Publications by authors named "Juliet Nabyonga-Orem"

58 Publications

Towards universal health coverage in the WHO African Region: assessing health system functionality, incorporating lessons from COVID-19.

BMJ Glob Health 2021 03;6(3)

Director of Programme Management, World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo.

The move towards universal health coverage is premised on having well-functioning health systems, which can assure provision of the essential health and related services people need. Efforts to define ways to assess functionality of health systems have however varied, with many not translating into concrete policy action and influence on system development. We present an approach to provide countries with information on the functionality of their systems in a manner that will facilitate movement towards universal health coverage. We conceptualise functionality of a health system as being a construct of four capacities: access to, quality of, demand for essential services and its resilience to external shocks. We test and confirm the validity of these capacities as appropriate measures of system functionality. We thus provide results for functionality of the 47 countries of the WHO African Region based on this. The functionality of health systems ranges from 34.4 to 75.8 on a 0-100 scale. Access to essential services represents the lowest capacity in most countries of the region, specifically due to poor physical access to services. Funding levels from public and out-of-pocket sources represent the strongest predictors of system functionality, compared with other sources. By focusing on the assessment on the capacities that define system functionality, each country has concrete information on where it needs to focus, in order to improve the functionality of its health system to enable it respond to current needs including achieving universal health coverage, while responding to shocks from challenges such as the 2019 coronavirus disease. This systematic and replicable approach for assessing health system functionality can provide the guidance needed for investing in country health systems to attain universal health coverage goals.
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http://dx.doi.org/10.1136/bmjgh-2020-004618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8015798PMC
March 2021

The cost of health workforce gaps and inequitable distribution in the Ghana Health Service: an analysis towards evidence-based health workforce planning and management.

Hum Resour Health 2021 Mar 31;19(1):43. Epub 2021 Mar 31.

Universal Health Coverage - Life Course, Inter-Country Support Team for Eastern and Southern Africa, World Health Organization, Regional Office for Africa, Harare, Zimbabwe.

Background: Despite tremendous health workforce efforts which have resulted in increases in the density of physicians, nurses and midwives from 1.07 per 1000 population in 2005 to 2.65 per 1000 population in 2017, Ghana continues to face shortages of health workforce alongside inefficient distribution. The Ministry of Health and its agencies in Ghana used the Workload Indicators of Staffing Needs (WISN) approach to develop staffing norms and standards for all health facilities, which is being used as an operational planning tool for equitable health workforce distribution. Using the nationally agreed staffing norms and standards, the aim of this paper is to quantify the inequitable distribution of health workforce and the associated cost implications. It also reports on how the findings are being used to shape health workforce policy, planning and management.

Methods: We conducted a health workforce gap analysis for all health facilities of the Ghana Health Service in 2018 in which we compared a nationally agreed evidence-based staffing standard with the prevailing staffing situation to identify need-based gaps and inequitable distribution. The cost of the prevailing staffing levels was also compared with the stipulated standard, and the staffing cost related to inequitable distribution was estimated.

Results: It was found that the Ghana Health Service needed 105,440 health workers to meet its minimum staffing requirements as at May 2018 vis-à-vis its prevailing staff at post of 61,756 thereby leaving unfilled vacancies of 47,758 (a vacancy rate of 41%) albeit significant variations across geographical regions, levels of service and occupational groups. Of note, the crude equity index showed that in aggregate, the best-staffed region was 2.17 times better off than the worst-staffed region. The estimated cost (comprising basic salaries, market premium and other allowances paid from central government) of meeting the minimum staffing requirements was estimated to be GH¢2,358,346,472 (US$521,758,069) while the current cost of staff at post was GH¢1,424,331,400 (US$315,117,566.37), resulting in a net budgetary deficit of 57% (~ US$295.4 million) to meet the minimum requirement of staffing for primary and secondary health services. Whilst the prevailing staffing expenditure was generally below the required levels, an average of 28% (range 14-50%) across the levels of primary and secondary healthcare was spent on staff deemed to have been inequitably distributed, thus providing scope for rationalisation. We estimate that the net budgetary deficit of meeting the minimum staffing requirement could be drastically reduced by some 30% just by redistributing the inequitably distributed staff.

Policy Implications: Efficiency gains could be made by redistributing the 14,142 staff deemed to be inequitably distributed, thereby narrowing the existing staffing gaps by 30% to 33,616, which could, in turn, be filled by leveraging synergistic strategy of task-sharing and/or new recruitments. The results of the analysis provided insights that have shaped and continue to influence important policy decisions in health workforce planning and management in the Ghana Health Service.
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http://dx.doi.org/10.1186/s12960-021-00590-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010987PMC
March 2021

Redesigning health systems for global heath security.

Lancet Glob Health 2021 04 10;9(4):e393-e394. Epub 2021 Feb 10.

World Health Organization Regional Office for Africa, Brazzaville, Republic of the Congo.

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http://dx.doi.org/10.1016/S2214-109X(20)30545-3DOI Listing
April 2021

The state of health research governance in Africa: what do we know and how can we improve?

Health Res Policy Syst 2021 Jan 22;19(1):11. Epub 2021 Jan 22.

The European & Developing Countries Clinical Trials Partnership (EDCTP), Anna van Saksenlaan 51, 2593 HW, The Hague, The Netherlands.

Background: The developments in global health, digital technology, and persistent health systems challenges, coupled with global commitments like attainment of universal health coverage, have elevated the role of health research in low- and middle-income countries. However, there is a need to strengthen health research governance and create a conducive environment that can promote ethics and research integrity and increase public trust in research.

