Capacity Gaps Research Articles

Evaluation of Turkish Health System Capacity at Provincial Level by WISP Method Based on Weighting Methods

Purpose: The study aims to evaluate the capacity and capacity gaps of the Turkish health system at the provincial level in relative terms. The secondary objective of the study is to develop application algorithms for the weighting methods utilized in the R programming language. Methodology: The decision criteria used in evaluation of health system capacity were weighted by CRITIC, Shannon Entropy, and NMV methods. The WISP method was used to evaluate the health system capacity of provinces. Data were drawn from the Ministry of Health's Health Statistics Yearbook for 2022. Findings: Tunceli, Bayburt, and Kilis are the three provinces closest to the optimal solution among 81 provinces in terms of health system capacity in Türkiye, according to CRITIC-based WISP scores. On the contrary, Bursa, İstanbul and Şanlıurfa are the three provinces furthest from an optimal solution. Originality: At the provincial level, gaps in the health system's capacity can be identified and subsequently improved. It is possible to develop self-sufficient health system capacity and enhance its resilience. The development of application algorithms for weighting methods makes a significant contribution. Decision makers are capable of generating immediate solutions for both small and large-scale data sets using the algorithms.

Community-driven ecotourism in the trans Himalayan region: A sustainable model for cultural and environmental preservation

ABSTRACT Himalayan destinations, rich in natural and cultural wealth, are increasingly vulnerable to ecological degradation due to unregulated tourism growth. This research examines community-driven ecotourism (CDE) as a model to reconcile economic imperatives with environmental stewardship in Ladakh, a region facing rapid tourism expansion and ecological fragility. Using a qualitative case study approach, the study draws on semi-structured interviews with 22 stakeholders, including community leaders, tourism entrepreneurs, environmental experts, and hospitality managers. Thematic analysis reveals the interplay between local engagement, cultural preservation, and ecological resilience. Key findings introduce a strategic framework that supports cultural and environmental sustainability while aligning with Sustainable Development Goals (SDGs) 8, 12, and 15. Community-managed homestays, wildlife tours, and heritage conservation emerge as key mechanisms for fostering local livelihoods and preserving heritage. However, challenges such as infrastructure deficits, capacity gaps, and insufficient policy coherence limit the broader impact of these initiatives. This study underscores the importance of local community participation in shaping resilient tourism practices and offers recommendations to bridge policy and practice. The research positions Ladakh as a model for sustainable tourism in the Himalayas, emphasizing the symbiosis between cultural identity and environmental integrity.

Exploring Canadian Dietitians' Knowledge Attitude and Practices Providing Culturally Safe Care to Muslims who fast During the Month of Ramadan: A Cross-sectional Study.

Fasting during Ramadan involves abstaining from food and drink from dawn to dusk for 29 to 30 days, annually. Dietitians, experts in food and nutrition, play a vital role in fostering the well-being of Canadians. Given that 1 in 20 Canadians are Muslim, access to culturally safe care is essential for their health. The consumption of adequate nutrients during the non-fasting hours is important for Muslims well-being. It is unknown whether dietitians in Canada feel comfortable and knowledgeable providing safe care during Ramadan. An online survey, was developed using the World Health Organization's Knowledge Attitude and Practice Protocol, and then reviewed for content validity by 6 dietitians. From March 5, 2023 to April 1, 2023, 159 Canadian dietitians, from a variety of practice areas including acute care, community health, and private practice, completed the online survey. Descriptive statistics, cross tabulations, and chi-square tests, enhanced by post hoc analyses with Bonferroni correction, were employed to determine any relationship between categorical variables and identify significant associations or differences. While most participants demonstrated an adequate understanding of Ramadan fasting practices, including its duration and restrictions, 91% reported not receiving information on how to provide culturally safe care during their university degree. Many dietitians expressed discomfort providing care (43.7%, 69/158) and lacked adequate resources (51.3%, 81/158). Among the 37% of dietitians who did offer care to Muslims (58/157), the majority felt comfortable (72.1%, 44/58). This study reveals a gap in capacity to provide culturally safe care, highlighting the need for training interventions for nutrition professionals, and curriculum for dietetics programs.

