Publications by authors named "Tolib Mirzoev"

50 Publications

Analysis of equity and social inclusiveness of national urban development policies and strategies through the lenses of health and nutrition.

Int J Equity Health 2021 Apr 16;20(1):101. Epub 2021 Apr 16.

Health Policy Research Group, University of Nigeria, Nsukka, Nigeria.

Introduction: Rapid urbanization increases competition for scarce urban resources and underlines the need for policies that promote equitable access to resources. This study examined equity and social inclusion of urban development policies in Nigeria through the lenses of access to health and food/nutrition resources.

Method: Desk review of 22 policy documents, strategies, and plans within the ambit of urban development was done. Documents were sourced from organizational websites and offices. Data were extracted by six independent reviewers using a uniform template designed to capture considerations of access to healthcare and food/nutrition resources within urban development policies/plans/strategies in Nigeria. Emerging themes on equity and social inclusion in access to health and food/nutirition resources were identified and analysed.

Results: Access to health and food/nutrition resources were explicit in eight (8) and twelve (12) policies/plans, respectively. Themes that reflect potential policy contributions to social inclusion and equitable access to health resources were: Provision of functional and improved health infrastructure; Primary Health Care strengthening for quality health service delivery; Provision of safety nets and social health insurance; Community participation and integration; and Public education and enlightenment. With respect to nutrition resources, emergent themes were: Provision of accessible and affordable land to farmers; Upscaling local food production, diversification and processing; Provision of safety nets; Private-sector participation; and Special considerations for vulnerable groups.

Conclusion: There is sub-optimal consideration of access to health and nutrition resources in urban development policies in Nigeria. Equity and social inclusivity in access to health and nutrition resources should be underscored in future policies.
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http://dx.doi.org/10.1186/s12939-021-01439-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051828PMC
April 2021

Exploring mechanisms that explain how coalition groups are formed and how they work to sustain political priority for maternal and child health in Nigeria using the advocacy coalition framework.

Health Res Policy Syst 2021 Mar 1;19(1):26. Epub 2021 Mar 1.

Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.

Background: The unacceptably high rate of maternal and child mortality in Nigeria prompted the government to introduce a free maternal and child health (MCH) programme, which was stopped abruptly following a change in government. This triggered increased advocacy for sustaining MCH as a political priority in the country and led to the formation of advocacy coalitions. This study set out to explain the process involved in the formation of advocacy coalition groups and how they work to bring about sustained political prioritization for MCH in Nigeria. It will contribute to the understanding of the Nigerian MCH sector subsystem and will be beneficial to health policy advocates and public health researchers in Nigeria.

Methods: This study employed a qualitative case study approach. Data were collected using a pretested interview guide to conduct 22 in-depth interviews, while advocacy events were reviewed pro forma. The document review was analysed using the manual content analysis method, while qualitative data audiotapes were transcribed verbatim, anonymized, double-coded in MS Word using colour-coded highlights and analysed using manual thematic and framework analysis guided by the advocacy coalition framework (ACF). The ACF was used to identify the policy subsystem including the actors, their belief, coordination and resources, as well as the effects of advocacy groups on policy change. Ethics and consent approval were obtained for the study.

Results: The policy subsystem identified the actors and characterized the coalitions, and described their group formation processes and resources/strategies for engagement. The perceived deep core belief driving the MCH agenda is the right of an individual to health. The effects of advocacy groups on policy change were identified, along with the factors that enabled effectiveness, as well as constraints to coalition formation. External factors and triggers of coalition formation were identified to include high maternal mortality and withdrawal of the free MCH programme, while the contextual issues were the health system issues and the socioeconomic factors affecting the country.

Conclusion: Our findings add to an increasing body of evidence that the use of ACF is beneficial in exploring how advocacy coalitions are formed and in identifying the effects of advocacy groups on policy change.
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http://dx.doi.org/10.1186/s12961-020-00660-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923834PMC
March 2021

Implementation of medicines pricing policies in sub-Saharan Africa: protocol for a systematic review.

BMJ Open 2021 02 23;11(2):e044293. Epub 2021 Feb 23.

Leeds Institute of Health Sciences, University of Leeds, Leeds, West Yorkshire, UK.