Objective: To assess whether the necessary structures are in place to ensure health research governance.

Methods: Employing a cross-sectional survey, we collected data on research governance components from 35 Member States of the World Health Organization (WHO) African Region. Data were analysed using basic descriptive and comparative analysis.

Results: Eighteen out of 35 countries had legislation to regulate the conduct of health research, while this was lacking in 12 countries. Some legislation was either grossly outdated or too limiting in scope, while some countries had multiple laws. Health research policies and strategies were in place in 16 and 15 countries, respectively, while research priority lists were available in 25 countries. Overlapping mandates of institutions responsible for health research partly explained the lack of strategic documents in some countries. The majority of countries had ethical committees performing a dual role of ethical and scientific review. Research partnership frameworks were available to varying degrees to govern both in-country and north-south research collaboration. Twenty-five countries had a focal point and unit within the ministries of health (MoH) to coordinate research.

Conclusion: Governance structures must be adaptive to embrace new developments in science. Further, strong coordination is key to ensuring comprehensiveness and complementarity in both research development and generation of evidence. The majority of committees perform a dual role of ethics and scientific review, and these need to ensure representation of relevant expertise. Opportunities that accrue from collaborative research need to be seized through strong MoH leadership and clear partnership frameworks that guide negotiations.
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http://dx.doi.org/10.1186/s12961-020-00676-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7821686PMC
January 2021

Knowledge translation in Africa: are the structures in place?

Implement Sci Commun 2020 Dec 11;1(1):111. Epub 2020 Dec 11.

Inter-Country Support Team for Eastern & Southern Africa, Universal Health Coverage - Life Course Cluster, World Health Organization, P.O Box CY 348, 82-86 Enterprise/Glenara Roads, Highlands, Causeway, Harare, Zimbabwe.

Background: Contextualised evidence to generate local solutions on the progressive path to universal health coverage is essential. However, this evidence must be translated into action. Knowledge translation (KT) experts have highlighted the plausible mechanisms to foster the uptake of evidence. The objective of this study was to assess the extent to which structures are in place to boost uptake of evidence, in countries of the WHO African Region.

Methods: Employing a cross-sectional survey, we collected data on the availability of structures to foster the uptake of evidence into policy in 35 out of the 47 member states of the WHO African Region. Data were analysed using a simple counting of the presence or absence of such structures.

Results: Less than half of the countries had evidence collation and synthesis mechanisms. The lack of such mechanisms presents a missed opportunity to identify comprehensive solutions that can respond to health sector challenges. Close to 50% of the countries had KT platforms in place. However, the availability of these was in several forms, as an institution-based platform, as an annual event to disseminate evidence and as a series of conferences at the national level. In some countries, KT was mainstreamed into routine health sector performance review processes. Several challenges impacted the functionality of the KT platforms including inadequate funding and lack of dedicated personnel. Regarding dissemination of evidence, sharing reports, scientific publications and one-off presentations in meetings were the main approaches employed.

Conclusion: The availability of KT platforms in the WHO African countries can be described as at best and non-existent at the worst. The current structures, where these exist, cannot adequately foster KT. Knowledge translation platforms need to be viewed as sector-wide platforms and mainstreamed in routine health sector performance reviews and policymaking processes. Funds for their functionality must be planned for as part of the health sector budget. Dissemination of evidence needs to be viewed differently to embrace the concept of "disseminate for impact". Further, funding for dissemination activities needs to be planned for as part of the evidence generation plan.
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http://dx.doi.org/10.1186/s43058-020-00101-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729704PMC
December 2020

Monitoring Sustainable Development Goals 3: Assessing the Readiness of Low- and Middle-Income Countries.

Int J Health Policy Manag 2020 07 1;9(7):297-308. Epub 2020 Jul 1.

World Health Organization (WHO), Inter-Country Support Team for Eastern & Southern Africa, Harare, Zimbabwe.

Background: The Millennium Development Goals (MDGs) availed opportunities for scaling up service coverage but called for stringent monitoring and evaluation (M&E) focusing mainly on MDG related programs. The Sustainable Development Goals 3 (SDGs) and the universal health coverage (UHC) agenda present a broader scope and require more sophisticated M&E systems. We assessed the readiness of low- and middle-income countries to monitor SDG 3.

Methods: Employing mixed methods, we reviewed health sector M&E plans of 6 countries in the World Health Organization (WHO) Africa Region to assess the challenges to M&E, the indicator selection pattern and the extent of multisectoral collaboration. Qualitative data were analysed using content thematic analysis while quantitative data were analysed using Excel.

Results: Challenges to monitoring SDG 3 include weak institutional capacity; fragmentation of M&E functions; inadequate domestic financing; inadequate data availability, dissemination and utilization of M?&E products. The total number of indictors in the reviewed plans varied from 38 for Zimbabwe to 235 for Zanzibar. Sixty-nine percent of indicators for the Gambia and 89% for Zanzibar were not classified in any domain in the M&E results chain. Countries lay greater M&E emphasis on service delivery, health systems, maternal and child health as well as communicable diseases with a seeming neglect of the non-communicable diseases (NCDs). Inclusion of SDG 3 indicators only ranged from 48% for Zanzibar to 67% for Kenya. Although monitoring SDG 3 calls for multisectoral collaboration, consideration of the role of other sectors in the M&E plans was either absent or limited to the statistical departments.

