District Health Management Research Articles

Workplace-based learning in district health leadership and management strengthening: a framework synthesis.

Effective leadership and management has been identified as critical in enabling health systems to respond adequately to their population needs. The changing nature of low- and middle-income countries' health systems, given resource scarcity, a high disease burden and other contextual challenges, has also led to learning-including workplace-based learning (WPBL)-being recognized as a key process supporting health system reform and transformation. This review used a framework synthesis approach in addressing the question: 'What forms of WPBL, support leadership and management development; and how does such learning impact district health leadership and management strengthening?'. A search for English language empirical qualitative, mixed-methods and quantitative studies and grey literature published from January 1990 to May 2024 was conducted using four electronic databases (PubMed, EBSCOhost, Scopus and Web of Science). Twenty-five articles were included in the synthesis. The findings reveal that over the last decade, WPBL has received consideration as an approach for leadership and management development. While WPBL interventions differed in type and nature, as well as length of delivery, there was no conclusive evidence about which approach had a greater influence than others on strengthening district health leadership and management. However, the synthesis demonstrates the need for a focus on the sustainability and institutionalization of interventions, including the need to integrate WPBL interventions in health systems. To support sustainability and institutionalization, there should be flexibility in the design and delivery of such interventions and they are best supported through national or regional institutions.

Coping mechanisms and strategies adopted to improve the quality and timeliness of immunization data among lower-level private-for-profit service providers in Kampala Capital City, Uganda.

Lower-level urban private-for-profit health service providers are actively engaged in the delivery of immunization services. However, not much is known about their everyday endeavours to improve data quality and ensure the submitted data meets the quality and timeliness requirements as per established guidelines. The objective of this paper was to examine the coping mechanisms and strategies adopted to improve the quality and timeliness of immunization data among lower-level private-for-profit service providers in Kampala Capital City, Uganda. A qualitative study design was adopted with in-depth interviews (n = 17) and key informant interviews (n = 8) completed among frontline health workers, district health managers and immunization implementing partners. Analysis followed a thematic approach with coding conducted using Atlas. ti, a qualitative data management software. Overall, coping mechanisms and strategies adopted to improve the data quality among lower-level urban private-for-profit immunization service providers included; Experiential attachment for practical skills acquisition in data management, data quality peer-to-peer learning among private-for-profit immunization service providers, registration using cohort system for easy tracking of records during subsequent visits, separation of visiting service user records from regular attendants, service delivery modifications such as reward for better performance, engagement of Village Health Teams (VHTs) in outreaches and data completion, and data quality checks through review of monitoring charts to identify gaps in data quality. Within the urban context, the delivery of immunization services by lower-level private-for-profit services faces data quality challenges some of which stem from the implementation context. Different coping strategies focusing on frontline health worker skills, enhanced experience sharing through peer-to-peer learning, modifications to registration and routine review of monitoring charts. However, these efforts were often faced with chronic barriers such as the high staff turnover calling for dedicated efforts to optimize the available implementation opportunities like guidelines mandating the public health facilities to supervise the lower-level private immunization service providers within their catchment areas to respond to the identified gaps.

Determinants of translating routine health information system data into action in Mozambique: a qualitative study

IntroductionRoutine health information systems (RHISs) are an essential source of data to inform decisions and actions around health facility performance, but RHIS data use is often limited in low and...

