Building leadership and management competencies of national immunization teams in 16 Gavi-eligible countries through the EPI leadership and management programme.

BACKGROUND: Strengthening leadership and management competencies among national Expanded Programme on Immunization (EPI) teams will be critical to achieving global immunization targets and other sustainable developmental goals. However, there is little empirical evidence of the effectiveness of investments in leadership and management capacity in the context of national EPI programs. Therefore, we sought to evaluate the EPI Leadership and Management Programme (EPI LAMP), a nine-month certificate program for EPI teams in national Ministries of Health from Gavi priority countries in Anglophone and Francophone Africa and Asia. METHODS: We used a mixed-methods longitudinal evaluation to describe EPI LAMP at four levels: (1) participant response to the training experience based on program administration records and satisfaction surveys; (2) change in management and leadership skill based on competency surveys and exit interviews; (3) change in behavior in the workplace based on exit interviews; and (4) impact of the training on EPI program performance based on the results of each delegate's leadership project. RESULTS: In the first three cohorts, the programme engaged 16 countries (63 participants) and achieved an 86% graduation rate (54 alumni). Participants demonstrated significant improvement in management and leadership competencies across eight domains with the largest improvement observed in the domain of governance and leadership. Women showed greater increases than men, especially in the domains of Operations Management and Political Advocacy and Dialogue. We observed no difference in the gains made by French-speaking delegates compared to English-speaking participants. Breakthrough projects developed by each team improved EPI program performance, as measured by metrics specific to each project. DISCUSSION: Our results show that team-based leadership programs can foster improvements in management practice, collaboration, and problem-solving, and that engagement the broader policy and organizational context is needed to foster the systems thinking capacity required to address complex challenges and improve system performance.

Typhoid Conjugate Vaccines: Advancing the Research and Public Health Agendas.

The disease burden of typhoid fever remains high in endemic areas in Asia and Africa, especially in children. Recent clinical trials conducted by the Typhoid Vaccine Acceleration Consortium show typhoid conjugate vaccine (TCV) to be safe, immunogenic, and efficacious at preventing blood culture-confirmed typhoid fever in African and Asian children. Pakistan, Liberia, and Zimbabwe recently introduced TCV through campaigns and routine childhood immunizations, providing protection for this vulnerable population. It is essential to continue this momentum while simultaneously filling data gaps-including typhoid complications-to inform decision-making on TCV introduction. A multidisciplinary approach including surveillance, water, sanitation, and hygiene investments, and large-scale TCV introduction is needed to decrease the burden and mortality of typhoid fever.

Accelerating Typhoid Conjugate Vaccine Introduction: What Can Be Learned From Prior New Vaccine Introduction Initiatives?

The health consequences of typhoid, including increasing prevalence of drug-resistant strains, can stress healthcare systems. While vaccination is one of the most successful and cost-effective health interventions, vaccine introduction can take years and require considerable effort. The Typhoid Vaccine Acceleration Consortium (TyVAC) employs an integrated, proactive approach to accelerate the introduction of a new typhoid conjugate vaccine to reduce the burden of typhoid in countries eligible for support from Gavi, the Vaccine Alliance. TyVAC and its partners are executing a plan, informed by prior successful vaccine introductions, and tailored to the nuances of typhoid disease and the typhoid conjugate vaccine. The iterative process detailed herein summarizes the strategy and experience gained from the first 2 years of the project.

The understanding of healthcare workers on the content of palliative care policy in Shesilweni Swaziland: a qualitative study.

We undertook a qualitative study design to explore the understanding of healthcare workers of the content of the palliative care policy in Swaziland. A total of 17 health workers participated in this study. The study showed that there was a lack of knowledge about palliative care, confusion as to where palliative care should be offered and by whom and the role of providing medication as a part of palliative care. Interestingly, the health workers mentioned the importance of different actors, the importance of teamwork and some perceived successes of palliative care implementation. Several challenges were reflected which included the availability of medicines, human resources, transport, infrastructure and a lack of coordination of Rural Health Motivators. Suggested strategies for improving palliative care which have been pointed out include training, improving medicine supply and organisational issues.