Conclusion: There are common challenges confronting M&E at county-level. Countries have omitted key indicators for monitoring components of the SDG 3 targets especially those on NCDs and injuries. The role of other sectors in monitoring SDG 3 targets is not adequately reflected. These could be bottlenecks to tracking progress towards SDG 3 if not addressed. Beyond providing compendium of indicators to guide countries, we advocate for a more binding minimum set of indicators for all countries to which they may add depending on their context. Ministries of Health (MoHs) should prioritise M&E as an important pillar for health service planning and implementation and not as an add-on activity.
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http://dx.doi.org/10.15171/ijhpm.2019.134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444433PMC
July 2020

The imperative of evidence-based health workforce planning and implementation: lessons from nurses and midwives unemployment crisis in Ghana.

Hum Resour Health 2020 03 6;18(1):16. Epub 2020 Mar 6.

World Health Organization, Regional Office for Africa, Inter-Country Support Team for Eastern and Southern Africa, Harare, Zimbabwe.

Following periods of health workforce crisis characterised by a severe shortage of nurses, midwives and doctors due to low production rates and excessive out-migration, the Government of Ghana through the Ministry of Health (MOH) responded by expanding training and allowing private sector involvement in the training of health workers especially nurses and midwives. This resulted in substantial increases in the production levels of nurses and midwives even above the projections of the MOH. In this paper, we discuss how a strategy that was seemingly well planned suffered a decade of uncorrected implementation lapses resulting in a lingering need-based shortage of nurses and midwives at service delivery points whilst thousands of trained nurses and midwives remained unemployed for up to 4 years and constantly protesting for jobs. In the short term, we argue that the Government of Ghana would need to increase investment to recruit trained and unemployed nurses and midwives whilst a comprehensive health labour market analysis is conducted to provide robust evidence towards the development of a long-term health workforce plan that would guide future production of nurses and midwives. The Government of Ghana may also explore the option of a managed migration programme to export nurses/midwives to countries that are already destinations to individual migration initiatives in a bid to mitigate the potential skill loss associated with long periods of unemployment after training, especially for those who trained from the private institutions.
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http://dx.doi.org/10.1186/s12960-020-0462-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059310PMC
March 2020

Towards universal health coverage: reforming the neglected district health system in Africa.

BMJ Glob Health 2019 5;4(Suppl 9):e001498. Epub 2019 Oct 5.

Health systems and services cluster, World Health Organization, Inter-Country Support Team for Eastern & Southern Africa, Harare, Zimbabwe.

In most African countries, the district sphere of governance is a colonial creation for harnessing resources from the communities that are located far away from the centre with the assistance of minimally skilled personnel who are subordinate to the central authority with respect to decision-making and initiative. Unfortunately, postcolonial reforms of district governance have retained the hierarchical structure of the local government. Anchored to such a district arrangement, the (district) health system (DHS) is too weak and impoverished to function in spite of enormous knowledge and natural resources for a seamless implementation of universal health coverage (UHC). Sadly, the quick-fix projects of the 1990s with the laudable intention to reduce the burden of disease within a specified time-point dealt the fatal blow on the DHS administration by diminishing it to a stop-post and a warehouse for commodities (such as bednets and vaccines) destined for the communities. We reviewed the situation of the district in sub-Saharan African countries and identified five attributes that are critical for developing a UHC-friendly DHS. In this analytical paper, we discuss decision-making authority, coordination, resource control, development initiative and management skills as critical factors. We highlight the required strategic shifts and recommend a dialogue for charting an African regional course for a reformed DHS for UHC. Further examination of these factors and perhaps other ancillary criteria will be useful for developing a checklist for assessing the suitability of a DHS for the UHC that Africa deserves.
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http://dx.doi.org/10.1136/bmjgh-2019-001498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797439PMC
October 2019

Resilient health systems for attaining universal health coverage.

BMJ Glob Health 2019 5;4(Suppl 9):e002006. Epub 2019 Oct 5.

Health Systems and Services Cluster, World Health Organization Regional Office for Africa, Brazzaville, Congo.

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http://dx.doi.org/10.1136/bmjgh-2019-002006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797417PMC
October 2019

Towards universal health coverage: can national health research systems deliver contextualised evidence to guide progress in Africa?

BMJ Glob Health 2019 11;4(Suppl 9):e001910. Epub 2019 Oct 11.

Health Systems and Services Cluster, World Health Organization Regional Office for Africa, Brazzaville, Congo.

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http://dx.doi.org/10.1136/bmjgh-2019-001910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797336PMC
October 2019

Towards a regional strategy for resolving the human resources for health challenges in Africa.

BMJ Glob Health 2019 11;4(Suppl 9):e001533. Epub 2019 Oct 11.

Health Systems Cluster, World Health Organisation, Regional Office for Africa, Brazzaville, Congo.

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http://dx.doi.org/10.1136/bmjgh-2019-001533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797424PMC
October 2019

Towards universal health coverage: advancing the development and use of traditional medicines in Africa.

BMJ Glob Health 2019 11;4(Suppl 9):e001517. Epub 2019 Oct 11.

World Health Organization, Inter-Country Support Team for Eastern & Southern Africa, Health systems and services cluster, Causeway, Harare, Zimbabwe.