Community overview on the differential prevalence of Hepatitis E in two sub-counties in Kitgum District, Uganda: a mixed study design

BackgroundAn epidemic of Hepatitis E infection occurred in Kitgum district, northern Uganda in 2009. In that epidemic, more than 10,422 people were infected, and over 166 deaths were registered. Kitgum District Health Management Information Systems (HMIS) showed that Hepatitis E cases continued to occur in Mucwini more than in Kitgum Matidi sub-county despite instituting similar epidemic control measures in the two communities. The tenacity of the virus in Mucwini sub-county had remained unclear. This study aimed to assess communities’ views and perspectives on the differential prevalence of Hepatitis E in the two sub-counties of Kitgum Matidi and Mucwini in northern Uganda.MethodsA mixed study using qualitative and quantitative methods was used. Four Focus group discussions and six key informant interviews were conducted with the village health teams, local council chairpersons, health workers, and community members. These participants were chosen purposively because of their expertise and experience in community health services. Face-to-face interview guides were administered to obtain detailed information on factors associated with the differential occurrence of Hepatitis E in the two sub-counties. This study was approved by a local IRB and the Uganda National Council of Science and Technology (UNCS&T).ResultsThe most substantial findings were the differences in prevention and control practices in the two communities. Residents of Mucwini were less compliant with infection, prevention, and control guidelines, and disagreements between local councilors and village health teams in Mucwini over allowances led to poor implementation and non-adherence to guidelines on community control of the epidemic.ConclusionA differentially higher prevalence of Hepatitis E in Mucwini than in Kitgum Matidi resulted from poor personal and community hygiene and non-adherence to behavior change communication among residents of Mucwini than their counterparts in Kitgum Matidi. The authors recommend a more proactive approach to managing an epidemic by securing the willingness of the affected community to adopt appropriate infection prevention and control guidelines. In addition, disagreements among stakeholders should be resolved quickly so that all community members adhere to control measures.

Leveraging community health workers for COVID-19 response in Democratic Republic of Congo, Nigeria, Senegal, and Uganda: roles, barriers, and facilitators

BackgroundThe Corona Virus Disease 2019 (COVID-19) pandemic overwhelmed health systems and disrupted the delivery of health services globally. Community Health Workers (CHWs) play a critical role in linking communities to health systems, supporting the prevention and control of diseases in many low- and middle-income countries. However, their roles, barriers, and facilitators in the response and control of the COVID-19 pandemic have not been well documented. We described the roles of CHWs in the COVID-19 response, including the barriers and facilitators.MethodsA cross-sectional study design was used to assess the COVID-19 response in the Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda. This involved 110 key informant interviews with policymakers, health facility managers, district health managers, and CHWs to understand the role of CHWs in the COVID 19 response, selected purposively. The total sample size was based on information saturation in each of the countries. A document review on the COVID-19 response was also conducted. We searched Google, Google Scholar, and PubMed for published and grey literature. Data from the selected documents were extracted into a Google master matrix in MS Excel and analyzed thematically.ResultsIn COVID-19 Control, CHWs supported community-based surveillance, contact tracing, risk communication, community mobilization, and home-based care. To support the continuity of other non-COVID-19 services, the CHWs conducted community mobilization, sensitizations, outreaches, referrals, and patient follow-ups. CHWs were challenged by movement restrictions, especially in the initial stages of the lockdown, inadequate PPE, increased workload, low allowances, and motivation. CHW were facilitated by trainings, the development of guidelines, development partners’ support/funding, and the provision of personal protective equipment (PPE) and tools.ConclusionCHWs supported both the COVID-19 control and continuity of non-COVID-19 health care during the COVID-19 pandemic. CHWs are a critical resource that must be adequately supported to build resilient health systems.

Decentralisation of the Health System Derailed by Organisational Inertia in Machinga, Malawi.

