Transformed through the CARTA experience: changes reported by CARTA fellows about their PhD journey

Transformative learning occurs when a person, group, or larger social unit encounters ideas that are at odds with their prevailing perspective. This discrepant perspective can lead to an examination of previously held beliefs, values, and assumptions. The Consortium for Advanced Research Training in Africa (CARTA) has since 2011 been training and supporting faculty from different African universities, to become more reflective and productive researchers, research leaders, educators, and change agents who will drive institutional changes in their institutions. As part of a mid-term evaluation of CARTA, an open-ended question was posed to the CARTA fellows asking them to describe any changes they had experienced in their professional lives as a result of the CARTA Programme. The 135 responses were inductively coded and analysed using qualitative thematic analysis. These themes were subsequently mapped onto Hoggan's typology of transformative learning outcomes. CARTA fellows reported shifts in their sense of self; worldviews; beliefs about the definition of knowledge, how it is constructed and evaluated; and changes in behaviour/practices and capacities. This paper argues that the changes described by the CARTA fellows reflect transformative learning that is embedded in CARTA's Theory of Change. The reported transformation was enabled by a curriculum intentionally designed to facilitate critical reflection, further exploration, and questioning, both formally and informally during the fellows' PhD journey with the support of CARTA facilitators. Documenting and disseminating these lessons provide a guide for future practice, and educators wishing to revitalise their PhD training may find it useful to review the CARTA PhD curriculum.

Resilience of research capacity strengthening initiatives in Africa during crises: the case of CARTA during COVID

Background: Several research capacity strengthening (RCS) initiatives have been established in Africa over the past decade. One such initiative is the Consortium for Advanced Research Training in Africa (CARTA) that has gained traction over the years and has been proven as an effective multidisciplinary approach to strengthen research capacity to address public and population health in Africa. Objectives: In this article, we document the experiences and management-related interventions that cushioned the CARTA programme and enabled it to remain resilient during the COVID pandemic. We further make recommendations on the enablers of resilience and optimal performance of such RCS initiatives during crises and beyond. Methods: We used routine information gathered by the CARTA secretariat from consortium correspondence, meeting minutes, reports and other related documents produced in the year 2020 in order to consolidate the experiences and interventions taken by the programme at programmatic, institutional and fellowship levels. Results: We identified a series of management-related cyclic phases that CARTA went through during the pandemic period, which included immobilisation, reflection, brainstorming, decision-making, intervening and recovery. We further identified strategic management-related interventions that contributed to the resilience of the programme during the pandemic including assessment and monitoring, communication management, policy and resource management, making investments and execution. Moreover, we observed that the strength of the leadership and management of CARTA, coupled with the consortium´s culture of collaboration, mutual trust, respect, openness, transparency, equitability, ownership, commitment and accountability, all contributed to its success during the pandemic period. Conclusion: We conclude that RCS initiatives undergo a series of phases during crises and that they need to promptly adopt and adapt appropriate management-related strategic interventions in order to remain resilient during such periods. This can be significantly realised if RCS initiatives build a culture of trust, commitment and joint ownership, and if they invest in strong management capacity.

Understanding the impact of the COVID‑19 pandemic on healthcare services for adults during three waves of COVID‑19 infections: A South African private sector experience

BACKGROUND

Since the onset of the COVID‑19 pandemic, healthcare resources have been repurposed to focus on COVID‑19. Resource reallocation and restrictions to movement that affected general access to care may have inadvertently resulted in undue disruptions in the continuum of care for patients requiring non-COVID‑19 healthcare services.

OBJECTIVES

To describe the change in pattern of health service use in the South African (SA) private sector.

METHODS

We conducted a retrospective study of a nationwide cohort of privately insured individuals. An analysis of claims data was performed for non-COVID‑19 related healthcare services provided from April 2020 to December 2020 (year 1 of COVID‑19) and April 2021 to December 2021 (year 2 of COVID‑19) relative to the same period in 2019 prior to the COVID‑19 pandemic in SA. Over and above plotting the monthly trends, we tested for statistical significance of the changes using a Wilcoxon test given the non-normality of all the outcomes.

RESULTS

Between April and December 2020, relative to the same period in 2021, and also relative to the same period in 2019, we found a 31.9% (p<0.01) and a 16.6% (p<0.01) reduction in emergency room visits, respectively; a 35.9% (p<0.01) and 20.5% (p<0.01) reduction in medical hospital admissions; a 27.4% (p=0.01) and 13.0% (p=0.03) reduction in surgical hospital admissions; a 14.5% (p<0.01) and 4.1% (p=0.16) reduction in face-to-face general practitioner consultations for chronic members; a 24.9% (p=0.06) and 5.2% (p=0.54) reduction in mammography for female members; a 23.4% (p=0.03) and 10.8% (p=0.09) reduction in Pap smear screenings for female members; a 16.5% (p=0.08) and 12.1% (p=0.27) reduction in colorectal cancer registrations and an 18.2% (p=0.08) and 8.9% (p=0.07) decrease in all oncology diagnoses. Uptake of telehealth services throughout the healthcare delivery system increased by 5 708% in 2020 compared with 2019, and 36.1% for 2021 compared with 2020.

CONCLUSION

A significant reduction in emergency room visits, hospital admissions and utilisation of primary care services was observed since the start of the pandemic. Further research is required to understand if there are long-term consequences of delayed care. An increase in the use of digital consultations was observed. Research on their acceptability and effectiveness may open new modalities of care, which may have cost- and time-saving benefits.

Considerations for an integrated population health databank in Africa: lessons from global best practices

Background: The rising digitisation and proliferation of data sources and repositories cannot be ignored. This trend expands opportunities to integrate and share population health data. Such platforms have many benefits, including the potential to efficiently translate information arising from such data to evidence needed to address complex global health challenges. There are pockets of quality data on the continent that may benefit from greater integration. Integration of data sources is however under-explored in Africa. The aim of this article is to identify the requirements and provide practical recommendations for developing a multi-consortia public and population health data-sharing framework for Africa.

Methods: We conducted a narrative review of global best practices and policies on data sharing and its optimisation. We searched eight databases for publications and undertook an iterative snowballing search of articles cited in the identified publications. The Leximancer software © enabled content analysis and selection of a sample of the most relevant articles for detailed review. Themes were developed through immersion in the extracts of selected articles using inductive thematic analysis. We also performed interviews with public and population health stakeholders in Africa to gather their experiences, perceptions, and expectations of data sharing.

Results: Our findings described global stakeholder experiences on research data sharing. We identified some challenges and measures to harness available resources and incentivise data sharing.  We further highlight progress made by the different groups in Africa and identified the infrastructural requirements and considerations when implementing data sharing platforms. Furthermore, the review suggests key reforms required, particularly in the areas of consenting, privacy protection, data ownership, governance, and data access.