The capacity and training needs of primary health care workers in Nyeri and Nakuru counties of Kenya: a cross-sectional study.

Health systems based on primary healthcare (PHC) have reduced costs and are effective for improved health outcomes. Kenya's health system grapples with providing equitable access to essential health services, but there is increasing commitment by the government to strengthen primary healthcare. The aim of this paper is to provide a baseline assessment of the capacity and training needs of healthcare workers (HCWs) in Nakuru and Nyeri Counties and identify priorities for intervention. A cross-sectional study was carried out among 171 healthcare workers in Nyeri and Nakuru counties. Multistage sampling was employed to select sub-counties in the first stage and health facilities by level within each sub-county in the second level. Systematic random sampling was then employed to select HCWs from each level of facility. We targeted healthcare workers of all cadres within the health facilities, and included all who consented to participating. Structured self-administered pen-and-paper questionnaires were used for data collection, and a five-point Likert scale was used to measure the perceived capacity of the healthcare workers to provide primary healthcare. As for the training needs data, the participants selected any of the 12 components that they needed training in. Descriptive statistics was employed, and stacked bar charts were used to visualize the capacity and training needs for the components of PHC adopted in Kenya. In total, we obtained questionnaires from 95 participants in Nakuru and 76 participants in Nyeri. Nakuru HCWs rated themselves higher than their Nyeri counterparts in maternal and newborn child healthcare, local endemic disease control, appropriate treatment of common diseases and injuries, provision of essential basic medication, dental health, HIV/AIDs & TB management, and primary eye care. In both counties, there were significant differences in capacity between the different levels of health facilities. We observed substantial capacity gaps for HIV/AIDs & TB management, mental health and dental health services in both counties. This study found a substantial capacity gap in several of the elements of PHC, especially in Nyeri County. Critical areas for intervention are HIV/AIDs & TB management and mental health training for both counties. Within the health system, there is need to strengthen the capacity of HCWs in lower-level health facilities to reduce the volume of referrals to secondary care facilities. We strongly recommend training programs in dental health, mental health, primary eye care, nutritional services and HIV/AIDs &TB management, that are carefully designed to emphasize skills and abilities.

Achievement of one health multi-sectoral collaboration in containment of Rift Valley Fever outbreak, Sudan, Red Sea State 2019.

Rift Valley Fever is endemic in Sudan, with a notable outbreak declared in 2019, affecting multiple states. In this study, we examine the Red Sea State, Sudan's experience in applying the One Health approach, to contain Red-Sea RVF outbreak. A retrospective analysis of national and sub-national data and a review of literature were conducted to assess the application of One Health response and to derive lessons learned. The analysis revealed a total of 576 human cases and two deaths, with a case fatality rate of 0.35%, from 25 September 2019 to 25 January 2020. Most cases (99%) were from the Red Sea and River Nile States, and only six sporadic cases were from other five states. The Red Sea State reported 322 human and 74 animal cases, including 74 abortions and 12 animal deaths. Triggers and risk factors include floods, uncontrolled movement of animal, close contact with animals, poor disposal, and unsafe burial practices for animals. One Health approach was utilized all through the defeat of outbreak. A multi-sectoral response plan was implemented, leading to the declaration of the end of the outbreak in 2020 which was reviewed and lessons were derived. One Health approach provided a coordinated action between health, veterinary, and environmental authorities at national and subnational levels. Synergistic efforts have minimized risk of RVF spreading among human and animal. The experience was leveraged to strengthen response approaches for zoonotic diseases. Structural and capacity gaps and financial constraints were identified as implementation challenges.

Enhancing Public Financial Transparency Through the Integration of Taxation, Accounting, and Social Welfare Systems

This study explores the impact of taxation, accounting, and social welfare system integration on public financial transparency in Indonesia. The study collected data from government reports and interviews with financial policy experts, auditors, and government officials using mixed methods, including quantitative and qualitative analysis. The analysis results show that system integration significantly improves transparency through more accurate fiscal reporting and better access to public financial information. Challenges such as technology implementation costs, bureaucratic resistance, and capacity gaps still hamper the integration process. These findings align with existing literature, which underlines the importance of political support and capacity building to overcome these obstacles. This study recommends better training and international support to support system integration efforts and improve accountability and public trust in state financial management.