African traditional medicine (ATM) and traditional health practitioners (THPs) could make significant contributions to the attainment of universal health coverage (UHC). Consequently, the WHO provided technical tools to assist African countries to develop ATM as a significant component of healthcare. Many African countries adopted the WHO tools after appropriate modifications to advance research and development (R&D) of ATM. An analysis of the extent of this development was undertaken through a survey of 47 countries in the WHO African region. Results show impressive advances in R&D of ATM, the collaboration between THP and conventional health practitioners, quality assurance as well as regulation, registration and THP integration into the national health systems. We highlight the various ways investment in the R&D of ATM can impact on policy, practice and the three themes of UHC. We underscore the need for frameworks for fair and equitable sharing of all benefits arising from the R&D of ATM products involving all the stakeholders. We argue for further investment in ATM as a complement to conventional medicine to promote attainment of the objectives of UHC.
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http://dx.doi.org/10.1136/bmjgh-2019-001517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797325PMC
October 2019

Supportive supervision to improve service delivery in low-income countries: is there a conceptual problem or a strategy problem?

BMJ Glob Health 2019 11;4(Suppl 9):e001151. Epub 2019 Oct 11.

Health Systems and Services Cluster, World Health Organization, Inter-Country Support Team for Eastern and Southern Africa, Harare, Zimbabwe.

Supportive supervision is perceived as an intervention that strengthens the health system, enables health workers to offer quality services and improve performance. Unfortunately, numerous studies show that supervisory mechanisms in many low-income countries (LICs) are suboptimal. Further, the understanding of the concept and its implementation is still shrouded in misinterpretations and inconsistencies. This analysis contributes to a deeper understanding of the concept of supportive supervision and how reorganisation of the approach can contribute to improved performance. The effectiveness of supportive supervision is mixed, with some studies noting that evidence on its role, especially in LICs is inconclusive. Quality of care is a core component of universal health coverage which, accentuates the need for supportive supervision. In the context of LICs, it is imperative for supportive supervision to be implemented as an on-going approach. Factors that affect supportive supervision encompass cultural, social, organizational and context dimensions but the capacity of majority of LIC to address these is limited. To this end, we underscore the need to review the supportive supervision approach to improve its effectiveness, and ensure that facility-based supervision embodies as many of the envisioned qualities as possible. We thus make a case for a stronger focus on internal supportive supervision where internal refers to health facility/unit/ward level. Inherent in the approach is what we refer to as 'supervisee initiated supportive supervision'. The success of this approach must be anchored on a strong system for monitoring, data and information management at the health facility level.
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http://dx.doi.org/10.1136/bmjgh-2018-001151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797347PMC
October 2019

Strengthening national health research systems in the WHO African Region - progress towards universal health coverage.

Global Health 2019 07 26;15(1):50. Epub 2019 Jul 26.

Inter-Country Support Team for Eastern & Southern Africa, Health Systems and Services Cluster, World Health Organization, P.O Box CY 348, Causeway, Harare, Zimbabwe.

Background: Health challenges and health systems set-ups differ, warranting contextualised healthcare interventions to move towards universal health coverage. As such, there is emphasis on generation of contextualized evidence to solve local challenges. However, weak research capacity and inadequate resources remain an impendiment to quality research in the African region. WHO African Region (WHO AFR) facilitated the adoption of a regional strategy for strengthening national health research systems (NHRS) in 2015. We assessed the progress in strengthening NHRS among the 47 member states of the WHO AFR.

Methods: We employed a cross sectional survey design using a semi structured questionnaire. All the 47member states of WHO AFR were surveyed. We assessed performance against indicators of the regional research strategy, explored facilitating factors and barriers to strengthening NHRS. Using the research barometer, which is a metric developed for the WHO AFR we assessed the strength of NHRS of member states. Data were analysed in Excel Software to calculate barometer scores for NHRS function and sub-function. Thematic content was employed in analysing the qualitative data. Data for 2014 were compared to 2018 to assess progress.

Results: WHO AFR member states have made significant progress in strengthening their NHRS. Some of the indicators have either attained or exceeded the 2025 targets. The average regional barometer score improved from 43% in 2014 to 61% in 2018. Significant improvements were registered in the governance of research for health (R4H); developing and sustaining research resources and producing and using research. Financing R4H improved only modestly. Among the constraints are the lengthy ethical clearance processes, weak research coordination mechanisms, weak enforcement of research laws and regulation, inadequate research infrastructure, limited resource mobilisation skills and donor dependence.

Conclusion: There has been significant improvement in the NHRS of member states of the WHO AFRO since the last assessment in 2014. Improvement across the different objectives of the regional research strategy is however varied which compromises overall performance. The survey highlighted the areas with slow improvement that require a concerted effort. Furthermore, the study provides an opportunity for countries to share best practice in areas of excellence.
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http://dx.doi.org/10.1186/s12992-019-0492-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6660673PMC
July 2019

The Global call for action on infection prevention and control.

Int J Health Care Qual Assur 2019 Jul;32(6):927-940

Department of Health Systems and Services, World Health Organization, Inter-Country Support Team for Eastern and Southern Africa, Harare, Zimbabwe.

Purpose: Healthcare-associated infections (HAIs) constitute a major threat to patient safety and affect hundreds of millions of people worldwide. The World Health Organization in 2016 published guidelines on the core components for infection prevention and control (IPC) programme. This was in response to a global call for focused action. The purpose of this paper is to examine and promote understanding of the tenets of the IPC guidelines and highlight their implications for implementation in low-income countries.

Design/methodology/approach: Drawing from personal experiences in leading the implementation of health programmes as well as a review of published and grey literature on IPC, authors discussed and proposed practical approaches to implement IPC priorities in low-income setting.

