Prospective policy analysis-a critical interpretive synthesis review.

Most policy analysis methods and approaches are applied retrospectively. As a result, there have been calls for more documentation of the political-economy factors central to health care reforms in real-time. We sought to highlight the methods and previous applications of prospective policy analysis (PPA) in the literature to document purposeful use of PPA and reflect on opportunities and drawbacks. We used a critical interpretive synthesis (CIS) approach as our initial scoping revealed that PPA is inconsistently defined in the literature. While we found several examples of PPA, all were researcher-led, most were published recently and few described mechanisms for engagement in the policy process. In addition, methods used were often summarily described and reported on relatively short prospective time horizons. Most of the studies stemmed from high-income countries and, across our sample, did not always clearly outline the rationale for a PPA and how this analysis was conceptualized. That only about one-fifth of the articles explicitly defined PPA underscores the fact that researchers and practitioners conducting PPA should better document their intent and reflect on key elements essential for PPA. Despite a wide recognition that policy processes are dynamic and ideally require multifaceted and longitudinal examination, the PPA approach is not currently frequently documented in the literature. However, the few articles reported in this paper might overestimate gaps in PPA applications. More likely, researchers are embedded in policy processes prospectively but do not necessarily write their articles from that perspective, and analyses led by non-academics might not make their way into the published literature. Future research should feature examples of testing and refining the proposed framework, as well as designing and reporting on PPA. Even when policy-maker engagement might not be feasible, real-time policy monitoring might have value in and of itself.

The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21).

Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.

Managing transitions from external assistance: cross-national learning about sustaining effective coverage.

The often-prominent role of external assistance in health financing in low- and middle-income countries raises the question of how such resources can enable the sustained or even expanded coverage of key health services and initiatives even after donor funding is no longer available. In response to this question, this paper analyses the process and outcomes of donor transitions in health-where countries or regions within countries are no longer eligible to receive grants or concessional loans from external sources based on eligibility criteria or change in donor policy. The comparative analysis of multiple donor transitions in four countries-China, Georgia, Sri Lanka and Uganda-identifies 16 factors related to policy actors, policy process, the content of donor-funded initiatives and the broader political-economic context that were associated with sustained coverage of previously donor supported interventions. From a contextual standpoint, these factors relate to favourable economic and political environments for domestic systems to prioritize coverage for donor-supported interventions. Clear and transparent transition processes also enabled a smoother transition. How the donor-supported initiatives and services were organized within the context of the overall health system was found to be critically important, both before and during the transition process. This includes a targeted approach to integrate, strengthen and align key elements of the governance, financing, input management and service delivery arrangements with domestic systems. The findings of this analysis have important implications for how both donors and country policy makers can better structure external assistance that enables sustained coverage regardless of the source of funding. In particular, donors can better support sustained coverage through supporting long-term structural and institutional reform, clear co-financing policies, ensuring alignment with local salary scales and engaging with communities to ensure a continued focus on equitable access post-transition.

HIV and viremia prevalence in non-migrating members of migrant households in Rakai region, Uganda: A cross-sectional population-based study.

