Publications by authors named "Bruno Marchal"

101 Publications

How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia.

BMJ Open 2021 Jun 29;11(6):e047948. Epub 2021 Jun 29.

Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK.

Objectives: This paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt.

Methods: Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders' assumptions on challenges and possible solutions for better TB control. Two participatory workshops were conducted with key actors, interspersed by reflection meetings within the research team and discussions with policymakers. Using concept mapping and causal mapping techniques, and drawing causal loop diagrams, we visualised how actors understood TB service provision challenges and the potential means by which a results-based financing (RBF) policy could address these.

Setting: The study was conducted in Tbilisi, Georgia.

Participants: A total of 64 key actors from the Ministry of Labour, Health and Social Affairs, staff of the Global Fund to Fight AIDS, TB and Malaria Georgia Project, the National Centre for Disease Control and Public Health, the National TB programme, TB service providers and members of the research team were involved in the workshops.

Results: Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organisational incentives, retraining service providers, clear redistribution of roles to support an integrated care model, and refinement of monitoring tools. Health system elements, such as effective referral systems and health information systems were highlighted as necessary for service improvement.

Conclusions: Developing policies that address complex issues requires methods that facilitate linkages between multiple stakeholders and between theory and practice. Such participatory approaches can be informed by realist evaluation principles and visually facilitated by causal loop diagrams. This approach allowed us leverage stakeholders' knowledge and expertise on TB service delivery and RBF to codesign a new policy.
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http://dx.doi.org/10.1136/bmjopen-2020-047948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245474PMC
June 2021

Applying the Realist Evaluation Approach to the Complex Process of Policy Implementation-The Case of the User Fee Exemption Policy for Cesarean Section in Benin.

Front Public Health 2021 8;9:553980. Epub 2021 Jun 8.

Complexity and Health Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Realist evaluation is making inroads in the field of health policy and systems research to a large extent because of its good fit with complex issues. Until now, most realist studies focused on evaluating interventions or projects related to health care delivery, organization of health services, education, management, and leadership of health workers in high income countries. With this paper, we apply the realist approach to the study of national health policy implementation in a low resource country. We use the case of the user fee exemption policy for cesarean section in Benin, which we followed up from 2009 to 2018. We report on how realist evaluation can be applied for policy implementation research. We illustrate how we developed the initial programme theory-the starting point of any realist evaluation -, how we designed the study and data collection tools, and how we analyzed the data. For each step, we present current good practices, how we adapted them when needed, the challenges and the lessons learned. We report also on how the dynamic interactions between the central level (the national implementing agency) and the peripheral level (an implementing hospital) shaped the policy implementation. We found that at central level, availability of resources for a given policy is constantly challenged in the competitive national resource allocation arena. Key factors include the political power and the legitimacy of the group supporting the policy. These are influenced by the policy implementation structure, how the actual outputs of the implementation align with promises of the group supporting the policy and consequently how these outputs, the policy and its promoters are perceived by the community. We found that the service providers are key to the implementation, and that they are constrained or influenced by the dependability of the funding, their autonomy, their personal background, and the accountability arrangements. This study can inform the design and implementation of national health policies that involve interactions between central and operational level in other low-income countries.
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http://dx.doi.org/10.3389/fpubh.2021.553980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8219213PMC
July 2021

Bottom-up innovation for health management capacity development: a qualitative case study in a South African health district.

BMC Public Health 2021 03 24;21(1):587. Epub 2021 Mar 24.

Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.

Background: As part of health system strengthening in South Africa (2012-2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the health system rather than only of individuals, the research explored the mechanisms triggered in context to produce outputs, including the initial sensemaking by the district manager, the subsequent sensegiving and sensemaking in the team and how these homegrown innovations interacted with existing social processes and norms within the system.

Methods: We conducted a realist evaluation, adopting the case study design, over a two-year period (2013-2015) in the district of focus. The initial programme theory was developed from 10 senior manager interviews and a literature review. To understand the processes and mechanisms triggered in the local context and identify outputs, we conducted 15 interviews with managers in the management team and seven with non-state actors. These were supplemented by researcher notes based on time spent in the district. Thematic analysis was conducted using the Context-Mechanism-Outcome configuration alongside theoretical constructs.

Results: The new district manager drew on systems thinking, tacit and experiential knowledge to design bottom-up innovations. Capacity was triggered through micro-practices of sensemaking and sensegiving which included using sticks (positional authority, enforcement of policies, over-coding), intentionally providing justifications for change and setting the scene (a new agenda, distributed leadership). These micro-practices in themselves, and by managers engaging with them, triggered a generative process of buy-in and motivation which influenced managers and partners to participate in new practices within a routine meeting.

Conclusion: District managers are well placed to design local capacity development innovations and must draw on systems thinking, tacit and experiential knowledge to enable relevant 'bottom-up' capacity development in district health systems. By drawing on soft skills and the policy resources (hardware) of the system they can influence motivation and buy-in to improve management practices. From a systems perspective, we argue that capacity development can be conceived of as part of the daily activity of managing within routine spaces.
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http://dx.doi.org/10.1186/s12889-021-10546-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7992952PMC
March 2021

Towards Health Equity and Transformative Action on tribal health (THETA) study to describe, explain and act on tribal health inequities in India: A health systems research study protocol.

Wellcome Open Res 2019 13;4:202. Epub 2019 Dec 13.

Institute of Tropical Medicine, Antwerp, Nationalestraat 155, 2000, Belgium.