Findings: Availability of locally generated evidence is paramount to guide strengthening leadership and institutionalisation of IPC programmes. Preventing infections is everybody's responsibility and should be viewed as such and accorded the required attention.

Originality/value: Drawing from recent experiences from disease outbreaks and given the heavy burden of HAIs especially in low-income settings, this paper highlights practical approaches to guide implementation of the major components of IPC.
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http://dx.doi.org/10.1108/IJHCQA-03-2018-0063DOI Listing
July 2019

Nurses and midwives demographic shift in Ghana-the policy implications of a looming crisis.

Hum Resour Health 2019 05 22;17(1):32. Epub 2019 May 22.

World Health Organization, Regional Office for Africa, Inter-Country Support Team for Eastern and Southern Africa, Harare, Zimbabwe.

As part of measures to address severe shortage of nurses and midwives, Ghana embarked on massive scale-up of the production of nurses and midwives which has yielded remarkable improvements in nurse staffing levels. It has, however, also resulted in a dramatic demographic shift in the nursing and midwifery workforce in which 71 to 93% of nurses and midwives by 2018 were 35 years or younger, as compared with 2.8 to 44% in 2008. In this commentary, we examine how the drastic generational transition could adversely impact on the quality of nursing care and how the educational advancement needs of the young generation of the nursing and midwifery workforce are not being met. We propose the institution of a national nursing and midwifery mentorship programme and a review of the study leave policy to make it flexible and be based on a comprehensive training needs assessment of the nursing and midwifery workforce. We further advocate that policymakers should also consider upgrading all professional nursing and midwifery programmes to bachelor degrees as this would not only potentially enhance the quality of training but also address the phenomenon of large numbers of nurses and midwives seeking bachelor degree training soon after employment-sometimes putting them at the offending side of organisational policy.
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http://dx.doi.org/10.1186/s12960-019-0377-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6530167PMC
May 2019

Moving towards universal health coverage: The need for a strengthened planning process.

Int J Health Plann Manage 2018 Oct 3;33(4):1093-1109. Epub 2018 Aug 3.

World Health Organization Regional Office for Africa, Health Systems and Services Cluster, Brazzaville, Republic of Congo.

As countries embrace the ambitious universal health coverage (UHC) agenda whose major tenents include reaching everyone with the needed good quality services, strengthening the planning process to work towards a common objective is paramount. Drawing from country experiences-Swaziland and Zanzibar, we reviewed strategic planning processes to assess the extent to which they impact on realising alignment towards a collective health sector objective. Employing qualitative approaches, we reviewed strategic plans under implementation in the health sector and using an interview guide consisting of open-ended questions, interviewed key informants at the national and district level. Results showed that strategic plans are too many with majority of program strategies not well aligned to the health sector strategic plan, are not costed, and there overlaps in objectives among the several strategies addressing the same program. Weaknesses in the development process, perceived poor quality of the strategies, limited capacity, high staff turnover, and inadequate funding were the identified challenges that abate the utility of the strategic plans. Moving towards UHC starts with a robust planning process that rallies all actors and all available resources around a common objective. The planning process should be strengthened through ensuring participatory processes, evidence informed prioritisation, MoH institutional capacity to lead the process, and consideration for implementation feasibility. Flexibility to take into consideration emerging evidence and new developments in global health needs consideration.
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http://dx.doi.org/10.1002/hpm.2585DOI Listing
October 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

Monitoring Sustainable Development Goal 3: how ready are the health information systems in low-income and middle-income countries?

BMJ Glob Health 2017 25;2(4):e000433. Epub 2017 Oct 25.

Inter-Country Support Team for Eastern &Southern Africa; Health systems and services cluster, World Health Organisation, Harare, Zimbabwe.

Sustainable Development Goals (SDGs) present a broader scope and take a holistic multisectoral approach to development as opposed to the Millennium Development Goals (MDGs). While keeping the health MDG agenda, SDG3 embraces the growing challenge of non-communicable diseases and their risk factors. The broader scope of the SDG agenda, the need for a multisectoral approach and the emphasis on equity present monitoring challenges to health information systems of low-income and middle-income countries. The narrow scope and weaknesses in existing information systems, a multiplicity of data collection systems designed along disease programme and the lack of capacity for data analysis are among the limitations to be addressed. On the other hand, strong leadership and a comprehensive and longer-term approach to strengthening a unified health information system are beneficial. Strengthening country capacity to monitor SDGs will involve several actions: domestication of the SDG agenda through country-level planning and monitoring frameworks, prioritisation of interventions, indicators and setting country-specific targets. Equity stratifiers should be country specific in addressing policy concerns. The scope of existing information systems should be broadened in line with the SDG agenda monitoring requirements and strengthened to produce reliable data in a timely manner and capacity for data analysis and use of data built. Harnessing all available opportunities, emphasis should be on strengthening health sector as opposed to SDG3 monitoring. In this regard, information systems in related sectors and the private sector should be strengthened and data sharing institutionalised. Data are primarily needed to inform planning and decision-making beyond SGD3 reporting requirements.
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http://dx.doi.org/10.1136/bmjgh-2017-000433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5663251PMC
October 2017

Harmonisation and standardisation of health sector and programme reviews and evaluations - how can they better inform health policy dialogue?

Health Res Policy Syst 2016 Dec 16;14(1):87. Epub 2016 Dec 16.

