include forgone institutional delivery, antenatal care, medical care for a child with fever or cough, and medical care for a child with diarrhea. Wagstaff's standardized concentration indices (CIs) are computed at the national level, over urban and rural sub-populations, and by state. Regression decomposition is performed to determine the influence of specific drivers on overall inequality. There was significant variation in the national-level prevalence and CIs for forgone antenatal care (17.8%, CI: -0.423), forgone medical care for a child with fever or cough (32.4%, CI: -0.199), forgone medical care for a child with diarrhea (33.8%, CI: -0.172), and forgone institutional delivery (24.5%, CI: -0.436). For all outcomes, forgone care is disproportionately concentrated among the poor, particularly in rural areas. There is also significant heterogeneity in state-level inequalities. Decomposition analyses show that socioeconomic status, maternal education, rural status, and state-level per capita health spending are the leading drivers of observed inequalities in forgone care. Results suggest attending to both the operation and financing of India's health care system as well as the social determinants that make poor women more likely to forgo maternal health care.
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Affiliation(s)
- Bryan Patenaude
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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13
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Affiliation(s)
- Zubin Cyrus Shroff
- Alliance for Health Policy and Systems Research, WHO, Geneva 1211, Switzerland
| | - Robert Marten
- Alliance for Health Policy and Systems Research, WHO, Geneva 1211, Switzerland.
| | | | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Abdul Ghaffar
- Alliance for Health Policy and Systems Research, WHO, Geneva 1211, Switzerland
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14
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Zweig SA, Zapf AJ, Xu H, Li Q, Agarwal S, Labrique AB, Peters DH. Impact of Public Health and Social Measures on the COVID-19 Pandemic in the United States and Other Countries: Descriptive Analysis. JMIR Public Health Surveill 2021; 7:e27917. [PMID: 33975277 PMCID: PMC8174555 DOI: 10.2196/27917] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background The United States of America has the highest global number of COVID-19 cases and deaths, which may be due in part to delays and inconsistencies in implementing public health and social measures (PHSMs). Objective In this descriptive analysis, we analyzed the epidemiological evidence for the impact of PHSMs on COVID-19 transmission in the United States and compared these data to those for 10 other countries of varying income levels, population sizes, and geographies. Methods We compared PHSM implementation timing and stringency against COVID-19 daily case counts in the United States and against those in Canada, China, Ethiopia, Japan, Kazakhstan, New Zealand, Singapore, South Korea, Vietnam, and Zimbabwe from January 1 to November 25, 2020. We descriptively analyzed the impact of border closures, contact tracing, household confinement, mandated face masks, quarantine and isolation, school closures, limited gatherings, and states of emergency on COVID-19 case counts. We also compared the relationship between global socioeconomic indicators and national pandemic trajectories across the 11 countries. PHSMs and case count data were derived from various surveillance systems, including the Health Intervention Tracking for COVID-19 database, the World Health Organization PHSM database, and the European Centre for Disease Prevention and Control. Results Implementing a specific package of 4 PHSMs (quarantine and isolation, school closures, household confinement, and the limiting of social gatherings) early and stringently was observed to coincide with lower case counts and transmission durations in Vietnam, Zimbabwe, New Zealand, South Korea, Ethiopia, and Kazakhstan. In contrast, the United States implemented few PHSMs stringently or early and did not use this successful package. Across the 11 countries, national income positively correlated (r=0.624) with cumulative COVID-19 incidence. Conclusions Our findings suggest that early implementation, consistent execution, adequate duration, and high adherence to PHSMs represent key factors of reducing the spread of COVID-19. Although national income may be related to COVID-19 progression, a country’s wealth appears to be less important in controlling the pandemic and more important in taking rapid, centralized, and consistent public health action.
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Affiliation(s)
- Sophia Alison Zweig
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Alexander John Zapf
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Hanmeng Xu
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Qingfeng Li
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Smisha Agarwal
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Alain Bernard Labrique
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - David H Peters
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
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15
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Rowe AK, Rowe SY, Peters DH, Holloway KA, Ross-Degnan D. The effectiveness of training strategies to improve healthcare provider practices in low-income and middle-income countries. BMJ Glob Health 2021; 6:e003229. [PMID: 33452138 PMCID: PMC7813291 DOI: 10.1136/bmjgh-2020-003229] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/20/2020] [Accepted: 11/10/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION In low/middle-income countries (LMICs), training is often used to improve healthcare provider (HCP) performance. However, important questions remain about how well training works and the best ways to design training strategies. The objective of this study is to characterise the effectiveness of training strategies to improve HCP practices in LMICs and identify attributes associated with training effectiveness. METHODS We performed a secondary analysis of data from a systematic review on improving HCP performance. The review included controlled trials and interrupted time series, and outcomes measuring HCP practices (eg, percentage of patients correctly treated). Distributions of effect sizes (defined as percentage-point (%-point) changes) were described for each training strategy. To identify effective training attributes, we examined studies that directly compared training approaches and performed random-effects linear regression modelling. RESULTS We analysed data from 199 studies from 51 countries. For outcomes expressed as percentages, educational outreach visits (median effect size when compared with controls: 9.9 %-points; IQR: 4.3-20.6) tended to be somewhat more effective than in-service training (median: 7.3 %-points; IQR: 3.6-17.4), which seemed more effective than peer-to-peer training (4.0 %-points) and self-study (by 2.0-9.3 %-points). Mean effectiveness was greater (by 6.0-10.4 %-points) for training that incorporated clinical practice and training at HCPs' work site. Attributes with little or no effect were: training with computers, interactive methods or over multiple sessions; training duration; number of educational methods; distance training; trainers with pedagogical training and topic complexity. For lay HCPs, in-service training had no measurable effect. Evidence quality for all findings was low. CONCLUSIONS Although additional research is needed, by characterising the effectiveness of training strategies and identifying attributes of effective training, decision-makers in LMICs can improve how these strategies are selected and implemented.
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Affiliation(s)
- Alexander K Rowe
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kathleen A Holloway
- International Institute of Health Management Research, Jaipur, India
- Institute of Development Studies, University of Sussex, Brighton, Brighton and Hove, UK
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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16
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Bennett S, Ekirapa-Kiracho E, Mahmood SS, Paina L, Peters DH. Strengthening social accountability in ways that build inclusion, institutionalization and scale: reflections on FHS experience. Int J Equity Health 2020; 19:220. [PMID: 33302969 PMCID: PMC7731752 DOI: 10.1186/s12939-020-01341-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 11/10/2022] Open
Abstract
This editorial provides an introduction to the special issue on "Lessons about intervening in accountability ecosystems: implementation of community scorecards in Bangladesh and Uganda". We start by describing the rationale for this work in the two study countries. While our project, the Future Health Systems (FHS) project, had been working over the course of more than a decade to strengthen health services, particularly for low income households in rural areas, our teams increasingly recognized how difficult it would be to sustain service improvements without fundamental changes to local accountabilities. Accordingly, in the final phase of the project 2016-2018, we designed, implemented and assessed community scorecard initiatives, in both Bangladesh and Uganda, with the aim of informing the design of a scalable social accountability initiative that could fundamentally shift the dynamics of health system accountability in favor of the poor and marginalized.We describe the particular characteristics of our approach to this task. Specifically we (i) conducted a mapping of accountabilities in each of the contexts so as to understand how our actions may interact with existing accountability mechanisms (ii) developed detailed theories of change that unpacked the mechanisms through which we anticipated the community scorecards would have effect, as well as how they would be institutionalized; and (iii) monitored closely the extent of inclusion and the equity effects of the scorecards. In summarizing this approach, we articulate the contributions made by different papers in this volume.