Introduction: Ensuring universal availability and accessibility of medicines and supplies is critical for national health systems to equitably address population health needs. In sub-Saharan Africa (SSA), this is a recognised priority with multiple medicines pricing policies enacted. However, medicine prices have remained high, continue to rise and constrain their accessibility. In this systematic review, we aim to identify and analyse experiences of implementation of medicines pricing policies in SSA. Our ambition is for this evidence to contribute to improved implementation of medicines pricing policies in SSA.

Methods And Analysis: We will search: Medline, Web of Science, Scopus, Global Health, Embase, Cairn.Info International Edition, Erudit and African Index Medicus, the grey literature and reference from related publications. The searches will be limited to literature published from the year 2000 onwards that is, since the start of the Millennium Development Goals.Published peer-reviewed studies of implementation of medicines pricing policies in SSA will be eligible for inclusion. Broader policy analyses and documented experiences of implementation of other health policies will be excluded. The team will collaboratively screen titles and abstracts, then two reviewers will independently screen full texts, extract data and assess quality of the included studies. Disagreements will be resolved by discussion or a third reviewer. Data will be extracted on approaches used for policy implementation, actors involved, evidence used in decision making and key contextual influences on policy implementation. A narrative approach will be used to synthesise the data. Reporting will be informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guideline.

Ethics And Dissemination: No ethics approvals are required for systematic reviews.Results will be disseminated through academic publications, policy briefs and presentations to national policymakers in Ghana and mode widely across countries in SSA.

Prospero Registration Number: CRD42020178166.
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http://dx.doi.org/10.1136/bmjopen-2020-044293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907884PMC
February 2021

Feasibility of Good Governance at Health Facilities: A Proposed Framework and its Application Using Empirical Insights From Kenya.

Int J Health Policy Manag 2021 Jan 23. Epub 2021 Jan 23.

Leeds Institute of Health Sciences, University of Leeds, United Kingdom.

Background: Governance is a social phenomenon which permeates throughout systemic, organisational and individual levels. Studies of health systems governance traditionally assessed performance of systems or organisations against principles of good governance. However, understanding key pre-conditions to embed good governance required for healthcare organisations is limited. We explore the feasibility of embedding good governance at healthcare facilities in Kenya.

Methods: Our conceptualisation of organisational readiness for embedding good governance stems from a theory of institutional analysis and frameworks for understanding organisational readiness for change. Four inter-related constructs underpin to embed good governance: () individual motivations, determined by () mechanisms for encouraging adherence to good governance through () organisation's institutional arrangements, all within () a wider context. We propose a framework, validated through qualitative methods and collected through 39 semi-structured interviews with healthcare providers, county and national-level policy-makers in Kenya. Data was analysed using framework approach, guided by the four constructs of the theoretical framework. We explored each construct in relation to three key principles of good governance: accountability, participation and transparency of information.

Results: Embedding good governance in healthcare organisations in Kenya is influenced by political and socio-cultural contexts. Individual motivations were a critical element of self-enforcement to embed principles of good governance by healthcare providers within their facilities. Healthcare providers possess strong moral incentives to self-enforce accountability to local populations, but their participation in decision-making was limited. Health facilities lacked effective mechanisms for enforcing good governance such as combating corruption, which led to a proliferation of informal institutional arrangements.

Conclusion: Organisational readiness for good governance is context-specific so future work should recognise different interpretations of acceptable degrees of transparency, accountability and participation. While good governance involves collective social action, organisational readiness relies on individual choices and decisions within the context of organisational rules and cultural and historical environments.
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http://dx.doi.org/10.34172/ijhpm.2021.01DOI Listing
January 2021

How do patient feedback systems work in low-income and middle-income countries? Insights from a realist evaluation in Bangladesh.

BMJ Glob Health 2021 Feb;6(2)

Research and Development, ARK Foundation, Dhaka, Bangladesh.

Background: Well-functioning patient feedback systems can contribute to improved quality of healthcare and systems accountability. We used realist evaluation to examine patient feedback systems at health facilities in Bangladesh, informed by theories of citizenship and principal-agent relationships.

Methods: We collected and analysed data in two stages, using: document review; secondary analysis of data from publicly available web-portals; in-depth interviews with patients, health workers and managers; non-participant observations of feedback environments; and stakeholder workshops. Stage 1 focused on identifying and articulating the initial programme theory (PT) of patient feedback systems. In stage 2, we iteratively tested and refined this initial theory, through analysing data and grounding emerging findings within substantive theories and empirical literature, to arrive at a refined PT.