Introduction: In sub-Saharan Africa, migrants are more likely to be HIV seropositive and viremic than non-migrants. However, little is known about HIV prevalence and viremia in non-migrants living in households with in- or out-migration events. We compared HIV outcomes in non-migrating persons in households with and without migration events using data from the Rakai Community Cohort Study (RCCS), an open population-based cohort in Uganda. Methods: We analyzed RCCS survey data from one survey round collected between August 2016 and May 2018 from non-migrating participants aged 15-49. Migrant households were classified as those reporting ≥1 member moving into or out of the household since the prior survey. A validated rapid test algorithm determined HIV serostatus. HIV viremia was defined as >1,000 copies/mL. Modified Poisson regression was used to estimate associations between household migration and HIV outcomes, with results reported as adjusted prevalence ratios (adjPR) with 95% confidence intervals (95%CI). Analyses were stratified by gender, direction of migration (into/out of the household), and relationship between non-migrants and migrants (e.g., spouse). Results: There were 14,599 non-migrants (7,654, 52% women) identified in 9,299 households. 4,415 (30%) lived in a household with ≥1 recent migrant; of these, 972(22%) had migrant spouses, 1,102(25%) migrant children, and 875(20%) migrant siblings. Overall, HIV prevalence and viremia did not differ between non-migrants in migrant and non-migrant households. However, in stratified analyses, non-migrant women with migrant spouses were significantly more likely to be HIV seropositive compared to non-migrant women with non-migrant spouses (adjPR:1.44, 95%CI:1.21-1.71). Conversely, non-migrant mothers living with HIV who had migrant children were less likely to be viremic (adjPR:0.34, 95%CI:0.13-0.86). Among non-migrant men living with HIV, spousal migration was associated with a non-significant increased risk of viremia (adjPR:1.37, 95%CI:0.94-1.99). Associations did not typically differ for migration into or out of the household. Conclusions: Household migration was associated with HIV outcomes for certain non-migrants, suggesting that the context of household migration influences the observed association with HIV outcomes. In particular, non-migrating women with migrating spouses were more likely to have substantially higher HIV burden. Non-migrants with migrant spouses may benefit from additional support when accessing HIV services.

Post-epidemic health system recovery: A comparative case study analysis of routine immunization programs in the Republics of Haiti and Liberia.

Large-scale epidemics in resource-constrained settings disrupt delivery of core health services, such as routine immunization. Rebuilding and strengthening routine immunization programs following epidemics is an essential step toward improving vaccine equity and averting future outbreaks. We performed a comparative case study analysis of routine immunization program recovery in Liberia and Haiti following the 2014-16 West Africa Ebola epidemic and 2010s cholera epidemic, respectively. First, we triangulated data between the peer-reviewed and grey literature; in-depth key informant interviews with subject matter experts; and quantitative metrics of population health and health system functioning. We used these data to construct thick descriptive narratives for each case. Finally, we performed a cross-case comparison by applying a thematic matrix based on the Essential Public Health Services framework to each case narrative. In Liberia, post-Ebola routine immunization coverage surpassed pre-epidemic levels, a feat attributable to investments in surveillance, comprehensive risk communication, robust political support for and leadership around immunization, and strong public-sector recovery planning. Recovery efforts in Haiti were fragmented across a broad range of non-governmental agencies. Limitations in funding, workforce development, and community engagement further impeded vaccine uptake. Consequently, Haiti reported significant disparities in subnational immunization coverage following the epidemic. This study suggests that embedding in-country expertise within outbreak response structures, respecting governmental autonomy, aligning post-epidemic recovery plans and policies, and integrating outbreak response assets into robust systems of primary care contribute to higher, more equitable levels of routine immunization coverage in resource-constrained settings recovering from epidemics.

Incidence of child marriage among refugees and internally displaced persons in the Middle East and South Asia: evidence from six cross-sectional surveys.

OBJECTIVE: To examine incidence of child marriage among displaced and host populations in humanitarian settings. DESIGN: Cross-sectional surveys. SETTING: Data were collected in Djibouti, Yemen, Lebanon and Iraq in the Middle East and in Bangladesh and Nepal in South Asia. PARTICIPANTS: Adolescent girls aged 10-19 in the six settings and age cohort comparators. OUTCOME MEASURES: Cumulative incidence of marriage by age 18. RESULTS: In Bangladesh and Iraq, the hazard of child marriage did not differ between internally displaced populations (IDPs) and hosts (p value=0.25 and 0.081, respectively). In Yemen, IDPs had a higher hazard of child marriage compared with hosts (p value<0.001). In Djibouti, refugees had a lower hazard of child marriage compared with hosts (p value<0.001). In pooled data, the average hazard of child marriage was significantly higher among displaced compared with host populations (adjusted HR (aHR) 1.3; 95% CI 1.04 to 1.61).In age cohort comparisons, there was no significant difference between child marriage hazard across age cohorts in Bangladesh (p value=0.446), while in Lebanon and Nepal, younger cohorts were less likely to transition to child marriage compared with older comparators (p value<0.001). Only in Yemen were younger cohorts more likely to transition to child marriage, indicating an increase in child marriage rates after conflict (p value=0.034). Pooled data showed a downward trend, where younger age cohorts had, on average, a lower hazard of child marriage compared with older cohorts (aHR 0.36; 95% CI 0.29 to 0.4). CONCLUSIONS: We did not find conclusive evidence that humanitarian crises are associated with universal increases in child marriage rates. Our findings indicate that decision-making about investments in child marriage prevention and response must be attuned to the local context and grounded in data on past and current trends in child marriage among communities impacted by crisis.