The quality of rapid HIV testing in South Africa: an assessment of testers' compliance.

BACKGROUND: The aim of this study was to assess the quality of rapid HIV testing in South Africa. METHOD: A two-stage sampling procedure was used to select HCT sites in eight provinces of South Africa. The study employed both semi-structured interviews with HIV testers and observation of testing sessions as a means of data collection. In total, 63 HCT sites (one HIV tester per site) were included in the survey assessing qualification, training, testing practices and attitudes towards rapid tests. Quantitative data was analysed using descriptive statistics and qualitative data was content analysed. RESULTS: Of the 63 HIV testers, 20.6% had a nursing qualification, 14.3% were professional counsellors, 58.7% were lay HIV counsellors and testers and 6.4% were from other professions. Most HIV testers (87.3%) had had a formal training in testing, which ranged between 10-14 days, while 6 (9.5%) had none. Findings revealed sub-standard practices in relation to testing. These were mainly related to non-adherence to testing algorithms, poor external quality control practices, poor handling and communication of discordant results. CONCLUSION: Quality of HIV rapid testing may be highly compromised through poor adherence to guidelines as observed in our study.

Assessing policy dialogues and the role of context: Liberian case study before and during the Ebola outbreak.

BACKGROUND: In the last decade participatory approaches have gained prominence in policy-making, becoming the focus of good policy-making processes. Policy dialogue is recognised as an important aspect of policy-making among several interactive and innovative policy-making models applied in different contexts and sectors. Recently there has been emphasis on the quality of policy dialogue in terms of how it should be conducted to attain participation and inclusiveness. However, there is paucity of evidence on how the context influences policy dialogue, particularly participation of stakeholders. Liberia's context, which is characterised as post-war, highly donor dependent and in recovery from the recent catastrophic Ebola outbreak, provides an opportunity to understand the influence of context on policy dialogue. METHODS: This was an exploratory study using qualitative methods. Key informant interviews were conducted using an interview guide. A total of 16 interviews were conducted, 12 at the national level and 4 at the sub national level. Data were analysed using inductive thematic content analysis. RESULTS: The respondents felt that the dialogues were a success and involved important stakeholders; however, there were concerns about the improper methodology and facilitation used to conduct them. Opinions among the respondents about the process of generating and selecting the themes for the dialogues were extremely divergent. Both before and during the Ebola outbreak, the context was instrumental in shaping the dialogues according to the issue of focus, requirements for participation and the decisions to be made. Policy dialogues have become a platform for policy discussions and decisions in Liberia. It is a process that is well recognised and appreciated and is highly attributed to the success of the negotiations during the Ebola outbreak. CONCLUSIONS: To sustain and strengthen policy dialogues in future, there needs to be proper information sharing through diverse forums and avenues, stakeholders' empowerment and competent facilitation. These will ensure that the process is credible and legitimate.

Policy dialogues - the "bolts and joints" of policy-making: experiences from Cabo Verde, Chad and Mali.

BACKGROUND: Policy processes that yield good outcomes are inherently complex, requiring interactions of stakeholders in problem identification, generation of political will and selection of practical solutions. To make policy processes rational, policy dialogues are increasingly being used as a policy-making tool. Despite their increasing use for policy-making in Africa, evidence is limited on how they have evolved and are being used on the continent or in low and middle income countries elsewhere. METHODS: This was an exploratory study using qualitative methods. It utilised data related to policy dialogues for three specific policies and strategies to understand the interplay between policy dialogue and policy-making in Cabo Verde, Chad and Mali. The specific methods used to gather data were key informant interviews and document review. Data were analysed inductively and deductively using thematic content analysis. RESULTS: Participation in the policy dialogues was inclusive, and in some instances bottom-up participatory approaches were used. The respondents felt that the execution of the policy dialogues had been seamless, and the few divergent views expressed often were resolved in a unanimous manner. The policies and strategies developed were seen by all stakeholders as relating to priority issues. Other specific process factors that contributed to the success of the dialogues included the use of innovative approaches, good facilitation, availability of resources for the dialogues, good communication, and consideration of the different opinions. Among the barriers were contextual issues, delays in decision-making and conflicting coordination roles and mandates. CONCLUSIONS: Policy dialogues have proved to be an effective tool in health sector management and could be a crucial component of the governance dynamics of the sector. The policy dialogue process needs to be institutionalised for continuity and maintenance of institutional intelligence. Other essential influencing factors include building capacity for coordination and facilitation of policy dialogues, provision of sustainable financing for execution of the dialogues, use of inclusive and bottom-up approaches, and timely provision of reliable evidence. Ensuring continued participation of all the actors necessitates innovation to allow dialogue outside the formal frameworks and spaces that should feed into the formal dialogue processes.