Conclusions: The findings underscore the critical role of inclusion, social justice, public good, data security, accountability, legislation, reciprocity, and mutual respect in developing a responsive, ethical, durable, and integrated research data sharing ecosystem.

Positioning Africa's public health doctoral students to lead societal transformation and development

The public health context is becoming increasingly more complex requiring highly trained professionals equipped with knowledge, competencies and tools to address or transform current and future challenges. Doctoral degree training offers an opportunity to build the capacity to detect and respond to such dynamic health challenges. In this paper, we discuss how Africa's public health doctoral students can be better positioned for the different career pathways to provide leadership on complex health and development challenges. Public health PhD graduates can take up careers in academia, civil service, private sector and civil society, among others. To thrive in these pathways, PhD training should equip them with knowledge, skills and competencies in leadership, creativity and social competence among others. To produce career-ready PhD graduates, there is need to rethink training curricula to build critical skills for diverse career pathways, introduce students to entrepreneurship, and enhance linkages between universities and industry. Experiential learning, exposure to networks and partnerships, postdoctoral programmes and mentorship and exchange programmes can further equip PhD students with key knowledge, skills and competencies. For students to position themselves for the different careers, they ought to plan their careers early, albeit with flexibility. Students should build their soft skills and embrace technology among other transferable competencies. By identifying potential career pathways and being positioned for these early, Africa can produce transformative PhD students on a path for success not just for themselves but for society at large, including in new environments such as that created by COVID-19.

Prevalence and factors associated with catastrophic health expenditure among slum and non-slum dwellers undergoing emergency surgery in a metropolitan area of South Western Nigeria

BACKGROUND

Out of Pocket (OOP) payment continues to persist as the major mode of payment for healthcare in Nigeria despite the introduction of the National Health Insurance Scheme (NHIS). Although the burden of health expenditure has been examined in some populations, the impact of OOP among slum dwellers in Nigeria when undergoing emergencies, is under-researched. This study sought to examine the prevalence, factors and predictors of catastrophic health expenditure amongst selected slum and non-slum communities undergoing emergency surgery in Southwestern Nigeria.

METHODS

The study utilised a descriptive cross-sectional survey design to recruit 450 households through a multistage sampling technique. Data were collected using pre-tested semi-structured questionnaires in 2017. Factors considered for analysis relating to the payer were age, sex, relationship of payer to patient, educational status, marital status, ethnicity, occupation, income and health insurance coverage. Variables factored into analysis for the patient were indication for surgery, grade of hospital, and type of hospital. Households were classified as incurring catastrophic health expenditure (CHE), if their OOP expenditure exceeded 5% of payers' household budget. Analysis of the data took into account the multistage sampling design.

RESULTS

Overall, 65.6% (95% CI: 55.6-74.5) of the total population that were admitted for emergency surgery, experienced catastrophic expenditure. The prevalence of catastrophic expenditure at 5% threshold, among the population scheduled for emergency surgeries, was significantly higher for slum dwellers (74.1%) than for non-slum dwellers (47.7%) (F = 8.59; p = 0.019). Multiple logistic regression models revealed the significant independent factors of catastrophic expenditure at the 5% CHE threshold to include setting of the payer (whether slum or non-slum dweller) (p = 0.019), and health insurance coverage of the payer (p = 0.012). Other variables were nonetheless significant in the bivariate analysis were age of the payer (p = 0.017), income (p<0.001) and marital status of the payer (p = 0.022).

CONCLUSION

Although catastrophic health expenditure was higher among the slum dwellers, substantial proportions of respondents incurred catastrophic health expenditure irrespective of whether they were slum or non-slum dwellers. Concerted efforts are required to implement protective measures against catastrophic health expenditure in Nigeria that also cater to slum dwellers.

Quantifying the cost of in-kind contributions to a multidonor-funded health research capacity-building programme: the case of the Consortium for Advanced Research Training in Africa

Introduction

There are significant investments in health research capacity development in the ‘global-south’. The monetary value of contributions from institutions running these programmes is not known.

Methods

Using the Consortium for Advanced Research Training in Africa (CARTA) as a case study we estimate in-kind contributions made by consortium members. We measured unpaid hours of labour contributed by consortium members and converted this to full-time equivalents. We assigned a monetary value to the time contributed by staff based on salaries by seniority and region. We estimated the monetary value of the contribution made by the African institutions that hosted CARTA events by comparing the difference in cost between university-hosted events with those held in commercial venues. We calculated the foregone overhead costs associated with hosting the CARTA secretariat. We excluded many costs where data were difficult to verify.

Results

Annually, CARTA member institutions committed a minimum of 4.3 full-time staff equivalents that are not funded by the grants. CARTA’s annual in-kind contribution represents at least 20% of total annual donor expenditure. African institutions accounted for 82.9% of the in-kind labour contribution and 91.6% of total in-kind contribution.

Conclusion

The consortium’s institutions and academic and non-academic staff make significant contributions to ensure the effective implementation of donor-funded programmes. This is not unique to CARTA. These contributions are usually not counted, often not recognised at institutional level nor remunerated through grants. Knowing these costs would allow for sustainability appraisals and cost-benefit assessments. This paper offers a method of how to measure these contributions and begins a discussion around this.

Acceptability and feasibility of inter-related activities to improve agency among African district health managers: A four-country study

District health managers (DHMs) lead and manage Ministry of Health programmes and system performance. We report on the acceptability and feasibility of inter-related activities to increase the agency of DHMs in Kenya, Nigeria, South Africa and Uganda using a cross-sectional rapid appraisal with 372 DHMs employing structured questionnaires. We found differences and similarities between the countries, in particular, who becomes a DHM. The opportunity to provide leadership and effect change and being part of a team were reported as rewarding aspects of DHMs' work. Demotivating factors included limited resources, bureaucracy, staff shortages, lack of support from leadership and inadequate delegation of authority. District managers ranked the acceptability of the inter-related activities similarly despite differences between contexts. Activities highly ranked by DHMs were to employ someone to support primary care staff to compile and analyse district-level data; to undertake study tours to well-functioning districts; and joining an African Regional DHM Association. DHMs rated these activities as feasible to implement. This study confirms that DHMs are in support of a process to promote bottom-up, data-driven, context-specific actions that can promote self-actualisation, recognises the roles DHMs play, provides opportunities for peer learning and can potentially improve quality of care.

