Unsalaried health workers in Sierra Leone: a scoping review of the literature to establish their impact on healthcare delivery.

BACKGROUND: The World Health Organisation (WHO) estimates a 10 million health worker shortage by 2030. Despite this shortage, some low-income African countries paradoxically struggle with health worker surpluses. Technically, these health workers are needed to meet the minimum health worker-population ratio, but insufficient job opportunities in the public and private sector leaves available health workers unemployed. This results in emigration and un- or underemployment, as few countries have policies or plans in place to absorb this excess capacity. Sierra Leone, Liberia and Guinea have taken a different approach; health authorities and/or public hospitals 'recruit' medical and nursing graduates on an unsalaried basis, promising eventual paid public employment. 50% Sierra Leone's health workforce is currently unsalaried. This scoping review examines the existing evidence on Sierra Leone's unsalaried health workers (UHWs) to establish what impact they have on the equitable delivery of care. METHODS: A scoping review was conducted using Joanna Briggs Institute guidance. Medline, PubMed, Scopus, Web of Science were searched to identify relevant literature. Grey literature (reports) and Ministry of Health and Sanitation policy documents were also included. RESULTS: 36 texts, containing UHW related data, met the inclusion criteria. The findings divide into two categories and nine sub-categories: Charging for care and medicines that should be free; Trust and mistrust; Accountability; Informal provision of care, Private practice and lack of regulation. Over-production of health workers; UHW issues within policy and strategy; Lack of personnel data undermines MoHS planning; Health sector finance. CONCLUSION: Sierra Leone's example demonstrates that UHWs undermine equitable access to healthcare, if they resort to employing a range of coping strategies to survive financially, which some do. Their impact is wide ranging and will undermine Sierra Leone's efforts to achieve Universal Health Coverage if unaddressed. These findings are relevant to other LICs with similar health worker surpluses.

Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review.

BACKGROUND: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund, which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) grew out of step 10, with a focus on community-based implementation. The aim of this scoping review is to map and examine the evidence relating to the implementation of BFHI and BFCI globally. METHODS: This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria followed the Population, Concepts, Contexts approach. All articles were screened by two reviewers, using Covidence software. Data were charted according to: country, study design, setting, study population, BFHI steps, study aim and objectives, description of intervention, summary of results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken. RESULTS: A total of 278 articles were included in the review. Patterns identified were: i) national policy and health systems: effective and visible national leadership is needed, demonstrated with legislation, funding and policy; ii) hospital policy is crucial, especially in becoming breastfeeding friendly and neonatal care settings iii) implementation of specific steps; iv) the BFCI is implemented in only a few countries and government resources are needed to scale it; v) health worker breastfeeding knowledge and training needs strengthening to ensure long term changes in practice; vi) educational programmes for pregnant and postpartum women are essential for sustained exclusive breastfeeding. Evidence gaps include study design issues and need to improve the quality of breastfeeding data and to perform prevalence and longitudinal studies. CONCLUSION: At a national level, political support for BFHI implementation supports expansion of Baby-Friendly Hospitals. Ongoing quality assurance is essential, as is systematic (re)assessment of BFHI designated hospitals. Baby Friendly Hospitals should provide breastfeeding support that favours long-term healthcare relationships across the perinatal period. These results can help to support and further enable the effective implementation of BFHI and BFCI globally.

Conducting rapid research to aid the design of a health systems governance intervention in the Somali Region of Ethiopia.

Introduction: The rapid research described in this chapter was conducted as an assignment for a UN agency in Ethiopia's Somali Region. The agency's aim was support the implementation of an interim citizen engagement intervention, with a view of supporting of the Ethiopian Government's Citizen Score Card at primary healthcare facilities and hospitals in future. Many health facilities in Somali Region struggle with budget shortages related to ineffective budget planning and budget execution at woreda health office levels. In this context, an intervention to first improve budget accountability, through the implementation of citizen audits, was proposed. Methodology: The rapid study focused on five woredas (districts) within Somali Region, where interviews were conducted with the heads of woreda health offices. In the same five woredas, directors of healthcare facilities were interviewed and offices and healthcare facilities were observed. The framework of assessment and analysis was based on health systems literature on fragile and conflict affected states guided the questions for the health authorities and health facility management. Findings: The research yielded five distinct mini case studies covering woreda health office planning and budgeting capacity and support (or lack thereof), and related impressions of challenges regarding healthcare delivery at health facilities in the same five woredas. Results: The findings demonstrated that the capacity for healthcare planning and budgeting Somali Region at woreda level varied significantly and that little guidance was available from regional level health authorities. Frontline health services clearly suffered from budget shortages as a result. Conclusion: The research provided an evidence base for the delay of the roll-out of the Community Scorecard implementation across Somali Region. In a context whereby health facilities remain under-resourced due to budgeting constraints, a citizen-service provider-focused accountability intervention would have been of limited utility. The rapid case study research, conducted by condensing the usual case study research process, allowed for the production of evidence that was "robust enough" to demonstrate heterogeneity and challenges regarding budgeting quality across the five research sites. This evidence clearly transcended the hitherto anecdotal evidence that woreda-level health budget planning remains an area that faces significant shortcomings.