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Affiliation(s)
- Sara Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 614 N Wolfe St, Baltimore, MD USA
| | - Eizabeth Ekirapa-Kiracho
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Shehrin Shaila Mahmood
- Health Systems and Population Studies Division, icddr,b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Ligia Paina
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 614 N Wolfe St, Baltimore, MD USA
| | - David H. Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 614 N Wolfe St, Baltimore, MD USA
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Bhandari S, Wahl B, Bennett S, Engineer CY, Pandey P, Peters DH. Identifying core competencies for practicing public health professionals: results from a Delphi exercise in Uttar Pradesh, India. BMC Public Health 2020; 20:1737. [PMID: 33203407 PMCID: PMC7670983 DOI: 10.1186/s12889-020-09711-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 10/15/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Ensuring the current public health workforce has appropriate competencies to fulfill essential public health functions is challenging in many low- and middle-income countries. The absence of an agreed set of core competencies to provide a basis for developing and assessing knowledge, skills, abilities, and attitudes contributes to this challenge. This study aims to identify the requisite core competencies for practicing health professionals in mid-level supervisory and program management roles to effectively perform their public health responsibilities in the resource-poor setting of Uttar Pradesh (UP), India. METHODS We used a multi-step, interactive Delphi technique to develop an agreed set of public health competencies. A narrative review of core competency frameworks and key informant interviews with human resources for health experts in India were conducted to prepare an initial list of 40 competency statements in eight domains. We then organized a day-long workshop with 22 Indian public health experts and government officials, who added to and modified the initial list. A revised list of 54 competency statements was rated on a 5-point Likert scale. Aggregate statement scores were shared with the participants, who discussed the findings. Finally, the revised list was returned to participants for an additional round of ratings. The Wilcoxon matched-pairs signed-rank test was used to identify stability between steps, and consensus was defined using the percent agreement criterion. RESULTS Stability between the first and second Delphi scoring steps was reached in 46 of the 54 statements. By the end of the second Delphi scoring step, consensus was reached on 48 competency statements across eight domains: public health sciences, assessment and analysis, policy and program management, financial management and budgeting, partnerships and collaboration, social and cultural determinants, communication, and leadership. CONCLUSIONS This study produced a consensus set of core competencies and domains in public health that can be used to assess competencies of public health professionals and revise or develop new training programs to address desired competencies. Findings can also be used to support workforce development by informing competency-based job descriptions for recruitment and performance management in the Indian context, and potentially can be adapted for use in resource-poor settings globally.
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Affiliation(s)
- Sudip Bhandari
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Brian Wahl
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sara Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Cyrus Y Engineer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Pooja Pandey
- Indian Administrative Service, Lucknow, Uttar Pradesh, India
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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18
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Kiracho EE, Namuhani N, Apolot RR, Aanyu C, Mutebi A, Tetui M, Kiwanuka SN, Ayen FA, Mwesige D, Bumbha A, Paina L, Peters DH. Influence of community scorecards on maternal and newborn health service delivery and utilization. Int J Equity Health 2020; 19:145. [PMID: 33131498 PMCID: PMC7604954 DOI: 10.1186/s12939-020-01184-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The community score card (CSC) is a participatory monitoring and evaluation tool that has been employed to strengthen the mutual accountability of health system and community actors. In this paper we describe the influence of the CSC on selected maternal and newborn service delivery and utilization indicators. METHODS This was a mixed methods study that used both quantitative and qualitative data collection methods. It was implemented in five sub-counties and one town council in Kibuku district in Uganda. Data was collected through 17 key informant interviews and 10 focus group discussions as well as CSC scoring and stakeholder meeting reports. The repeated measures ANOVA test was used to test for statistical significance. Qualitative data was analyzed manually using content analysis. The analysis about the change pathways was guided by the Wild and Harris dimensions of change framework. RESULTS There was an overall improvement in the common indicators across sub-counties in the project area between the 1st and 5th round scores. Almost all the red scores had changed to green or yellow by round five except for availability of drugs and mothers attending Antenatal care (ANC) in the first trimester. There were statistically significant differences in mean scores for men escorting their wives for ante natal care (ANC) (F(4,20) = 5.45, P = 0.01), availability of midwives (F(4,16) =5.77, P < 0.01), availability of delivery beds (F(4,12) =9.00, P < 0.01) and mothers delivering from traditional birth attendants (TBAs), F(4,16) = 3.86, p = 0.02). The qualitative findings suggest that strengthening of citizens' demand, availability of resources through collaborative problem solving, increased awareness about targeted maternal health services and increased top down performance pressure contributed to positive changes as perceived by community members and their leaders. CONCLUSIONS AND RECOMMENDATIONS The community score cards created opportunities for community leaders and communities to work together to identify innovative ways of dealing with the health service delivery and utilization challenges that they face. Local leaders should encourage the availability of safe spaces for dialogue between communities, health workers and leaders where performance and utilization challenges can be identified and solutions proposed and implemented jointly.
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Affiliation(s)
- Elizabeth Ekirapa Kiracho
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Noel Namuhani
- Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Rebecca Racheal Apolot
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Christine Aanyu
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Aloysuis Mutebi
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Moses Tetui
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Suzanne N. Kiwanuka
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O.Box 7072, Kampala, Uganda
| | - Faith Adong Ayen
- District Health Service, Kibuku Local Government, P.O Box 150, Mbale, Uganda
| | - Dennis Mwesige
- District Health Service, Kibuku Local Government, P.O Box 150, Mbale, Uganda
| | - Ahmed Bumbha
- District Health Service, Kibuku Local Government, P.O Box 150, Mbale, Uganda
| | - Ligia Paina
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - David H. Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
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19
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Zheng Q, Jones FK, Leavitt SV, Ung L, Labrique AB, Peters DH, Lee EC, Azman AS. HIT-COVID, a global database tracking public health interventions to COVID-19. Sci Data 2020; 7:286. [PMID: 32855428 PMCID: PMC7453020 DOI: 10.1038/s41597-020-00610-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/28/2020] [Indexed: 11/09/2022] Open
Abstract
The COVID-19 pandemic has sparked unprecedented public health and social measures (PHSM) by national and local governments, including border restrictions, school closures, mandatory facemask use and stay at home orders. Quantifying the effectiveness of these interventions in reducing disease transmission is key to rational policy making in response to the current and future pandemics. In order to estimate the effectiveness of these interventions, detailed descriptions of their timelines, scale and scope are needed. The Health Intervention Tracking for COVID-19 (HIT-COVID) is a curated and standardized global database that catalogues the implementation and relaxation of COVID-19 related PHSM. With a team of over 200 volunteer contributors, we assembled policy timelines for a range of key PHSM aimed at reducing COVID-19 risk for the national and first administrative levels (e.g. provinces and states) globally, including details such as the degree of implementation and targeted populations. We continue to maintain and adapt this database to the changing COVID-19 landscape so it can serve as a resource for researchers and policymakers alike.
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Affiliation(s)
- Qulu Zheng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Forrest K Jones
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sarah V Leavitt
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Lawson Ung
- Infectious Disease Institute and Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Alain B Labrique
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth C Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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20
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Gupta M, Wahl B, Adhikari B, Bar-Zeev N, Bhandari S, Coria A, Erchick DJ, Gupta N, Hariyani S, Kagucia EW, Killewo J, Limaye RJ, McCollum ED, Pandey R, Pomat WS, Rao KD, Santosham M, Sauer M, Wanyenze RK, Peters DH. The need for COVID-19 research in low- and middle-income countries. Glob Health Res Policy 2020; 5:33. [PMID: 32617414 PMCID: PMC7326528 DOI: 10.1186/s41256-020-00159-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/11/2020] [Indexed: 12/21/2022] Open
Abstract
In the early months of the pandemic, most reported cases and deaths due to COVID-19 occurred in high-income countries. However, insufficient testing could have led to an underestimation of true infections in many low- and middle-income countries. As confirmed cases increase, the ultimate impact of the pandemic on individuals and communities in low- and middle-income countries is uncertain. We therefore propose research in three broad areas as urgently needed to inform responses in low- and middle-income countries: transmission patterns of SARS-CoV-2, the clinical characteristics of the disease, and the impact of pandemic prevention and response measures. Answering these questions will require a multidisciplinary approach led by local investigators and in some cases additional resources. Targeted research activities should be done to help mitigate the potential burden of COVID-19 in low- and middle-income countries without diverting the limited human resources, funding, or medical supplies from response activities.