Results: Multiple patient feedback systems operate in Bangladesh, essentially comprising stages of collection, analysis and actions on feedback. Key contextual enablers include political commitment to accountability, whereas key constraints include limited patient awareness of feedback channels, lack of guidelines and documented processes, local political dynamics and priorities, institutional hierarchies and accountability relationships. Findings highlight that relational trust may be important for many people to exercise citizenship and providing feedback, and that appropriate policy and regulatory frameworks with clear lines of accountability are critical for ensuring effective patient feedback management within frontline healthcare facilities.

Conclusion: Theories of citizenship and principal-agent relationships can help understand how feedback systems work through spotlighting the citizenship identity and agency, shared or competing interests, and information asymmetries. We extend the understanding of these theories by highlighting how patients, health workers and managers act as both principals and agents, and how information asymmetry and possible agency loss can be addressed. We highlight the importance of awareness raising and non-threatening environment to provide feedback, adequate support to staff to document and analyse feedback and timely actions on the information.
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http://dx.doi.org/10.1136/bmjgh-2020-004357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878124PMC
February 2021

Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol.

PLoS One 2021 22;16(1):e0245755. Epub 2021 Jan 22.

Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC, Australia.

Background: Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam.

Methods: We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors' expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions' actual performance.

Discussion: The study's key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245755PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822243PMC
January 2021

Intimate Partner Violence Against Indigenous Women in Sololá, Guatemala: Qualitative Insights Into Perspectives of Service Providers.

Violence Against Women 2021 Jan 20:1077801220981145. Epub 2021 Jan 20.

University of Leeds, UK.

Over a third of women in Guatemala are subjected to intimate partner violence (IPV). Indigenous Mayan women are particularly vulnerable, due to the intersection of race, gender, and poverty. However, no research exists into the causes of IPV among this group. Our pioneering study addresses this knowledge gap. Our results from in-depth interviews with service providers in Sololá highlight four interlinked causes of IPV: rigid gender roles, lack of awareness of women's rights, use of alcohol by men, and poor reproductive health. From these, we draw implications for service provision to victims of IPV.
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http://dx.doi.org/10.1177/1077801220981145DOI Listing
January 2021

Tracing theories in realist evaluations of large-scale health programmes in low- and middle-income countries: experience from Nigeria.

Health Policy Plan 2020 Nov;35(9):1244-1253

University of Leeds, School of Sociology & Social Policy, Social Sciences Building, Leeds LS2 9JT, UK.

Realist evaluations (RE) are increasingly popular in assessing health programmes in low- and middle-income countries (LMICs). This article reflects on processes of gleaning, developing, testing, consolidating and refining two programme theories (PTs) from a longitudinal mixed-methods RE of a national maternal and child health programme in Nigeria. The two PTs, facility security and patient-provider trust, represent complex and diverse issues: trust is all encompassing although less tangible, while security is more visible. Neither PT was explicit in the original programme design but emerged from the data and was supported by substantive theories. For security, we used theories of fear of crime, which perceive security as progressing from structural, political and socio-economic factors. Some facilities with the support of communities erected fences, improved lighting and employed guards, which altogether contributed to reduced fear of crime from staff and patients and improved provision and uptake of health care. The social theories for the trust PT were progressively selected to disentangle trust-related micro, meso and macro factors from the deployment and training of staff and conditional cash transfers to women for service uptake. We used taxonomies of trust factors such as safety, benevolent concerns and capability. We used social capital theory to interpret the sustainability of 'residual' trust after the funding for the programme ceased. Our overarching lesson is that REs are important though time-consuming ways of generating context-specific implications for policy and practice within ever-changing contexts of health systems in LMICs. It is important to ensure that PTs are 'pitched at the right level' of abstraction. The resource-constrained context of LMICs with insufficient documentation poses challenges for the timely convergence of nuggets of evidence to inform PTs. A retroductive approach to REs requires iterative data collection and analysis against the literature, which require continuity, coherence and shared understanding of the analytical processes within collaborative REs.
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http://dx.doi.org/10.1093/heapol/czaa076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810445PMC
November 2020

Did an Intervention Programme Aimed at Strengthening the Maternal and Child Health Services in Nigeria Improve the Completeness of Routine Health Data Within the Health Management Information System?

Int J Health Policy Manag 2020 Dec 5. Epub 2020 Dec 5.

Department of Health Administration and Management, College of Medicine, University of Nigeria (Enugu Campus), Nsukka, Nigeria.