From Fragmentation to Coherence: Enhancing Human Resource Capacity in Indonesian Law Reform for Effective Justice Delivery

Indonesian law reform faces persistent challenges stemming from fragmented human resource capacity, which undermines the coherence and effectiveness of justice delivery. This study critically examines the interplay between human resource development and the success of legal reform in Indonesia, emphasizing the urgent need to address systemic inefficiencies and skill gaps. As globalization and complex socio-legal issues demand more sophisticated legal systems, the pressure on Indonesia’s legal institutions to enhance their human resource capabilities has intensified. The novelty of this research lies in its focused analysis of human resource capacity as a critical yet underexplored dimension of Indonesian law reform. By employing a socio-legal methodology, the study identifies key factors contributing to fragmentation, including uneven competency levels, inadequate training, and lack of coordination among legal institutions. It further evaluates the role of education, professional development, and policy frameworks in fostering a coherent and competent legal workforce. The findings demonstrate that a robust, well-coordinated human resource strategy is essential for advancing legal reforms and delivering justice effectively. This research contributes to the discourse by proposing actionable solutions, including curriculum reforms, capacity-building initiatives, and collaborative networks among legal practitioners, academics, and policymakers. By addressing the critical gap in human resource capacity, this study provides a pathway for achieving a coherent legal system that upholds justice and aligns with Indonesia’s broader development goals.

Integrating political prioritisation into national surgical planning: a scoping review of surgical, obstetric and anaesthesia care in Cameroon

BackgroundSurgical diseases contribute substantially to death and disability in Cameroon. Strategic planning for surgical, obstetric and anaesthesia (SOA) care in low-income and middle-income countries (LMICs) requires consideration of the policy...

Cobuilding patient and public capacity in knowledge synthesis: designed and delivered by patient and public partners for patient and public partners.

To describe the Strategy for Patient-Oriented Research Evidence Alliance's cocreation and evaluation of two capacity building courses on knowledge synthesis for patient and public partners. Two 3-week courses were collaboratively designed by, with, and for patient and public partners on engagement in knowledge synthesis. The first course, offered virtually in 2021, focused on patient and public engagement in systematic reviews and rapid reviews. The second course was offered virtually in 2022 with an expanded scope covering the most common type of knowledge synthesis (eg, systematic reviews with or without meta-analysis, scoping reviews, overview of reviews) under systematic, rapid, and living review contexts. A total of 46 patient and public learners were trained across the two courses. Learners represented 11 provinces and territories in Canada, with two-third of learners residing in Ontario across both years (2021: 39%; 2022: 35%). Weekly formative evaluations and a summative evaluation were conducted for both courses. The evaluations revealed that the majority of respondents agreed (2021: 91%; 2022: 88%) that they achieved their learning goals and that their overall learning experience was valuable (2021: 95%; 2022: 89%). The capacity-building courses in 2021 and 2022 successfully engaged 46 patient and public partners across Canada. As a result, these partners are now well-prepared to participate in knowledge synthesis activities. The positive experiences from respondents indicated successful and satisfactory experiences and that similar capacity building opportunities should be offered to continue to address research capacity gaps. In 2021 and 2022, the Strategy for Patient-Oriented Research Evidence Alliance adopted a cocreation approach to deliver two courses on patient and public engagement in knowledge synthesis for patient and public partners. These courses aimed to build confidence and provide foundational knowledge for patient and public partner engagement in knowledge synthesis. A total of 46 learners were trained across the two courses. Formal evaluations revealed that the courses were effective in meeting their learning goals. Feedback suggests a continued need and opportunity to offer similar courses designed by, with, and for patient and public partners.