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Affiliation(s)
- Madhu Gupta
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Madhya Marg, Sector 12, Chandigarh, 160012 India
| | - Brian Wahl
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Binita Adhikari
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Health Foundation Nepal, Kathmandu, Nepal
| | - Naor Bar-Zeev
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Sudip Bhandari
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - Daniel J Erchick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Nidhi Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Shreya Hariyani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - E Wangeci Kagucia
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Japhet Killewo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rupali Jayant Limaye
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Eric D McCollum
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, USA
| | - Raghukul Pandey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - William S Pomat
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Mathuram Santosham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Molly Sauer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.,International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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21
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Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, Breda J. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020; 395:1678-1680. [PMID: 32401713 PMCID: PMC7211494 DOI: 10.1016/s0140-6736(20)31067-9] [Citation(s) in RCA: 183] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022]
Affiliation(s)
| | - Kremlin Wickramasinghe
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow 125009, Russia.
| | - Holly L Rippin
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow 125009, Russia
| | - Romeu Mendes
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow 125009, Russia; EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - David H Peters
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anna Kontsevaya
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Joao Breda
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow 125009, Russia
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22
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Alonge O, Sonkarlay S, Gwaikolo W, Fahim C, Cooper JL, Peters DH. Understanding the role of community resilience in addressing the Ebola virus disease epidemic in Liberia: a qualitative study (community resilience in Liberia). Glob Health Action 2020; 12:1662682. [PMID: 31507254 PMCID: PMC6746278 DOI: 10.1080/16549716.2019.1662682] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background: There is an increasing recognition that community resilience plays a significant role in addressing health shocks like the Ebola virus disease (EVD) epidemic. However, the factors that constitute community resilience, and how these operate dynamically with other health system factors are less understood. Objective: This paper seeks to understand key factors that constitute community resilience and their role in responding to the EVD outbreak in Liberia. Methods: Key informant interviews were conducted between November 2017 and April 2018 with community representatives in Bomi, Margibi and Montserrado counties, and other national stakeholders involved in the EVD response in Liberia from 2014 to 2016. A national stakeholder meeting was conducted to verify and interpret information emerging from the interviews. Results: Factors that were critical for addressing the EVD epidemic in Liberia were identified as: strong leadership, tight bonds and sense of kinship at the community level; trusted communication channels; and trust among various health system stakeholders. These factors facilitated collective actions within communities and helped to direct response initiatives from other levels of the health system to the community. Foreign assistance was seen as crucial for recovery and revitalization of affected communities. However, such aid is often not targeted at addressing critical challenges in a sustainable way, especially when the assistance is highly restricted to specific activities, and those activities are determined without consultation with local actors and community groups. Conclusion: Efforts to systematically build responsible leadership and social capital at community level, including those that strengthen bonds in communities and trust across key actors in the health system, are needed to address health shocks like EVD outbreaks. Without building such capabilities in community resilience, it will be difficult to reap the expected gains from investments focusing on building physical capital and technical capabilities in health services and emergency preparedness.
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Affiliation(s)
- O Alonge
- Bloomberg School of Public Health, Department of International Health, Johns Hopkins University , Baltimore , MD , USA
| | - S Sonkarlay
- Liberia Center for Outcome Research on Mental Health , Monrovia , Liberia
| | - W Gwaikolo
- Liberia Center for Outcome Research on Mental Health , Monrovia , Liberia
| | - C Fahim
- Bloomberg School of Public Health, Department of International Health, Johns Hopkins University , Baltimore , MD , USA
| | - J L Cooper
- Liberia Center for Outcome Research on Mental Health , Monrovia , Liberia
| | - D H Peters
- Bloomberg School of Public Health, Department of International Health, Johns Hopkins University , Baltimore , MD , USA
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Breda J, Wickramasinghe K, Peters DH, Rakovac I, Oldenburg B, Mikkelsen B, Shao R, Varghese C, Collins T, Wall K, Farrington J, Townsend N. One size does not fit all: implementation of interventions for non-communicable diseases. BMJ 2019; 367:l6434. [PMID: 31810904 DOI: 10.1136/bmj.l6434] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- João Breda
- WHO European Office for Prevention and Control of NCDs, Moscow, Russia
| | | | - David H Peters
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA
| | - Ivo Rakovac
- WHO European Office for Prevention and Control of NCDs, Moscow, Russia
| | - Brian Oldenburg
- WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Bente Mikkelsen
- Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Ruitai Shao
- World Health Organization, Geneva, Switzerland
| | | | - Téa Collins
- World Health Organization, Geneva, Switzerland
| | - Kristen Wall
- WHO European Office for Prevention and Control of NCDs, Moscow, Russia
| | - Jill Farrington
- Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe, Copenhagen, Denmark
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Peters DH, Hanssen O, Gutierrez J, Abrahams J, Nyenswah T. Financing Common Goods for Health: Core Government Functions in Health Emergency and Disaster Risk Management. Health Syst Reform 2019; 5:307-321. [PMID: 31661356 DOI: 10.1080/23288604.2019.1660104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
In the absence of good data on the costs and comparative benefits from investing in health emergency and disaster risk management (EDRM), governments have been reluctant to invest adequately in systems to reduce the risks and consequences of emergencies and disasters. Yet they spend heavily on their response. We describe a set of key functional areas for investment and action in health EDRM, and calculate the costs needed to establish and operate basic health EDRM services in low- and middle-income countries, focusing on management of epidemics and disasters from natural hazards.We find that health EDRM costs are affordable for most governments. They range from an additional 4.33 USD capital and 4.16 USD annual recurrent costs per capita in low-income countries to 1.35 USD capital to 1.41 USD recurrent costs in upper middle-income countries. These costs pale in comparison to the costs of not acting-the direct and indirect costs of epidemics and other emergencies from natural hazards are more than 20-fold higher.We also examine options for the institutional arrangements needed to design and implement health EDRM. We discuss the need for creating adaptive institutions, strengthening capacities of countries, communities and health systems for managing risks of emergencies, using "all-of-society" and "all-of-state institutions" approaches, and applying lessons about rules and regulations, behavioral norms, and organizational structures to better implement health EDRM. The economic and social value, and the feasibility of institutional options for implementing health EDRM systems should compel governments to invest in these common goods for health that strengthen national health security.
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Affiliation(s)
- David H Peters
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Jose Gutierrez
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jonathan Abrahams
- Country Health Emergency Preparedness and International Health Regulation Department, WHO Emergencies Programme, World Health Organization, Geneva, Switzerland
| | - Tolbert Nyenswah
- National Public Health Institute of Liberia, Monrovia, Republic of Liberia
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Shelley KD, Frumence G, Mpembeni R, Mwinnyaa G, Joachim J, Kisusi HK, Killewo J, Baqui AH, Peters DH, George AS. "Because Even the Person Living With HIV/AIDS Might Need to Make Babies" - Perspectives on the Drivers of Feasibility and Acceptability of an Integrated Community Health Worker Model in Iringa, Tanzania. Int J Health Policy Manag 2019; 8:538-549. [PMID: 31657176 PMCID: PMC6815988 DOI: 10.15171/ijhpm.2019.38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 05/20/2019] [Indexed: 12/04/2022] Open
Abstract
Background: Countries with health workforce shortages are increasingly turning to multipurpose community health workers (CHWs) to extend integrated services to the community-level. However, there may be tradeoffs with the number of tasks a CHW can effectively perform before quality and/or productivity decline. This qualitative study was conducted within an existing program in Iringa, Tanzania where HIV-focused CHWs working as volunteers received additional training on maternal, newborn, and child health (MNCH) promotion, thereby establishing a dual role CHW model. Methods: To evaluate the feasibility and acceptability of the combined HIV/MNCH CHW model, qualitative in-depth interviews (IDIs) with 36 CHWs, 21 supervisors, and 10 program managers were conducted following integration of HIV and MNCH responsibilities (n=67). Thematic analysis explored perspectives on task planning, prioritization and integration, workload, and the feasibility and acceptability of the dual role model. Interview data and field observations were also used to describe implementation differences between HIV and MNCH roles as a basis for further contextualizing the qualitative findings. Results: Perspectives from a diverse set of stakeholders suggested provision of both HIV and MNCH health promotion by CHWs was feasible. Most CHWs attempted to balance HIV/MNCH responsibilities, although some prioritized MNCH tasks. An increased workload from MNCH did not appear to interfere with HIV responsibilities but drew time away from other income-generating activities on which volunteer CHWs rely. Satisfaction with the dual role model hinged on increased community respect, gaining new knowledge/skills, and improving community health, while the remuneration-level caused dissatisfaction, a complaint that could challenge sustainability. Conclusions: Despite extensive literature on integration, little research at the community level exists. This study demonstrated CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload. Further research is necessary to determine the quality of health promotion in both HIV and MNCH domains, and whether the dual role model can be maintained over time among these volunteers.
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Affiliation(s)
- Katharine D Shelley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gasto Frumence
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rose Mpembeni
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - George Mwinnyaa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juliana Joachim
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Japhet Killewo
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Asha S George
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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Sim SY, Jit M, Constenla D, Peters DH, Hutubessy RCW. A Scoping Review of Investment Cases for Vaccines and Immunization Programs. Value Health 2019; 22:942-952. [PMID: 31426936 DOI: 10.1016/j.jval.2019.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Many investment cases have recently been published intending to show the value of new health investments, but without consistent methodological approaches. OBJECTIVES To conduct a scoping review of existing investment cases (using vaccines and immunization programs as an example), identify common characteristics that define these investment cases, and examine their role within the broader context of the vaccine development and introduction. METHODS A systematic search was conducted from January 1980 to November 2017 to identify investment cases in the area of vaccines and immunization programs from gray literature and electronic bibliographic databases. Investment case outcomes, objectives, key variables, target audiences, and funding sources were extracted and analyzed according to their reporting frequency. RESULTS We found 24 investment cases, and most of them aim to provide information for decisions (12 cases) or advocate for a specific agenda (9 cases). Outcomes presented fell into 4 broad categories-burden of disease, cost of investment, impact of investment, and other considerations for implementation. Number of deaths averted (70%), incremental cost-effectiveness ratios (67%), and reduction in health and socioeconomic inequalities (54%) were the most frequently reported outcome measures for impact of investment. Health system capacity (79%) and vaccine financing landscape (75%) were the most common considerations for implementation. A sizable proportion (41.4%) of investment cases did not reveal their funding sources. CONCLUSIONS This review describes information that is critical to decision making about resource mobilization and allocation concerning vaccines. Global efforts to harmonize investment cases more broadly will increase transparency and comparability.