Geographic prioritisation in Kenya and Uganda: a power analysis of donor transition.

Introduction Donor transition for HIV/AIDS programmes remains sensitive, marking a significant shift away from the traditional investment model of large-scale, vertical investments to control the epidemic and achieve rapid scaling-up of services. In late 2015, the United States President's Emergency Plan for AIDS Relief (PEPFAR) headquarters instructed their country missions to implement 'geographic prioritisation' (GP), whereby PEPFAR investments would target geographic areas with high HIV burden and reduce or cease support in areas with low burden.Methods Using Gaventa's power cube framework, we compare how power is distributed and manifested using qualitative data collected in an evaluation of the GP's impact in Kenya and Uganda.Results We found that the GP was designed with little space for national and local actors to shape either the policy or its implementation. While decision-making processes limited the scope for national-level government actors to shape the GP, the national government in Kenya claimed such a space, proactively pressuring PEPFAR to change particular aspects of its GP plan. Subnational level actors were typically recipients of top-down decision-making with apparently limited scope to resist or change GP. While civil society had the potential to hold both PEPFAR and government actors accountable, the closed-door nature of policy-making and the lack of transparency about decisions made this difficult.Conclusion Donor agencies should exercise power responsibly, especially to ensure that transition processes meaningfully engage governments and others with a mandate for service delivery. Furthermore, subnational actors and civil society are often better positioned to understand the implications and changes arising from transition. Greater transparency and accountability would increase the success of global health programme transitions, especially in the context of greater decentralisation, requiring donors and country counterparts to be more aware and flexible of working within political systems that have implications for programmatic success.

'All my co-workers are good people, but ': collaboration dynamics between frontline workers in rural Uttar Pradesh, India.

Multisectoral collaboration has been identified as a critical component in a wide variety of health and development initiatives. For India's Integrated Child Development Services (ICDS) scheme, which serves >100 million people annually across more than one million villages, a key point of multisectoral collaboration-or 'convergence', as it is often called in India-is between the three frontline worker cadres jointly responsible for delivering essential maternal and child health and nutritional services throughout the country: the Accredited Social Health Activist (ASHA), Anganwadi worker (AWW) and auxiliary nurse midwife (ANM) or 'AAA' workers. Despite the long-recognized importance of collaboration within this triad, there has been relatively little documentation of what this looks like in practice and what is needed in order to improve it. Informed by a conceptual framework of collaborative governance, this study applies inductive thematic analysis of in-depth interviews with 18 AAA workers and 6 medical officers from 6 villages across three administrative blocks in Hardoi district of Uttar Pradesh state to identify the key elements of collaboration. These are grouped into three broad categories: 'organizational' (including interdependence, role clarity, guidance/support and resource availability); 'relational' (interpersonal and conflict resolution) and 'personal' (flexibility, diligence and locus of control). These findings underscore the importance of 'personal' and 'relational' collaboration features, which are underemphasized in India's ICDS, the largest of its kind globally, and in the multisectoral collaboration literature more broadly-both of which place greater emphasis on 'organizational' aspects of collaboration. These findings are largely consistent with prior studies but are notably different in that they highlight the importance of flexibility, locus of control and conflict resolution in collaborative relationships, all of which relate to one's ability to adapt to unexpected obstacles and find mutually workable solutions with colleagues. From a policy perspective, supporting these key elements of collaboration may involve giving frontline workers more autonomy in how they get the work done, which may in some cases be impeded by additional training to reinforce worker role delineation, closer monitoring or other top-down efforts to push greater convergence. Given the essential role that frontline workers play in multisectoral initiatives in India and around the world, there is a clear need for policymakers and managers to understand the elements affecting collaboration between these workers when designing and implementing programmes.