Ghana Health Service, Research and Development Division, PMB M9, Ministries, Accra, Ghana.

Background: Health sector and programme performance assessments provide a rich source of contextual data directly linked to implementation of programmes and can inform health policy dialogue, planning and resource allocation. In seeking to maximise this opportunity, there are challenges to overcome. A meeting convened by the World Health Organization African Region discussed the strengths, weaknesses and challenges to harmonising and standardising health sector and programme performance assessments, as well as use of evidence from such processes in decision making. This article synthesises the deliberations which emerged from the meeting. Discussing these in light of other literature we propose practical options to standardising health sector and programme performance assessment and improve realisation of using evidence in decision making.

Discussion: Use of evidence generated from health sector and programme performance assessments into regular country processes of sectoral monitoring, dialogue and policy modification is crucial. However, this process faces several challenges. Identified challenges were categorised under several themes, namely the weak institutional capacities for monitoring and evaluation in reference to weak health information systems, a lack of tools and skills, and weak accountability mechanisms; desynchronised planning timeframes between programme and overall health sector strategies; inadequate time to undertake comprehensive and good quality performance assessment; weak mechanisms for following up on implementation of recommendations; lack of effective stakeholder participation; and divergent political aspirations.

Conclusion: The question of what performance assessment is for in a country must be asked and answered clearly if the utility of these processes is to be realised. Standardising programme and sector reviews offers numerable opportunities that need to be maximised. Identified challenges need to be overcome through strengthened Ministry of Health leadership, effective stakeholder engagement and institutionalising follow-up mechanisms for agreed recommendations. In addition, health sector performance assessments need to be institutionalised as part of the accountability mechanism, and they must be planned for and funding secured within annual budget and medium term expenditure frameworks.
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http://dx.doi.org/10.1186/s12961-016-0161-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5162096PMC
December 2016

Space and place for WHO health development dialogues in the African Region.

BMC Health Serv Res 2016 07 18;16 Suppl 4:221. Epub 2016 Jul 18.

Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo.

Background: Majority of the countries in the World Health Organization (WHO) African Region are not on track to achieve the health-related Millennium Development Goals, yet even more ambitious Sustainable Development Goals (SDGs), including SDG 3 on heath, have been adopted. This paper highlights the challenges - amplified by the recent Ebola virus disease (EVD) outbreak in West Africa - that require WHO and other partners' dialogue in support of the countries, and debate on how WHO can leverage the existing space and place to foster health development dialogues in the Region.

Discussion: To realise SDG 3 on ensuring healthy lives and promoting well-being for all at all ages, the African Region needs to tackle the persistent weaknesses in its health systems, systems that address the social determinants of health and national health research systems. The performance of the third item is crucial for the development and innovation of systems, products and tools for promoting, maintaining and restoring health in an equitable manner. Under its new leadership, the WHO Regional Office for Africa is transforming itself to galvanise existing partnerships, as well as forging new ones, with a view to accelerating the provision of timely and quality support to the countries in pursuit of SDG 3. WHO in the African Region engages in dialogues with various stakeholders in the process of health development. The EVD outbreak in West Africa accentuated the necessity for optimally exploiting currently available space and place for health development discourse. There is urgent need for the WHO Regional Office for Africa to fully leverage the space and place arenas of the World Health Assembly, WHO Regional Committee for Africa, African Union, Regional economic communities, Harmonization for Health in Africa, United Nations Economic Commission for Africa, African Development Bank, professional associations, and WHO African Health Forum, when it is created, for dialogues to mobilise the required resources to give the African Region the thrust it needs to attain SDG 3.

Conclusions: The pursuit of SDG 3 amidst multiple challenges related to political leadership and governance, weak health systems, sub-optimal systems for addressing the socioeconomic determinants of health, and weak national health research systems calls for optimum use of all the space and place available for regional health development dialogues to supplement Member States' efforts.
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http://dx.doi.org/10.1186/s12913-016-1452-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959356PMC
July 2016

Perspectives on health policy dialogue: definition, perceived importance and coordination.

BMC Health Serv Res 2016 07 18;16 Suppl 4:218. Epub 2016 Jul 18.

University of Ghana, School of Public Health, P.O. Box LG 13, Accra, Ghana.

Background: Countries in the World Health Organization African Region have witnessed an increase in global health initiatives in the recent past. Although these have provided opportunities for expanding coverage of health interventions; their poor alignment with the countries' priorities and weak coordination, are among the challenges that have affected their impact. A well-coordinated health policy dialogue provides an opportunity to address these challenges, but calls for common understanding among stakeholders of what policy dialogue entails. This paper seeks to assess stakeholders' understanding and perceived importance of health policy dialogue and of policy dialogue coordination.

Methods: This was a cross-sectional descriptive study using qualitative methods. Interviews were conducted with 90 key informants from the national and sub-national levels in Lusophone Cabo Verde, Francophone Chad, Guinea and Togo, and Anglophone Liberia using an open-ended interview guide. The interviews were transcribed verbatim, coded and then put through inductive thematic content analysis using QRS software Version 10.

Results: There were variations in the definition of policy dialogue that were not necessarily linked to the linguistic leaning of respondents' countries or whether the dialogue took place at the national or sub-national level. The definitions were grouped into five categories based on whether they had an outcome, operational, process, forum or platform, or interactive and evidence-sharing orientation. The stakeholders highlighted multiple benefits of policy dialogue including ensuring stakeholder participation, improving stakeholder harmonisation and alignment, supporting implementation of health policies, fostering continued institutional learning, providing a guiding framework and facilitating stakeholder analysis.