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Affiliation(s)
- So Yoon Sim
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mark Jit
- London School of Hygiene & Tropical Medicine, London, UK; Modelling and Economics Unit, Public Health England, London, UK
| | - Dagna Constenla
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Raymond C W Hutubessy
- Initiative for Vaccine Research, Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland.
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Shelley KD, Frumence G, Mpembeni R, George AS, Stuart EA, Killewo J, Baqui AH, Peters DH. Can volunteer community health workers manage multiple roles? An interrupted time-series analysis of combined HIV and maternal and child health promotion in Iringa, Tanzania. Health Policy Plan 2019; 33:1096-1106. [PMID: 30590539 DOI: 10.1093/heapol/czy104] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2018] [Indexed: 11/14/2022] Open
Abstract
Community health workers (CHWs) play a critical role in health promotion, but their workload is often oriented around a single disease. Renewed interest in expansion of multipurpose CHWs to cover an integrated package of services must contend with the debate over how effectively CHWs can perform an increased range of tasks. In this study, we examine whether an existing cadre of HIV-focused paid volunteer CHWs in Iringa, Tanzania, can take on new maternal, newborn and child health (MNCH) promotion tasks without adversely affecting their HIV role. HIV household visits conducted per month were extracted from CHW summary forms covering up to 14 months pre-intervention and 12 months of intervention data. A comparative interrupted time series using a generalized estimating equation assessed population-averaged longitudinal trends in monthly HIV visit count in the intervention ('dual-role' CHWs) vs comparison group ('single-role' CHWs). Analyses were stratified by district, accounting for secular trends, seasonality and covariates. The time series consisted of 4022 observations for HIV visit count from 187 CHWs (41% dual role). Prior to MNCH training, dual-role CHWs averaged 25-30% more HIV visits per month compared with single-role CHWs, with no other significant pre-intervention differences between groups. CHWs began conducting MNCH visits shortly after receiving training, but in the initial month of intervention, there was a 6-9% drop in the mean number of HIV visits per month among dual-role CHWs. Otherwise, there was no significant difference between single- and dual-role CHWs in the trajectories of monthly HIV visits before and after adding MNCH tasks. Dual-role CHWs appeared able to maintain their HIV client workload after adding MNCH tasks to their routines, albeit with an initial slight decline in HIV workload. This dual-role CHW model suggests potential spare capacity in vertically oriented programmes, with productivity gains possible through integration.
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Affiliation(s)
- Katharine D Shelley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
| | - Gasto Frumence
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rose Mpembeni
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Asha S George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Elizabeth A Stuart
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Japhet Killewo
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
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Shelley KD, Mpembeni R, Frumence G, Stuart EA, Killewo J, Baqui AH, Peters DH. Integrating Community Health Worker Roles to Improve Facility Delivery Utilization in Tanzania: Evidence from an Interrupted Time Series Analysis. Matern Child Health J 2019; 23:1327-1338. [PMID: 31228143 DOI: 10.1007/s10995-019-02783-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania. METHODS A 36-month time series data set (2014-2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility. RESULTS There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals, from an average of 202-234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001). CONCLUSIONS FOR PRACTICE Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care.
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Affiliation(s)
- Katharine D Shelley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Rose Mpembeni
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Gasto Frumence
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Elizabeth A Stuart
- Department of Mental Health, Department of Biostatistics, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Japhet Killewo
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Peters DH, Peters MA, Wickramasinghe K, Osewe PL, Davidson PM. Asking the right question: implementation research to accelerate national non-communicable disease responses. BMJ 2019; 365:l1868. [PMID: 31110030 PMCID: PMC6526393 DOI: 10.1136/bmj.l1868] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Non-communicable disease programmes can be strengthened by systematically identifying implementation challenges and translating them into questions that can be answered through appropriate research, say David H Peters and colleagues
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Affiliation(s)
- David H Peters
- Johns Hopkins University Bloomberg School of Public Health, USA
| | | | - Kremlin Wickramasinghe
- World Health Organization European Office for Prevention and Control of NCDs, Russian Federation
| | | | - Patricia M Davidson
- Johns Hopkins University School of Nursing, Secretariat, World Health Organization Collaborating Centres of Nursing and Midwifery, USA
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Alonge O, Rodriguez DC, Brandes N, Geng E, Reveiz L, Peters DH. How is implementation research applied to advance health in low-income and middle-income countries? BMJ Glob Health 2019; 4:e001257. [PMID: 30997169 PMCID: PMC6441291 DOI: 10.1136/bmjgh-2018-001257] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/14/2019] [Accepted: 01/19/2019] [Indexed: 12/30/2022] Open
Abstract
This paper examines the characteristics of implementation research (IR) efforts in low-income and middle-income countries (LMICs) by describing how key IR principles and concepts have been used in published health research in LMICs between 1998 and 2016, with focus on how to better apply these principles and concepts to support large-scale impact of health interventions in LMICs. There is a stark discrepancy between principles of IR and what has been published. Most IR studies have been conducted under conditions where the researchers have considerable influence over implementation and with extra resources, rather than in ‘real world’ conditions. IR researchers tend to focus on research questions that test a proof of concept, such as whether a new intervention is feasible or can improve implementation. They also tend to use traditional fixed research designs, yet the usual conditions for managing programmes demand continuous learning and change. More IR in LMICs should be conducted under usual management conditions, employ pragmatic research paradigm and address critical implementation issues such as scale-up and sustainability of evidence-informed interventions. This paper describes some positive examples that address these concerns and identifies how better reporting of IR studies in LMICs would include more complete descriptions of strategies, contexts, concepts, methods and outcomes of IR activities. This will help practitioners, policy-makers and other researchers to better learn how to implement large-scale change in their own settings.
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Affiliation(s)
- Olakunle Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniela Cristina Rodriguez
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neal Brandes
- Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, District of Columbia, USA
| | - Elvin Geng
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Ludovic Reveiz
- Knowledge Management, Bioethics, and Research Department, Pan American Health Organization, Washington, District of Columbia, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Theobald S, Brandes N, Gyapong M, El-Saharty S, Proctor E, Diaz T, Wanji S, Elloker S, Raven J, Elsey H, Bharal S, Pelletier D, Peters DH. Implementation research: new imperatives and opportunities in global health. Lancet 2018; 392:2214-2228. [PMID: 30314860 DOI: 10.1016/s0140-6736(18)32205-0] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 08/22/2018] [Accepted: 08/29/2018] [Indexed: 12/31/2022]
Abstract
Implementation research is important in global health because it addresses the challenges of the know-do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.