From 'no problem' to 'a lot of difficulties': barriers to health service utilization among migrants in Rakai, Uganda.

Migration is increasingly common in Africa, especially for employment. Migrants may face additional barriers to accessing health care, including human immunodeficiency virus (HIV) prevention and treatment, compared with long-term residents. Exploring migrants' experiences with health services can provide insights to inform the design of health programmes. In this study, we used qualitative methods to understand migrants' barriers to health service utilization in south-central Uganda. This secondary data analysis used data from in-depth semi-structured interviews with 35 migrants and 25 key informants between 2017 and 2021. Interviews were analysed thematically through team debriefings and memos. We constructed three representative migrant journeys to illustrate barriers to accessing health services, reflecting experiences of migrant personas with differing HIV status and wealth. Migrants reported experiencing a range of barriers, which largely depended on the resources they could access, their existing health needs and their ability to form connections and relationships at their destination. Migrants were less familiar with local health services, and sometimes needed more time and resources to access care. Migrants living with HIV faced additional barriers to accessing health services due to anticipated discrimination from community members or health workers and difficulties in continuing antiretroviral therapy when switching health facilities. Despite these barriers, social networks and local connections facilitated access. However, for some migrants, such as those who were poorer or living with HIV, these barriers were more pronounced. Our work highlights how local connections with community members and health workers help migrants access health services. In practice, reducing barriers to health services is likely to benefit both migrants and long-term residents.

Political economy analysis of subnational health management in Kenya, Malawi and Uganda.

The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers' ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N = 112) with government actors, development partners and civil societies in three districts or counties in each country (N = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach.

SDG5 "Gender Equality" and the COVID-19 pandemic: A rapid assessment of health system responses in selected upper-middle and high-income countries.

Introduction: The COVID-19 pandemic disrupted healthcare and societies, exacerbating existing inequalities for women and girls across every sphere. Our study explores health system responses to gender equality goals during the COVID-19 pandemic and inclusion in future policies. Methods: We apply a qualitative comparative approach, drawing on secondary sources and expert information; the data was collected from March-July 2022. Australia, Brazil, Germany, the United Kingdom, and the USA were selected, reflecting upper-middle and high-income countries with established public health and gender policies but different types of healthcare systems and epidemiological and geo-political conditions. Three sub-goals of SDG5 were analyzed: maternity care/reproductive health, gender-based violence, and gender equality/women's leadership. Results: We found similar trends across countries. Pandemic policies strongly cut into women's health, constrained prevention and support services, and weakened reproductive rights, while essential maternity care services were kept open. Intersecting gender inequalities were reinforced, sexual violence increased and women's leadership was weak. All healthcare systems failed to protect women's health and essential public health targets. Yet there were relevant differences in the responses to increased violence and reproductive rights, ranging from some support measures in Australia to an abortion ban in the US. Conclusions: Our study highlights a need for revising pandemic policies through a feminist lens.

Social Accountability Reporting for Research (SAR4Research): checklist to strengthen reporting on studies on social accountability in the literature.