Managing the transition of a health system (HS) from a centralised to a decentralised model has been touted as a panacea to the complex challenges in developing countries like Malawi. However, recent studies have demonstrated that decentralisation of the HS has had mixed effects in service provision with more dominant negative outcomes than positive results. The aim of this study was to develop a substantive grounded theory (GT) that elaborates on how activities of central decision-makers and local healthcare mangers shape the process of shifting the HS to a decentralised model in Machinga, Malawi. The study was qualitative in nature and employed the Straussian version of GT. Some participants were interviewed twice, and a total of 36 semi-structured interviews were conducted with 25 purposively selected participants using an interview guide. The interviews were conducted at the headquarters of the Ministry of Health (MoH) and other ministries and agencies, and in Machinga District. Data were analysed using open, axial, and selective coding processes of the GT methodology; and the conditional matrix and paradigm model were used as data analysis tools. The findings of this study revealed seven different activities, forming two opposing and interactional sub-processes of enabling and impeding patterns that derailed the decentralisation drive. The study generated a GT labelled "decentralisation of the HS derailed by organisational inertia," which elaborates that decentralisation of the HS produced mixed results with more predominant negative outcomes than positive effects due to resistance at the upper organisational echelons and members of the District Health Management Team (DHMT). This article concludes that organisational inertia at the personal and strategic levels of leadership entrusted with decentralising the HS in Malawi, contributed immensely to the derailment of shifting the HS from the centralised to the decentralised model of health service provision.

Healthcare workers’ views on decentralized primary health care management in Lesotho: a qualitative study

BackgroundLesotho experienced high rates of maternal (566/100,000 live births) and under-five mortality (72.9/1000 live births). A 2013 national assessment found centralized healthcare management in Ministry of Health led to fragmented, ineffective district health team management. Launched in 2014 through collaboration between the Ministry of Health and Partners In Health, Lesotho’s Primary Health Care Reform (LPHCR) aimed to improve service quality and quantity by decentralizing healthcare management to the district level. We conducted a qualitative study to explore health workers’ perceptions regarding the effectiveness of LPHCR in enhancing the primary health care system.MethodsWe conducted 21 semi-structured key informant interviews (KII) with healthcare workers and Ministry of Health officials purposively sampled from various levels of Lesotho’s health system, including the central Ministry of Health, district health management teams, health centers, and community health worker programs in four pilot districts of the LPHCR initiative. The World Health Organization’s health systems building blocks framework was used to guide data collection and analysis. Interviews assessed health care workers’ perspectives on the impact of the LPHCR initiative on the six-health system building blocks: service delivery, health information systems, access to essential medicines, health workforce, financing, and leadership/governance. Data were analyzed using directed content analysis.ResultsParticipants described benefits of decentralization, including improved efficiency in service delivery, enhanced accountability and responsiveness, increased community participation, improved data availability, and better resource allocation. Participants highlighted how the reform resulted in more efficient procurement and distribution processes and increased recognition and status in part due to the empowerment of district health management teams. However, participants also identified limited decentralization of financial decision-making and encountered barriers to successful implementation, such as staff shortages, inadequate management of the village health worker program, and a lack of clear communication regarding autonomy in utilizing and mobilizing donor funds.ConclusionOur study findings indicate that the implementation of decentralized primary health care management in Lesotho was associated a positive impact on health system building blocks related to primary health care. However, it is crucial to address the implementation challenges identified by healthcare workers to optimize the benefits of decentralized healthcare management.

From PERFORM to PERFORM2Scale: lessons from scaling-up a health management strengthening intervention to support Universal Health Coverage in three African countries.

Strengthening management and leadership competencies among district and local health managers has emerged as a common approach for health systems strengthening and to achieve Universal Health Coverage (UHC). While the literature is rich with localized examples of initiatives that aim to strengthen the capacity of district or local health managers, particularly in sub-Saharan Africa, considerably less attention is paid to the science of 'how' to scale-up these initiatives. The aim of this paper is thus to examine the 'process' of scaling-up a management strengthening intervention (MSI) and identify new knowledge and key lessons learned that can be used to inform the scale-up process of other complex health interventions, in support of UHC. Qualitative methods were used to identify lessons learned from scaling-up the MSI in Ghana, Malawi and Uganda. We conducted 14 interviews with district health management team (DHMT) members, three scale-up assessments with 20 scale-up stakeholders, and three reflection discussions with 11 research team members. We also kept records of activities throughout MSI and scale-up implementation. Data were recorded, transcribed and analysed against the Theory of Change to identify both scale-up outcomes and the factors affecting these outcomes. The MSI was ultimately scaled-up across 27 districts. Repeated MSI cycles over time were found to foster greater feelings of autonomy among DHMTs to address longstanding local problems, a more innovative use of existing resources without relying on additional funding and improved teamwork. The use of 'resource teams' and the emergence of MSI 'champions' were instrumental in supporting scale-up efforts. Challenges to the sustainability of the MSI include limited government buy-in and lack of sustained financial investment.