Increasing collaborative research output between early-career health researchers in Africa: lessons from the CARTA fellowship program

In 2008 nine African Universities and four African research institutions, in partnership with non-African institutions started the Consortium for Advanced Research Training in Africa (CARTA) to strengthen doctoral training and research capacity on health in Africa. This study describes particular aspects of the CARTA program that promotes collaboration between the PhD fellows in the program, and determines the patterns of collaborative publications that resulted from the intervention. We reviewed program monitoring and evaluation documents and conducted a bibliometric analysis of 806 peer-reviewed publications by CARTA fellows published between 2011 and 2018. Results indicate that recruiting multidisciplinary fellows from various institutions, encouraging registration of doctoral-level fellows outside home institutions, and organizing joint research seminars stimulated collaborative research on health-related topics. Fellows collaborated among themselves and with non-CARTA researchers. Fellows co-authored 75 papers (10%) between themselves, of which 53 (71%) and 42 (56%) included fellows of different cohorts and different disciplines respectively, and 19 (25%) involved fellows of different institutions. CARTA graduates continued to publish with each other after graduating - 11% of the collaborative publications occurred post-graduation - indicating that the collaborative approach was maintained after exiting from the program. However, not all fellows contributed to publishing collaborative papers. The study recommends concerted effort towards enhancing collaborative publications among the CARTA fellows, both doctoral and post-doctoral, which can include holding research exchange forums and collaborative grant-writing workshops.

Institutionalizing research capacity strengthening in LMICs: A systematic review and meta-synthesis

Background: Evidence on effective strategies to ensure sustainability of research capacity strengthening interventions in low- and middle-income country (LMIC) institutions is lacking. This systematic review identified publications describing research capacity building programs and noted their effect, their contexts, and the mechanisms, processes and social actors employed in them. Methods: We searched online databases for the period 2011-2018. Inclusion criteria were that the publications 1) described the intervention; 2) were implemented in LMICs; 3) were based in, or relevant to, university staff or post docs; 4) aimed to improve research capacity; 5) aimed to effect change at the institutional level. Two reviewers screened titles, abstracts and full text in consecutive rounds, a third resolved disagreements. Two people extracted the data of each full text using a data extraction tool covering data relevant to our question. Results: In total 4052 citations were identified and 19 papers were included, which referred to 14 interventions. Only three interventions mentioned using a conceptual framework to develop their approach and none described using a theory of change to assess outcomes. The most frequent inputs described were some method of formal training, promotion of a research-conducive environment and establishment of research support systems. A range of outcomes were reported, most frequently an increased number of publications and proportion of staff with PhDs. When factors of success were discussed, this was attributed to a rigorous approach to implementation, adequate funding, and local buy-in. Those who mentioned sustainability linked it to availability of funds and local buy-in. The lack of a common lexicon and a framework against which to report outcomes made comparison between initiatives difficult. Conclusions: The reduced number of interventions that met the inclusion criteria suggests that programs should be well-described, evaluated systematically, and findings published so that the research capacity strengthening community can extract important lessons.

Effective supervision of doctoral students in public and population health in Africa: CARTA supervisors' experiences, challenges and perceived opportunities

The quality and success of postgraduate education largely rely on effective supervision. Since its inception in 2008, the Consortium for Advanced Research Training in Africa (CARTA) has been at the forefront of providing training to both students and supervisors in the field of public and population health. However, there are few studies on supervisors' perceptions on effective doctoral supervision. We used a mostly descriptive study design to report CARTA-affiliated doctoral supervisors' reflections and perceptions on doctoral supervision, challenges and opportunities. A total of 77 out of 160 CARTA supervisors' workshop participants responded to the evaluation. The respondents were affiliated with 10 institutions across Africa. The respondents remarked that effective supervision is a two-way process, involving both supervisor and supervisee's commitment. Some reported that the requirements for effective supervision included the calibre of the PhD students, structure of the PhD programme, access to research infrastructure and resources, supervision training, multidisciplinary exposure and support. Male supervisors have significantly higher number of self-reported PhD graduates and published articles on Scopus but no difference from the females in h-index. We note both student and systemic challenges that training institutions may pursue to improve doctoral supervision in Africa.

Institutionalizing research capacity strengthening in LMICs: A systematic review and meta-synthesis

Background: Evidence on effective strategies to ensure sustainability of research capacity strengthening interventions in low- and middle-income country (LMIC) institutions is lacking. This systematic review identified publications describing research capacity building programs and noted their effect, their contexts, and the mechanisms, processes and social actors employed in them. Methods: We searched online databases for the period 2011-2018. Inclusion criteria were that the publications 1) described the intervention; 2) were implemented in LMICs; 3) were based in, or relevant to, university staff or post docs; 4) aimed to improve research capacity; 5) aimed to effect change at the institutional level. Two reviewers screened titles, abstracts and full text in consecutive rounds, a third resolved disagreements. Two people extracted the data of each full text using a data extraction tool covering data relevant to our question. Results: In total 4052 citations were identified and 19 papers were included, which referred to 14 interventions. Only three interventions mentioned using a conceptual framework to develop their approach and none described using a theory of change to assess outcomes. The most frequent inputs described were some method of formal training, promotion of a research-conducive environment and establishment of research support systems. A range of outcomes were reported, most frequently an increased number of publications and proportion of staff with PhDs. When factors of success were discussed, this was attributed to a rigorous approach to implementation, adequate funding, and local buy-in. Those who mentioned sustainability linked it to availability of funds and local buy-in. The lack of a common lexicon and a framework against which to report outcomes made comparison between initiatives difficult. Conclusions: The reduced number of interventions that met the inclusion criteria suggests that programs should be well-described, evaluated systematically, and findings published so that the research capacity strengthening community can extract important lessons.

Institutionalizing research capacity strengthening in LMICs: A systematic review and meta-synthesis

Background: Evidence on effective strategies to ensure sustainability of research capacity strengthening interventions in low- and middle-income country (LMIC) institutions is lacking. This systematic review identified publications describing research capacity building programs and noted their effect, their contexts, and the mechanisms, processes and social actors employed in them. Methods: We searched online databases for the period 2011-2018. Inclusion criteria were that the publications 1) described the intervention; 2) were implemented in LMICs; 3) were based in, or relevant to, university staff or post docs; 4) aimed to improve research capacity; 5) aimed to effect change at the institutional level. Two reviewers screened titles, abstracts and full text in consecutive rounds, a third resolved disagreements. Two people extracted the data of each full text using a data extraction tool covering data relevant to our question. Results: In total 4052 citations were identified and 19 papers were included, which referred to 14 interventions. Only three interventions mentioned using a conceptual framework to develop their approach and none described using a theory of change to assess outcomes. The most frequent inputs described were some method of formal training, promotion of a research-conducive environment and establishment of research support systems. A range of outcomes were reported, most frequently an increased number of publications and proportion of staff with PhDs. When factors of success were discussed, this was attributed to a rigorous approach to implementation, adequate funding, and local buy-in. Those who mentioned sustainability linked it to availability of funds and local buy-in. The lack of a common lexicon and a framework against which to report outcomes made comparison between initiatives difficult. Conclusions: The reduced number of interventions that met the inclusion criteria suggests that programs should be well-described, evaluated systematically, and findings published so that the research capacity strengthening community can extract important lessons.