BACKGROUND: An increasing number of evaluations of social accountability (SA) interventions have been published in the past decade, however, reporting gaps make it difficult to summarize findings. We developed the Social Accountability Reporting for Research (SAR4Research) checklist to support researchers to improve the documentation of SA processes, context, study designs, and outcomes in the peer reviewed literature and to enhance application of findings. METHODS: We used a multi-step process, starting with an umbrella review of reviews on SA to identify reporting gaps. Next, we reviewed existing guidelines for reporting on behavioral interventions to determine whether one could be used in its current or adapted form. We received feedback from practitioners and researchers and tested the checklist through three worked examples using outcome papers from three SA projects. RESULTS: Our umbrella review of SA studies identified reporting gaps in all areas, including gaps in reporting on the context, intervention components, and study methods. Because no existing guidelines called for details on context and the complex processes in SA interventions, we used CONSORT-SPI as the basis for the SAR4Research checklist, and adapted it using other existing checklists to fill gaps. Feedback from practitioners, researchers and the worked examples suggested the need to eliminate redundancies, add explanations for items, and clarify reporting for quantitative and qualitative study components. CONCLUSIONS: Results of SA evaluations in the peer-reviewed literature will be more useful, facilitating learning and application of findings, when study designs, interventions and their context are described fully in one or a set of papers. This checklist will help authors report better in peer-reviewed journal articles. With sufficient information, readers will better understand whether the results can inform accountability strategies in their own contexts. As a field, we will be better able to identify emerging findings and gaps in our understanding of SA.

Reflections on benefits and challenges of longitudinal organisational network analysis as a tool for health systems research and practice.

As health systems practitioners and researchers increasingly turn towards systems thinking approaches and work on building interorganisational networks, they have demonstrated increasing interest in network analysis for investigating relationships and interactions between system actors, both at the individual and organisational levels. Despite the potential of network-based approaches to improve health system efficiency, effectiveness and responsiveness, both the theoretical and practical guidance on designing and evaluating network-building strategies is underdeveloped within the field. While there are multiple tools and resources to help users collect, manage and analyse network data, there is much less guidance on the practical applications of this information. One apparent gap is the limited application of longitudinal organisational network analysis, in which data are collected from the same organisational actors repeatedly over multiple time points. This yields insights into the dynamic nature of networks, including how the network structure and interactions change over time. Given that networks are rarely static, the addition of the time dimension has the potential to substantially enhance the analytical value of network analysis and contribute to more nuanced guidance for interested practitioners and policymakers. In this article, the authors draw on their experiences in conducting longitudinal network analysis of interorganisational relationships in the USA and India to comment on the opportunities and challenges of the methodology within the field of health systems research. We also provide suggestions as to how some of these challenges may be addressed or mitigated.

Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda.

INTRODUCTION: In 2015, the President's Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda. METHODS: Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners. RESULTS: In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing. DISCUSSION: Loss of external support for outreach raises concerns for countries' ability to reach the 90-90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected. CONCLUSION: Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level.

The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda.

BACKGROUND: Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 'low-volume' facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda. METHODS: We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis. RESULTS: While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the 'mentor mother' ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition. CONCLUSIONS: Participants perceived transition to have had the effect of narrowing the scope and quality of HIV services offered by case-study facilities due to a reduction in HIV funding as well as the loss of the additional personnel previously hired by the PEPFAR implementing organizations for HIV programming. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90-90-90 targets in Uganda.

South African physician emigration and return migration, 1991-2017: a trend analysis.

Although critical for understanding health labour market trends in low- and middle-income countries (LMICs), longitudinal LMIC health worker emigration and return migration trends are not routinely documented. This article seeks to better understand SA's trends in physician emigration and return migration and whether economic growth and related policies affect migration patterns. This study used physician registry data to analyse patterns of emigration and return migration only among SA-trained physicians registered to practice in top destination countries such as Australia, Canada, New Zealand, the USA or the UK between 1991 and 2017, which represent the top five emigration destinations for this group. A linear regression model analysed the relationship between migration trends (as dependent variables) and SA's economic growth, health financing and HIV prevalence (as independent variables). There has been a 6-fold decline in emigration rates from SA between 1991 and 2017 (from 1.8% to 0.3%/year), with declines in emigration to all five destination countries. About one in three (31.8% or 5095) SA physicians returned from destination countries as of 2017. Annual physician emigration fell by 0.16% for every $100 rise in SA GDP per capita (2011 international dollars) (95% confidence interval -0.60% to -0.086%). As of 2017, 21.6% (11 224) of all SA physicians had active registration in destination nations, down from a peak of 33.5% (16 366) in 2005, a decline largely due to return migration. Changes to the UK's licensing regulations likely affected migration patterns while the Global Code of Practice on International Recruitment contributed little to changes. A country's economic growth might influence physician emigration, with significant contribution from health workforce policy interventions. Return migration monitoring should be incorporated into health workforce planning.

