Barriers and Enablers to Task Shifting for Caesarean Sections in sub-Saharan Africa: A Scoping Review.

Task shifting of Caesarean-sections to non-physician clinicians (NPCs) has raised concerns over NPCs' competences and rationale of using them in facilities where medical doctors (MDs) are scarce to provide mentorship. We conducted a scoping review to provide an update on NPCs' contribution to C-sections including barriers and enablers to task shifting. Using the PRISMA Flow Diagram, we identified 15 eligible articles from Google Scholar, PubMed and Africa Index Medicus using specific search terms and a pre-established inclusion criterion. All 15 studies characterised NPCs: their names, training, challenges and enablers to task shifting. NPCs performed 50%-94% C-sections. Outcomes of such C-sections were comparable to those performed by MDs. Enablers included supportive policies, pre-existing human resources for health shortage, well- resourced health facilities and supervision of NPCs. Weak health systems were major barriers. While NPCs make a significant contribution to accessing C-sections services, there is need to address challenges to fully realize benefits.

Policy and programmatic implications of task shifting in Uganda: a case study.

BACKGROUND: Uganda has a severe health worker shortage and a high demand for health care services. This study aimed to assess the policy and programmatic implications of task shifting in Uganda. METHODS: This was a qualitative, descriptive study through 34 key informant interviews and eight (8) focus group discussions, with participants from various levels of the health system. RESULTS: Policy makers understood task shifting, but front-line health workers had misconceptions on the meaning and intention(s) of task shifting. Examples were cited of task shifting within the Ugandan health system, some formalized (e.g. psychiatric clinical officers), and some informal ones (e.g. nurses inserting IV lines and initiating treatment). There was apparently high acceptance of task shifting in HIV/AIDS service delivery, with involvement of community health workers (CHW) and PLWHA in care and support of AIDS patients.There was no written policy or guidelines on task shifting, but the policy environment was reportedly conducive with plans to develop a policy and guidelines on task shifting.Factors favouring task shifting included successful examples of task shifting, proper referral channels, the need for services, scarcity of skills and focused initiatives such as home based management of fever. Barriers to task shifting included reluctance to change, protection of professional turf, professional boundaries and regulations, heavy workload and high disease burden, poor planning, lack of a task shifting champion, lack of guidelines, the name task shifting itself, and unemployed health professionals.There were both positive and negative views on task shifting: the positive ones cast task shifting as one of the solutions to the dual problem of lack of skills and high demand for service, and as something that is already happening; while negative ones saw it as a quick fix intended for the poor, a threat to quality care and likely to compromise the health system. CONCLUSION: There were widespread examples of task in Uganda, and task shifting was mainly attributed to HRH shortages coupled with the high demand for healthcare services. There is need for clear policy and guidelines to regulate task shifting and protect those who undertake delegated tasks.

Policy development in malaria vector management in Mozambique, South Africa and Zimbabwe

Introduction Indoor residual spraying (IRS) and insecticide-treated nets (ITNs), two principal malaria control strategies, are similar in cost and efficacy. We aimed to describe recent policy development regarding their use in Mozambique, South Africa and Zimbabwe. Methods Using a qualitative case study methodology, we undertook semi-structured interviews of key informants from May 2004 to March 2005, carried out document reviews and developed timelines of key events. We used an analytical framework that distinguished three broad categories: interests, ideas and events. Results A disparate mix of interests and ideas slowed the uptake of ITNs in Mozambique and Zimbabwe and prevented uptake in South Africa. Most respondents strongly favoured one strategy over the other. In all three countries, national policy makers favoured IRS, and only in Mozambique did national researchers support ITNs. Outside interests in favour of IRS included manufacturers who supplied the insecticides and groups opposing environmental regulation. International research networks, multilateral organizations, bilateral donors and international NGOs supported ITNs. Research evidence, local conditions, logistic feasibility, past experience, reaction to outside ideas, community acceptability, the role of government and NGOs, and harm from insecticides used in spraying influenced the choice of strategy. The end of apartheid permitted a strongly pro-IRS South Africa to influence the region, and in Mozambique and Zimbabwe, floods provided conditions conducive to ITN distribution. Conclusions Both IRS and ITNs have a place in integrated malaria vector management, but pro-IRS interests and ideas slowed or prevented the uptake of ITNs. Policy makers needed more than evidence from trials to change from the time-honoured IRS strategy that they perceived was working. Those intending to promote new policies such as ITNs should examine the interests and ideas motivating key stakeholders and their own institutions, and identify where shifts in thinking or coalitions among the like-minded may be possible.