South Africa's COVID-19 Tracing Database: Risks and rewards of which doctors should be aware

In response to the COVID-19 pandemic, South Africa (SA) has established a Tracing Database, collecting both aggregated and individualised mobility and locational data on COVID-19 cases and their contacts. There are compelling public health reasons for this development, since the database has the potential to assist with policy formulation and with contact tracing. While potentially demonstrating the rapid facilitation through technology of an important public service, the Tracing Database does, however, infringe immediately upon constitutional rights to privacy and heightens the implications of ethical choices facing medical professionals. The medical community should be aware of this surveillance innovation and the risks and rewards it raises. To deal with some of these risks, including the potential for temporary rights- infringing measures to become permanent, there are significant safeguards designed into the Tracing Database, including a strict duration requirement and reporting to a designated judge. African states including SA should monitor this form of contact tracing closely, and also encourage knowledge-sharing among cross-sectoral interventions such as the Tracing Database in responding to the COVID-19 pandemic.

Youth underrepresentation as a barrier to sexual and reproductive healthcare access in Kasulu district, Tanzania: A qualitative thematic analysis

OBJECTIVES

Representation of the key groups in community-level healthcare decisions is a prerequisite for accountable and responsive primary healthcare systems. However, meaningful representation requires both the presence of individuals who represent the key community groups and their capacity to influence the key healthcare plans and decisions. Our study explored how the underrepresentation of the youth in health facility committees, the decentralized community- and facility-level healthcare decision-making forums affects youth access to sexual and reproductive health services.

METHODS

A multisite case study involving focus group discussions, interviews, and meeting observation was conducted in eight primary healthcare facilities in Kasulu, a rural district in Tanzania. Inductive thematic analysis was used to identify the key emerging themes.

RESULTS

Five major themes were identified in connection with youth underrepresentation and limited access to sexual reproductive health as a 'taboo' phenomenon in the communities. These were: numbers do not matter, passive representation, sociopolitical gerontocracy, economic vulnerability, and mistrust and suspicion.

CONCLUSIONS

Gradual emancipatory and transformative efforts are needed to normalize the representation of the youth and their concerns in formal community-level decision-making institutions.

Gender responsive multidisciplinary doctoral training program: the Consortium for Advanced Research Training in Africa (CARTA) experience

Doctoral training has increasingly become the requirement for faculty in institutions of higher learning in Africa. Africa, however, still lacks sufficient capacity to conduct research, with just 1.4% of all published research authored by African researchers. Similarly, women in Sub-Saharan Africa only constitute 30% of the continent’s researchers, and correspondingly publish little research. Challenging these gendered inequities requires a gender responsive doctoral program that caters for women’s gender roles that likely affect their enrollment in, and completion of, doctoral programs. In this article, we describe a public and population health multidisciplinary doctoral training program – CARTA and its approach to supporting women. This has resulted in women’s enrollment in the program equaling men’s and similar throughput rates. CARTA has achieved this by meeting women’s practical needs around childbearing and childrearing and we argue that this has produced some outcomes that challenge gender norms, such as fathers being child minders in support of their wives and creating visible female role models.

Family influences on child nutritional outcomes in Nairobi's informal settlements

BACKGROUND

Improving child nutritional status is an important step towards achieving the Sustainable Development Goals 2 and 3 in developing countries. Most child nutrition interventions in these countries remain variably effective because the strategies often target the child's mother/caregiver and give limited attention to other household members. Quantitative studies have identified individual level factors, such as mother and child attributes, influencing child nutritional outcomes.

METHODS

We used a qualitative approach to explore the influence of household members on child feeding, in particular, the roles of grandmothers and fathers, in two Nairobi informal settlements. Using in-depth interviews, we collected data from mothers of under-five children, grandmothers, and fathers from the same households.

RESULTS

Our findings illustrate that poverty is a root cause of poor nutrition. We found that mothers are not the sole decision makers within the household regarding the feeding of their children, as grandmothers appear to play key roles. Even in urban informal settlements, three-generation households exist and must be taken into account. Fathers, however, are described as providers of food and are rarely involved in decision making around child feeding. Lastly, we illustrate that promotion of exclusive breastfeeding for 6 months, as recommended by the World Health Organization, is hard to achieve in this community.

CONCLUSIONS

These findings call for a more holistic and inclusive approach for tackling suboptimal feeding in these communities by addressing poverty, targeting both mothers and grandmothers in child nutrition strategies, and promoting environments that support improved feeding practices such as home-based support for breastfeeding and other baby-friendly initiatives.

Factors associated with recovery from stunting among under-five children in two Nairobi informal settlements

Childhood stunting is a public health concern in many low-and-middle income countries, as it is associated with both short-term and long-term negative effects on child cognitive development, physical health, and schooling outcomes. There is paucity of studies on recovery from stunting among under five children in these countries. Most studies focused on the recovery much later in adolescence. We used longitudinal data from two Nairobi urban settlements to determine the incidence of recovery from stunting and understand the factors associated with post-stunting linear growth among under-five children. A total of 1,816 children were recruited between birth and 23 months and were followed-up until they reached five years. We first looked at the time to recover from stunting using event history analysis and Cox regression. Second, we used height-for-age z-score slope modelling to estimate the change in linear growth among children who were stunted. Finally, we fitted a linear regression model of the variation in HAZ on a second degree fractional polynomials in child’s age to identify the factors associated with post-stunting linear growth. The principal findings are: i) the incidence of recovery from stunting was 45% among stunted under-five children in the two settlements; ii) timely child immunization, age at stunting, mother’s parity and household socioeconomic status are important factors associated with time to recover from stunting within the first five years of life; and iii) child illness status and age at first stunting, mother’s parity and age have a strong influence on child post-stunting linear growth. Access to child health services and increased awareness among health professionals and child caregivers, would be critical in improving child growth outcomes in the study settings. Additionally, specific maternal and reproductive health interventions targeting young mothers in the slums may be needed to reduce adolescent and young mother’s vulnerability and improve their child health outcomes.

Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda

BACKGROUND

Africa's health systems rely on services provided by mid-level health workers (MLWs). Investment in their training is worthwhile since they are more likely to be retained in underserved areas, require shorter training courses and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need up-dating to be relevant to their practice and to reflect advances in health professional education. This study was conducted to review the training and curricula of MLWs in Kenya, Nigeria, South Africa and Uganda, to ascertain areas for improvement.

METHODS

Key informants from professional associations, regulatory bodies, training institutions, labour organisations and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. 421 District managers and 975 MLWs from urban and rural government district health facilities completed self-administered questionnaires regarding MLW training and performance.

RESULTS

Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns regarding skills gaps and quality of training were raised. Nevertheless, quantitative data showed that most MLWs felt their basic training was adequate for the work they do. MLWs and district managers indicated that training methods needed updating with additional skills offered. MLWs wanted their training to include more problem-solving approaches and practical procedures that could be life-saving.

CONCLUSIONS

MLWs are essential frontline workers in health services, not just a stop-gap. In Kenya, Nigeria and Uganda, their important role is appreciated by health service managers. At the same time, significant deficiencies in training program content and educational methodologies exist in these countries, whereas programs in South Africa appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable them to function with greater effectiveness and contribute to better quality care and outcomes.

Sexual autonomy and contraceptive use among women in Nigeria: findings from the Demographic and Health Survey data

CONTEXT

The persistent low contraceptive use and high fertility in Nigeria despite improvements in educational achievements calls for an examination of the role of factors, which may moderate the use of modern contraception. This article explores the influence of sexual autonomy on the use of modern contraceptive methods among women and its relative importance compared with other, more traditional, indicators of women's autonomy such as education and occupation.

DATA AND METHODS

Data from two Demographic and Health Surveys (DHS), 2008 and 2013, were used in this study. An index of sexual autonomy was constructed by combining related DHS variables, and its association with current use of modern contraception was examined at each time point as well as over time using multivariate regression analysis.

RESULTS

The observed prevalence for use of modern contraception was 2.8 and 2.6 times higher among women who had high sexual autonomy in 2008 and 2013, respectively. The corresponding figures for women with secondary or higher education were 8.2 and 11.8 times higher, respectively, compared with women with no education. But after controlling for wealth index, religion, place of residence, autonomy and experience of intimate partner violence (IPV), the likelihood of use of modern contraception was lowered to about 2.5 (from 8.2) and 2.8 (from 11.8) times during 2008 and 2013, respectively, among women with secondary or higher education. The likelihood of use of modern contraception lowered only to 1.6 (from 2.8) and 1.8 (from 2.6) times among women with high sexual autonomy after controlling for other covariates, respectively, during the same period.

CONCLUSION

Sexual autonomy seems to play an important role in women's use of modern contraceptive methods independent of education and a number of other factors related to women's status. Sexual autonomy needs to be simultaneously promoted alongside increasing educational opportunities to enhance women's ability to use modern contraception.

Building the capacity to solve complex health challenges in sub-Saharan Africa: CARTA's multidisciplinary PhD training

OBJECTIVES

To develop a curriculum (Joint Advanced Seminars [JASs]) that produced PhD fellows who understood that health is an outcome of multiple determinants within complex environments and that approaches from a range of disciplines is required to address health and development within the Consortium for Advanced Research Training in Africa (CARTA). We sought to attract PhD fellows, supervisors and teaching faculty from a range of disciplines into the program.

METHODS

Multidisciplinary teams developed the JAS curriculum. CARTA PhD fellowships were open to academics in consortium member institutions, irrespective of primary discipline, interested in doing a PhD in public and population health. Supervisors and JAS faculty were recruited from CARTA institutions. We use routine JAS evaluation data (closed and open-ended questions) collected from PhD fellows at every JAS, a survey of one CARTA cohort, and an external evaluation of CARTA to assess the impact of the JAS curriculum on learning.

RESULTS

We describe our pedagogic approach, arguing its centrality to an appreciation of multiple disciplines, and illustrate how it promotes working in multidisciplinary ways. CARTA has attracted PhD fellows, supervisors and JAS teaching faculty from across a range of disciplines. Evaluations indicate PhD fellows have a greater appreciation of how disciplines other than their own are important to understanding health and its determinants and an appreciation and capacity to employ mixed methods research.

CONCLUSIONS

In the short term, we have been effective in promoting an understanding of multidisciplinarity, resulting in fellows using methods from beyond their discipline of origin. This curriculum has international application.

The influence of health system organizational structure and culture on integration of health services: the example of HIV service monitoring in South Africa

Administrative integration of disease control programmes (DCPs) within the district health system has been a health sector reform priority in South Africa for two decades. The reforms entail district managers assuming authority for the planning and monitoring of DCPs in districts, with DCP managers providing specialist support. There has been little progress in achieving this, and a dearth of research exploring why. Using a case study of HIV programme monitoring and evaluation (M&E), this article explores whether South Africa's health system is configured to support administrative integration. The article draws on data from document reviews and interviews with 54 programme and district managers in two of nine provinces, exploring their respective roles in decision-making regarding HIV M&E system design and in using HIV data for monitoring uptake of HIV interventions in districts. Using Mintzberg's configurations framework, we describe three organizational parameters: (a) extent of centralization (whether district managers play a role in decisions regarding the design of the HIV M&E system); (b) key part of the organization (extent to which sub-national programme managers vs district managers play the central role in HIV monitoring in districts); and (c) coordination mechanisms used (whether highly formalized and rules-based or more output-based to promote agency). We find that the health system can be characterized as Mintzberg's machine bureaucracy. It is centralized and highly formalized with structures, management styles and practices that promote programme managers as lead role players in the monitoring of HIV interventions within districts. This undermines policy objectives of district managers assuming this leadership role. Our study enhances the understanding of organizational factors that may limit the success of administrative integration reforms and suggests interventions that may mitigate this.

Exploring corruption in the South African health sector

Recent scholarly attention has focused on weak governance and the negative effects of corruption on the provision of health services. Employing agency theory, this article discusses corruption in the South African health sector. We used a combination of research methods and triangulated data from three sources: Auditor-General of South Africa reports for each province covering a 9-year period; 13 semi-structured interviews with health sector key informants and a content analysis of print media reports covering a 3-year period. Findings from the Auditor-General reports showed a worsening trend in audit outcomes with marked variation across the nine provinces. Key-informants indicated that corruption has a negative effect on patient care and the morale of healthcare workers. The majority of the print media reports on corruption concerned the public health sector (63%) and involved provincial health departments (45%). Characteristics and complexity of the public health sector may increase its vulnerability to corruption, but the private-public binary constitutes a false dichotomy as corruption often involves agents from both sectors. Notwithstanding the lack of global validated indicators to measure corruption, our findings suggest that corruption is a problem in the South African healthcare sector. Corruption is influenced by adverse agent selection, lack of mechanisms to detect corruption and a failure to sanction those involved in corrupt activities. We conclude that appropriate legislation is a necessary, but not sufficient intervention to reduce corruption. We propose that mechanisms to reduce corruption must include the political will to run corruption-free health services, effective government to enforce laws, appropriate systems, and citizen involvement and advocacy to hold public officials accountable. Importantly, the institutionalization of a functional bureaucracy and public servants with the right skills, competencies, ethics and value systems and whose interests are aligned with health system goals are critical interventions in the fight against corruption.