Development and psychometric testing of the FLW-MSC scale for measuring frontline worker multisectoral collaboration in rural India.

OBJECTIVES: Multisectoral collaboration (MSC) is widely recognised as a critical aspect of policies, programmes and interventions addressing complex public health issues, yet it is undertheorised and difficult to measure. Limited understanding of the intermediate steps linking MSC formation to intended health outcomes leaves a substantial knowledge gap about the types of strategies that may be most effective in making such collaborations successful. This paper, which reports the quantitative strand of a broader mixed-methods study, takes a step toward filling in this 'missing middle' of MSC evaluation by developing and testing the FLW-MSC scale, an instrument to assess collaboration among the frontline workers of one of India's largest and most widely known MSCs: the Integrated Child Development Services (ICDS) scheme. DESIGN: This study involved development, field-testing and psychometric testing of an 18-item, Likert-type frontline worker collaboration scale, including internal consistency, construct validity and criterion validity. SETTING: Village-level primary healthcare in rural Uttar Pradesh, India. PARTICIPANTS: 281 anganwadi workers, 266 accredited social health activists and 124 auxiliary nurse midwives selected based on random sampling of anganwadi catchment areas from 346 gram panchayats (GPs), including 173 intervention GPs and 173 pair-matched control GPs from a parent evaluation study. RESULTS: Results support the scale's internal consistency (ordinal α=0.92-0.95), construct validity (reasonable exploratory factor analysis model fit for five of the six dyadic relationships Tucker-Lewis Index=0.84-0.88; Root Mean Squared Error of Approximation=0.09-0.11), and criterion validity (regression of collaboration score on an information-sharing indicator ß=3.528; p=0.006). CONCLUSIONS: The scale may be useful for ICDS managers to detect and address poor collaboration as the Indian government redoubles its efforts to strengthen and monitor MSC, or 'convergence', with important implications for the critical priority of child development. Further, the FLW-MSC scale may be adapted for measuring frontline worker collaboration across sectors in many other scenarios and low/middle-income country contexts.

Designing for Scale and taking scale to account: lessons from a community score card project in Uganda.

BACKGROUND: Planning for the implementation of community scorecards (CSC) is an important, though seldom documented process. Makerere University School of Public Health (MakSPH) and Future Health Systems Consortium set out to develop and test a sustainable and scalable CSC model. This paper documents the process of planning and adapting the design of the CSC, incorporating key domains of the scalable model such as embeddedness, legitimacy, feasibility and ownership, challenges encountered in this process and how they were mitigated. METHODS: The CSC intervention comprised of five rounds of scoring in five sub counties and one town council of Kibuku district. Data was drawn from ten focus group discussions, seven key informant interviews with local and sub national leaders, and one reflection meeting with the project team from MakSPH. More data was abstracted from notes of six quarterly stakeholder meetings and six quarterly project meetings. Data was analyzed using a thematic approach, drawing constructs outlined in the project's theory of change. RESULTS: Embeddedness, legitimacy and ownership were promoted through aligning the model with existing processes and systems as well as the meaningful and strategic involvement of stakeholders and leaders at local and sub national level. The challenges encountered included limited technical capacity of stakeholders facilitating the CSC, poor functionality of existing community engagement platforms, and difficulty in promoting community participation without financial incentives. However, these challenges were mitigated through adjustments to the intervention design based on the feedback received. CONCLUSION: Governments seeking to scale up CSCs and to take scale to account should keenly adapt existing models to the local implementation context with strategic and meaningful involvement of key legitimate local and sub national leaders in decision making during the design and implementation process. However, they should watch out for elite capture and develop mitigating strategies. Social accountability practitioners should document their planning and adaptive design efforts to share good practices and lessons learned. Enhancing local capacity to implement CSCs should be ensured through use of existing local structures and provision of technical support by external or local partners familiar with the skill until the local partners are competent.