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Affiliation(s)
- Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Neal Brandes
- US Agency for International Development, Bureau for Global Health, Washington, DC, USA
| | | | - Sameh El-Saharty
- Middle East and North Africa Region, Human Development Sector, The World Bank, Washington, DC, USA
| | - Enola Proctor
- Brown School of Social Work, Washington University in St Louis, St Louis, MO, USA
| | - Theresa Diaz
- Department of Maternal, Newborn, Child, and Adolescent Health, WHO, Geneva, Switzerland
| | - Samuel Wanji
- Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon
| | - Soraya Elloker
- City of Cape Town, City Health Department, Cape Town, South Africa
| | - Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Elsey
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | | | - David Pelletier
- Programme in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - David H Peters
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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32
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Rowe AK, Rowe SY, Peters DH, Holloway KA, Chalker J, Ross-Degnan D. Effectiveness of strategies to improve health-care provider practices in low-income and middle-income countries: a systematic review. Lancet Glob Health 2018; 6:e1163-e1175. [PMID: 30309799 PMCID: PMC6185992 DOI: 10.1016/s2214-109x(18)30398-x] [Citation(s) in RCA: 232] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/13/2018] [Accepted: 08/15/2018] [Indexed: 11/09/2022]
Abstract
Background Inadequate health-care provider performance is a major challenge to the delivery of high-quality health care in low-income and middle-income countries (LMICs). The Health Care Provider Performance Review (HCPPR) is a comprehensive systematic review of strategies to improve health-care provider performance in LMICs. Methods For this systematic review we searched 52 electronic databases for published studies and 58 document inventories for unpublished studies from the 1960s to 2016. Eligible study designs were controlled trials and interrupted time series. We only included strategy-versus-control group comparisons. We present results of improving health-care provider practice outcomes expressed as percentages (eg, percentage of patients treated correctly) or as continuous measures (eg, number of medicines prescribed per patient). Effect sizes were calculated as absolute percentage-point changes. The summary measure for each comparison was the median effect size (MES) for all primary outcomes. Strategy effectiveness was described with weighted medians of MES. This study is registered with PROSPERO, number CRD42016046154. Findings We screened 216 477 citations and selected 670 reports from 337 studies of 118 strategies. Most strategies had multiple intervention components. For professional health-care providers (generally, facility-based health workers), the effects were near zero for only implementing a technology-based strategy (median MES 1·0 percentage points, IQR −2·8 to 9·9) or only providing printed information for health-care providers (1·4 percentage points, −4·8 to 6·2). For percentage outcomes, training or supervision alone typically had moderate effects (10·3–15·9 percentage points), whereas combining training and supervision had somewhat larger effects than use of either strategy alone (18·0–18·8 percentage points). Group problem solving alone showed large improvements in percentage outcomes (28·0–37·5 percentage points), but, when the strategy definition was broadened to include group problem solving alone or other strategy components, moderate effects were more typical (12·1 percentage points). Several multifaceted strategies had large effects, but multifaceted strategies were not always more effective than simpler ones. For lay health-care providers (generally, community health workers), the effect of training alone was small (2·4 percentage points). Strategies with larger effect sizes included community support plus health-care provider training (8·2–125·0 percentage points). Contextual and methodological heterogeneity made comparisons difficult, and most strategies had low quality evidence. Interpretation The impact of strategies to improve health-care provider practices varied substantially, although some approaches were more consistently effective than others. The breadth of the HCPPR makes its results valuable to decision makers for informing the selection of strategies to improve health-care provider practices in LMICs. These results also emphasise the need for researchers to use better methods to study the effectiveness of interventions. Funding Bill & Melinda Gates Foundation, CDC Foundation.
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Affiliation(s)
- Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Samantha Y Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA; CDC Foundation, Atlanta, GA, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathleen A Holloway
- World Health Organization, Southeast Asia Regional Office, New Delhi, India; International Institute of Health Management Research, Jaipur, India; Institute of Development Studies, University of Sussex, Brighton, UK
| | - John Chalker
- Pharmaceuticals & Health Technologies Group, Management Sciences for Health, Arlington, VA, USA
| | - Dennis Ross-Degnan
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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33
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Mirelman AJ, Trujillo AJ, Niessen LW, Ahmed S, Khan JA, Peters DH. Household coping strategies after an adult noncommunicable disease death in
Bangladesh. Int J Health Plann Manage 2018; 34:e203-e218. [DOI: 10.1002/hpm.2637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/01/2018] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Antonio J. Trujillo
- Department of International HealthJohns Hopkins Bloomberg School of Public Health Baltimore Maryland
| | - Louis W. Niessen
- Department of Clinical SciencesLiverpool School of Tropical Medicine Liverpool UK
| | - Sayem Ahmed
- Health Systems and Population Studies Divisionicddr,b Dhaka Bangladesh
| | - Jahangir A.M. Khan
- Department of Clinical SciencesLiverpool School of Tropical Medicine Liverpool UK
- Health Systems and Population Studies Divisionicddr,b Dhaka Bangladesh
| | - David H. Peters
- Department of International HealthJohns Hopkins Bloomberg School of Public Health Baltimore Maryland
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Swanson KC, Altare C, Wesseh CS, Nyenswah T, Ahmed T, Eyal N, Hamblion EL, Lessler J, Peters DH, Altmann M. Contact tracing performance during the Ebola epidemic in Liberia, 2014-2015. PLoS Negl Trop Dis 2018; 12:e0006762. [PMID: 30208032 PMCID: PMC6152989 DOI: 10.1371/journal.pntd.0006762] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 09/24/2018] [Accepted: 08/16/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND During the Ebola virus disease (EVD) epidemic in Liberia, contact tracing was implemented to rapidly detect new cases and prevent further transmission. We describe the scope and characteristics of contact tracing in Liberia and assess its performance during the 2014-2015 EVD epidemic. METHODOLOGY/PRINCIPAL FINDINGS We performed a retrospective descriptive analysis of data collection forms for contact tracing conducted in six counties during June 2014-July 2015. EVD case counts from situation reports in the same counties were used to assess contact tracing coverage and sensitivity. Contacts who presented with symptoms and/or died, and monitoring was stopped, were classified as "potential cases". Positive predictive value (PPV) was defined as the proportion of traced contacts who were identified as potential cases. Bivariate and multivariate logistic regression models were used to identify characteristics among potential cases. We analyzed 25,830 contact tracing records for contacts who had monitoring initiated or were last exposed between June 4, 2014 and July 13, 2015. Contact tracing was initiated for 26.7% of total EVD cases and detected 3.6% of all new cases during this period. Eighty-eight percent of contacts completed monitoring, and 334 contacts were identified as potential cases (PPV = 1.4%). Potential cases were more likely to be detected early in the outbreak; hail from rural areas; report multiple exposures and symptoms; have household contact or direct bodily or fluid contact; and report nausea, fever, or weakness compared to contacts who completed monitoring. CONCLUSIONS/SIGNIFICANCE Contact tracing was a critical intervention in Liberia and represented one of the largest contact tracing efforts during an epidemic in history. While there were notable improvements in implementation over time, these data suggest there were limitations to its performance-particularly in urban districts and during peak transmission. Recommendations for improving performance include integrated surveillance, decentralized management of multidisciplinary teams, comprehensive protocols, and community-led strategies.
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Affiliation(s)
| | - Chiara Altare
- Liberia Country Office, Action Contre la Faim, Paris, France
| | | | - Tolbert Nyenswah
- Public Health Emergencies, Liberia Ministry of Health, Monrovia, Liberia
| | - Tashrik Ahmed
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Nir Eyal
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | | | - Justin Lessler
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - David H. Peters
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Mathias Altmann
- Liberia Country Office, Action Contre la Faim, Paris, France
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Abstract
Health policy and systems research (HPSR) has changed considerably over the last 20 years, but its main purpose remains to inform and influence health policies and systems. Whereas goals that underpin health systems have endured – such as a focus on health equity – contexts and priorities change, research methods progress, and health organisations continue to learn and adapt, in part by using HPSR. For HPSR to remain relevant, its practitioners need to re-think how health systems are conceptualised, to keep up with rapid changes in how we diagnose and manage disease and use information, and consider factors affecting people’s health that go well beyond healthcare systems. The Sustainable Development Goals (SDGs) represent a shifting paradigm in human development by seeking convergence across sectors. They also offer an opportunity for HPSR to play a larger role, given its pioneering work on applying systems thinking to health, its focus on health equity, and the strength of its multi-disciplinary approaches that make it a good fit for the SDG era. Globally, population health is being challenged in different ways, from climate change and growing air pollution and toxic environmental exposure to food insecurity, massive population migration and refugee crises, to emerging and re-emerging diseases. Each of these trends reinforce each other and concentrate their harms on the most vulnerable populations. Multi-level governance, together with novel regulatory strategies and socially oriented investments, are key to successful action against many of the new challenges, with HPSR guiding their design and evolution. The HPSR community cannot be complacent about its successful, yet short, history. Tensions remain about how different stakeholders use HPSR such as the contrast between embedding research within government institutions versus independently evaluating and holding decision-makers accountable. Such tensions are inevitable in the boundary-spanning field that HPSR has become. We should strive to enhance the influence of HPSR by staying relevant in a changing world and embracing the strength of our diversity of disciplines, the range of problems addressed, and the opportunity of the SDGs to ensure that health and social benefits are more inclusive for people within and across countries.
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Affiliation(s)
- David H Peters
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, 615 N. Wolfe St, Suite E-8527, Baltimore, MD, 21205, United States of America.