The role of regulatory agencies in public health emergencies: A critical review of global approaches and challenges

Regulatory agencies play a pivotal role in public health emergencies by ensuring that medical products, including vaccines, diagnostics, and therapeutics, are rapidly available while maintaining safety and efficacy standards. The COVID-19 pandemic, along with past crises such as the Ebola and Zika outbreaks, exposed both strengths and vulnerabilities in global regulatory frameworks. This paper critically reviews the role of regulatory agencies in public health emergencies, synthesizing existing literature to present new insights into their operational challenges and the reliance strategies employed to bridge capacity gaps. By examining case studies, such as the reliance on the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) by low- and middle-income countries (LMICs), this paper highlights the importance of global cooperation and reliance mechanisms in managing crises. Furthermore, it addresses challenges such as resource constraints, disparities in regulatory capacity, and ethical dilemmas faced when approving products based on limited data. The paper also explores the future direction of regulatory science, emphasizing the need for greater global regulatory convergence, capacity building, and the adoption of innovative digital tools. Ultimately, the paper argues that while reliance strategies are vital, long-term investment in national regulatory systems and global harmonization efforts are essential for a more equitable and effective response to future public health emergencies.

Current data science capacity building initiatives for health researchers in LMICs: global & regional efforts.

Data science approaches have proved crucial for generating major insights to address public health challenges. While such approaches have played significant roles during the COVID-19 pandemic, there has been limited investment in capacity building in data science skills and infrastructure for health researchers in LMICs. This review aims to identify current health data science capacity building initiatives and gaps in Africa, Asia, and Latin America and the Caribbean (LAC), to support knowledge sharing and collaborations, and inform future initiatives and associated investment. We conducted a literature review using PubMed and Scopus, supplemented by a grey literature search on Google to identify relevant initiatives. Articles were screened based on inclusion criteria. From 212 records, 85 met inclusion criteria, with 20 from PubMed and Scopus, and 65 from grey literature. The majority of programmes are tailored to specific disease areas, varying by region. Despite these efforts, there are limited initiatives with a clear, documented strategy on data science capacity building to accelerate global research insights, with the majority adopting a fragmented approach. Despite the integration of data science approaches into health research initiatives in LMICs, there is a need for a standardised framework on data science capacity building to facilitate multidisciplinary and global collaboration. Structured approaches, inter-disciplinary, inter-regional connections and robust impact measurement will all be vital for advancing health research insights in these settings.

Analisis Pelembagaan Partisipasi Politik Akar Rumput melalui Gerakan Kelompok Tani di Kabupaten Bireuen, Provinsi Aceh

Increasing political participation is certainly not an easy job, there needs to be support from several parties or groups. One group that is considered capable of inviting people to increase political participation is farmer groups. Especially for people who live in rural areas. One of the villages that has a farmer group is Gampong Blang Cut, Peusangan District in Bireuen Regency. The purpose of the research is to find out the role of the farmer group in increasing community political participation and to find out the obstacles faced by farmer groups in increasing community political participation. The research method uses qualitative techniques. The results of this study indicate that; the level of participation of farmer groups tends to be low. Constraining factors such as gaps in the political capacity of farmer groups, fragmentation and limited resources, apathy and dependence on the government are often the main causes of the low political participation of farmer groups. This situation ultimately weakens the capacity of farmer groups to develop and fight for a political agenda that truly reflects their needs and aspirations. Therefore, systematic efforts are needed to restructure farmer group organizations to be more oriented towards political participation such as; (1) Recognition of Customary Values; (2) Community involvement in the decision-making process of village development; (3) Strengthening the partnership network of grassroots institutions; (4) Strengthening discussion and dialogue forums.