The role of power in health policy dialogues: lessons from African countries.

BACKGROUND: Policy-making is a dynamic process involving the interplay of various factors. Power and its role are some of its core components. Though power exerts a profound role in policy-making, empirical evidence suggests that health policy analysis has paid only limited attention to the role of power, particularly in policy dialogues. METHODS: This exploratory study, which used qualitative methods, had the main aim of learning about and understanding policy dialogues in five African countries and how power influences such processes. Data were collected using key informant interviews. An interview guide was developed with standardised questions and probes on the policy dialogues in each country. This paper utilises these data plus document review to understand how power was manifested during the policy dialogues. Reference is made to the Arts and Tatenhove conceptual framework on power dimensions to understand how power featured during the policy dialogues in African health contexts. Arts and Tatenhove conceptualise power in policy-making in relational, dispositional and structural layers. RESULTS: Our study found that power was applied positively during the dialogues to prioritise agendas, fast-track processes, reorganise positions, focus attention on certain items and foster involvement of the community. Power was applied negatively during the dialogues, for example when position was used to control and shape dialogues, which limited innovation, and when knowledge power was used to influence decisions and the direction of the dialogues. Transitive power was used to challenge the government to think of implementation issues often forgotten during policy-making processes. Dispositional power was the most complex form of power expressed both overtly and covertly. Structural power was manifested socially, culturally, politically, legally and economically. CONCLUSIONS: This study shows that we need to be cognisant of the role of power during policy dialogues and put mechanisms in place to manage its influence. There is need for more research to determine how to channel power influence policy-making processes positively, for example through interactive policy dialogues.

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

BACKGROUND: The advent of global health initiatives (GHIs) has changed the landscape and architecture of health financing in low and middle income countries, particularly in Africa. Over the last decade, the African Region has realised improvements in health outcomes as a result of interventions implemented by both governments and development partners. However, alignment and harmonisation of partnerships and GHIs are still difficult in the African countries with inadequate capacity for their effective coordination. METHOD: Both published and grey literature was reviewed to understand the governance, priorities, harmonisation and alignment of GHIs in the African Region; to synthesise the knowledge and highlight the persistent challenges; and to identify gaps for future research. RESULTS: GHI governance structures are often separate from those of the countries in which they operate. Their divergent funding channels and modalities may have contributed to the failure of governments to track their resources. There is also evidence that basically, earmarking and donor conditions drive funding allocations regardless of countries' priorities. Although studies cite the lack of harmonisation of GHI priorities with national strategies, evidence shows improvements in that area over time. GHIs have used several strategies and mechanisms to involve the private sector. These have widened the pool of health service policy-makers and providers to include groups such as civil society organisations (CSOs), with both positive and negative implications. GHI strategies such as co-financing by countries as a condition for support have been positive in achieving sustainability of interventions. CONCLUSIONS: GHI approaches have not changed substantially over the years but there has been evolution in terms of donor funding and conditions. GHIs still largely operate in a vertical manner, bypassing country systems; they compete for the limited human resources; they influence country policies; and they are not always harmonised with other donors. To maximise returns on GHI support, there is need to ensure that their approaches are more comprehensive as opposed to being selective; to improve GHI country level governance and alignment with countries' changing epidemiologic profiles; and to strengthen their involvement of CSOs.

An analytical perspective of Global health initiatives in Tanzania and Zambia.