Background: During 2012-2015, the Federal Government of Nigeria launched the Subsidy Reinvestment and Empowerment Programme, a health system strengthening (HSS) programme with a Maternal and Child Health component (Subsidy Reinvestment and Empowerment Programme [SURE-P]/MCH), which was monitored using the Health Management Information Systems (HMIS) data reporting tools. Good quality data is essential for health policy and planning decisions yet, little is known on whether and how broad health systems strengthening programmes affect quality of data. This paper explores the effects of the SURE-P/MCH on completeness of MCH data in the National HMIS.

Methods: This mixed-methods study was undertaken in Anambra state, southeast Nigeria. A standardized proforma was used to collect facility-level data from the facility registers on MCH services to assess the completeness of data from 2 interventions and one control clusters. The facility data was collected to cover before, during, and after the SURE-P intervention activities. Qualitative in-depth interviews were conducted with purposefully-identified health facility workers to identify their views and experiences of changes in data quality throughout the above 3 periods.

Results: Quantitative analysis of the facility data showed that data completeness improved substantially, starting before SURE-P and continuing during SURE-P but across all clusters (ie, including the control). Also health workers felt data completeness were improved during the SURE-P, but declined with the cessation of the programme. We also found that challenges to data completeness are dependent on many variables including a high burden on providers for data collection, many variables to be filled in the data collection tools, and lack of health worker incentives.

Conclusion: Quantitative analysis showed improved data completeness and health workers believed the SURE-P/MCH had contributed to the improvement. The functioning of national HMIS are inevitably linked with other health systems components. While health systems strengthening programmes have a great potential for improved overall systems performance, a more granular understanding of their implications on the specific components such as the resultant quality of HMIS data, is needed.
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http://dx.doi.org/10.34172/ijhpm.2020.226DOI Listing
December 2020

Was the Maternal Health Cash Transfer Programme in Nigeria Sustainable and Cost-Effective?

Front Public Health 2020 4;8:582072. Epub 2020 Nov 4.

Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.

The Subsidy Reinvestment and Empowerment Programme (SURE-P), Maternal and Child Health (MCH) was introduced by the Nigerian government to increase the use of skilled maternal health services and reduce maternal mortality. The programme, funded out of a reduction in the fuel subsidy, was implemented between October 2012 and April 2015 and incorporated a conditional cash transfer to women to encourage use of facility based maternal services. We seek to assess the incremental cost effectiveness and long term impact of the conditional cash transfer element of the programme. An impact analysis and incremental cost-effectiveness analysis of conditional cash transfers (CCTs) is undertaken taking a health service perspective toward costs of the intervention. The study was undertaken in Anambra state, comparing areas that received only the investment in health services with areas that implemented the conditional cash transfer programme. An interrupted time series analysis of the programme outputs was undertaken. These were combined with a programme costing to determine the incremental cost per output. Maternal services provided to patients in conditional cash transfer areas accelerated rapidly from the middle of 2014 until after the programme in late 2015. The costs of providing services in each Primary Health Center facility was US $52,128 in the areas that only invested in health services compared to US $90,702 in facilities that also provided cash transfers. Much of the additional cost was in managing cash transfers. The incremental cost in the cash transfer areas was $572 for delivery care and $11 for antenatal care. If the programme was to be integrated as a regular service in the public health system, the cost of a delivery is estimated to fall to $389 and to $188 if 2015 levels of activity are assumed. Although the cost of CCTs as originally constituted as a vertical programme are relatively high compared to other similar programmes, these would fall substantially if integrated into the main health system. There is also evidence of sustained impact beyond the end of the funding suggesting that short term programmes can lead to a long-term change in patterns of health seeking behavior.
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http://dx.doi.org/10.3389/fpubh.2020.582072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673437PMC
November 2020

"If you are on duty, you may be afraid to come out to attend to a person": fear of crime and security challenges in maternal acute care in Nigeria from a realist perspective.

BMC Health Serv Res 2020 Sep 29;20(1):903. Epub 2020 Sep 29.

Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Level 10 Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK.

Background: Maternal and Child Health is a global priority. Access and utilization of facility-based health services remain a challenge in low and middle-income countries. Evidence on barriers to providing and accessing services omits information on the role of security within facilities. This paper explores the role of security in the provision and use of maternal health services in primary healthcare facilities in Nigeria.