Conclusion: Policy dialogue offers the opportunity to improve stakeholder participation in policy development and promote aid effectiveness. However, conceptual clarity is needed to ensure pursuance of common objectives. While it is clear that stakeholder involvement is an important component of policy dialogue, numbers must be manageable for meaningful dialogue. Ownership and coordination of the policy dialogue are important aspects of the process, and building the institutional capacity of the ministry of health requires a comprehensive approach as opposed to strengthening selected departments within it. Likewise, capacity for policy dialogue needs to be built at the sub-national level, alongside improving the bottom-up approach in policy processes.
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http://dx.doi.org/10.1186/s12913-016-1451-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959390PMC
July 2016

Policy dialogue to improve health outcomes in low income countries: what are the issues and way forward?

BMC Health Serv Res 2016 07 18;16 Suppl 4:217. Epub 2016 Jul 18.

Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo.

Background: This paper has three objectives: to review the health development landscape in the World Health Organization African Region, to discuss the role of health policy dialogue in improving harmonisation and alignment to national health policies and strategic plans, and to provide an analytical view of the critical factors in realising a good outcome from a health policy dialogue process.

Discussion: Strengthening policy dialogue to support the development and implementation of robust and comprehensive national health policies and plans, as well as to improve aid effectiveness, is seen as a strategic entry point to improving health sector results. However, unbalanced power relations, the lack of contextualised and relevant evidence, the diverse interests of the actors involved, and the lack of conceptual clarity on what policy dialogue entails impact the outcomes of a policy dialogue process. The critical factors for a successful policy dialogue have been identified as adequate preparation; secured time and resources to facilitate an open, inclusive and informed discussion among the stakeholders; and stakeholders' monitoring and assessment of the dialogue's activities for continued learning. Peculiarities of low income countries pose a challenge to their policy dialogue processes, including the chaotic-policy making processes, the varied capacity of the actors and donor dependence.

Conclusion: Policy dialogue needs to be appreciated as a complex and iterative process that spans the whole process of policy-making, implementation, review and monitoring, and subsequent policy revisions. The existence of the critical factors for a successful policy dialogue process needs to be ensured whilst paying special attention to the peculiarities of low income countries and potential power relations, and mitigating the possible negative consequences. There is need to be cognisant of the varied capacities and interests of stakeholders and the need for capacity building, and to put in place mechanisms to manage conflict of interest. The likelihood of a favourable outcome from a policy dialogue process will depend on the characteristics of the issue under consideration and whether it is contested or not, and the policy dialogue process needs to be tailored accordingly.
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http://dx.doi.org/10.1186/s12913-016-1450-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959394PMC
July 2016

An analytical perspective of Global health initiatives in Tanzania and Zambia.

BMC Health Serv Res 2016 07 18;16 Suppl 4:223. Epub 2016 Jul 18.

Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo.

Background: A number of Global health initiatives (GHIs) have been created to support low and middle income countries. Their support has been of different forms. The African Region has benefitted immensely from GHIs and continues to register an increase in health partnerships and initiatives. However, information on the functioning and operationalisation of GHIs in the countries is limited.

Methods: This study involved two country case studies, one in Tanzania and the other one in Zambia. Data were collected using a semi-structured questionnaire. The aims were to understand and profile the GHIs supporting health development and to assess their governance and alignment with country priorities, harmonisation and alignment of their interventions and efforts, and contribution towards health systems strengthening. The respondents included senior officers from health stakeholder agencies at the national and sub-national levels. The qualitative data were analysed using thematic content analysis in MAXQDA software.

Results: Health systems in both Tanzania and Zambia are decentralised. They have benefitted from GHI support in fighting the common health problems of HIV/AIDS, tuberculosis, malaria and vaccine-preventable diseases. In both countries, no GHI adequately made use of the existing Sector-wide Approach (SWAp) mechanisms but they largely operate through their unique structures and committees. GHI efforts to improve general health governance have not been matched with similar efforts from the countries. Their support to health system strengthening has not been comprehensive but has involved the selection of a few areas some of which were disease-focused. On the positive side, however, in both Tanzania and Zambia improved alignment with the countries' priorities is noted in that most of the proposals submitted to the GHIs refer to the priorities, objectives and strategies in the national health development plans and, GHIs depend on the national health information systems.

Conclusion: GHIs are important funders of health in low and middle income countries. However, there is a need for the countries to take a proactive role in improving the governance, coordination and planning of the GHIs that they benefit from. This will also maximise the return on investment for the GHIs.
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http://dx.doi.org/10.1186/s12913-016-1449-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959379PMC
July 2016

Global health initiatives in Africa - governance, priorities, harmonisation and alignment.

BMC Health Serv Res 2016 07 18;16 Suppl 4:212. Epub 2016 Jul 18.

Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo.

Background: The advent of global health initiatives (GHIs) has changed the landscape and architecture of health financing in low and middle income countries, particularly in Africa. Over the last decade, the African Region has realised improvements in health outcomes as a result of interventions implemented by both governments and development partners. However, alignment and harmonisation of partnerships and GHIs are still difficult in the African countries with inadequate capacity for their effective coordination.

Method: Both published and grey literature was reviewed to understand the governance, priorities, harmonisation and alignment of GHIs in the African Region; to synthesise the knowledge and highlight the persistent challenges; and to identify gaps for future research.