Process Mapping Midwifery Students' Clinical Placement in Sierra Leone: Identifying Facilitators and Barriers.

Background: Improving midwifery education is critical to improving maternal and infant health outcomes in Sierra Leone. A significant priority within midwifery education is to strengthen the clinical teaching and students' hands-on experience in the clinical setting. Objectives: To identify facilitators and challenges within midwifery students' clinical placements and to highlight areas to strengthen the clinical midwifery education system as well as the role of preceptors. Methods: We conducted a participatory process mapping with two schools of midwifery in Sierra Leone to detail steps taken by practicing midwives and midwifery faculty when students are placed in clinical settings for midwifery rotations. Findings: There were 42 participants from the Bo and Makeni regions of Sierra Leone. Participants included midwifery faculty from the Schools of Midwifery in Makeni and Bo, clinical midwives from two regional government hospitals, clinical midwives from two affiliated community health centers, and midwives from the District Health Management Teams. Three recurring themes emerged in the process. First, there was always some element of preparing or teaching the student. Second, there were administrative tasks to coordinate between the schools, clinical sites, and students, before, during, and after clinical placements. And third, there were elements of communication and collaboration between schools and clinical sites/preceptors that could be improved through shared understanding and standardization. Additional themes were inconsistencies across activities before, during, and after students' clinical placement and limited opportunities and confusion around systems of evaluating all components of the clinical placement experience. Conclusions: This study provides insight into the process of midwifery students' clinical placement and highlights facilitators to be standardized and some modifiable barriers to be addressed. As Sierra Leone and many other similar countries in sub-Saharan Africa attempt to strengthen students' clinical education through educating and developing preceptors, processing mapping can be a useful tool.

Strengthening district health management and planning: an evaluation of a multi-country initiative in Eastern and Southern Africa

Background District health management and leadership capacity is increasingly recognised as critical to health system performance. District health managers play a central role in effective implementation and tailoring of national health policies, and they need adequate skills and support. The District Health System Strengthening Initiative (DHSSi) was implemented over 2019-22 in Malawi, Kenya, Tanzania and Uganda to strengthen sub-national capacity for evidence-based planning and a broader set of management competencies needed to operationalize district plans. To support learning and adaptation, a three-year evaluation was conducted to assess progress against outcomes and to inform ongoing implementation and future investment. Methods The evaluation used a mixed-methods theory-based approach. Evaluation questions were structured using criteria of relevance, coherence, efficiency, effectiveness, sustainability and impact, and corresponded to outputs, outcomes and impacts in the DHSSi Theory of Change. The evaluation was conducted over three annual rounds, and combined data from document review, observation, interviews and group discussions with cross-country, national and district stakeholders, and analysis of secondary quantitative data. Results Experience of DHSSi implementation indicated the relevance of supporting district management and planning, with gaps in current capacity, government interest, and indications of the potential to improve district practice. DHSSi experience also highlighted challenges to effective achievement of stronger capacity, and to translation of skills to improved management practice and, ultimately, to improved service delivery. A range of factors beyond skills affected district capacities, motivation and opportunities for effective planning and management, including areas such as funding, planning templates, health information systems, staff turnover, partner alignment and political structures. Conclusions Strengthening sub-national health management is an important agenda in efforts to expand high-quality primary health care. Future initiatives should prioritize detailed understanding of the range of influences on district management, and work to strengthen the enabling environment for effective district practice.

Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial.

Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique. This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective. SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning. ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Perceived progress toward scale of 14 maternal, newborn, child health, and nutrition (MNCHN) assets at subnational level in Burkina Faso, Ethiopia, India, Kenya, and Nigeria.

Inequitable coverage of evidence-based MNCHN interventions is particularly pronounced in low and middle income countries where access and delivery of these interventions can vary dramatically at the subnational level. We conducted health system assessments in nine subnational geographies in five countries (Burkina Faso, Ethiopia, India, Kenya and Nigeria) to explore progress toward scale of 14 evidence-based MNCHN interventions (iron-folic acid, oxytocin, magnesium sulfate, misoprostol; 7.1% chlorhexidine for umbilical cord care, neonatal resuscitation, kangaroo mother care, community regimen for the treatment of possible severe bacterial infection; amoxicillin dispersible tablets, multiple micronutrient supplements, balanced energy protein supplementation, early and exclusive breastfeeding, feeding of small and sick newborns, and management of severe and moderate acute malnutrition in children less than five years old). Between March and October 2021, we conducted key informant interviews with a purposive sample of 275 healthcare providers and 94 district health management (DHMT) staff to better understand bottlenecks, facilitators and uptake of the interventions across varied subnational settings. Across all interventions and geographies, providers and DHMT staff perceived lack of robust HMIS data as the most significant barrier to scale followed by weak facility infrastructure. DHMT staff viewed limited budget allocation and training as a much larger barrier than healthcare providers, most likely given their purview as subnational managers. Healthcare providers were focused on supply chain and staffing, which affect workflows and service provision. Understanding provider and health facility management views of why interventions do or do not advance towards effective coverage can assist in creating enabling environments for the scale of best practices. These types of data are most helpful when collected at the subnational level, which allows for comparisons both within and between countries to show health disparities. Importantly, this strategic data collection can provide a starting point for improvement efforts to address existing health system gaps.

Mid-level managers’ perspectives on implementing isoniazid preventive therapy for people living with HIV in Ugandan health districts: a qualitative study

BackgroundIsoniazid preventive therapy (IPT) works to prevent tuberculosis (TB) among people living with HIV (PLHIV), but uptake remains low in Sub-Saharan Africa. In this analysis, we sought to identify barriers mid-level managers face in scaling IPT in Uganda and the mechanisms by which the SEARCH-IPT trial intervention influenced their abilities to increase IPT uptake.MethodsThe SEARCH-IPT study was a cluster randomized trial conducted from 2017–2021. The SEARCH-IPT intervention created collaborative groups of district health managers, facilitated by local HIV and TB experts, and provided leadership and management training over 3-years to increase IPT uptake in Uganda. In this qualitative study we analyzed transcripts of annual Focus Group Discussions and Key Informant Interviews, from a subset of SEARCH-IPT participants from intervention and control groups, and participant observation field notes. We conducted the analysis using inductive and deductive coding (with a priori codes and those derived from analysis) and a framework approach for data synthesis.ResultsWhen discussing factors that enabled positive outcomes, intervention managers described feeling ownership over interventions, supported by the leadership and management training they received in the SEARCH-IPT study, and the importance of collaboration between districts facilitated by the intervention. In contrast, when discussing factors that impeded their ability to make changes, intervention and control managers described external funders setting agendas, lack of collaboration in meetings that operated with more of a ‘top-down’ approach, inadequate supplies and staffing, and lack of motivation among frontline providers. Intervention group managers mentioned redistribution of available stock within districts as well as between districts, reflecting efforts of the SEARCH-IPT intervention to promote between-district collaboration, whereas control group managers mentioned redistribution within their districts to maximize the use of available IPT stock.ConclusionsIn Uganda, mid-level managers’ perceptions of barriers to scaling IPT included limited power to set agendas and control over funding, inadequate resources, lack of motivation of frontline providers, and lack of political prioritization. We found that the SEARCH-IPT intervention supported managers to design and implement strategies to improve IPT uptake and collaborate between districts. This may have contributed to the overall intervention effect in increasing the uptake of IPT among PLHIV compared to standard practice.Trial registrationClinicalTrials.gov, NCT03315962, Registered 20 October 2017.