Policy development in malaria vector management in Mozambique, South Africa and Zimbabwe.

INTRODUCTION: Indoor residual spraying (IRS) and insecticide-treated nets (ITNs), two principal malaria control strategies, are similar in cost and efficacy. We aimed to describe recent policy development regarding their use in Mozambique, South Africa and Zimbabwe. METHODS: Using a qualitative case study methodology, we undertook semi-structured interviews of key informants from May 2004 to March 2005, carried out document reviews and developed timelines of key events. We used an analytical framework that distinguished three broad categories: interests, ideas and events. RESULTS: A disparate mix of interests and ideas slowed the uptake of ITNs in Mozambique and Zimbabwe and prevented uptake in South Africa. Most respondents strongly favoured one strategy over the other. In all three countries, national policy makers favoured IRS, and only in Mozambique did national researchers support ITNs. Outside interests in favour of IRS included manufacturers who supplied the insecticides and groups opposing environmental regulation. International research networks, multilateral organizations, bilateral donors and international NGOs supported ITNs. Research evidence, local conditions, logistic feasibility, past experience, reaction to outside ideas, community acceptability, the role of government and NGOs, and harm from insecticides used in spraying influenced the choice of strategy. The end of apartheid permitted a strongly pro-IRS South Africa to influence the region, and in Mozambique and Zimbabwe, floods provided conditions conducive to ITN distribution. CONCLUSIONS: Both IRS and ITNs have a place in integrated malaria vector management, but pro-IRS interests and ideas slowed or prevented the uptake of ITNs. Policy makers needed more than evidence from trials to change from the time-honoured IRS strategy that they perceived was working. Those intending to promote new policies such as ITNs should examine the interests and ideas motivating key stakeholders and their own institutions, and identify where shifts in thinking or coalitions among the like-minded may be possible.

Translating research into policy: lessons learned from eclampsia treatment and malaria control in three southern African countries.

BACKGROUND: Little is known about the process of knowledge translation in low- and middle-income countries. We studied policymaking processes in Mozambique, South Africa and Zimbabwe to understand the factors affecting the use of research evidence in national policy development, with a particular focus on the findings from randomized control trials (RCTs). We examined two cases: the use of magnesium sulphate (MgSO(4)) in the treatment of eclampsia in pregnancy (a clinical case); and the use of insecticide treated bed nets and indoor residual household spraying for malaria vector control (a public health case). METHODS: We used a qualitative case-study methodology to explore the policy making process. We carried out key informants interviews with a range of research and policy stakeholders in each country, reviewed documents and developed timelines of key events. Using an iterative approach, we undertook a thematic analysis of the data. FINDINGS: Prior experience of particular interventions, local champions, stakeholders and international networks, and the involvement of researchers in policy development were important in knowledge translation for both case studies. Key differences across the two case studies included the nature of the evidence, with clear evidence of efficacy for MgSO(4 )and ongoing debate regarding the efficacy of bed nets compared with spraying; local researcher involvement in international evidence production, which was stronger for MgSO(4 )than for malaria vector control; and a long-standing culture of evidence-based health care within obstetrics. Other differences were the importance of bureaucratic processes for clinical regulatory approval of MgSO(4), and regional networks and political interests for malaria control. In contrast to treatment policies for eclampsia, a diverse group of stakeholders with varied interests, differing in their use and interpretation of evidence, was involved in malaria policy decisions in the three countries. CONCLUSION: Translating research knowledge into policy is a complex and context sensitive process. Researchers aiming to enhance knowledge translation need to be aware of factors influencing the demand for different types of research; interact and work closely with key policy stakeholders, networks and local champions; and acknowledge the roles of important interest groups.