BACKGROUND: A number of Global health initiatives (GHIs) have been created to support low and middle income countries. Their support has been of different forms. The African Region has benefitted immensely from GHIs and continues to register an increase in health partnerships and initiatives. However, information on the functioning and operationalisation of GHIs in the countries is limited. METHODS: This study involved two country case studies, one in Tanzania and the other one in Zambia. Data were collected using a semi-structured questionnaire. The aims were to understand and profile the GHIs supporting health development and to assess their governance and alignment with country priorities, harmonisation and alignment of their interventions and efforts, and contribution towards health systems strengthening. The respondents included senior officers from health stakeholder agencies at the national and sub-national levels. The qualitative data were analysed using thematic content analysis in MAXQDA software. RESULTS: Health systems in both Tanzania and Zambia are decentralised. They have benefitted from GHI support in fighting the common health problems of HIV/AIDS, tuberculosis, malaria and vaccine-preventable diseases. In both countries, no GHI adequately made use of the existing Sector-wide Approach (SWAp) mechanisms but they largely operate through their unique structures and committees. GHI efforts to improve general health governance have not been matched with similar efforts from the countries. Their support to health system strengthening has not been comprehensive but has involved the selection of a few areas some of which were disease-focused. On the positive side, however, in both Tanzania and Zambia improved alignment with the countries' priorities is noted in that most of the proposals submitted to the GHIs refer to the priorities, objectives and strategies in the national health development plans and, GHIs depend on the national health information systems. CONCLUSION: GHIs are important funders of health in low and middle income countries. However, there is a need for the countries to take a proactive role in improving the governance, coordination and planning of the GHIs that they benefit from. This will also maximise the return on investment for the GHIs.

Policy analysis for deciding on a malaria vaccine RTS,S in Tanzania.

BACKGROUND: Traditionally, it has taken decades to introduce new interventions in low-income countries. Several factors account for these delays, one of which is the absence of a framework to facilitate comprehensive understanding of policy process to inform policy makers and stimulate the decision-making process. In the case of the proposed introduction of malaria vaccines in Tanzania, a specific framework for decision-making will speed up the administrative process and shorten the time until the vaccine is made available to the target population. METHODS: Qualitative research was used as a basis for developing the Policy Framework. Interviews were conducted with government officials, bilateral and multilateral partners and other stakeholders in Tanzania to assess malaria treatment policy changes and to draw lessons for malaria vaccine adoption. RESULTS: The decision-making process for adopting malaria interventions and new vaccines in general takes years, involving several processes: meetings and presentations of scientific data from different studies with consistent results, packaging and disseminating evidence and getting approval for use by the Ministry of Health and Social Welfare (MOHSW). It is influenced by contextual factors; Promoting factors include; epidemiological and intervention characteristics, country experiences of malaria treatment policy change, presentation and dissemination of evidence, coordination and harmonization of the process, use of international scientific evidence. Barriers factors includes; financial sustainability, competing health and other priorities, political will and bureaucratic procedures, costs related to the adoption and implementations of interventions, supply and distribution and professional compliance with anti-malarial drugs. CONCLUSION: The framework facilitates the synthesis of information in a coherent way, enabling a clearer understanding of the policy process, thereby speeding up the policy decision-making process and shortening the time for a malaria vaccine to become available.

Evaluation of the HIV lay counselling and testing profession in South Africa.