Methods: Study was carried out in Anambra state, Nigeria. Qualitative data were initially collected from 35 in-depth interviews and 24 focus groups with purposively identified key informants. Information gathered was used to build a programme theory that was tested with another round of interviews (17) and focus group (4) discussions. Data analysis and reporting were based on the Context-Mechanism-Outcome heuristic of Realist Evaluation methodology.

Results: The presence of a male security guard in the facility was the most important security factor that facilitated provision and uptake of services. Others include perimeter fencing, lighting and staff accommodation. Lack of these components constrained provision and use of services, by impacting on behaviour of staff and patients. Security concerns of facility staff who did not feel safe to let in people into unguarded facilities, mirrored those of pregnant women who did not utilize health facilities because of fear of not being let in and attended to by facility staff.

Conclusion: Health facility security should be key consideration in programme planning, to avert staff and women's fear of crime which currently constrains provision and use of maternal healthcare at health facilities.
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http://dx.doi.org/10.1186/s12913-020-05747-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525946PMC
September 2020

What makes advocacy work? Stakeholders' voices and insights from prioritisation of maternal and child health programme in Nigeria.

BMC Health Serv Res 2020 Sep 18;20(1):884. Epub 2020 Sep 18.

Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK.

Background: The Nigerian government introduced and implemented a health programme to improve maternal and child health (MCH) called Subsidy Reinvestment and Empowerment programme for MCH (SURE-P/MCH). It ran from 2012 and ended abruptly in 2015 and was followed by increased advocacy for sustaining the MCH (antenatal, delivery, postnatal and immunization) services as a policy priority. Advocacy is important in allowing social voice, facilitating prioritization, and bringing different forces/actors together. Therefore, the study set out to understand how advocacy works - through understanding what effective advocacy implementation processes comprise and what mechanisms are triggered by which contexts to produce the intended outcomes.

Methods: The study used a Realist Evaluation design through a mixed quantitative and qualitative methods case study approach. The programme theory (PT) was developed from three substantive social theories (power politics, media influence communication theory, and the three-streams theory of agenda-setting), data and programme design documentation, and subsequently tested. We report information from 22 key informant interviews including national and State policy and law makers, policy implementers, CSOs, Development partners, NGOs, health professional groups, and media practitioners and review of relevant documents on advocacy events post-SURE-P.

Results: Key advocacy organizations and individuals including health professional groups, the media, civil society organizations, powerful individuals, and policymakers were involved in advocacy activities. The nature of their engagement included organizing workshops, symposiums, town hall meetings, individual meetings, press conferences, demonstrations, and engagements with media. Effective advocacy mechanism involved alliance brokering to increase influence, the media supporting and engaging in advocacy, and the use of champions, influencers, and spouses (Leadership and Elite Gendered Power Dynamics). The key contextual influences which determined the effectiveness of advocacy measures for MCH included the political cycle, availability of evidence on the issue, networking with powerful and interested champions, and alliance building in advocacy. All these enhanced the entrenchment of MCH on the political and financial agenda at the State and Federal levels.

Conclusions: Our result suggest that advocacy can be a useful tool to bring together different forces by allowing expression of voices and ensuring accountability of different actors including policymakers. In the context of poor health outcomes, interest from policymakers and politicians in MCH, combined with advocacy from key policy actors armed with evidence, can improve prioritization and sustained implementation of MCH services.
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http://dx.doi.org/10.1186/s12913-020-05734-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7501647PMC
September 2020

Which mechanisms explain motivation the of primary health workers? Insights from the realist evaluation of a maternal and child health programme in Nigeria.

BMJ Glob Health 2020 08;5(8)

Nuffield Centre for International Health and Development, University of Leeds School of Medicine, Leeds, UK.

Introduction: Well-trained, adequately skilled and motivated primary healthcare (PHC) workers are essential for attaining universal health coverage (UHC). While there is abundant literature on the drivers of workforce motivation, published knowledge on the mechanisms of motivation within different contexts is limited, particularly in resource-limited countries. This paper contributes to health workforce literature by reporting on how motivation works among PHC workers in a maternal and child health (MCH) programme in Nigeria.

Methods: We adopted a realist evaluation design combining document review with 56 in-depth interviews of PHC workers, facility managers and policy-makers to assess the impact of the MCH programme in Anambra State, Nigeria. A realist process of theory development, testing and consolidation was used to understand how and under what circumstances the MCH programme impacted on workers' motivation and which mechanisms explain how motivation works. We drew on Herzberg's two-factor and Adam's equity theories to unpack how context shapes worker motivation.