Results: GHI governance structures are often separate from those of the countries in which they operate. Their divergent funding channels and modalities may have contributed to the failure of governments to track their resources. There is also evidence that basically, earmarking and donor conditions drive funding allocations regardless of countries' priorities. Although studies cite the lack of harmonisation of GHI priorities with national strategies, evidence shows improvements in that area over time. GHIs have used several strategies and mechanisms to involve the private sector. These have widened the pool of health service policy-makers and providers to include groups such as civil society organisations (CSOs), with both positive and negative implications. GHI strategies such as co-financing by countries as a condition for support have been positive in achieving sustainability of interventions.

Conclusions: GHI approaches have not changed substantially over the years but there has been evolution in terms of donor funding and conditions. GHIs still largely operate in a vertical manner, bypassing country systems; they compete for the limited human resources; they influence country policies; and they are not always harmonised with other donors. To maximise returns on GHI support, there is need to ensure that their approaches are more comprehensive as opposed to being selective; to improve GHI country level governance and alignment with countries' changing epidemiologic profiles; and to strengthen their involvement of CSOs.
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http://dx.doi.org/10.1186/s12913-016-1448-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959383PMC
July 2016

Health policy dialogue: experiences from Africa.

BMC Health Serv Res 2016 07 18;16 Suppl 4:214. Epub 2016 Jul 18.

Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo.

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http://dx.doi.org/10.1186/s12913-016-1447-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959386PMC
July 2016

Improved harmonisation from policy dialogue? Realist perspectives from Guinea and Chad.

BMC Health Serv Res 2016 07 18;16 Suppl 4:222. Epub 2016 Jul 18.

Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo.

Background: Harmonisation is a key principle of the Paris Declaration. The Universal Health Coverage (UHC) Partnership, an initiative of the European Union, the Government of Luxembourg and the World Health Organization, supported health policy dialogues between 2012 and 2015 in identified countries in the WHO African Region. The UHC Partnership has amongst its key objectives to strengthen national health policy development. In Guinea and Chad, policy dialogue focused on elaborating the national health plan and other key documents. This study is an analytical reflection inspired by realist evaluative approaches to understand whether policy dialogue led to improved harmonisation amongst health actors in Guinea and Chad, and if so, how and why.

Methods: Interviews were conducted in Guinea and Chad with key informants at the national and sub-national government levels, civil society, and development partners. A review of relevant policy documents and reports was added to data collection to construct a full picture of the policy dialogue process. Context-mechanism-outcome configurations were used as the realist framework to guide the analysis on how participants' understanding of what policy dialogue was and the way the policy dialogue process unfolded led to improved harmonisation.

Results: Improved harmonisation as a result of policy dialogue was perceived to be stronger in Guinea than in Chad. While in both countries the participants held a shared view of what policy dialogue was and what it could achieve, and both policy dialogue processes were considered to be well implemented (i.e., well-facilitated, evidence-based, participatory, and consisted of recurring meetings and activities), certain contextual factors in Chad tempered the view of harmonisation as having improved. These were the pre-existence of dialogic policy processes that had exposed the actors to the potential that policy dialogue could have; a focus on elaborating provincial level strategies, which gave the sense that the process was more bottom-up; and the perception that there were acute resource constraints, which conditioned partners' interactions.

Conclusions: Policy dialogue improves harmonisation in terms of fostering information exchange amongst partners; however, it does not appear to influence the operational procedures of the actors. This has implications for aid effectiveness.
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http://dx.doi.org/10.1186/s12913-016-1458-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959368PMC
July 2016

Coordination of the health policy dialogue process in Guinea: pre- and post-Ebola.

BMC Health Serv Res 2016 07 18;16 Suppl 4:220. Epub 2016 Jul 18.

Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06, Brazzaville, Congo.

Background: Policy dialogue can be defined as an iterative process that involves a broad range of stakeholders discussing a particular issue with a concrete purpose in mind. Policy dialogue in health is increasingly being recognised by health stakeholders in developing countries, as an important process or mechanism for improving collaboration and harmonization in health and for developing comprehensive and evidence-based health sector strategies and plans. It is with this perspective in mind that Guinea, in 2013, started a policy dialogue process, engaging a plethora of actors to revise the country's national health policy and develop a new national health development plan (2015-2024). This study examines the coordination of the policy dialogue process in developing these key strategic governance documents of the Guinean health sector from the actors' perspective.

Methods: A qualitative case study approach was undertaken, comprising of interviews with key stakeholders who participated in the policy dialogue process. A review of the literature informed the development of a conceptual framework and the data collection survey questionnaire. The results were analysed both inductively and deductively.

Results: A total of 22 out of 32 individuals were interviewed. The results suggest both areas of strengths and weaknesses in the coordination of the policy dialogue process in Guinea. The aspects of good coordination observed were the iterative nature of the dialogue and the availability of neutral and well-experienced facilitators. Weak coordination was perceived through the unavailability of supporting documentation, time and financial constraints experienced during the dialogue process. The onset of the Ebola epidemic in Guinea impacted on coordination dynamics by causing a slowdown of its activities and then its virtual halt.

Conclusions: The findings herein highlight the need for policy dialogue coordination structures to have the necessary administrative and institutional support to facilitate their effective functioning. The findings also point to the need for further research on the practical and operational aspects of national dialogue coordination structures to determine how to best strengthen their capacities.
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http://dx.doi.org/10.1186/s12913-016-1457-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959384PMC
July 2016
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