Exploring Park and Ride: A Spatial Analysis of Transit Catchment in Outer Melbourne

Public transportation is essential for improving urban mobility, enhancing travel quality, reducing reliance on private vehicles, and alleviating traffic congestion. However, inadequate public transportation in outer Melbourne is a significant issue limiting urban development. While existing research primarily focuses on walking distance to define service catchments, commuters in transit-disadvantaged or outlying urban areas often drive to transit, noted as the park-and-ride mode. This research uniquely examines drive-distance catchments for park-and-ride transit accessibility in outer Melbourne, using spatial SQL and GIS techniques to provide a detailed, multi-dimensional analysis of population coverage, parking capacity, and accessibility gaps. This approach fills a gap in the existing literature by offering adaptable insights and approaches to other outer urban areas with transit disadvantages. The findings underscore the necessity for targeted enhancements in public transportation in outer Melbourne: Most of the outer residents concentrate near the train stations, though significant spatial gaps exist; The general accessibility status of residential mesh blocks is found; Parking capacity varies with high tension found at certain stations. This study contributes insights to create more equitable and sustainable transportation systems by providing a detailed spatial analysis of current transit coverage and identifying critical gaps.

Evaluating the implementation of the National Primary Health Care Development Agency (NPHCDA) gateway for the Basic Healthcare Provision Fund (BHCPF) across six Northern states in Nigeria

BackgroundThis evaluation research utilized both qualitative and quantitative methods to assess the implementation of the National Primary Health Care Development Agency (NPHCDA) gateway of the Basic Health Care Provision Fund (BHCPF) across six states in Northern Nigeria: Bauchi, Borno, Kaduna, Kano, Sokoto, and Yobe.MethodsThis was a mixed-method research that utilized longitudinal surveys and Key informant interviews to gather information about the implementation status of the BHCPF-NPHCDA gateway. Checklists were developed based on the BHCPF’s national guidelines to gather quantitative data, while simple open-ended questionnaires were used to collect qualitative data from the state BHCPF Program Implementation Unit (PIU) focal persons as key informants.ResultsThe result revealed that the NPHCDA had accredited these six states to use one Primary Health Care (PHC) facility in each political ward to implement the BHCPF. Factors that contributed to the success achieved in some states included the early completion of contingent start-up activities, well-established coordination structures, strong support from partners, and the availability of established financial management systems. However, the delays in the submission of quarterly business plans by the BHCPF facilities affected timely approval and fund disbursement. Other challenges included staff capacity gaps, inadequate human resources, and poor management and supervision from the state health agency teams.ConclusionThere was suboptimal implementation of the BHCPF in at least one thematic area across all states. Therefore, actions such as government commitment for improved coordination, continuous capacity building, effective monitoring and evaluation, and targeted supportive supervision using innovative approaches should be undertaken to improve the program’s implementation. In a broader setting, the insights from BHCPF implementation are valuable for LMICs, offering guidance on overcoming implementation challenges associated with PHC financing. This research provides a resource for enhancing healthcare financing strategies in similar contexts.

Bridging the implementation gap for climate mitigation in ASEAN: a comprehensive capacity-building framework

PurposeThe paper systematically examines the capacity building needs of energy and climate stakeholders in the Association of Southeast Asian Nations (ASEAN). It looks at conditions and opportunities for improvements in institutional, organisational, technological, innovation and financing capacities. This paper provides a guide to concrete capacity building programs and implementations to accelerate the implementation of National Determined Contributions (NDCs) and low-carbon energy transition in the ASEAN region.Design/methodology/approachThis paper proposes a comprehensive capacity-building framework, drawing on transition management theory and the interactive systems framework for capacity building. The assessment is based on interviews with representatives of the ministry responsible for energy policy and the ministry responsible for climate policy in each ASEAN country, as well as a survey among a broader set of Southeast Asian energy and climate experts from academia, think tanks and international development partners.FindingsThe paper identifies the priority areas for capacity building for each ASEAN country and the region as a whole. Each country has a unique set of needs and priorities. At the regional level, the widest capacity gaps were observed in institutional capacity, technical capacity, human resources capacity, financing capacity and the capacity to develop policy and legislation. Specific gaps for capacity building are discussed in delivering strategic areas of energy transition, such as electrification of transportation, development of the green supply chain, deploying renewable energy, energy efficiency, strengthening finance and investment and reducing dependencies on fossil fuels.Originality/valueThis paper helps fill the gap for detailed capacity needs analysis and facilitates long-term plans/strategies and their implementation. The insights help to increase ASEAN energy and climate stakeholders’ understanding of the interaction between energy and climate, therefore enhanced capability in developing more effective action maps and intervention points in achieving NDCs and sustainable development goals.