What are the mechanisms and contexts by which care groups achieve social and behavioural change in low- and middle-income countries? Group motivation findings from a realist synthesis.

OBJECTIVE: Infant and under-five mortality rates in low- and middle-income countries (LMIC) can be reduced by encouraging behaviours such as sleeping under insecticide-treated bed nets, exclusive breast-feeding for the first 6 months, regular handwashing, etc. Community-based volunteer or peer-to-peer mechanisms are cost-effective ways of promoting these lifesaving practices. However, the sustainability and reach of community-based behaviour change promotion remains a challenge. Our inquiry focuses on the utilisation, by non-governmental organisations (NGO), of Care Groups, a peer-to-peer behaviour change intervention. We asked: What are the mechanisms and contexts by which Care Groups achieve social and behavioural change in nutrition, health and other sectors? DESIGN: Realist synthesis reviewing forty-two texts that contained empirical evidence about Care Group interventions. SETTING: LMIC. PARTICIPANTS: We held consultations with a research reference group, which included Care Group and nutrition experts, and Care Group - implementing NGO staff in Malawi. RESULTS: Different types of motivation drive the establishment and the sustainability of peer group interventions. A certain amount of motivation was derived from the resources provided by the NGO establishing the Care Groups. Subsequently, both volunteers and neighbourhood group members were motivated by the group dynamics and mutual support, as well as support from the wider community. Finally, volunteers and group members alike became self-motivated by their experience of being involved in group activities. CONCLUSIONS: When designing and implementing community-based behaviour change interventions, awareness of the multi-directional nature of the motivating drivers that are experienced by peer- or community group members is important, to optimise these groups' reach and sustainability.

Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol.

Background: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. Exclusively breastfeeding infants for the first six months would lead to the largest infant mortality reduction. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund (UNICEF), which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) is an extension of the BHFI's 10 th step of the Ten Steps to Successful Breastfeeding and of the BFHI overall. Its focus is on community-based breastfeeding supports for women. There have been no known attempts to synthesise the overall body of evidence on the BFHI in recent years, and no synthesis of empirical research on the BFCI. This scoping review asks the question: what is known about the implementation of the BFHI and the BFCI globally? Methods and analysis: This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria will follow the Population, Concepts, Contexts approach. A data charting form will be developed and applied to all the included studies. Qualitative and quantitative descriptive analysis will be undertaken. In order to address equity of access to the BFHI/BFCI, the Levesque et al. (2013) access to health care framework will be used as a lens to analyse the charted data in relation to this aspect of the review. An already established group of stakeholders with experience of infant feeding policy and implementation in Malawi will be consulted, to obtain expert views on the findings of the scoping review. Conclusion: This review will establish gaps in current evidence which will inform areas for future research in relation to this global initiative.

Locally produced personal protective equipment can offer hospital staff protection against Covid-19 if combined with surgical masks and rigorous personal protective equipment cleaning routine.

Locally made, washable and reusable personal protective equipment (PPE), used in combination with N95 masks that were reused safely, has proven to be a viable alternative to disposable gowns and caps for hospital staff in low- and middle-income countries. Muhimbili University Hospital's children's cancer ward in Dar es Salaam, Tanzania, developed locally made PPE and created rigorous cleaning and disinfecting protocols, when the daily use of imported, disposable materials were not an option. These items continue to protect staff, children and parents. The novel PPE approach was able to prevent staff from becoming infected during the pandemic despite the fact that several parents, and subsequently their children, became infected with Covid-19 during cancer treatment at the facility.

Exploring how and why Care Groups work to improve infant feeding practices in low- and middle-income countries: a realist review protocol.