In India, heterogenous tribal populations are grouped together under a common category, Scheduled Tribe, for affirmative action. Many tribal communities are closely associated with forests and difficult-to-reach areas and have worse-off health and nutrition indicators. However, poor population health outcomes cannot be explained by geography alone. Social determinants of health, especially various social disadvantages, compound the problem of access and utilisation of health services and undermine their health and nutritional status. The Towards Health Equity and Transformative Action on tribal health (THETA) study has three objectives: (1) describe and analyse extent and patterns of health inequalities, (2) generate theoretical explanations, and (3) pilot an intervention to validate the explanation.     For objective 1, we will conduct household surveys in seven forest areas covering 2722 households in five states across India, along a gradient of socio-geographic disadvantage. For objective 2, we will purposefully select case studies illustrating processes through which socio-geographic disadvantages act at the individual, household/neighbourhood, village or population level, paying careful attention to the interactions across various known axes of inequity. We will use a realist evaluation approach with context-mechanism-outcome configurations generated from the wider literature on tribal health and results of objective 1. For objective 3, we will partner with willing stakeholders to design and pilot an equity-enhancing intervention, drawing on the theoretical explanation generated and evaluate it to further refine our final explanatory theory. THETA project seeks to generate site-specific evidence to guide public health policy and programs to better contribute to equitable health in tribal populations. It fulfills the current gap in generating and testing explanatory social theories on the persistent and unfair accumulation of geographical and social disadvantage among tribal populations and finally examines if such approaches could help design equity-enhancing interventions to improve tribal health.
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http://dx.doi.org/10.12688/wellcomeopenres.15549.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076281PMC
December 2019

Action research and health system strengthening: the case of the health sector support programme in Mauritania, West Africa.

Health Res Policy Syst 2020 Feb 19;18(1):25. Epub 2020 Feb 19.

Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.

Background: Access to qualitative and equitable healthcare is a major challenge in Mauritania. In order to support the country's efforts, a health sector strengthening programme was set up with participatory action research at its core. Reinforcing a health system requires a customised and comprehensive approach to face the complexity inherent to health systems. Yet, limited knowledge is available on how policies could enhance the performance of the system and how multi-stakeholder efforts could give rise to changes in health policy. We aimed to analyse the ongoing participatory action research and, more specifically, see in how far action research as an embedded research approach could contribute to strengthening health systems.

Methods: We adopted a single-case study design, based on two subunits of analysis, i.e., two selected districts. Qualitative data were collected by analysing country and programme documents, conducting 12 semi-structured interviews and performing participatory observations. Interviewees were selected based on their current position and participation in the programme. The data analysis was designed to address the objectives of the study, but evolved according to emerging insights and through triangulation and identification of emergent and/or recurrent themes along the process.

Results: An evaluation of the progress made in the two districts indicates that continuous capacity-building and empowerment efforts through a participative approach have been key elements to enhance dialogue between, and ownership of, the actors at the local health system level. However, the strong hierarchical structure of the Mauritanian health system and its low level of decentralisation constituted substantial barriers to innovation. Other constraints were sociocultural and organisational in nature. Poor work ethics due to a weak environmental support system played an important role. While aiming for an alignment between the flexible iterative approach of action research and the prevailing national linear planning process is quite challenging, effects on policy formulation and implementation were not observed. An adequate time frame, the engagement of proactive leaders, maintenance of a sustained dialogue and a pragmatic, flexible approach could further facilitate the process of change.

Conclusion: Our study showcases that the action research approach used in Mauritania can usher local and national actors towards change within the health system strengthening programme when certain conditions are met. An inclusive, participatory approach generates dynamics of engagement that can facilitate ownership and strengthen capacity. Continuous evaluation is needed to measure how these processes can further develop and presume a possible effect at policy level.
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http://dx.doi.org/10.1186/s12961-020-0531-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031916PMC
February 2020

The effect of leadership on public service motivation: a multiple embedded case study in Morocco.

BMJ Open 2020 01 2;10(1):e033010. Epub 2020 Jan 2.

Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Objectives: We aimed at exploring the underlying mechanisms and contextual conditions by which leadership may influence 'public service motivation' of health providers in Moroccan hospitals.

Design: We used the realist evaluation (RE) approach in the following steps: eliciting the initial programme theory, designing the study, carrying out the data collection, doing the data analysis and synthesis. In practice, we adopted a multiple embedded case study design.

Settings: We used purposive sampling to select hospitals representing extreme cases displaying contrasting leadership practices and organisational performance scores using data from the Ministry of Health quality assurance programmes from 2011 to 2016.

Participants: We carried out, on average, 17 individual in-depth interviews in 4 hospitals as well as 7 focus group discussions and 8 group discussions with different cadres (administrators, nurses and doctors). We collected relevant documents (eg, performance audit, human resource availability) and carried out observations.

Results: Comparing the Intervention-Context-Actor-Mechanism-Outcome configurations across the hospitals allowed us to confirm and refine our following programme theory: "Complex leaders, applying an appropriate mix of transactional, transformational and distributed leadership styles that fit organisational and individuals characteristics [I] can increase public service motivation, organisational commitment and extra role behaviours [O] by increasing perceived supervisor support and perceived organizational support and satisfying staff basic psychological needs [M], if the organisational culture is conducive and in the absence of perceived organisational politics [C]".

Conclusions: In hospitals, the archetype of complex professional bureaucracies, leaders need to be able to balance between different leadership styles according to the staff's profile, the nature of tasks and the organisational culture if they want to enhance public service motivation, intrinsic motivation and organisational commitment.
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http://dx.doi.org/10.1136/bmjopen-2019-033010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6955481PMC
January 2020

Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation.