Decentralization of Power: Opportunities and Challenges for Regions

Focuses on the opportunities and challenges faced by regions in implementing regional autonomy in Indonesia. Decentralization, which is regulated in Article 18 of the 1945 Constitution and clarified through Law Number 23 of 2014 concerning Regional Government, gives regional governments the authority to manage local affairs in the hope of increasing government efficiency and bringing public services closer to the community. However, its implementation faces a number of challenges, such as gaps in human resource capacity, disparities in development between regions, and coordination problems between the central and regional governments. This article uses a normative legal approach to explore how decentralization of power works within the framework of the Unitary State of the Republic of Indonesia (NKRI), and identifies the opportunities offered by regional autonomy to encourage more equitable development. This study emphasizes the importance of strengthening regional capacity, harmonizing central-regional policies, and effective supervision from the central government to ensure that decentralization can truly bring the expected benefits.

Intimate partner violence, behaviours associated with risk of HIV acquisition and condom use in married women in Manicaland, East Zimbabwe: An HIV prevention cascade analysis

BackgroundIntimate partner violence (IPV) is widespread in the WHO African region with generalised HIV epidemics and may contribute to ongoing HIV transmission through its associations with behaviours associated with HIV acquisition risk and low use of prevention methods particularly in marital relationships.MethodsWe conducted a male condom HIV prevention cascade analysis using data from a general-population survey in Manicaland, Zimbabwe (July 2018-December 2019) to develop an understanding of how interventions that reduce IPV might be built upon to also reduce HIV incidence. Multivariable logistic regression was used to measure associations between currently-married HIV-negative women’s experience of IPV and: (1) being in the priority population for HIV prevention methods (i.e. married women engaging in behaviours associated with HIV acquisition risk or with a spouse who engages in similar behaviours or is living with HIV), and (2) male condom use by women in this priority population. Male condom HIV prevention cascades, with explanatory barriers for gaps between successive cascade bars (motivation, access and effective use), were compared for women in the priority population reporting and not reporting IPV.ResultsWe found a positive association between IPV and being in the priority population for HIV prevention methods (72.3% versus 58.5%; AOR = 2.26, 95% CI:1.74–2.93). Condom use was low (< 15%) for women in the priority population and did not differ between those reporting and not reporting IPV. The HIV prevention cascades for women reporting and not reporting IPV were similar; both showing large gaps in motivation and capacity to use male condoms effectively. Women reporting motivation and access to male condoms were more likely to report their partner being a barrier to condom use if they experienced IPV (84.8% versus 75.5%; AOR = 2.25, 95% CI:1.17–4.31).ConclusionThe findings of this study support the case for trials of integrated IPV/HIV prevention interventions that are tailored to improve HIV risk perception among HIV-negative married women and to make condom provision more acceptable for this group.

Reform of the Irish health system towards Universal Health Coverage and the role of the private sector

Abstract Introduction Ireland stands as a compelling case study of a High Income Country setting out on Universal Health Coverage (UHC) reforms. The Irish health system has historically been a two-tier system with a large private sector and a high proportion of the population holding private health insurance (48% in 2023). The reform programme Sláintecare, adopted as a policy direction by all political parties, aims to introduce UHC, strengthen primary care capacity, address inequitable access and decentralise decision-making. The overall aim of this study is to chart the progress of the Sláintecare reforms, from their introduction in May 2017 up to December 2023, and to explore how they have changed throughout implementation. Methods A document analysis was undertaken using the READ approach. Department of Health publications, Budget reports, Service Plans, National Development plans, minutes of Health Service Executive committee meetings and transcripts of the Joint Committee of Health sessions in the Irish parliament were uploaded to NVivo and a content analysis was conducted, utilising predetermined themes. Results Areas that have made the most significant progress include the expansion of community care and lowering of some out-of-pocket costs. Since implementation began, one approach the government has taken has been to use the private sector to fill capacity gaps in the public system. For example, strategies for reducing waiting lists and using community diagnostics have largely used the private sector. However, through using the private sector, money is taken away from building capacity in the public system, which was the original goal of Sláintecare. Conclusions The private sector plays a significant role in providing care in Ireland and leveraging this for the benefit of public patients could play a positive role towards UHC, provided that funding for a purchaser-providers type model for some services from the government could be guaranteed into the future.