Nesting doctoral students in collaborative North-South partnerships for health systems research

BACKGROUND

The European Union (EU) supports North-South Partnerships and collaborative research projects through its Framework Programmes and Horizon 2020. There is limited research on how such projects can be harnessed to provide a structured platform for doctoral level studies as a way of strengthening health system research capacity in sub-Saharan Africa (SSA).

OBJECTIVE

The aim of this study was to explore the challenges of, and facilitating factors for, 'nesting' doctoral students in North-South collaborative research projects. The term nesting refers to the embedding of the processes of recruiting, supervising, and coordinating doctoral students in the overall research plan and processes.

DESIGN

This cross-sectional qualitative study was undertaken by the EU-funded QUALMAT Project. A questionnaire was implemented with doctoral students, supervisors, and country principal investigators (PIs), and content analysis was undertaken.

RESULTS

Completed questionnaires were received from nine doctoral students, six supervisors, and three country PIs (86% responses rate). The doctoral students from SSA described high expectations about the input they would receive (administrative support, equipment, training, supervision). This contrasted with the expectations of the supervisors for proactivity and self-management on the part of the students. The rationale for candidate selection, and understandings of the purpose of the doctoral students in the project were areas of considerable divergence. There were some challenges associated with the use of the country PIs as co-supervisors. Doctoral student progress was at times impeded by delays in the release of funding instalments from the EU. The paper provides a checklist of essential requirements and a set of recommendations for effective nesting of doctoral students in joint North-South projects.

CONCLUSION

There are considerable challenges to the effective nesting of doctoral students within major collaborative research projects. However, ways can be found to overcome them. The nesting process ultimately helped the institutions involved in this example to take better advantage of the opportunities that collaborative projects offer to foster North-South partnerships as a contribution to the strengthening of local research capacity.

Developing a new mid-level health worker: lessons from South Africa's experience with clinical associates

Background

Mid-level medical workers play an important role in health systems and hold great potential for addressing the human resource shortage, especially in low- and middle-income countries. South Africa began the production of its first mid-level medical workers – known as clinical associates – in small numbers in 2008.

Objective

We describe the way in which scopes of practice and course design were negotiated and assess progress during the early years. We derive lessons for other countries wishing to introduce new types of mid-level worker.

Methods

We conducted a rapid assessment in 2010 consisting of a review of 19 documents and 11 semi-structured interviews with a variety of stakeholders. A thematic analysis was performed.

Results

Central to the success of the clinical associate training programme was a clear definition and understanding of the interests of various stakeholders. Stakeholder sensitivities were taken into account in the conceptualisation of the role and scope of practice of the clinical associate. This was achieved by dealing with quality of care concerns through service-based training and doctor supervision, and using a national curriculum framework to set uniform standards.

Conclusions

This new mid-level medical worker can contribute to the quality of district hospital care and address human resource shortages. However, a number of significant challenges lie ahead. To sustain and expand on early achievements, clinical associates must be produced in greater numbers and the required funding, training capacity, public sector posts, and supervision must be made available. Retaining the new cadre will depend on the public system becoming an employer of choice. Nonetheless, the South African experience yields positive lessons that could be of use to other countries contemplating similar initiatives.

A South African university-practitioner partnership to strengthen capacity in social and behaviour change communication

Globally, communication plays an integral role in public health strategies, from infectious diseases to diseases related to lifestyles. The evolution of the field of social and behaviour change communication (SBCC), combined with the need for evidence based practice and multi-level interventions to promote health, and human resource gaps in sub-Saharan Africa have led to the imperative to standardise and formalise the field. Moreover, current practitioners come from different disciplinary backgrounds underlining the need to define common core skills and competencies. This paper describes the partnership between the Wits School of Public Health and the Soul City Institute for Health and Development Communication and how the partners responded to this need. It highlights the factors influencing sustainable institutional capacity to provide quality assured, accredited training. We describe an unexpected positive response from a number of practitioner organisations that have chosen to send multiple staff members for training, specifically to build a critical mass within their organisations. Finally, we note the interest from (mostly) southern-based academic institutions in setting up similar programmes and postulate that south-south collaborations can contribute to building sustainable context specific and evidence-informed SBCC programmes in the global south.

Administrative integration of vertical HIV monitoring and evaluation into health systems: a case study from South Africa

BACKGROUND

In light of an increasing global focus on health system strengthening and integration of vertical programmes within health systems, methods and tools are required to examine whether general health service managers exercise administrative authority over vertical programmes.

OBJECTIVE

To measure the extent to which general health service (horizontal) managers, exercise authority over the HIV programme's monitoring and evaluation (M&E) function, and to explore factors that may influence this exercise of authority.

METHODS

This cross-sectional survey involved interviews with 51 managers. We drew ideas from the concept of 'exercised decision-space' - traditionally used to measure local level managers' exercise of authority over health system functions following decentralisation. Our main outcome measure was the degree of exercised authority - classified as 'low', 'medium' or 'high' - over four M&E domains (HIV data collection, collation, analysis, and use). We applied ordinal logistic regression to assess whether actor type (horizontal or vertical) was predictive of a higher degree of exercised authority, independent of management capacity (training and experience), and M&E knowledge.

RESULTS

Relative to vertical managers, horizontal managers had lower HIV M&E knowledge, were more likely to exercise a higher degree of authority over HIV data collation (OR 7.26; CI: 1.9, 27.4), and less likely to do so over HIV data use (OR 0.19; CI: 0.05, 0.84). A higher HIV M&E knowledge score was predictive of a higher exercised authority over HIV data use (OR 1.22; CI: 0.99, 1.49). There was no association between management capacity and degree of authority.

CONCLUSIONS

This study demonstrates a HIV M&E model that is neither fully vertical nor integrated. The HIV M&E is characterised by horizontal managers producing HIV information while vertical managers use it. This may undermine policies to strengthen integrated health system planning and management under the leadership of horizontal managers.