BMJ Open 2020 01 2;10(1):e031160. Epub 2020 Jan 2.

Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Objectives: This study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco.

Design: We adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations.

Settings: Since 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called 'advanced regionalisation'. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National 'Concours Qualité', a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence.

Participants: We carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January-February 2018.

Results: We confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving.

Conclusions: We found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.
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http://dx.doi.org/10.1136/bmjopen-2019-031160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6955542PMC
January 2020

Determinants of effective organisational capacity training: lessons from a training programme on health workforce development with participants from three African countries.

BMC Public Health 2019 Nov 26;19(1):1557. Epub 2019 Nov 26.

School of Public Health, University of the Western Cape, Cape Town, South Africa.

Background: Health systems in sub-Saharan Africa face multifaceted capacity challenges to fulfil their mandates of service provision and governance of their resources. Four academic institutions in Africa implemented a World Health Organisation-funded collaborative project encompassing training, curriculum development, and partnership to strengthen national leadership and training capacity for health workforce development. This paper looks into the training component of the project, a blended Masters programme in public health that sought to improve the capacity of personnel involved in teaching or management/development of human resources for health. The paper aims to explore factors influencing contribution of training to organisational capacity development.

Methods: We chose a case study design. Semi-structured interviews were held with 18 trainees that were enrolled in the training programme, and who were affiliated to health ministries or public health training institutions. We gathered additional data through document reviews, observation, and interviews with 14 key informants associated with the programme and/or working in the collaborating institutions. The evidence gathered were analysed thematically.

Results: Thirteen of the 18 training participants stayed in the target institutions and contributed to improved capacity of their institutions in the fields of management, policy, planning, research, training, or curriculum development. Five left for private and international agencies due to dissatisfaction with payment, work conditions, or career prospect. Factors that were associated with the training, trainees, and the institutional and broader context, determine contribution of training to organisational capacity development. These include relevance of newly acquired knowledge and skills set of trainees to the role/position they assume in the organisation; recognition of trainees by employing organisations in terms of promotion or assignment of challenging tasks; and motivation and retention of trained staff.

Conclusion: Training, even if relevant and applicable, makes no more than a 'latent' contribution, one which is activated and realised through alignment of clusters of interacting contextual and relational factors related to the target institutions and trained personnel. While not predictable, implementers need to focus more deliberately on the likely interaction and best possible alignments between training relevance, student selection for potential to contribute, recognition and career advancement potential.
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http://dx.doi.org/10.1186/s12889-019-7883-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6878696PMC
November 2019

Opening the 'implementation black-box' of the user fee exemption policy for caesarean section in Benin: a realist evaluation.

Health Policy Plan 2020 Mar;35(2):153-166

School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville 7535, Republic of South Africa.

To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low- and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. We selected two hospitals with contrastive outcomes. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We identified two main causal pathways. First, in the state-owned hospital, which has a public-oriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor. We found that trust, perceived coercion, adherence to policy goals, perceived financial incentives and fairness in their allocation drive compliance, persuasion, positive responses to incentives and self-efficacy at the operational level to generate the policy implementation outcomes. Compliance with the policy depended on enforcement by hierarchical authority and bottom-up pressure. Persuasion depended on the alignment of the policy with personal and organizational values. Incentives may determine the adoption if they influence the local stakeholder's revenue are trustworthy and perceived as fairly allocated. Failure to anticipate the differential responses of implementers will prevent the proper implementation of user fee exemption policies and similar universal health coverage reforms.
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http://dx.doi.org/10.1093/heapol/czz146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050689PMC
March 2020

Does public service motivation matter in Moroccan public hospitals? A multiple embedded case study.

Int J Equity Health 2019 10 22;18(1):160. Epub 2019 Oct 22.

Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Background: The motivation of health workers is a key concern of policy makers, practitioners and researchers. Public Service Motivation (PSM), defined as the altruistic desire to serve the common interest, to serve others and to help patients and their families regardless of financial or external rewards, has been shown to be key to the performance of public servants. Yet, limited attention has been paid to this kind of motivation in health care settings in low- and middle-income countries. Little is known about PSM and its contextual specificity in the Moroccan health system. We set out to qualitatively explore the meaning of PSM and its expression among health workers in four public hospitals.

Methods: We adopted a multiple embedded case study design to explore PSM in two well-performing and two poor-performing hospitals. We carried out 68 individual interviews, eight focus group discussions and 11 group discussions with different cadres (doctors, administrators and nurses). We carried out thematic analysis using NVivo 10.

Results: Our analysis shows that public service motivation is a notion that seems natural to the health workers we interviewed. Daily interactions with patients catalysed health providers' affective motives (compassion and self- sacrifice), a central element of PSM. It also provided them with job satisfaction aligned with their intrinsic motivation. Managers and administrative personnel express other PSM components: attraction to public policy making and commitment to public values. A striking result is that health workers expressed strong religious beliefs about expected rewards from God when properly serving patients.

Conclusion: This study highlights the presence of PSM as a driver of motivation among health workers in four Moroccon hospitals, and the prominence of intrinsic motivation and compassion in the motivation of frontline health workers. Religious beliefs were found to shape the expression of PSM in Morocco.
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http://dx.doi.org/10.1186/s12939-019-1053-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6805632PMC
October 2019

The Need for a Dynamic Approach to Health System-Centered Innovations Comment on "What Health System Challenges Should Responsible Innovation in Health Address? Insights From an International Scoping Review".

Int J Health Policy Manag 2019 07 1;8(7):444-446. Epub 2019 Jul 1.

Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Lehoux and colleagues plea for a health systems perspective to evaluate innovations. Since many innovations and their scale-up strategies emerge from processes that are not (centrally) steered, we plea for any assessment with a dynamic, instead of a sequential, approach. We provide further guidance on how to adopt such dynamic approach, in order to better un-derstand and steer innovations for better health systems. A systems-level challenge is constituted by interactions and feedback loops between different actors and components of the health system. It is therefore essential to explore both the entry-point of innovation and the interactions with other components. If innovation is regarded as an injection of resources and opportunities into a health system, this system needs to have the capacity to transform these into desired outputs, the 'absorption capacity.' The highly organic diffusion of innovation in complex adapative systems cannot be easily controlled, but the system behaviours can be analysed, with occurance of phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions. This helps to anticipate unintended consequences, and to engage key actors in ongoing problem-solving and adaptation. By adopting a prospective approach, responsible innovation could set in motion prospective policy evaluations, which on the basis of iterative learning would allow decisionmakers to continuously adapt their policies and programmes. Priority-setting for innovation is an essentially political process that is geared towards consensus-building and grounded in values.
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http://dx.doi.org/10.15171/ijhpm.2019.25DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6706970PMC
July 2019

Understanding acceptance of and adherence to a new formulation of paediatric antiretroviral treatment in the form of pellets (LPV/r)-A realist evaluation.

PLoS One 2019 21;14(8):e0220408. Epub 2019 Aug 21.

Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Background: Improving access to paediatric HIV treatment requires large-scale antiretroviral treatment programmes and medication adapted to infants and children's needs. The World Health Organisation recommends lopinavir/ritonavir plus two nucleoside reverse transcriptase inhibitors as first-line treatment for all HIV-infected children younger than three years, usually given as a syrup. A pellet formulation (i.e. tiny cylinders of compressed medication put in capsules) was developed to overcome the syrup formulation's disadvantages such as bitterness, toxicity and cold storage. This study assessed multi-level factors influencing caregivers' acceptance of and adherence to lopinavir/ritonavir pellets as well as their underlying mechanisms.

Methods: A realist evaluation (a theory-driven evaluation method considering the social context and mechanisms of change), embedded in a clinical trial was carried out in three hospital settings in Kenya. Data were collected through document review, observations (n = 34) in home and clinic settings and semi-structured interviews (n = 44) with caregivers and providers. Data analysis was based on realist principles.

Results: High levels of treatment initiation and adherence were observed. Taste masking, neutral packaging and easy storage made the new formulation highly acceptable. Caregivers developed individual strategies to deliver the treatment, particularly to overcome specific problems e.g. in case of just-weaned babies or food shortage. A refined program theory emerged from the triangulated findings showing that ease of administration combined with increased self-efficacy and competences of the caregivers, and effective provider support contributed to high levels of adherence.

Conclusions: Formulating combined antiretroviral treatment in the form of pellets is clearly a more acceptable solution for infants and children and their caregivers compared to the syrup. Further research in non-trial settings may shed light on factors related to providers, services and the health system that contribute to better adherence of such formulations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0220408PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703671PMC
March 2020

A systems perspective on the importance of global health strategy developments for accomplishing today's Sustainable Development Goals.

Health Policy Plan 2019 11;34(9):635-645

Steno Diabetes Center Copenhagen, Niels Steensens Vej 6, DK Gentofte, Denmark.

Priority setting within health systems has not led to accountable, fair and sustainable solutions to improving population health. Providers, users and other stakeholders each have their own health and service priorities based on selected evidence, own values, expertise and preferences. Based on a historical account, this article analyses if contemporary health systems are appropriate to optimize population health within the framework of cross cutting targets of the Sustainable Development Goals (SDGs). We applied a scoping review approach to identify and review literature of scientific databases and other programmatic web and library-based documents on historical and contemporary health systems policies and strategies at the global level. Early literature supported the 1977 launching of the global target of Health for All by the year 2000. Reviewed literature was used to provide a historical overview of systems components of global health strategies through describing the conceptualizations of health determinants, user involvement and mechanisms of priority setting over time, and analysing the importance of historical developments on barriers and opportunities to accomplish the SDGs. Definitions, scope and application of health systems-associated priority setting fluctuated and main health determinants and user influence on global health systems and priority setting remained limited. In exploring reasons for the identified lack of SDG-associated health systems and priority setting processes, we discuss issues of accountability, vested interests, ethics and democratic legitimacy as conditional for future sustainability of population health. To accomplish the SDGs health systems must engage beyond their own sector boundary. New approaches to Health in All Policies and One Health may be conducive for scaling up more democratic and inclusive priority setting processes based on proper process guidelines from successful pilots. Sustainable development depends on population preferences supported by technical and managerial expertise.
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http://dx.doi.org/10.1093/heapol/czz042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880334PMC
November 2019

'At this [] club, we are a family now': A realist theory-testing case study of the antiretroviral treatment adherence club, South Africa.

South Afr J HIV Med 2019 26;20(1):922. Epub 2019 Jun 26.

School of Public Health, University of the Western Cape, Cape Town, South Africa.

Background: An estimated 7.9 million people were living with HIV in South Africa in 2017, with 63.3% of them remaining in antiretroviral therapy (ART) care and 62.9% accessing ART. Poor retention in care and suboptimal adherence to ART undermine the successful efforts of initiating people living with HIV on ART. To address these challenges, the antiretroviral adherence club intervention was designed to streamline ART services to 'stable' patients. Nevertheless, it is poorly understood exactly how and why and under what health system conditions the adherence club intervention works.