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Alonge O, Lin S, Igusa T, Peters DH. Improving health systems performance in low- and middle-income countries: a system dynamics model of the pay-for-performance initiative in Afghanistan. Health Policy Plan 2018; 32:1417-1426. [PMID: 29029075 PMCID: PMC5886199 DOI: 10.1093/heapol/czx122] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2017] [Indexed: 11/14/2022] Open
Abstract
System dynamics methods were used to explore effective implementation pathways for improving health systems performance through pay-for-performance (P4P) schemes. A causal loop diagram was developed to delineate primary causal relationships for service delivery within primary health facilities. A quantitative stock-and-flow model was developed next. The stock-and-flow model was then used to simulate the impact of various P4P implementation scenarios on quality and volume of services. Data from the Afghanistan national facility survey in 2012 was used to calibrate the model. The models show that P4P bonuses could increase health workers' motivation leading to higher levels of quality and volume of services. Gaming could reduce or even reverse this desired effect, leading to levels of quality and volume of services that are below baseline levels. Implementation issues, such as delays in the disbursement of P4P bonuses and low levels of P4P bonuses, also reduce the desired effect of P4P on quality and volume, but they do not cause the outputs to fall below baseline levels. Optimal effect of P4P on quality and volume of services is obtained when P4P bonuses are distributed per the health workers' contributions to the services that triggered the payments. Other distribution algorithms such as equal allocation or allocations proportionate to salaries resulted in quality and volume levels that were substantially lower, sometimes below baseline. The system dynamics models served to inform, with quantitative results, the theory of change underlying P4P intervention. Specific implementation strategies, such as prompt disbursement of adequate levels of performance bonus distributed per health workers' contribution to service, increase the likelihood of P4P success. Poorly designed P4P schemes, such as those without an optimal algorithm for distributing performance bonuses and adequate safeguards for gaming, can have a negative overall impact on health service delivery systems.
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Affiliation(s)
- O Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E8622, Baltimore, MD 21205, USA
| | - S Lin
- Department of Civil Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - T Igusa
- Department of Civil Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - D H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E8622, Baltimore, MD 21205, USA
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Joarder T, George A, Sarker M, Ahmed S, Peters DH. Who are more responsive? Mixed-methods comparison of public and private sector physicians in rural Bangladesh. Health Policy Plan 2018; 32:iii14-iii24. [PMID: 29149312 DOI: 10.1093/heapol/czx111] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 11/12/2022] Open
Abstract
Responsiveness of physicians (ROPs) reflects the social actions by physicians to meet the legitimate expectations of health care users. Responsiveness is important since it improves understanding and care seeking by users, as well as fostering trust in health systems rather than replicating discrimination and entrenching inequality. Given widespread public and private sector health care provision in Bangladesh, we undertook a mixed-methods study comparing responsiveness of public and private physicians in rural Bangladesh. The study included in-depth interviews with physicians (n = 12, seven public, five private) and patients (n = 7, three male, four female); focus group discussions with users (four sessions, two male and two female); and observations in consultation rooms of public and private sector physicians (1 week in each setting). This was followed by structured observation of patient consultations with 195 public and 198 private physicians using the ROPs Scale, consisting of five domains (Friendliness; Respecting; Informing and guiding; Gaining trust; and Financial sensitivity). Qualitative data were analysed by framework analysis and quantitative data were analyzed using two-sample t-test, multiple linear regression, multivariate analysis of variance, and descriptive discriminant analyses. The mean responsiveness score of public sector physicians was statistically different from private sector physicians: -0.29 vs 0.29, i.e. a difference of - 0.58 (P-value < 0.01; 95% CI - 0.77, -0.39) on a normalized scale. Despite relatively higher level of responsiveness of private sector, according to qualitative findings, neither of the sectors performed optimally. Private physicians scored higher in Friendliness, Respecting and Informing and guiding; while public sector physicians scored higher in other domains. 'Respecting' domain was found as the most important. Unlike findings from other studies in Bangladesh, instead of seeing one sector as better than the other, this study identified areas of responsiveness where each sector needs improvements.
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Affiliation(s)
- Taufique Joarder
- Department of International Health (Health Systems) Johns Hopkins Bloomberg School of Public Health, USA.,James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Level 6, icddr,b Building, Mohakhali, Dhaka 1212, Bangladesh
| | - Asha George
- Faculty of Community and Health Sciences, SARChI Health Systems, Complexity and Social Change School of Public Health, University of Western Cape, South Arica
| | - Malabika Sarker
- James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Level 6, icddr,b Building, Mohakhali, Dhaka 1212, Bangladesh
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - David H Peters
- Department of International Health (Health Systems) Johns Hopkins Bloomberg School of Public Health, USA
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Niessen LW, Mohan D, Akuoku JK, Mirelman AJ, Ahmed S, Koehlmoos TP, Trujillo A, Khan J, Peters DH. Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda. Lancet 2018; 391:2036-2046. [PMID: 29627160 DOI: 10.1016/s0140-6736(18)30482-3] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 07/24/2017] [Accepted: 01/17/2018] [Indexed: 12/01/2022]
Abstract
Five Sustainable Development Goals (SDGs) set targets that relate to the reduction of health inequalities nationally and worldwide. These targets are poverty reduction, health and wellbeing for all, equitable education, gender equality, and reduction of inequalities within and between countries. The interaction between inequalities and health is complex: better economic and educational outcomes for households enhance health, low socioeconomic status leads to chronic ill health, and non-communicable diseases (NCDs) reduce income status of households. NCDs account for most causes of early death and disability worldwide, so it is alarming that strong scientific evidence suggests an increase in the clustering of non-communicable conditions with low socioeconomic status in low-income and middle-income countries since 2000, as previously seen in high-income settings. These conditions include tobacco use, obesity, hypertension, cancer, and diabetes. Strong evidence from 283 studies overwhelmingly supports a positive association between low-income, low socioeconomic status, or low educational status and NCDs. The associations have been differentiated by sex in only four studies. Health is a key driver in the SDGs, and reduction of health inequalities and NCDs should become key in the promotion of the overall SDG agenda. A sustained reduction of general inequalities in income status, education, and gender within and between countries would enhance worldwide equality in health. To end poverty through elimination of its causes, NCD programmes should be included in the development agenda. National programmes should mitigate social and health shocks to protect the poor from events that worsen their frail socioeconomic condition and health status. Programmes related to universal health coverage of NCDs should specifically target susceptible populations, such as elderly people, who are most at risk. Growing inequalities in access to resources for prevention and treatment need to be addressed through improved international regulations across jurisdictions that eliminate the legal and practical barriers in the implementation of non-communicable disease control.
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Affiliation(s)
- Louis W Niessen
- Department of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jonathan K Akuoku
- Department of Health, Nutrition and Population Global Practice, The World Bank, Washington, DC, USA
| | | | - Sayem Ahmed
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh; Health Economics and Policy Research Group, Department of Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Tracey P Koehlmoos
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh; Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Antonio Trujillo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jahangir Khan
- Department of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Health Economics and Policy Research Group, Department of Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Kirsch TD, Moseson H, Massaquoi M, Nyenswah TG, Goodermote R, Rodriguez-Barraquer I, Lessler J, Cumings DAT, Peters DH. Impact of interventions and the incidence of ebola virus disease in Liberia-implications for future epidemics. Health Policy Plan 2018; 32:205-214. [PMID: 28207062 DOI: 10.1093/heapol/czw113] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 11/14/2022] Open
Abstract
To better understand the impact of national and global efforts to contain the Ebola virus disease epidemic of 2014–15 in Liberia, we provide a detailed timeline of the major interventions and relate them to the epidemic curve.
In addition to personal experience in the response, we systematically reviewed situation reports from the Liberian government, UN, CDC, WHO, UNICEF, IFRC, USAID, and local and international news reports to create the timeline. We extracted data on the timing and nature of activities and compared them to the timeline of the epidemic curve using the reproduction number—the estimate of the average number of new cases caused by a single case.
Interventions were organized around five major strategies, with the majority of resources directed to the creation of treatment beds. We conclude that no single intervention stopped the epidemic; rather, the interventions likely had reinforcing effects, and some were less likely than others to have made a major impact. We find that the epidemic’s turning coincided with a reorganization of the response in August–September 2014, the emergence of community leadership in control efforts, and changing beliefs and practices in the population. Ebola Treatment Units were important for Ebola treatment, but the vast majority of these treatment centre beds became available after the epidemic curve began declining. Similarly, the United Nations Mission for Ebola Emergency Response was launched after the epidemic curve had already turned.
These findings have significant policy implications for future epidemics and suggest that much of the decline in the epidemic curve was driven by critical behaviour changes within local communities, rather than by international efforts that came after the epidemic had turned. Future global interventions in epidemic response should focus on building community capabilities, strengthening local ownership, and dramatically reducing delays in the response.