Activism: working to reduce maternal mortality through civil society and health professional alliances in sub-Saharan Africa

Partnerships between civil society groups campaigning for reproductive and human rights, health professionals and others could contribute more to the strengthening of health systems needed to bring about declines in maternal deaths in Africa. The success of the HIV treatment literacy model developed by the Treatment Action Campaign in South Africa provides useful lessons for activism on maternal mortality, especially the combination of a right-to-health approach with learning and capacity building, community networking, popular mobilisation and legal action. This paper provides examples of these from South Africa, Botswana, Kenya and Uganda. Confidential enquiries into maternal deaths can be powerful instruments for change if pressure to act on their recommendations is brought to bear. Shadow reports presented during UN human rights country assessments can be used in a similar way. Public protests and demonstrations over avoidable deaths have succeeded in drawing attention to under-resourced services, shortages of supplies, including blood for transfusion, poor morale among staff, and lack of training and supervision. Activists could play a bigger role in holding health services, governments, and policy-makers accountable for poor maternity services, developing user-friendly information materials for women and their families, and motivating appropriate human resources strategies. Training and support for patients' groups, in how to use health facility complaints procedures is also a valuable strategy.

Are social franchises contributing to universal access to reproductive health services in low-income countries?

A social franchise in health is a network of for-profit private health practitioners linked through contracts to provide socially beneficial services under a common brand. The early 21st century has seen considerable donor enthusiasm for promoting social franchises for the provision of reproductive health services. Based on a compendium of descriptive information on 45 clinical social franchises, located in 27 countries of Africa, Asia and Latin America, this paper examines their contribution to universal access to comprehensive reproductive health services. It finds that these franchises have not widened the range of reproductive health services, but have mainly focused on contraceptive services, and to a lesser extent, maternal health care and abortion. In many instances, coverage had not been extended to new areas. Measures taken to ensure sustainability ran counter to the objective of access for low-income groups. In almost two-thirds of the franchises, the full cost of all services had to be paid out of pocket and was unaffordable for low-income women. While standards and protocols for quality assurance were in place in all franchises, evidence on adherence to these was limited. Informal interviews with patients indicated satisfaction with services. However, factors such as difficulties in recruiting franchisees and significant attrition, franchisees' inability to attend training programmes, use of lay health workers to deliver services without support or supervision, and logistical problems with applying quality assurance tools, all raise concerns. The contribution of social franchises to universal access to reproductive health services appears to be uncertain. Continued investment in them for the provision of reproductive health services does not appear to be justified until and unless further evidence of their value is forthcoming.

Sexual and reproductive health and rights in public health education

This paper addresses the challenges faced in mainstreaming the teaching of sexual and reproductive health and rights into public health education. For this paper, we define sexual and reproductive health and rights education as including not only its biomedical aspects but also an understanding of its history, values and politics, grounded in gender politics and social justice, addressing sexuality, and placed within a broader context of health systems and global health. Using a case study approach with an opportunistically selected sample of schools of public health within our regional contexts, we examine the status of sexual and reproductive health and rights education and some of the drivers and obstacles to the development and delivery of sexual and reproductive health and rights curricula. Despite diverse national and institutional contexts, there are many commonalities. Teaching of sexual and reproductive health and rights is not fully integrated into core curricula. Existing initiatives rely on personal faculty interest or short-term courses, neither of which are truly sustainable or replicable. We call for a multidisciplinary and more comprehensive integration of sexual and reproductive health and rights in public health education. The education of tomorrow's public health leaders is critical, and a strategy is needed to ensure that they understand and are prepared to engage with the range of sexual and reproductive health and rights issues within their historical and political contexts.

Investing in African research training institutions creates sustainable capacity for Africa: the case of the University of the Witwatersrand School of Public Health masters programme in epidemiology and biostatistics

Background

Improving health in Africa is a high priority internationally. Inadequate research capacity to produce local, relevant research has been identified as a limitation to improved population health. Increasing attention is being paid to the higher education sector in Africa as a method of addressing this; evidence that such investment is having the desired impact is required. A 1998 3-year investment by the Special Programme for Research and Training in Tropical Diseases (TDR) in research training at the School of Public Health, University of the Witwatersrand, South Africa was reviewed to assess its' impact.

Methods

A descriptive cross-sectional survey of the 70 students registered for the masters programme in epidemiology & biostatistics from 2000-2005 was conducted. Data were collected from self-administered questionnaires.

Results

Sixty percent (42/70) of students responded. At the time of the survey 19% of respondents changed their country of residence after completion of the masters course, 14% migrated within Africa and 5% migrated out of Africa. Approximately half (47%) were employed as researchers and 38% worked in research institutions. Sixty percent reported research output, and four graduates were pursuing PhD studies. Government subsidy to higher education institutions, investments of the University of the Witwatersrand in successful programmes and ongoing bursaries for students to cover tuition fees were important for sustainability.

Conclusions

Investing in African institutions to improve research training capacity resulted in the retention of graduates in Africa in research positions and produced research output. Training programmes can be sustained when national governments invest in higher education and where that funding is judiciously applied. Challenges remain if funding for students bursaries is not available.

Aligning vertical interventions to health systems: a case study of the HIV monitoring and evaluation system in South Africa

BACKGROUND

Like many low- and middle-income countries, South Africa established a dedicated HIV monitoring and evaluation (M&E) system to track the national response to HIV/AIDS. Its implementation in the public health sector has however not been assessed. Since responsibility for health services management lies at the district (sub-national) level, this study aimed to assess the extent to which the HIV M&E system is integrated with the overall health system M&E function at district level. This study describes implementation of the HIV M&E system, determines the extent to which it is integrated with the district health information system (DHIS), and evaluates factors influencing HIV M&E integration.

METHODS

The study was conducted in one health district in South Africa. Data were collected through key informant interviews with programme and health facility managers and review of M&E records at health facilities providing HIV services. Data analysis assessed the extent to which processes for HIV data collection, collation, analysis and reporting were integrated with the DHIS.

RESULTS

The HIV M&E system is top-down, over-sized, and captures a significant amount of energy and resources to primarily generate antiretroviral treatment (ART) indicators. Processes for producing HIV prevention indicators are integrated with the DHIS. However processes for the production of HIV treatment indicators by-pass the DHIS and ART indicators are not disseminated to district health managers. Specific reporting requirements linked to ear-marked funding, politically-driven imperatives, and mistrust of DHIS capacity are key drivers of this silo approach.

CONCLUSIONS

Parallel systems that bypass the DHIS represent a missed opportunity to strengthen system-wide M&E capacity. Integrating HIV M&E (staff, systems and process) into the health system M&E function would mobilise ear-marked HIV funding towards improving DHIS capacity to produce quality and timely HIV indicators that would benefit both programme and health system M&E functions. This offers a practical way of maximising programme-system synergies and translating the health system strengthening intents of existing HIV policies into tangible action.