BACKGROUND: Within our inquiry into the implementation of breastfeeding policy in Malawi, Care Groups have been mentioned as a means to improve maternal and child health and nutrition outcomes. The 'Care Group model' is an approach primarily used in international development settings, whereby social and behaviour changes are promoted through supported peer-to-peer (mostly mother-to-mother) knowledge sharing. The aim of most Care Groups is to promote improved infant nutrition, improve hygiene and increase the number of children who are fully vaccinated and exclusively breastfed for the first 6 months. The behavioural changes promoted by Care Groups (such as safe infant feeding, frequent hand washing, consistent mosquito net usage, providing suitable complementary foods from 6 months old) have the potential of averting preventable deaths particularly among children under five. While a variety of approaches are used to promote improved health and nutrition for children under five, the Care Groups model was best known and frequently referenced during our discussions with key stakeholders regarding the delivery at community level of Malawi's National Multi-Sector Nutrition Policy 2018-2022. A better understanding of how Care Groups achieve their social and behaviour change results and how community-based efforts are sustained can potentially help to ensure more effective planning and budgeting for Care Group interventions and enable greater sustainability and increased coverage of infant feeding support countrywide. This realist review is designed to improve our understanding of how, why, to what extent and under what circumstances Care Groups improve infant feeding practices in low- and middle-income countries (LMICs). METHODS AND ANALYSIS: A realist review is a theory-driven approach to evidence synthesis. To undertake this realist review, we will gather evidence by conducting peer-reviewed and grey literature database searches in order to find peer reviewed articles, programme guidelines and evaluation reports, among other texts, associated with the implementation of Care Groups in low- and middle-income countries. Our review process has five key steps: (1) locating existing theories; (2) searching for evidence in literature; (3) selecting articles and other suitable evidence; (4) extracting data, identifying configurations of context-mechanism-outcomes; and (5) synthesising the evidence, drawing conclusions. DISCUSSION: The results of this realist review will be written up according to RAMESES guidelines and disseminated through a stakeholder workshop in Malawi, through conference presentations and peer-reviewed publications. It is intended to improve the understanding of the potential and limits of working through Care Groups globally and among relevant Malawi Ministry of Health staff and the donor and NGO community, both internationally and within Malawi. This systematic review protocol has been submitted for registration on the PROSPERO database (receipt number: 170261).

Citizen feedback in a fragile setting: social accountability interventions in the primary healthcare sector in Sierra Leone.

Fragile and conflict-affected states are frequently characterised by their inability to fulfil three core governance functions: provision of security, effective delivery of basic public goods and services, and managing political participation and accountability. This article explores the utility of social accountability interventions in fragile environments. Successful social accountability interventions can lead to joint examinations of public service standards by service-users and providers, resulting in collaborative improvement efforts. The few available studies of such interventions implemented in fragile or conflict-affected states show reasons for optimism as well as challenges. This article advocates the continued use of social accountability methods in fragile settings and provides examples of social accountability interventions in the health sector in Sierra Leone. The study suggests that social accountability can improve interaction between citizens and public service providers. Successful social accountability interventions can also lead to better quality and more accessible public services, which, in turn, can enhance state legitimacy.

When free healthcare is not free. Corruption and mistrust in Sierra Leone's primary healthcare system immediately prior to the Ebola outbreak.

INTRODUCTION: Sierra Leone is one of three countries recently affected by Ebola. In debates surrounding the circumstances that contributed to the initial failure to contain the outbreak, the word 'trust' is often used: In December 2014, WHO director Margret Chan used 'lack of trust in governments'; The Lancet's Editor-in-Chief, wrote how Ebola has exposed the '… breakdown of trust between communities and their governments.' This article explores the lack of trust in public healthcare providers in Sierra Leone, predating the Ebola outbreak, apparently linked to widespread petty corruption in primary healthcare facilities. It compares four NGO-supported accountability interventions targeting Sierra Leone's primary health sector. METHODS: Field research was conducted in Kailahun, Kono and Tonkolili Districts, based on interviews with health workers and focus group discussions with primary healthcare users. RESULTS: Field research showed that in most clinics, women and children entitled to free care routinely paid for health services. CONCLUSIONS: A lack of accountability in Sierra Leone's health sector appears pervasive at all levels. Petty corruption is rife. Understaffing leads to charging for free care in order to pay clinic-based 'volunteers' who function as vaccinators, health workers and birth attendants. Accountability interventions were found to have little impact on healthworker (mis)behaviour.