Objectives: The aim of this study was to test a theory on how and why the adherence club intervention works and in what health system context(s) in a primary healthcare facility in the Western Cape Province.

Method: Within the realist evaluation framework, we applied a confirmatory theory-testing case study approach. Kaplan-Meier descriptions were used to estimate the rates of dropout from the adherence club intervention and virological failure as the principal outcomes of the adherence club intervention. Qualitative interviews and non-participant observations were used to explore the context and identify the mechanisms that perpetuate the observed outcomes or behaviours of the actors. Following the retroduction logic of making inferences, we configured information obtained from quantitative and qualitative approaches using the intervention-context-actor-mechanism-outcome heuristic tool to formulate generative theories.

Results: We confirmed that patients on ART in adherence clubs will continue to adhere to their medication and remain in care because their self-efficacy is improved; they are motivated or are being nudged.

Conclusion: A theory-based understanding provides valuable lessons towards the adaptive implementation of the adherence club intervention.
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http://dx.doi.org/10.4102/sajhivmed.v20i1.922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6620516PMC
June 2019

Designing and evaluating provider results-based financing for tuberculosis care in Georgia: a realist evaluation protocol.

BMJ Open 2019 04 14;9(4):e030257. Epub 2019 Apr 14.

Department of Public Health, Institute of Tropical Medicine, Health Systems and Equity Unit, Antwerp, Belgium.

Introduction: In 2016, Georgian researchers and policymakers were developing a policy to improve the performance of the national tuberculosis (TB) control programme. The research programme 'Designing and Evaluating Provider Results-Based Financing for Tuberculosis Care in Georgia: Understanding Costs, Mechanisms of Effect and Impact (Results4TB)' was initiated to inform the policy formulation phase, document the policy implementation and assess the effectiveness, cost-effectiveness and the processes of change. To achieve this, the research team intends to combine an impact evaluation, a cost-effectiveness study and a realist evaluation (RE) within an overarching theory-informed design. This protocol is the RE component of the programme.

Methods: A realist methodological approach will be adopted to guide the research design and evaluation. RE answers the question of 'what works in which conditions for whom?' and starts with the development of an initial programme theory (IPT). The IPT will feed into other phases of the realist research cycle (study design, data collection, data analysis and synthesis and theory refinement). Data will be collected in a multiple embedded case study design (five intervention and three control sites) through document reviews, in-depth interviews, non-participant observations and context mapping at facility and national levels. Additional data from other research components (cost-effectiveness and impact evaluation) will aid data triangulation.

Ethics And Dissemination: The Institutional Review Boards of the National Centre for Disease Control and Public Health in Georgia (ref. IRB # 2018-019) and the Institute of Tropical Medicine, Antwerp (ref. IRB #- 1240/18) have granted ethical approval to the study.

Trial Registration Number: ISRCTN14667607.
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http://dx.doi.org/10.1136/bmjopen-2019-030257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500265PMC
April 2019

A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa.

Int J Equity Health 2019 03 29;18(1):53. Epub 2019 Mar 29.

Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa.

Background: In 2012 the South African National Department of Health (SA NDoH) set out, using a top down process, to implement several innovations in eleven health districts in order to test reforms to strengthen the district health system. The process of disseminating innovations began in 2012 and senior health managers in districts were expected to drive implementation. The research explored, from a bottom up perspective, how efforts by the National government to disseminate and diffuse innovations were experienced by district level senior managers and why some dissemination efforts were more enabling than others.

Methods: A multiple case study design comprising three cases was conducted. Data collection in 2012 - early 2014 included 38 interviews with provincial and district level managers as well as non- participant observation of meetings. The Greenhalgh et al. (Milbank Q 82(4):581-629, 2004) diffusion of innovations model was used to interpret dissemination and diffusion in the districts.

Results: Managers valued the national Minister of Health's role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on: (1) the benefits of new innovations (2) total funding they will receive (3) their specific role in implementation and (4) the range of stakeholders involved.

Conclusion: Those driving reform processes from 'the top' must remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts must be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the at the coal face and national policies, managing long chains of dissemination and natural (often unpredictable) diffusion.
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http://dx.doi.org/10.1186/s12939-019-0952-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6441208PMC
March 2019

"They Are After Quantity, Not Quality": Health Providers' Perceptions of Fee Exemption Policies in Morocco.

Int J Health Policy Manag 2018 12 1;7(12):1110-1119. Epub 2018 Dec 1.

Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.

Background: A free obstetric care policy (FOCP) has been implemented in Morocco in 2008 in order to further decrease maternal mortality.

Methods: Through in-depth interviews we explored the perceptions of health professionals in public Moroccan hospitals with regard to fee exemption policies. We tried to understand what drives health professionals to ignore, modify or apply a health policy as formulated.

Results: Respondents express significant influences of such policies on their work environment (higher workload and scarcity of resources) and on the patient/provider relationship, both of which may cause a negative effect on health workers' motivation. A mix of motivational determinants incites health workers in their turn to influence policy implementation.

Conclusion: Understanding the motivational determinants of health workers may optimize policy implementation at the point of service delivery.
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http://dx.doi.org/10.15171/ijhpm.2018.76DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358657PMC
December 2018

Complex Leadership in Healthcare: A Scoping Review.

Int J Health Policy Manag 2018 12 1;7(12):1073-1084. Epub 2018 Dec 1.

Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium.

