Reducing deaths due to postpartum haemorrhage in homebirths in Zambia

The purpose of this report is to inform deliberations among policymakers and stakeholders. It summarises the best available evidence regarding community-based prevention of postpartum haemorrhage in Zambia. The report was prepared as a background document to be discussed at meetings of those engaged in developing policies for community-based prevention of postpartum haemorrhage and people with an interest in those policies (stakeholders). In addition, it is intended to inform other stakeholders and to engage them in deliberations about those policies. It is not intended to prescribe or proscribe specific options or implementation strategies. Rather, its purpose is to allow stakeholders to systematically and transparently consider the available evidence about the likely impacts of community-based prevention of postpartum haemorrhage. How this report is structured The executive summary of this report provides key messages and summarises each section of the full report. Although this entails some replication of information, the summary addresses the concern that not everyone for whom the report is intended will have time to read the full report. How this report was prepared This policy brief brings together global research evidence (from systematic reviews) and local evidence to inform deliberations about preventing postpartum haemorrhage at community level in Zambia. We searched for relevant evidence describing the problem, the impacts of options for addressing the problem, barriers to implementing those options, and implementation strategies to address those barriers. We searched particularly for relevant systematic reviews of the effects of policy options and implementation strategies. We supplemented information extracted from the included systematic reviews with information from other relevant studies and documents. (The methods used to prepare this report are described in more detail in Appendix 1.) Limitations of this report This policy brief is based largely on existing systematic reviews. For options where we did not find an up-to-date systematic review, we have attempted to fill in these gaps through other documents, through focused searches and personal contact with experts, and through external review of the report. Summarising evidence requires judgements about what evidence to include, the quality of the evidence, how to interpret it and how to report it. While we have attempted to be transparent about these judgements, this report inevitably includes judgements made by review authors and judgements made by ourselves. 6 Why we have focused on systematic reviews Systematic reviews of research evidence constitute a more appropriate source of research evidence for decision-making than the latest or most heavily publicized research study 1,2 . By systematic reviews, we mean reviews of the research literature with an explicit question, an explicit description of the search strategy, an explicit statement about what types of research studies were included and excluded, a critical examination of the quality of the studies included in the review, and a critical and transparent process for interpreting the findings of the studies included in the review. Systematic reviews have several advantages.3 Firstly, they reduce the risk of bias in selecting and interpreting the results of studies. Secondly, they reduce the risk of being misled by the play of chance in identifying studies for inclusion or the risk of focusing on a limited subset of relevant evidence. Thirdly, systematic reviews provide a critical appraisal of the available research and place individual studies or subgroups of studies in the context of all of the relevant evidence. Finally, they allow others to appraise critically the judgements made in selecting studies and the collection, analysis and interpretation of the results. While practical experience and anecdotal evidence can also help to inform decisions, it is important to bear in mind the limitations of descriptions of success (or failures) in single instances. They can be useful for helping to understand a problem, but they do not provide reliable evidence of the most probable impacts of policy options. Uncertainty does not imply indecisiveness or inaction Many of the systematic reviews included in this report conclude that there is "insufficient evidence". Nonetheless, policymakers must make decisions. Uncertainty about the potential impacts of policy decisions does not mean that decisions and actions can or should not be taken. However, it does suggest the need for carefully planned monitoring and evaluation when policies are implemented. "Both politically, in terms of being accountable to those who fund the system, and also ethically, in terms of making sure that you make the best use possible of available resources, evaluation is absolutely critical."

Creating a Knowledge Translation Platform: nine lessons from the Zambia Forum for Health Research.

The concept of the Knowledge Translation Platform (KTP) provides cohesion and leadership for national-level knowledge translation efforts. In this review, we discuss nine key lessons documenting the experience of the Zambia Forum for Health Research, primarily to inform and exchange experience with the growing community of African KTPs. Lessons from ZAMFOHR's organizational development include the necessity of selecting a multi-stakeholder and -sectoral Board of Directors; performing comprehensive situation analyses to understand not only the prevailing research-and-policy dynamics but a precise operational niche; and selecting a leader that bridges the worlds of research and policy. Programmatic lessons include focusing on building the capacity of both policy-makers and researchers; building a database of local evidence and national-level actors involved in research and policy; and catalyzing work in particular issue areas by identifying leaders from the research community, creating policy-maker demand for research evidence, and fostering the next generation by mentoring both up-and-coming researchers and policy-makers. Ultimately, ZAMFOHR's experience shows that an African KTP must pay significant attention to its organizational details. A KTP must also invest in the skill base of the wider community and, more importantly, of its own staff. Given the very real deficit of research-support skills in most low-income countries - in synthesis, in communications, in brokering, in training - a KTP must spend significant time and resources in building these types of in-house expertise. And lastly, the role of networking cannot be underestimated. As a fully-networked KTP, ZAMFOHR has benefited from the innovations of other KTPs, from funding opportunities and partnerships, and from invaluable technical support from both African and northern colleagues.