Twinning Partnership Network: A Learning and Experience-Sharing Network Among Health Professionals in Rwanda to Improve Health Services.

We describe the development, implementation, and evaluation of a novel twinning approach: the Twinning Partnership Network (TPN). Twinning is a well-known approach to peer learning that has been used in a variety of settings to build organizational capacity. Although twinning takes many forms, the heart of the approach is that institutions with shared characteristics collaborate via sharing information and experiences to achieve a specific goal. We adapted a twinning partnership strategy developed by the World Health Organization to create a network of like-minded health institutions. The key innovation of the TPN is the network, which ensures that an institution always has a high-performing peer with whom to partner on a specific topic area of interest. We identified 10 hospitals and 30 districts in Rwanda to participate in the TPN. These districts and hospitals participated in a kickoff workshop in which they identified capacity gaps, clarified goals, and selected twinning partners. After the workshop, districts and hospitals participated in exchange visits, coaching visits, and virtual and in-person learning events. We found that districts and hospitals that selected specific areas and worked on them throughout the duration of the TPN with their peers improved their performance significantly when compared with those that selected and worked on other areas. Accreditation scores improved by 5.6% more in hospitals selecting accreditation than those that did not. Districts that selected improving community-based health insurance coverage improved by 4.8% more than districts that did not select this topic area. We hypothesize that these results are due to senior management's interest and motivation to improve in these specific areas, the motivation gained by learning from high-performing peers with similar resources, and context-specific knowledge sharing from peer hospitals and districts.

Transition and change: opportunities and challenges of CHW programme reform for community health systems and vertical disease programmes in Liberia

BackgroundGlobally, community health worker (CHW) programmes are critical to addressing health worker shortages and have been recognised as critical pillars within the drive towards universal health coverage (UHC). In 2016, the Liberian Ministry of Health launched the National Community Health Services Policy 2016–2021, which included significant CHW programme reform to address ongoing health workforce capacity gaps in the country. However, little consideration was given to the impact of such reforms on ongoing health interventions that rely heavily on the use of CHW cadres. Our study explores how CHW programme reform in Liberia influenced performance of CHWs involved in the delivery of Neglected Tropical Disease (NTD) programmes to elucidate how health systems reform can impact the delivery of routine health interventions and vice versa.MethodsWe used a qualitative case study approach conducted between March 2017 and August 2018. Our instrumental case study approach uses qualitative methods, including document review of five CHW and NTD program-related policy documents; 25 key informant interviews with facility, county, and national level decision-makers; and 42 life and job histories with CHWs in Liberia. Data were analysed using a thematic framework approach, guided by Kok et al. framework of CHW performance. Data were coded in QRS NVIVO 11 Pro.ResultsOur findings show that CHW programme reform provides opportunities and challenges for supporting enhanced CHW performance. In relation to health system hardware, we found that CHW programme reform provides better opportunities for: formal recognition of CHWs; strengthening capacity for effective healthcare delivery at the community level through improved and formalised training; a more formal supervision structure; and provision of monthly incentives of 70 US dollars. Efficiency gaps in routine intervention delivery can be mitigated through the strengthening of these hardware components. Conversely, supervision deficits in routine CHW functioning can be supported through health interventions. In relation to systems software, we emphasise the ongoing importance of community engagement in CHW selection that is responsive to gendered power hierarchies and accompanied by gendered transformative approaches to improving literacy.ConclusionsThis study shows how CHW programme reform provides opportunities and challenges for health system strengthening that can both positively and negatively impact the functioning of routine health interventions. By working together, CHW programmes and routine health interventions have the opportunity to leverage mutually beneficial support for CHWs, which can enhance overall systems functioning by enhancing CHW performance.