Background: Nowadays, health systems are generally acknowledged to be complex social systems. Consequently, scholars, academics, practitioners, and policy-makers are exploring how to adopt a complexity perspective in health policy and system research. While leadership and complexity has been studied extensively outside health, the implications of complexity theories for the study of leadership in healthcare have received limited attention. We carried out a scoping review of complex leadership (CL) in healthcare to investigate how CL in healthcare has been defined, theorised and conceptualised and to explore how 'CL' has been applied in healthcare settings.

Methods: We followed the methodological steps proposed by (Arksey and O'Malley, 2005): (1) specifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating and summarizing the findings, and (6) reporting the results. We searched using Medline, Psychinfo, Wiley online library, and Google Scholar. Our inclusion criteria were: publication type (peer reviewed articles, theses, and book chapters); phenomenon of interest: complex leadership; context: healthcare and period of publication: between 2000 and 2016.

Results: Our search and selection resulted in 37 papers (16 conceptual papers, 14 empirical studies and 7 advocacy papers). We note that empirical studies on CL are few and almost all research reported by these papers was carried out in the North (mainly in USA and UK). We found that there is some variation in definitions of CL. Furthermore, the research papers adopt mostly an explorative or explanatory approach and do not focus on assessing effectiveness of CL approaches. Finally, we found that the majority of researchers seem to adhere to the mathematical complexity perspective.

Conclusion: Complexity concepts derived from natural sciences may not automatically fit management of health services. Further research into how social complexity theories may offer researchers useful grounds to empirically test CL theories in health settings is warranted. Specific attention should be paid to the multi-layered nature of leadership.
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http://dx.doi.org/10.15171/ijhpm.2018.75DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358662PMC
December 2018

Using qualitative comparative analysis and theory of change to unravel the effects of a mental health intervention on service utilisation in Nepal.

BMJ Glob Health 2018 30;3(6):e001023. Epub 2018 Dec 30.

Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.

Background: The integration of mental health services into primary care is essential to improve the coverage of mental health services in low resource settings, but the evaluation of this remains challenging. We used a programme's Theory of Change (ToC) as a conceptual framework to determine what combination(s) of conditions at facility and community level influenced the mental health service utilisation as a result of a district mental healthcare plan (MHCP) implemented in Chitwan, Nepal. In addition, we show how qualitative comparative analysis can be used to provide an integrated analysis of data from a ToC.

Methods: We conducted a longitudinal case study of 10 health facilities where the MHCP was implemented. We collected data from all facilities at baseline (October to December 2013) and quarterly following the implementation of the intervention (March 2014 to November 2016). The data were analysed using pooled qualitative comparative analysis in fsQCA V.2.5.

Results: The following conditions were necessary for high mental health service utilisation: presence of basic and advanced psychosocial care, evidence-based identification and treatment guidelines (WHO mhGAP), referral to tertiary services and the presence of trained female community health volunteers. Two additional combinations of conditions were also identified as sufficient for a high mental health service utilisation: high medication supply, trained facility staff and either the use of a community informant detection tool or having a larger proportion of the community attend community awareness activities.

Conclusions: Both supply-side interventions (formalised approaches to health worker detection and treatment, training of health workers, supervision) and demand-side interventions (community awareness and case finding) are important to integrate mental health in primary care. ToC can be used to provide an integrated analysis of data from a ToC, therefore helping to shed light on the black box of complex multilevel interventions.
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http://dx.doi.org/10.1136/bmjgh-2018-001023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326347PMC
December 2018

Unravelling how and why the Antiretroviral Adherence Club Intervention works (or not) in a public health facility: A realist explanatory theory-building case study.

PLoS One 2019 16;14(1):e0210565. Epub 2019 Jan 16.

School of Public Health, University of the Western Cape, Cape Town, South Africa.

Background: Although empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and for whom the adherence club model works at a public health facility in South Africa.

Methods: We applied an explanatory theory-building case study approach to examine the validity of an initial programme theory developed a priori. We collected data using a retrospective cohort quantitative design to describe the suppressive adherence and retention in care behaviours of patients on ART using Kaplan-Meier methods. In conjunction, we employed an explanatory qualitative study design using non-participant observations and realist interviews to gain insights into the important mechanisms activated by the adherence club intervention and the relevant contextual conditions that trigger the different mechanisms to cause the observed behaviours. We applied the retroduction logic to configure the intervention-context-actor-mechanism-outcome map to formulate generative theories.

Results: A modified programme theory involving targeted care for clinically stable adult patients (18 years+) receiving antiretroviral therapy was obtained. Targeted care involved receiving quick, uninterrupted supply of antiretroviral medication (with reduced clinic visit frequencies), health talks and counselling, immediate access to a clinician when required and guided by club rules and regulations within the context of adequate resources, and convenient (size and position) space and proper preparation by the club team. When grouped for targeted care, patients feel nudged, their self-efficacy is improved and they become motivated to adhere to their medication and remain in continuous care.

Conclusion: This finding has implications for understanding how, why and under what health system conditions the adherence club intervention works to improve its rollout in other contexts.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0210565PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334969PMC
October 2019

Unveiling the Black Box of Diagnostic and Clinical Decision Support Systems for Antenatal Care: Realist Evaluation.

JMIR Mhealth Uhealth 2018 Dec 21;6(12):e11468. Epub 2018 Dec 21.

Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Background: Digital innovations have shown promise for improving maternal health service delivery. However, low- and middle-income countries are still at the adoption-utilization stage. Evidence on mobile health has been described as a black box, with gaps in theoretical explanations that account for the ecosystem of health care and their effect on adoption mechanisms. Bliss4Midwives, a modular integrated diagnostic kit to support antenatal care service delivery, was piloted for 1 year in Northern Ghana. Although both users and beneficiaries valued Bliss4Midwives, results from the pilot showed wide variations in usage behavior and duration of use across project sites.