Infant mortality in South Africa--distribution, associations and policy implications, 2007: an ecological spatial analysis

BACKGROUND

Many sub-Saharan countries are confronted with persistently high levels of infant mortality because of the impact of a range of biological and social determinants. In particular, infant mortality has increased in sub-Saharan Africa in recent decades due to the HIV/AIDS epidemic. The geographic distribution of health problems and their relationship to potential risk factors can be invaluable for cost effective intervention planning. The objective of this paper is to determine and map the spatial nature of infant mortality in South Africa at a sub district level in order to inform policy intervention. In particular, the paper identifies and maps high risk clusters of infant mortality, as well as examines the impact of a range of determinants on infant mortality. A Bayesian approach is used to quantify the spatial risk of infant mortality, as well as significant associations (given spatial correlation between neighbouring areas) between infant mortality and a range of determinants. The most attributable determinants in each sub-district are calculated based on a combination of prevalence and model risk factor coefficient estimates. This integrated small area approach can be adapted and applied in other high burden settings to assist intervention planning and targeting.

RESULTS

Infant mortality remains high in South Africa with seemingly little reduction since previous estimates in the early 2000's. Results showed marked geographical differences in infant mortality risk between provinces as well as within provinces as well as significantly higher risk in specific sub-districts and provinces. A number of determinants were found to have a significant adverse influence on infant mortality at the sub-district level. Following multivariable adjustment increasing maternal mortality, antenatal HIV prevalence, previous sibling mortality and male infant gender remained significantly associated with increased infant mortality risk. Of these antenatal HIV sero-prevalence, previous sibling mortality and maternal mortality were found to be the most attributable respectively.

CONCLUSIONS

This study demonstrates the usefulness of advanced spatial analysis to both quantify excess infant mortality risk at the lowest administrative unit, as well as the use of Bayesian modelling to quantify determinant significance given spatial correlation. The "novel" integration of determinant prevalence at the sub-district and coefficient estimates to estimate attributable fractions further elucidates the "high impact" factors in particular areas and has considerable potential to be applied in other locations. The usefulness of the paper, therefore, not only suggests where to intervene geographically, but also what specific interventions policy makers should prioritize in order to reduce the infant mortality burden in specific administration areas.

Innovation to improve health care provision and health systems in sub-Saharan Africa - promoting agency in mid-level workers and district managers

Initiatives to address the human resource crisis in African health systems have included expanded training of mid-level workers (MLWs). Currently, MLWs are the backbone of many health systems in Africa but they are often de-motivated and they often operate in circumstances in which providing high quality care is challenging. Therefore, assuming that introducing additional people will materially change health system performance is unrealistic. We briefly critique such unifocal interventions and review the literature to understand the factors that affect the motivation and performance of MLWs. Three themes emerge: the low status and inadequate recognition of MLWs, quality of care issues and working in poorly managed systems. In response we propose three interrelated interventions: a regional association of MLWs to enhance their status and recognition, a job enrichment and mentoring system to address quality and a district managers' association to improve health systems management. The professionalisation of MLWs and district managers to address confidence, self-esteem and value is considered. The paper describes the thinking behind these interventions, which are currently being tested in Kenya, Nigeria, South Africa and Uganda for their acceptability and appropriateness. We offer the policy community a complementary repertoire to existing human resource strategies in order to effect real change in African health systems.

Building capacity for public and population health research in Africa: the consortium for advanced research training in Africa (CARTA) model

BACKGROUND

Globally, sub-Saharan Africa bears the greatest burden of disease. Strengthened research capacity to understand the social determinants of health among different African populations is key to addressing the drivers of poor health and developing interventions to improve health outcomes and health systems in the region. Yet, the continent clearly lacks centers of research excellence that can generate a strong evidence base to address the region's socio-economic and health problems.

OBJECTIVE AND PROGRAM OVERVIEW

We describe the recently launched Consortium for Advanced Research Training in Africa (CARTA), which brings together a network of nine academic and four research institutions from West, East, Central, and Southern Africa, and select northern universities and training institutes. CARTA's program of activities comprises two primary, interrelated, and mutually reinforcing objectives: to strengthen research infrastructure and capacity at African universities; and to support doctoral training through the creation of a collaborative doctoral training program in population and public health. The ultimate goal of CARTA is to build local research capacity to understand the determinants of population health and effectively intervene to improve health outcomes and health systems.

CONCLUSIONS

CARTA's focus on the local production of networked and high-skilled researchers committed to working in sub-Saharan Africa, and on the concomitant increase in local research and training capacity of African universities and research institutes addresses the inability of existing programs to create a critical mass of well-trained and networked researchers across the continent. The initiative's goal of strengthening human resources and university-wide systems critical to the success and sustainability of research productivity in public and population health will rejuvenate institutional teaching, research, and administrative systems.

Saving the lives of South Africa's mothers, babies, and children: can the health system deliver?

South Africa is one of only 12 countries in which mortality rates for children have increased since the baseline for the Millennium Development Goals (MDGs) in 1990. Continuing poverty and the HIV/AIDS epidemic are important factors. Additionally, suboptimum implementation of high-impact interventions limits programme effectiveness; between a quarter and half of maternal, neonatal, and child deaths in national audits have an avoidable health-system factor contributing to the death. Using the LiST model, we estimate that 11,500 infants' lives could be saved by effective implementation of basic neonatal care at 95% coverage. Similar coverage of dual-therapy prevention of mother-to-child transmission with appropriate feeding choices could save 37,200 children's lives in South Africa per year in 2015 compared with 2008. These interventions would also avert many maternal deaths and stillbirths. The total cost of such a target package is US$1.5 billion per year, 24% of the public-sector health expenditure; the incremental cost is $220 million per year. Such progress would put South Africa squarely on track to meet MDG 4 and probably also MDG 5. The costs are affordable and the key gap is leadership and effective implementation at every level of the health system, including national and local accountability for service provision.

Not only what you do, but how you do it: working with health care practitioners on gender equality

The Women's Health Project, School of Public Health, Johannesburg, South Africa, has for more than the past decade been running various gender and health training courses for participants from at least 20 different countries. In this paper I interrogate the motivation behind and methods of the gender training and offer three prompts that assist facilitators in promoting participants' understanding of gender theory. (1) Does this program/action take gender into account? (2) Does this program/action challenge gender norms? (3) Does this program/action promote women's autonomy? Examples of training sessions are described to illustrate how our methods iterate with the content of the courses and, in particular, how the training links to actions practitioners may engage in to redress gender inequalities at work. I go on to argue that both structural and inter-relational aspects of health programs are important in addressing gender and health concerns and discuss the impact of such training on participants and health services.