Strengthening the health system to enhance mental health in Zambia: a policy brief.

BACKGROUND: Mental illness constitutes a large proportion of the burden of disease in Zambia. Yet mental health services at the primary care level are either provided in a fragmented manner or are lacking altogether. METHODS: A literature review focused on terms including mental health and primary care and strategic options were analyzed. RESULTS: From the analysis, two options were considered for integrating mental health into primary health care. An incremental option would start with a pilot project introducing mental health services into primary care with a well-designed evaluation before scaling up. One key advantage of this option is that it is possible to make improvements in the plan, if needed, before scaling up. A comprehensive option would entail introducing mental health services into primary care in all nine provinces of Zambia. In this option, scaling up could occur more rapidly than an incremental approach. CONCLUSIONS: Strategies to implement either option must address several barriers, including insufficient funding for mental health services, inadequate mental health indicators, lack of general public awareness of and social stigma attached to mental illnesses and mental health care not being perceived as cost-effective or affordable.

Strengthening the health system for mental health in Zambia

The problem: Although mental illness constitutes a large proportion of the burden of disease in Zambia, it receives inadequate attention. Mental health was not among the twelve priority areas in the National Health development plan and was not provided for in the basic package of services defined by the Ministry of Health. Only 0.38% of health care funding was directed towards mental illness in 2008. Mental health services are lacking in general in general health care, including secondary and primary care levels. Policy options: An incremental versus a comprehensive option for integrating mental health into primary care. This option would start with a pilot project introducing mental health services into primary care with a well-designed evaluation prior to scaling up. Key advantages of this option are: 1- It is possible to make improvements in the plan, if needed, prior to scaling up; 2- The pilot would help ensure that full implementation of the plan achieves its intended objectives and could provide better data for estimating the costs of scaling up; 3- It may be more feasible than rapidly scaling up throughout the country.

Experiences with primary health care in Zambia / Experiences with primary health care in Zambia

Since 1978, primary health care has been accepted by all the Member States of the WHO as the key to attaining health for all. However, the application in practice of primary health care principles has proved to be more problematic that was first thought, and many national systems have encountered unexpected difficulties in their efforts to employ a consistent primary health care approach

As part of an attempt by WHO to stimulate discussion on this complex issue, this book contains reports of experiences in one country -Zambia- with the implementation of primary health care, from the perspective of health workers, programme managers, researchers, traditional healers, and nongovernmental organizations. The accounts given here show not only the variety of issues involved and the often disparate groups that need to play a part, but also the size of the obstablces that have to be overcome, from severly limited resources to a lack of understanding at many levels of what primary health care means. The problems faced in Zambia are by no means unique to that country and the lessons learned will be of relevance to many developing countries, as they attempt to reorient their health systems to primary health care

Experiences with primary health care in Zambia / edited by Joseph M. Kasonde & John D. Martin / Les Réalisations de la Zambie en matière de soins de santé primaires

Presents reports of widely diversified efforts to implement primary health care in Zambia. By looking at a range of different approaches and analysing the reasons for their successes and failures, the book aims to provide lessons that can help other countries set realistic goals, develop well-conceived plans, and avoid common errors. All contributors from frontline workers for nongovernmental agencies to officials in the Ministry of Health write on the basis of extensive personal experience with primary health care in Zambia. Their experiences combine to provide unique insight into the complex process of establishing a health system, in a least developed country, based on primary health care. All contributors share the conviction that the principles of primary health care, beginning with equity, remain the only means of achieving a meaningful improvement in the health of entire populations. The main part of the book presents first-hand accounts of various projects implemented over the past fifteen years. These include a pilot project to improve environmental sanitation in villages, Oxfam s grassroots experiences with primary health care, efforts to stimulate self-help in a poor and sparsely populated district, and the promotion of community involvement in AIDS care and prevention. Efforts to improve the management and monitoring of primary health care are also described. Other chapters discuss the role of traditional healers as a resource for primary health care, and summarize key problems encountered in most of the projects described. In the final chapter, a team from the Zambian Ministry of Health describes its vision for future health care and frankly confronts a number of controversial issues