Results: A complex and dynamic interaction between the MCH programme and organisational and wider contexts triggered five mechanisms which explain PHC worker motivation: (1) feeling supported, (2) feeling comfortable with work environment, (3) feeling valued, (4) morale and confidence to perform tasks and (5) companionship. Some mechanisms were mutually reinforcing while others operated in parallel. Other conditions that enabled worker motivation were organisational values of fairness, recognition of workers' contributions and culture of task-sharing and teamwork.

Conclusions: Policy designs and management strategies for improving workforce performance, particularly in resource-constrained settings should create working environments that foster feelings of being valued and supported while enabling workers to apply their knowledge and skills to improve healthcare delivery and promote UHC. Future research can test the explanatory framework generated by this study and explore differences in motivational mechanisms among different cadres of PHC workers to inform cadre-related motivational interventions.
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http://dx.doi.org/10.1136/bmjgh-2020-002408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449364PMC
August 2020

Implementation of Health Policy on Establishment of Provincial Center of Diseases Control (CDC) in Vietnam.

Risk Manag Healthc Policy 2020 30;13:915-926. Epub 2020 Jul 30.

Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK.

Purpose: There is increasing interest in the understanding of key influences over successful implementation of health policies within ever-changing contexts of national health systems. The epidemiological transition in Vietnam, combined with an urgent need for improving efficiency of the national health system under the government's administrative reforms, form important facilitators of restructuring the public health system. This paper explored the implementation processes of policy on establishment of the Centers for Diseases Control (CDC) in Vietnam during 2016-2019.

Methods: The study employed a cross-sectional and mixed methods design. Staff surveys were collected at 55 out of 63 provinces and in-depth interviews, focus groups were conducted in three purposefully selected provinces. Quantitative data were analysed using descriptive statistics and qualitative data were analyzed thematically. The innovation implementation framework guided the study.

Results: After 3 years of introduction, 82.5% of provinces had established the CDCs. Implementation of CDC establishment policy was influenced by 1) management support; 2) alignment between policy and practice; 3) values towards CDC,; and 4) implementation climate. Other external key influencers included political, social, and cultural factors.

Conclusion: Our study provides a framework and evidence to guide future inquiry into the factors that affect the relationship between policy implementation and other contextual factors in healthcare organizations.
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http://dx.doi.org/10.2147/RMHP.S250748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406358PMC
July 2020

Combating the COVID-19 Epidemic: Experiences from Vietnam.

Int J Environ Res Public Health 2020 04 30;17(9). Epub 2020 Apr 30.

National Agency for Science and Technology Information, Ministry of Science and Technology, Hanoi 100000, Vietnam.

The COVID-19 pandemic is spreading fast globally. Vietnam's strict containment measures have significantly reduced the spread of the epidemic in the country. This was achieved through the use of emergency control measures in the epidemic areas and integration of resources from multiple sectors including health, mass media, transportation, education, public affairs, and defense. This paper reviews and shares specific measures for successful prevention and control of COVID-19 in Vietnam, which could provide useful learning for other countries.
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http://dx.doi.org/10.3390/ijerph17093125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246912PMC
April 2020

Affirmative action, minorities, and public services in India: Charting a future research and practice agenda.

Indian J Med Ethics 2019 Oct-Dec;4 (NS)(4):265-273

Associate Professor, Faculty of Medicine and Health, School of Medicine, University of Leeds, Leeds, UK.

The National Health Policy in India mentions equity as a key policy principle and emphasises the role of affirmative action in achieving health equity for a range of excluded groups. We conducted a scoping review of literature and three multi-stakeholder workshops to better understand the available evidence on the impact of affirmative action policies in enhancing the inclusion of ethnic and religious minorities in health, education and governance in India. We consider these public services an important mechanism to enhance the social inclusion of many excluded groups. On the whole, the available empirical evidence regarding the uptake and impact of affirmative action policies is limited. Reservation policies in higher education and electoral constituencies have had a limited positive impact in enhancing the access and representation of minorities. However, reservations in government jobs remain poorly implemented. In general, class, gender and location intersect, creating inter- and intra-group differentials in the impact of these policies. Several government initiatives aimed at enhancing the access of religious minorities to public services/institutions remain poorly evaluated. Future research and practice need to focus on neglected but relevant research themes such as the role of private sector providers in supporting the inclusion of minorities, the political aspects of policy development and implementation, and the role of social mobilisation and movements. Evidence gaps also need to be filled in relation to information systems for monitoring and assessment of social disadvantage, implementation and evaluative research on inclusive policies and understanding how the pathways to inequities can be effectively addressed.
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http://dx.doi.org/10.20529/IJME.2019.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212055PMC
July 2020

Is evidence-informed urban health planning a myth or reality? Lessons from a qualitative assessment in three Asian cities.