The role of provincial health administration in supporting district health management teams in the Democratic Republic of Congo: eliciting an initial programme theory of a realist evaluation

BackgroundIn 2006, the Ministry of Health in the Democratic Republic of Congo designed a strategy to strengthen the health system by developing health districts. This strategy included a reform of the provincial health administration to provide effective technical support to district health management teams in terms of leadership and management. The provincial health teams were set up in 2014, but few studies have been done on how, for whom, and under what circumstances their support to the districts works. We report on the development of an initial programme theory that is the first step of a realist evaluation seeking to address this knowledge gap.MethodsTo inform the initial programme theory, we collected data through a scoping review of primary studies on leadership or management capacity building of district health managers in sub-Saharan Africa, a review of policy documents and interviews with the programme designers. We then conducted a two-step data analysis: first, identification of intervention features, context, actors, mechanisms and outcomes through thematic content analysis, and second, formulation of intervention–context–actor–mechanism–outcome (ICAMO) configurations using a retroductive approach.ResultsWe identified six ICAMO configurations explaining how effective technical support (i.e. personalised, problem-solving centred and reflection-stimulating) may improve the competencies of the members of district health management teams by activating a series of mechanisms (including positive perceived relevance of the support, positive perceived credibility of provincial health administration staff, trust in provincial health administration staff, psychological safety, reflexivity, self-efficacy and perceived autonomy) under specific contextual conditions (including enabling learning environment, integration of vertical programmes, competent public health administration staff, optimal decision space, supportive work conditions, availability of resources and absence of negative political influences).ConclusionsWe identified initial ICAMO configurations that explain how provincial health administration technical support for district health management teams is expected to work, for whom and under what conditions. These ICAMO configurations will be tested in subsequent empirical studies.

Data-driven decision-making for district health management: a cluster-randomised study in 24 districts of Ethiopia

BackgroundUse of local data for health system planning and decision-making in maternal, newborn and child health services is limited in low-income and middle-income countries, despite decentralisation and advances in data...

District health management and stillbirth recording and reporting: a qualitative study in the Ashanti Region of Ghana

BackgroundDespite global efforts to reduce maternal and neonatal mortality, stillbirths remain a significant public health challenge in many low- and middle-income countries. District health systems, largely seen as the backbone of health systems, are pivotal in addressing the data gaps reported for stillbirths. Available, accurate and complete data is essential for District Health Management Teams (DHMTs) to understand the burden of stillbirths, evaluate interventions and tailor health facility support to address the complex challenges that contribute to stillbirths. This study aims to understand stillbirth recording and reporting in the Ashanti Region of Ghana from the perspective of DHMTs.MethodsThe study was conducted in the Ashanti Region of Ghana. 15 members of the regional and district health directorates (RHD/DHD) participated in semi-structured interviews. Sampling was purposive, focusing on RHD/DHD members who interact with maternity services or stillbirth data. Thematic analyses were informed by an a priori framework, including theme 1) experiences, perceptions and attitudes; theme 2) stillbirth data use; and theme 3) leadership and support mechanisms, for stillbirth recording and reporting.ResultsUnder theme 1, stillbirth definitions varied among respondents, with 20 and 28 weeks commonly used. Fresh and macerated skin appearance was used to classify timing with limited knowledge of antepartum and intrapartum stillbirths. For theme 2, data quality checks, audits, and the district health information management system (DHIMS-2) data entry and review are functions played by the DHD. Midwives were blamed for data quality issues on omissions and misclassifications. Manual entry of data, data transfer from the facility to the DHD, limited knowledge of stillbirth terminology and periodic closure of the DHIMS-2 were seen to proliferate gaps in stillbirth recording and reporting. Under theme 3, perinatal audits were acknowledged as an enabler for stillbirth recording and reporting by the DHD, though audits are mandated for only late-gestational stillbirths (> 28 weeks). Engagement of other sectors, e.g., civil/vital registration and private health facilities, was seen as key in understanding the true population-level burden of stillbirths.ConclusionEffective district health management ensures that every stillbirth is accurately recorded, reported, and acted upon to drive improvements. A large need exists for capacity building on stillbirth definitions and data use. Recommendations are made, for example, terminology standardization and private sector engagement, aimed at reducing stillbirth rates in high-mortality settings such as Ghana.