Objective: To strengthen the design and implementation of an improved prototype, the study objectives were two-fold: to identify causal factors underlying the variation in Bliss4Midwives usage behavior and understand how to overcome or leverage these in subsequent implementation cycles.

Methods: Using a multiple case study design, a realist evaluation of Bliss4Midwives was conducted. A total of 3 candidate program theories were developed and empirically tested in 6 health facilities grouped into low and moderate usage clusters. Quantitative and qualitative data were collected and analyzed using realist thinking to build configurations that link intervention, context, actors, and mechanisms to program outcomes, by employing inductive and deductive reasoning. Nonparametric t test was used to compare the perceived usefulness and perceived ease of use of Bliss4Midwives between usage clusters.

Results: We found no statistically significant differences between the 2 usage clusters. Low to moderate adoption of Bliss4Midwives was better explained by fear, enthusiasm, and high expectations for service delivery, especially in the absence of alternatives. Recognition from pregnant women, peers, supervisors, and the program itself was a crucial mechanism for device utilization. Other supportive mechanisms included ownership, empowerment, motivation, and adaptive responses to the device, such as realignment and negotiation. Champion users displayed high adoption-utilization behavior in contexts of participative or authoritative supervision, yet used the device inconsistently. Intervention-related (technical challenges, device rotation, lack of performance feedback, and refresher training), context-related (staff turnover, competing priorities, and workload), and individual factors (low technological self-efficacy, baseline knowledge, and internal motivation) suppressed utilization mechanisms.

Conclusions: This study shed light on optimal conditions necessary for Bliss4Midwives to thrive in a complex social and organizational setting. Beyond usability and viability studies, advocates of innovative technologies for maternal care need to consider how implementation strategies and contextual factors, such as existing collaborations and supervision styles, trigger mechanisms that influence program outcomes. In addition to informing scale-up of the Bliss4Midwives prototype, our results highlight the need for interventions that are guided by research methods that account for complexity.
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http://dx.doi.org/10.2196/11468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6320439PMC
December 2018

Accessibility and factors associated with utilization of mental health services in youth health centers. A qualitative comparative analysis in northern Sweden.

Int J Ment Health Syst 2018 14;12:69. Epub 2018 Nov 14.

1Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.

Background: Youth-friendly health care services can facilitate young people's access to health care services and promote their health, including their mental health. In Sweden, a network of youth health centers exist since the 1970s, incorporated within the public health system. Even if such centers take a holistic approach to youth health, the focus has been in sexual and reproductive health care, and the extent of integrating mental health care services is less developed though it varies notably between different centers. This study aims to analyse the various conditions that are sufficient and/or necessary to make Swedish youth health centers accessible for mental and psychosocial health.

Methods: Multiple case study design, using qualitative comparative analysis to assess the various conditions that makes a youth health center accessible for mental and psychosocial issues and mental health. The cases included 18 youth health centers (from a total of 22) in the four northern counties of Sweden.

Results: In order to enhance accessibility for mental health services, youth health centers need to be trusted by young people. Trust was necessary but not sufficient, meaning that it had to be combined with other conditions: either having a team with a variety of professions represented in the youth health center, or being a youth health center that is both easy to contact and well-staffed with mental health professionals.

Conclusions: Differentiated, first-line services for youth can play an important role in promoting youth mental health if certain conditions are fulfilled. Trust is necessary, but has to be combined with either multidisciplinary teams, or expertise on mental health and easy accessibility.
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http://dx.doi.org/10.1186/s13033-018-0249-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234690PMC
November 2018

Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review.

Int J Care Coord 2018 Sep 19;21(3):73-86. Epub 2018 Jun 19.

Athena Institute, Vrije Universiteit, Amsterdam, Netherlands.

Introduction: Maternal health and the performance of health workers is a key concern in low- and middle-income countries. Mobile health technologies are reportedly able to improve workers' performance. However, this has been achieved for maternal health workers in low-resource settings is not fully substantiated. To address this gap by building theoretical explanations, two questions were posed: How does mobile health influence the performance of maternal health care workers in low- and middle-income countries? What mechanisms and contextual factors are associated with mobile health use for maternal health service delivery in low- and middle-income countries?

Methods: Guided by established guidelines, a realist review was conducted. Five databases were searched for relevant English language articles published between 2009 and 2016. A three-stage framework was developed and populated with explanatory configurations of Intervention-Context-Actors-Mechanism-Outcome. Articles were analyzed retroductively, with identified factors grouped into meaningful clusters.

Results: Of 1254 records identified, 23 articles representing 16 studies were retained. Four main mechanisms were identified: usability and empowerment explaining mobile health adoption, third-party recognition explaining mobile health utilization, and empowerment of health workers explaining improved competence. Evidence was skewed toward the adoption and utilization stage of the framework, with weak explanations for performance outcomes.

Conclusions: Findings suggest that health workers can be empowered to adopt and utilize mobile health in contexts where it is aligned to their needs, workload, training, and skills. In turn, mobile health can empower health workers with skills and confidence when it is perceived as useful and easy to use, in contexts that foster recognition from clients, peers, or supervisors.
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http://dx.doi.org/10.1177/2053434518779491DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6151957PMC
September 2018

"Patients Are Not Following the [Adherence] Club Rules Anymore": A Realist Case Study of the Antiretroviral Treatment Adherence Club, South Africa.

Qual Health Res 2018 10 21;28(12):1839-1857. Epub 2018 Jul 21.