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Affiliation(s)
- Thomas D Kirsch
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heidi Moseson
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Moses Massaquoi
- Liberian Ministry of Health, Tubman Blvd, Monrovia, Liberia and
| | | | - Rachel Goodermote
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Justin Lessler
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Derek A T Cumings
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Biology and Emerging Pathogens Institute, University of Florida, FL, USA
| | - David H Peters
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
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Kananura RM, Ekirapa-Kiracho E, Paina L, Bumba A, Mulekwa G, Nakiganda-Busiku D, Oo HNL, Kiwanuka SN, George A, Peters DH. Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda. Health Res Policy Syst 2017; 15:107. [PMID: 29297410 PMCID: PMC5751403 DOI: 10.1186/s12961-017-0274-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background The use of participatory monitoring and evaluation (M&E) approaches is important for guiding local decision-making, promoting the implementation of effective interventions and addressing emerging issues in the course of implementation. In this article, we explore how participatory M&E approaches helped to identify key design and implementation issues and how they influenced stakeholders’ decision-making in eastern Uganda. Method The data for this paper is drawn from a retrospective reflection of various M&E approaches used in a maternal and newborn health project that was implemented in three districts in eastern Uganda. The methods included qualitative and quantitative M&E techniques such as key informant interviews, formal surveys and supportive supervision, as well as participatory approaches, notably participatory impact pathway analysis. Results At the design stage, the M&E approaches were useful for identifying key local problems and feasible local solutions and informing the activities that were subsequently implemented. During the implementation phase, the M&E approaches provided evidence that informed decision-making and helped identify emerging issues, such as weak implementation by some village health teams, health facility constraints such as poor use of standard guidelines, lack of placenta disposal pits, inadequate fuel for the ambulance at some facilities, and poor care for low birth weight infants. Sharing this information with key stakeholders prompted them to take appropriate actions. For example, the sub-county leadership constructed placenta disposal pits, the district health officer provided fuel for ambulances, and health workers received refresher training and mentorship on how to care for newborns. Conclusion Diverse sources of information and perspectives can help researchers and decision-makers understand and adapt evidence to contexts for more effective interventions. Supporting districts to have crosscutting, routine information generating and sharing platforms that bring together stakeholders from different sectors is therefore crucial for the successful implementation of complex development interventions. Electronic supplementary material The online version of this article (doi:10.1186/s12961-017-0274-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rornald Muhumuza Kananura
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda. .,Department of Social Policy, London School of Economic and Political Science, London, United Kingdom.
| | - Elizabeth Ekirapa-Kiracho
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Ligia Paina
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, MD, United States of America
| | - Ahmed Bumba
- District Health Office, Kibuku District Local Government, Kampala, Uganda
| | - Godfrey Mulekwa
- District Health Office, Pallisa District Health Office, Kampala, Uganda
| | | | - Htet Nay Lin Oo
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, MD, United States of America
| | - Suzanne Namusoke Kiwanuka
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Asha George
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, MD, United States of America.,University of the Western Cape, Cape Town, South Africa
| | - David H Peters
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, MD, United States of America
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Peters DH, Bhuiya A, Ghaffar A. Engaging stakeholders in implementation research: lessons from the Future Health Systems Research Programme experience. Health Res Policy Syst 2017; 15:104. [PMID: 29297406 PMCID: PMC5751781 DOI: 10.1186/s12961-017-0269-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD, 21205, United States of America.
| | - Abbas Bhuiya
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD, 21205, United States of America
| | - Abdul Ghaffar
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
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Abstract
Implementation research (IR) focuses on understanding how and why interventions produce their effects in a given context. This often requires engaging a broad array of stakeholders at multiple levels of the health system. Whereas a variety of tools and approaches exist to facilitate stakeholder engagement at the national or institutional level, there is a substantial gap in the IR literature about how best to do this at the local or community level. Similarly, although there is extensive guidance on community engagement within the context of clinical trials-for HIV/AIDS in particular-the same cannot be said for IR. We identified a total of 59 resources by using a combination of online searches of the peer-reviewed and grey literature, as well as crowd-sourcing through the Health Systems Global platform. The authors then completed two rounds of rating the resources to identify the '10 best'. The resources were rated based on considerations of their relevance to IR, existence of an underlying conceptual framework, comprehensiveness of guidance, ease of application, and evidence of successful application in low- or middle-income countries or relevant contexts. These 10 resources can help implementation researchers think strategically and practically about how best to engage community stakeholders to improve the quality, meaningfulness, and application of their results in order to improve health and health systems outcomes. Building on the substantial work that has already been done in the context of clinical trials, there is a need for clearer and more specific guidance on how to incorporate relevant and effective community engagement approaches into IR project planning and implementation.
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Affiliation(s)
- Douglas Glandon
- Johns Hopkins Bloomberg School of Public Health, Schiffer 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Ligia Paina
- Johns Hopkins Bloomberg School of Public Health, Schiffer 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Olakunle Alonge
- Johns Hopkins Bloomberg School of Public Health, Schiffer 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - David H Peters
- Johns Hopkins Bloomberg School of Public Health, Schiffer 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Sara Bennett
- Johns Hopkins Bloomberg School of Public Health, Schiffer 615 North Wolfe Street, Baltimore, MD 21205, USA
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Peters DH, Keusch GT, Cooper J, Davis S, Lundgren J, Mello MM, Omatade O, Wabwire-Mangen F, McAdam KPWJ. In search of global governance for research in epidemics. Lancet 2017; 390:1632-1633. [PMID: 29131784 DOI: 10.1016/s0140-6736(17)32546-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 09/21/2017] [Indexed: 12/16/2022]
Affiliation(s)
- David H Peters
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - Gerald T Keusch
- Boston University Schools of Medicine and Public Health, Boston University, Boston, MA, USA
| | - Janice Cooper
- The Carter Center Liberia Mental Health Initiative, Monrovia, Liberia
| | | | | | - Michelle M Mello
- Stanford University School of Medicine, School of Law, Stanford, CA, USA
| | - Olayemi Omatade
- Institute of Child Health, University College Hospital, University of Ibadan, Ibadan, Nigeria
| | - Fred Wabwire-Mangen
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
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Venkataramani M, Edward A, Ickx P, Younusi M, Ali Shah Alawi S, Peters DH. Are children presenting with non-IMCI complaints at greater risk for suboptimal screening? An analysis of outpatient visits in Afghanistan. Int J Qual Health Care 2017; 29:662-668. [PMID: 28992150 DOI: 10.1093/intqhc/mzx084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 07/03/2017] [Indexed: 11/13/2022] Open
Abstract
Objective To determine if children presenting without complaints related to the Integrated Management of Childhood Illness (IMCI) are at greater risk for suboptimal screening for IMCI conditions. Design Cross-sectional study. Setting Thirty-three provinces in Afghanistan. Participants Observation of 3072 sick child visits selected by systematic random sampling. Main outcome measure(s) A 10 point IMCI assessment index. Results One hundred and thirty-one (4.3%) of the 3072 sick child visits involved no IMCI-related complaints. The mean assessment index for all sick child visits was 4.81 (SD 2.41). Visits involving any IMCI-related complaint were associated with a 1.02 point higher mean assessment index than those without IMCI-related complaints (95% CI, 0.52-1.53; P < 0.001). After adjusting for relevant covariates including patient age, caretaker gender, provider type, provider gender, provider IMCI training status and IMCI guideline availability, we found that children with IMCI-related presenting complaints had a significantly better quality of IMCI screening, than those without IMCI presenting complaints (by 0.75 points; 95% CI, 0.25-1.26; P = 0.003). Conclusions Our study indicates that children with non-IMCI presenting complaints are at greater risk of suboptimal screening compared to children with IMCI-related presenting complaints. The premise of IMCI is to routinely screen all children for conditions responsible for the major burden of childhood disease in countries like Afghanistan. The study illustrates an important finding that facility and provider capacity needs to be improved, particularly during training, supervision and guideline dissemination to ensure that all children receive routine screening for common IMCI conditions.