Accountability Mechanisms In Result Based Financing And Their Implementation In Lira District, Northern Uganda

Introduction: Results based financing has been proposed as an innovative reform to enhance systems performance in Uganda. Lira District is one of the districts implementing the national results-based financing (RBF) scheme under the Uganda Reproductive Maternal and Child Health services Improvement Project (URMCHIP). The diversity of relationships among various actors in RBF implementation underscores the need for mechanisms to ensure accountability among them. This was a case study which aimed at exploring the RBF accountability mechanisms, their implementation, and related factors in Lira District. Methodology: The study was a descriptive case study employing qualitative methods. The data collection methods included a) focus group discussions with the health workers from RBF facilities, b) key informant interviews with key actors in the RBF program at the MOH as well as in the district including district managers, health facility in charges, verifiers, members of the health facility management committees, c) document review of RBF documents, annual progress and audit reports. were analyzed thematically guided by a framework that explored the relationships and related accountability arrangements in RBF. Results: Several accountability relationships do exist among actors in RBF program and each relationship has associated accountability mechanisms for example, accountability mechanisms between MOH and the district include MOUs and business plans, while between the district and facilities mechanisms include reporting, data verifications, financial audits while display of results on notice boards, complaint boxes are mechanisms between the facility and the community. Regular support supervision and facility innovations such as meetings complimented RBF-specific designs. Challenges hindering smooth implementation of accountability mechanisms included infrequent financial support to enable regular support supervision/verification visits by Expanded District Health Management Team (EDHMT) and corruption tendencies. Conclusion: Implementation of accountability mechanisms in RBF in Lira is suboptimal due to the various RBF design and implementation challenges. There is need to support the EDHMT and facility managers’ in terms of capacity building and facilitation to do their work. Additionally, efforts need to be undertaken to address delayed disbursement of funds and corruption impeding the implementation of accountability mechanisms in the district.

Lessons learned from conceptualising and operationalising the National Adolescent Health Programme or Rashtriya Kishor Swasthya Karyakram’s Learning Districts Initiative in six districts of India

In 2018, WHO with the support of the Ministry of Health and Family Welfare, India and partner organisations launched a Learning Districts Initiative to strengthen the district-level application of the National Adolescent Health Programme and to draw out lessons. An assessment of this initiative from 2019 to 2023 using qualitative and quantitative programme monitoring data from interviews, discussions, observations and data from multiple secondary sources explored the evolution of the concept, the process of securing government agreement, operationalising the initiative and the feasibility, acceptability, effectiveness and the potential of sustainability and replicability within the government health system. As part of the process, WHO developed the concept with partners to address the challenges identified in a Rapid Programme Review requested by the Ministry. The Ministry concurred with the proposed participatory problem identification and problem-solving approach. A review-based process guided the implementation. Local non-government organisations supported District Health Management Units to strengthen planning, implementation and monitoring. An expert in adolescent health provided technical oversight. Three years later in 2022, adolescent health is on district agendas, staff capacity has been built, and clinic and community-based activities are carried out in a structured manner. The Initiative is feasible as it leverages local expertise. Its core interventions are acceptable to government officials. While there are improvements in inputs, processes and outputs, these need to be independently validated. Challenges such as unfilled vacancies, problems in supply procurement, inability of staff to discuss sensitive issues, weak intersectoral convergence and low engagement of adolescents in programme management remain to be addressed. Nevertheless, the overall experience augurs well for the future of the programme.