1 University of the Western Cape, Bellville, South Africa.

There is growing evidence that differentiated care models employed to manage treatment-experienced patients on antiretroviral therapy could improve adherence to medication and retention in care. We conducted a realist evaluation to determine how, why, for whom, and under what health system context the adherence club intervention works (or not) in real-life implementation. In the first phase, we developed an initial program theory of the adherence club intervention. In this study, we report on an explanatory theory-testing case study to test the initial theory. We conducted a retrospective cohort analysis and an explanatory qualitative study to gain insights into the important mechanisms activated by the adherence club intervention and the relevant context conditions that trigger the different mechanisms to achieve the observed outcomes. This study identified potential mitigating circumstances under which the adherence club program could be implemented, which could inform the rollout and implementation of the adherence club intervention.
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http://dx.doi.org/10.1177/1049732318784883DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154254PMC
October 2018

A realist approach to eliciting the initial programme theory of the antiretroviral treatment adherence club intervention in the Western Cape Province, South Africa.

BMC Med Res Methodol 2018 05 25;18(1):47. Epub 2018 May 25.

School of Public Health, University of the Western Cape, Cape town, South Africa.

Background: The successful initiation of people living with HIV/AIDS on antiretroviral therapy (ART) in South Africa has engendered challenges of poor retention in care and suboptimal adherence to medication. The adherence club intervention was implemented in the Metropolitan area of the Western Cape Province to address these challenges. The adherence club programme has shown potential to relieve clinic congestion, improve retention in care and enhance treatment adherence in the context of rapidly growing HIV patient populations being initiated on ART. Nevertheless, how and why the adherence club intervention works is not clearly understood. We aimed to elicit an initial programme theory as the first phase of the realist evaluation of the adherence club intervention in the Western Cape Province.

Methods: The realist evaluation approach guided the elicitation study. First, information was obtained from an exploratory qualitative study of programme designers' and managers' assumptions of the intervention. Second, a document review of the design, rollout, implementation and outcome of the adherence clubs followed. Third, a systematic review of available studies on group-based ART adherence support models in Sub-Saharan Africa was done, and finally, a scoping review of social, cognitive and behavioural theories that have been applied to explain adherence to ART. We used the realist evaluation heuristic tool (Intervention-context-actors-mechanism-outcome) to synthesise information from the sources into a configurational map. The configurational mapping, alignment of a specific combination of attributes, was based on the generative causality logic - retroduction.

Results: We identified two alternative theories: The first theory supposes that patients become encouraged, empowered and motivated, through the adherence club intervention to remain in care and adhere to the treatment. The second theory suggests that stable patients on ART are being nudged through club rules and regulations to remain in care and adhere to the treatment with the goal to decongest the primary health care facilities.

Conclusion: The initial programme theory describes how (dynamics) and why (theories) the adherence club intervention is expected to work. By testing theories in "real intervention cases" using the realist evaluation approach, the theories can be modified, refuted and/or reconstructed to elicit a refined theory of how and why the adherence club intervention works.
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http://dx.doi.org/10.1186/s12874-018-0503-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5970495PMC
May 2018

A critique of the Uganda district league table using a normative health system performance assessment framework.

BMC Health Serv Res 2018 05 10;18(1):355. Epub 2018 May 10.

Public Health Department, Institute of Tropical Medicine, 155 Nationalestraat, 2000, Antwerp, Belgium.

Background: In 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality.

Methods: A normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis.

Results: Stakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range.

Conclusions: The critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks. Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.
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http://dx.doi.org/10.1186/s12913-018-3126-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946482PMC
May 2018

Unearthing how, why, for whom and under what health system conditions the antiretroviral treatment adherence club intervention in South Africa works: A realist theory refining approach.

BMC Health Serv Res 2018 05 9;18(1):343. Epub 2018 May 9.

School of Public Health, University of the Western Cape, Cape Town, South Africa.

Background: Poor retention in care and suboptimal adherence to antiretroviral treatment (ART) undermine its successful rollout in South Africa. The adherence club intervention was designed as an adherence-enhancing intervention to enhance the retention in care of patients on ART and their adherence to medication. Although empirical evidence suggests the effective superiority of the adherence club intervention to standard clinic ART care schemes, it is poorly understood exactly how and why it works, and under what health system contexts. To this end, we aimed to develop a refined programme theory explicating how, why, for whom and under what health system contexts the adherence club intervention works (or not).

Methods: We undertook a realist evaluation study to uncover the programme theory of the adherence club intervention. We elicited an initial programme theory of the adherence club intervention and tested the initial programme theory in three contrastive sites. Using a cross-case analysis approach, we delineated the conceptualisation of the intervention, context, actor and mechanism components of the three contrastive cases to explain the outcomes of the adherence club intervention, guided by retroductive inferencing.

Results: We found that an intervention that groups clinically stable patients on ART in a convenient space to receive a quick and uninterrupted supply of medication, health talks, counselling, and immediate access to a clinician when required works because patients' self-efficacy improves and they become motivated and nudged to remain in care and adhere to medication. The successful implementation and rollout of the adherence club intervention are contingent on the separation of the adherence club programme from other patients who are HIV-negative. In addition, there should be available convenient space for the adherence club meetings, continuous support of the adherence club facilitators by clinicians and buy-in from the health workers at the health-care facility and the community.

Conclusion: Understanding what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, could inform guidelines for effective implementation in different contexts and scaling up of the intervention to improve population-level ART adherence.
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http://dx.doi.org/10.1186/s12913-018-3150-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944119PMC
May 2018
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