BACKGROUND: With the launch of the national HIV Counselling and Testing (HCT) campaign in South Africa (SA), lay HIV counsellors, who had been trained in blood withdrawal, have taken up the role of HIV testing. This study evaluated the experiences, training, motivation, support, supervision, and workload of HIV lay counsellors and testers in South Africa. The aim was to identify gaps in their resources, training, supervision, motivation, and workload related to HCT services. In addition it explored their experiences with providing HIV testing under the task shifting context. METHODS: The study was conducted in eight of South Africa's nine provinces. 32 lay counsellors were recruited from 67 HCT sites, and were interviewed using two questionnaires that included structured and semi-structured questions. One questionnaire focused on their role as HIV counsellors and the other on their role as HIV testers. RESULTS: Ninety-seven percent of counsellors reported that they have received training in counselling and testing. Many rated their training as more than adequate or adequate, with 15.6% rating it as not adequate. Respondents reported a lack of standardised counselling and testing training, and revealed gaps in counselling skills for specific groups such as discordant couples, homosexuals, older clients and children. They indicated health system barriers, including inadequate designated space for counselling, which compromises privacy and confidentiality. Lay counsellors carry the burden of counselling and testing nationally, and have other tasks such as administration and auxiliary duties due to staff shortages. CONCLUSIONS: This study demonstrates that HCT counselling and testing services in South Africa are mainly performed by lay counsellors and testers. They are challenged by inadequate work space, limited counselling skills for specific groups, a lack of standardised training policies and considerable administrative and auxiliary duties. To improve HCT services, there needs to be training needs with a standardised curriculum and refresher courses, for HIV counselling and testing, specifically for specific elderly clients, discordant couples, homosexuals and children. The Department of Health should formally integrate lay counsellors into the health care system with proper allocation of tasks under the task shifting policy.

Why don't clinicians adhere more consistently to guidelines for the Integrated Management of Childhood Illness (IMCI)?

The Integrated Management of Childhood Illness (IMCI) has been introduced to reduce child morbidity and mortality in countries with a poor health infrastructure. Previous studies have documented a poor adherence to clinical guidelines, but little is known about the reasons for non-adherence. This mixed-method study measures adherence to IMCI case-assessment guidelines and identifies the reasons for weak adherence. In 2007, adherence was measured through direct observation of 933 outpatient consultations performed by 103 trained clinicians in 82 health facilities in nine districts in rural Tanzania, while clinicians' knowledge of the guidelines was assessed through clinical vignettes. Other potential reasons for a weak adherence were assessed through both a health worker- and health facility survey, as well as by a qualitative follow-up study in 2009 in which in-depth interviews were conducted with 40 clinicians in 30 health facilities located in two of the same districts. Clinicians performed 28.4% of the relevant IMCI assessment tasks. The level of knowledge was considerably higher than actual performance, suggesting that lack of knowledge is not the only constraint for improved performance. Other important reasons for weak performance seem to be 1) lack of motivation to adhere to IMCI guidelines, stemming partly from a weak belief in the importance of following the guidelines and partly from weak intrinsic motivation, and 2) a physical and/or cognitive "overload", resulting in lack of capacity to concentrate fully on each and every case and a resort to simpler rules of thumb. Poor remunerations contribute to several of these factors.

Comparing the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa.

BACKGROUND: Job satisfaction is an important determinant of health worker motivation, retention, and performance, all of which are critical to improving the functioning of health systems in low- and middle-income countries. A number of small-scale surveys have measured the job satisfaction and intention to leave of individual health worker cadres in different settings, but there are few multi-country and multi-cadre comparative studies. OBJECTIVE: The objective of this study was to compare the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa. METHODS: We undertook a cross-sectional survey of a stratified cluster sample of 2,220 health workers, 564 from Tanzania, 939 from Malawi, and 717 from South Africa. Participants completed a self-administered questionnaire, which included demographic information, a 10-item job satisfaction scale, and one question on intention to leave. Multiple regression was used to identify significant predictors of job satisfaction and intention to leave. RESULTS: There were statistically significant differences in job satisfaction and intention to leave between the three countries. Approximately 52.1% of health workers in South Africa were satisfied with their jobs compared to 71% from Malawi and 82.6% from Tanzania (χ2=140.3, p<0.001). 18.8% of health workers in Tanzania and 26.5% in Malawi indicated that they were actively seeking employment elsewhere, compared to 41.4% in South Africa (χ2=83.5, p<0.001). The country differences were confirmed by multiple regression. The study also confirmed that job satisfaction is statistically related to intention to leave. CONCLUSIONS: We have shown differences in the levels of job satisfaction and intention to leave between different groups of health workers from Tanzania, Malawi, and South Africa. Our results caution against generalising about the effectiveness of interventions in different contexts and highlight the need for less standardised and more targeted HRH strategies than has been practised to date.