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Affiliation(s)
- Maya Venkataramani
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Suite 2-502, 2024 E Monument Street, Baltimore, MD 21287, USA
| | - Anbrasi Edward
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
| | - Paul Ickx
- Center for Health Services, Management Sciences for Health, 4301 Fairfax Dr, Arlington, VA 22203, USA
| | - Motawali Younusi
- Child and Adolescent Health Department, General Directorate of Preventive Medicine of the Ministry of Public Health of the Islamic Republic of Afghanistan, Kabul, Afghanistan
| | - Syed Ali Shah Alawi
- Child and Adolescent Health Department, General Directorate of Preventive Medicine of the Ministry of Public Health of the Islamic Republic of Afghanistan, Kabul, Afghanistan
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
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Rodríguez DC, Hoe C, Dale EM, Rahman MH, Akhter S, Hafeez A, Irava W, Rajbangshi P, Roman T, Ţîrdea M, Yamout R, Peters DH. Assessing the capacity of ministries of health to use research in decision-making: conceptual framework and tool. Health Res Policy Syst 2017; 15:65. [PMID: 28764787 PMCID: PMC5539643 DOI: 10.1186/s12961-017-0227-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 06/29/2017] [Indexed: 11/21/2022] Open
Abstract
Background The capacity to demand and use research is critical for governments if they are to develop policies that are informed by evidence. Existing tools designed to assess how government officials use evidence in decision-making have significant limitations for low- and middle-income countries (LMICs); they are rarely tested in LMICs and focus only on individual capacity. This paper introduces an instrument that was developed to assess Ministry of Health (MoH) capacity to demand and use research evidence for decision-making, which was tested for reliability and validity in eight LMICs (Bangladesh, Fiji, India, Lebanon, Moldova, Pakistan, South Africa, Zambia). Methods Instrument development was based on a new conceptual framework that addresses individual, organisational and systems capacities, and items were drawn from existing instruments and a literature review. After initial item development and pre-testing to address face validity and item phrasing, the instrument was reduced to 54 items for further validation and item reduction. In-country study teams interviewed a systematic sample of 203 MoH officials. Exploratory factor analysis was used in addition to standard reliability and validity measures to further assess the items. Results Thirty items divided between two factors representing organisational and individual capacity constructs were identified. South Africa and Zambia demonstrated the highest level of organisational capacity to use research, whereas Pakistan and Bangladesh were the lowest two. In contrast, individual capacity was highest in Pakistan, followed by South Africa, whereas Bangladesh and Lebanon were the lowest. Conclusion The framework and related instrument represent a new opportunity for MoHs to identify ways to understand and improve capacities to incorporate research evidence in decision-making, as well as to provide a basis for tracking change. Electronic supplementary material The online version of this article (doi:10.1186/s12961-017-0227-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniela C Rodríguez
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America.
| | - Connie Hoe
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | - M Hafizur Rahman
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Sadika Akhter
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Wayne Irava
- College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | | | | | - Marcela Ţîrdea
- Ministry of Health of the Republic of Moldova, Chisinau, Republic of Moldova
| | | | - David H Peters
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
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Paina L, Vadrevu L, Hanifi SMMA, Akuze J, Rieder R, Chan KS, Peters DH. What is the role of community capabilities for maternal health? An exploration of community capabilities as determinants to institutional deliveries in Bangladesh, India, and Uganda. BMC Health Serv Res 2016; 16:621. [PMID: 28185588 PMCID: PMC5123293 DOI: 10.1186/s12913-016-1861-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background While community capabilities are recognized as important factors in developing resilient health systems and communities, appropriate metrics for these have not yet been developed. Furthermore, the role of community capabilities on access to maternal health services has been underexplored. In this paper, we summarize the development of a community capability score based on the Future Health System (FHS) project’s experience in Bangladesh, India, and Uganda, and, examine the role of community capabilities as determinants of institutional delivery in these three contexts. Methods We developed a community capability score using a pooled dataset containing cross-sectional household survey data from Bangladesh, India, and Uganda. Our main outcome of interest was whether the woman delivered in an institution. Our predictor variables included the community capability score, as well as a series of previously identified determinants of maternal health. We calculate both population-averaged effects (using GEE logistic regression), as well as sub-national level effects (using a mixed effects model). Results Our final sample for analysis included 2775 women, of which 1238 were from Bangladesh, 1199 from India, and 338 from Uganda. We found that individual-level determinants of institutional deliveries, such as maternal education, parity, and ante-natal care access were significant in our analysis and had a strong impact on a woman’s odds of delivering in an institution. We also found that, in addition to individual-level determinants, greater community capability was significantly associated with higher odds of institutional delivery. For every additional capability, the odds of institutional delivery would increase by up to almost 6 %. Conclusion Individual-level characteristics are strong determinants of whether a woman delivered in an institution. However, we found that community capability also plays an important role, and should be taken into account when designing programs and interventions to support institutional deliveries. Consideration of individual factors and the capabilities of the communities in which people live would contribute to the vision of supporting people-centered approaches to health. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1861-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ligia Paina
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Lalitha Vadrevu
- Indian Institute of Health Management Research, 1 Prabhu Dayal Marg, Sanganer, Jaipur, 302029, India
| | | | - Joseph Akuze
- Department of Health Policy, Planning, and Management, Center of Excellence for Maternal and Newborn Health Research, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda
| | - Rachel Rieder
- DKT International Tanzania, Meranani St, Dar es Salaam, Tanzania
| | - Kitty S Chan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, #633, Baltimore, MD, 21205, USA
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Ekirapa-Kiracho E, Namazzi G, Tetui M, Mutebi A, Waiswa P, Oo H, Peters DH, George AS. Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda. BMC Health Serv Res 2016; 16:638. [PMID: 28185592 PMCID: PMC5123379 DOI: 10.1186/s12913-016-1864-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. METHODS A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. RESULTS Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women's access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. CONCLUSIONS This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.
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Affiliation(s)
- Elizabeth Ekirapa-Kiracho
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
| | - Gertrude Namazzi
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
| | - Moses Tetui
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit, Umeå University, 901 87 Umeå, Sweden
| | - Aloysius Mutebi
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
| | - Peter Waiswa
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
- Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Htet Oo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - David H. Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Asha S. George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- South African Research Chair, School of Public Health, University of the Western Cape, Cape Town, South Africa
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George AS, Scott K, Sarriot E, Kanjilal B, Peters DH. Unlocking community capabilities across health systems in low- and middle-income countries: lessons learned from research and reflective practice. BMC Health Serv Res 2016; 16:631. [PMID: 28185599 PMCID: PMC5123243 DOI: 10.1186/s12913-016-1859-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Asha S George
- School of Public Health, University of the Western Cape, Cape Town, 7535, South Africa. .,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.,Global Health Consultant, Bangalore, Karnataka, 560084, India
| | - Eric Sarriot
- Department of Global Health, Save the Children, Washington DC, 20002, USA
| | - Barun Kanjilal
- Indian Institute of Health Management Research, Jaipur, 302029, India
| | - David H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
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Abstract
The Ebola epidemic of 2014-2015 was one of the most significant public health threats of the 21st century, a crisis that challenged leadership in West Africa and around the world. Using the experience of Liberia's epidemic control efforts, we highlight the critical role that leadership played during four phases of the epidemic response: (1) crisis recognition and early mobilization; (2) the emergency phase; (3) the declining epidemic; and (4) the long tail. We examine how the decisions and actions taken in each phase of the epidemic address key crisis leadership tasks, including sense-making, decision making, meaning-making, crisis termination, and learning, and assess how leadership approaches evolved during the different epidemic phases to accomplish these tasks. A contingency leadership theory lens is used to identify situations where strong leadership, good leader-member relations, and well-structured tasks can facilitate different leadership approaches. The first phase of the epidemic was hampered by insufficient attention to sense-making and weak decision making, in part because of the existing hierarchical leadership approach. This contributed to amplification of the epidemic. The emergency phase of the epidemic brought a change in leadership that focused on sense-making, decision-making, and meaning-making tasks. A distributed leadership approach replaced the old hierarchies. In addition to sharing leadership responsibility and authority, the distributed leadership approach involved strategically engaging stakeholders and communicating intensively. Although much of the hierarchical leadership approaches returned in the latter phases of the epidemic, there remain more empowered leaders at different levels across the country. Systematically tackling crisis leadership tasks, recognizing situations where different leadership approaches can be used, and employing a distributed leadership approach are helpful lessons to prepare for and respond to future crises.
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Affiliation(s)
- Tolbert Nyenswah
- Department of Public Health Emergencies , Ministry of Health, Republic of Liberia , Monrovia, Montserrado , Liberia
| | - Cyrus Y Engineer
- Department of Interprofessional Health Studies , College of Health Professions, Towson University , Towson , MD , USA
| | - David H Peters
- Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Shroff Z, Bigdeli M, Babar ZUD, Wagner A, Ghaffar A, Peters DH. Using health markets to improve access to medicines: three case studies. J Pharm Policy Pract 2016; 9:19. [PMID: 27158514 PMCID: PMC4859952 DOI: 10.1186/s40545-016-0067-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 04/26/2016] [Indexed: 11/13/2022] Open
Abstract
This editorial introduces a series of case studies that together highlight the use of health market interventions to improve access to medicines in low-and-middle income countries (LMICs). It underscores the added value of using a systems approach for a holistic understanding of how these interventions interact with the rest of the health system and the intended and unintended consequences that result. It goes on to summarize key findings from each of the studies and concludes with lessons for decision-makers on the design and implementation of market based interventions in LMIC health systems
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Affiliation(s)
- Zubin Shroff
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
| | - Maryam Bigdeli
- Health Systems Governance, Policy and Aid Effectiveness, World Health Organization, Geneva, Switzerland
| | | | | | - Abdul Ghaffar
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
| | - David H Peters
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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