"We have nice policies but…": implementation gaps in the Ghana adolescent health service policy and strategy (2016-2020).

Although policies for adolescent health exist in Ghana, their implementation is challenging. Availability of services for adolescent sexual and reproductive health and adolescent mental health remains less than desired, with adolescent mental health being particularly neglected despite being an important contributor to poor health outcomes. This study presents an analysis of gaps in the implementation of the Ghana Adolescent Health Service Policy and Strategy (2016-2020), including how and why the context influenced the observed implementation gaps. Data for this study is drawn from 17 in-depth interviews with purposefully identified key stakeholders in adolescent mental, sexual, and reproductive health across the national and subnational levels; four focus group discussions (FGDs) with district health management teams; and 11 FGDs with adolescents in and out of schools in four selected districts in the Greater Accra region. Data were analyzed using both inductive and deductive approaches. The deductive analysis drew on Leichter's conceptualization of context as structural, cultural, situational, and environmental factors. Of the 23 planned strategies and programs for implementing the policy, 13 (57%) were partially implemented, 6 (26%) were not implemented at all, and only 4 (17%) were fully implemented. Multiple contextual factors constrained the policy implementation and contributed to the majority of strategies not being implemented or partially implemented. These factors included a lack of financial resources for implementation at all levels of the health system and the related high dependence on external funding for policy implementation. Service delivery for adolescent mental health, and adolescent sexual and reproductive health, appeared to be disconnected from the delivery of other health services, which resulted in weak or low cohesion with other interventions within the health system. Bottom-up approaches that engage closely with adolescent perspectives and consider structural and cultural contexts are essential for effective policy implementation. It is also important to apply systemic and multi-sectoral approaches that avoid fragmentation and synergistically integrate policy interventions.

Health System Considerations for Community-Based Implementation of Automated Respiratory Counters to Identify Childhood Pneumonia in 5 Regions of Ethiopia: A Qualitative Study.

In Ethiopia, childhood pneumonia is diagnosed in primary healthcare settings by measuring respiratory rate (RR) along with the presence of cough, chest indrawing, difficulty breathing, and fast breathing. Our aim was to identify health system-level lessons from implementing two automated RR counters, Children's Automated Respiration Monitor (ChARM) by Phillips® and Rad-G by Masimo®, to provide considerations for integrating such devices into child health programmes and health systems. This study was part of an initiative called the Acute Respiratory Infection Diagnostic Aids (ARIDA). Key informant interviews (KIIs) were conducted with 57 participants (health workers in communities and facilities, trainers of health workers, district management, and key decision-makers) in five regions of Ethiopia. Data were analyzed in ATLAS.ti using thematic content analysis and themes were categorized using the Tanahashi bottleneck analysis. All participants recommended scaling up the ARIDA initiative nationally as part of Integrated Management of Newborn and Childhood Illness (IMNCI) in primary healthcare. Health workers perceived the devices as: time saving, acceptable by parents and children, and facilitating diagnosis and referrals. Health workers perceived an increased demand for services and reduced numbers of sick children not seeking care. Participants recommended increasing the number of devices distributed and health workers trained. Strengthening drug supply chains, improving oxygen gas availability, and strengthening referral networks would maximize perceived benefits. While training improved knowledge, more supportive supervision, integration with current guidelines and more guidance related to community engagement was recommended. Automatic RR counters for the decentralized diagnosis of childhood pneumonia could have positive impact on improving the quality of diagnosis and management of pneumonia in children. However, the study has shown that a health system approach is required to ensure all steps along the pneumonia pathway are adequate, including drug and oxygen supply, community engagement, health worker training and support, and referral pathways.