Motivation of human resources for health: a case study at rural district level in Tanzania.

An increasing number of studies explore the association between financial and non-financial incentives and the retention of health workers in developing countries. This study aims to contribute to empirical evidence on human resource for health motivation factors to assist policy makers in promoting effective and realistic interventions. A cross-sectional survey was conducted in four rural Tanzanian districts to explore staff stability and health workers' motivation. Data were collected using qualitative and quantitative techniques, covering all levels and types of health facilities. Stability of staff was found to be quite high. Public institutions remained very attractive with better job security, salary and retirement benefits. Satisfaction over working conditions was very low owing to inadequate working equipment, work overload, lack of services, difficult environment, favouritism and 'empty promotions'. Positive incentives mentioned were support for career development and supportive supervision. Attracting new staff in rural areas appeared to be more difficult than retaining staff in place. The study concluded that strategies to better motivate health personnel should focus on adequate remuneration, positive working and living environment and supportive management. However, by multiplying health facilities, the latest Tanzanian human resource for health plan could jeopardize current positive results.

Informal payments and the quality of health care: Mechanisms revealed by Tanzanian health workers.

Informal payments for health services are common in many transitional and developing countries. The aim of this paper is to investigate the nature of informal payments in the health sector of Tanzania and to identify mechanisms through which informal payments may affect the quality of health care. Our focus is on the effect of informal payments on health worker behaviours, in particular the interpersonal dynamics among health workers at their workplaces. We organised eight focus groups with 58 health workers representing different cadres and levels of care in one rural and one urban district in Tanzania. We found that health workers at all levels receive informal payments in a number of different contexts. Health workers sometimes share the payments received, but only partially, and more rarely within the cadre than across cadres. Our findings indicate that health workers are involved in 'rent-seeking' activities, such as creating artificial shortages and deliberately lowering the quality of service, in order to extract extra payments from patients or to bargain for a higher share of the payments received by their colleagues. The discussions revealed that many health workers think that the distribution of informal payments is grossly unfair. The findings suggest that informal payments can impact negatively on the quality of health care through rent-seeking behaviours and through frustrations created by the unfair allocation of payments. Interestingly, the presence of corruption may also induce non-corrupt workers to reduce the quality of care. Positive impacts can occur because informal payments may induce health workers to increase their efforts, and maybe more so if there is competition among health workers about receiving the payments. Moreover, informal payments add to health workers' incomes and might thus contribute to retention of health workers within the health sector.

Understanding informal payments in health care: motivation of health workers in Tanzania.

BACKGROUND: There is growing evidence that informal payments for health care are fairly common in many low- and middle-income countries. Informal payments are reported to have a negative consequence on equity and quality of care; it has been suggested, however, that they may contribute to health worker motivation and retention. Given the significance of motivation and retention issues in human resources for health, a better understanding of the relationships between the two phenomena is needed. This study attempts to assess whether and in what ways informal payments occur in Kibaha, Tanzania. Moreover, it aims to assess how informal earnings might help boost health worker motivation and retention. METHODS: Nine focus groups were conducted in three health facilities of different levels in the health system. In total, 64 health workers participated in the focus group discussions (81% female, 19% male) and where possible, focus groups were divided by cadre. All data were processed and analysed by means of the NVivo software package. RESULTS: The use of informal payments in the study area was confirmed by this study. Furthermore, a negative relationship between informal payments and job satisfaction and better motivation is suggested. Participants mentioned that they felt enslaved by patients as a result of being bribed and this resulted in loss of self-esteem. Furthermore, fear of detection was a main demotivating factor. These factors seem to counterbalance the positive effect of financial incentives. Moreover, informal payments were not found to be related to retention of health workers in the public health system. Other factors such as job security seemed to be more relevant for retention. CONCLUSION: This study suggests that the practice of informal payments contributes to the general demotivation of health workers and negatively affects access to health care services and quality of the health system. Policy action is needed that not only provides better financial incentives for individuals but also tackles an environment in which corruption is endemic.