Health Policy Plan 2019 Dec;34(10):773-783

University of Leeds, Leeds Institute of Health Sciences, Nuffield Centre for International Health and Development, 10.31b, Worsley Building, Clarendon Way, Leeds LS2 9NL, UK.

City governments are well-positioned to effectively address urban health challenges in the context of rapid urbanization in Asia. They require good quality and timely evidence to inform their planning decisions. In this article, we report our analyses of degree of data-informed urban health planning from three Asian cities: Dhaka, Hanoi and Pokhara. Our theoretical framework stems from conceptualizations of evidence-informed policymaking, health planning and policy analysis, and includes: (1) key actors, (2) approaches to developing and implementing urban health plans, (3) characteristics of the data itself. We collected qualitative data between August 2017 and October 2018 using: in-depth interviews with key actors, document review and observations of planning events. Framework approach guided the data analysis. Health is one of competing priorities with multiple plans being produced within each city, using combinations of top-down, bottom-up and fragmented planning approaches. Mostly data from government information systems are used, which were perceived as good quality though often omits the urban poor and migrants. Key common influences on data use include constrained resources and limitations of current planning approaches, alongside data duplication and limited co-ordination within Dhaka's pluralistic system, limited opportunities for data use in Hanoi and inadequate and incomplete data in Pokhara. City governments have the potential to act as a hub for multi-sectoral planning. Our results highlight the tensions this brings, with health receiving less attention than other sector priorities. A key emerging issue is that data on the most marginalized urban poor and migrants are largely unavailable. Feasible improvements to evidence-informed urban health planning include increasing availability and quality of data particularly on the urban poor, aligning different planning processes, introducing clearer mechanisms for data use, working within the current systemic opportunities and enhancing participation of local communities in urban health planning.
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http://dx.doi.org/10.1093/heapol/czz097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913712PMC
December 2019

Rethinking health systems in the context of urbanisation: challenges from four rapidly urbanising low-income and middle-income countries.

BMJ Glob Health 2019 16;4(3):e001501. Epub 2019 Jun 16.

Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.

The world is now predominantly urban; rapid and uncontrolled urbanisation continues across low-income and middle-income countries (LMICs). Health systems are struggling to respond to the challenges that urbanisation brings. While better-off urbanites can reap the benefits from the 'urban advantage', the poorest, particularly slum dwellers and the homeless, frequently experience worse health outcomes than their rural counterparts. In this position paper, we analyse the challenges urbanisation presents to health systems by drawing on examples from four LMICs: Nigeria, Ghana, Nepal and Bangladesh. Key challenges include: responding to the rising tide of non-communicable diseases and to the wider determinants of health, strengthening urban health governance to enable multisectoral responses, provision of accessible, quality primary healthcare and prevention from a plurality of providers. We consider how these challenges necessitate a rethink of our conceptualisation of health systems. We propose an urban health systems model that focuses on: multisectoral approaches that look beyond the health sector to act on the determinants of health; accountability to, and engagement with, urban residents through participatory decision making; and responses that recognise the plurality of health service providers. Within this model, we explicitly recognise the role of data and evidence to act as glue holding together this complex system and allowing incremental progress in equitable improvement in the health of urban populations.
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http://dx.doi.org/10.1136/bmjgh-2019-001501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6577312PMC
June 2019

Dealing with context in logic model development: Reflections from a realist evaluation of a community health worker programme in Nigeria.

Eval Program Plann 2019 04 7;73:97-110. Epub 2018 Dec 7.

Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK. Electronic address:

Logic models (LMs) have been used in programme evaluation for over four decades. Current debate questions the ability of logic modelling techniques to incorporate contextual factors into logic models. We share experience of developing a logic model within an ongoing realist evaluation which assesses the extent to which, and under what circumstances a community health workers (CHW) programme promotes access to maternity services in Nigeria. The article contributes to logic modelling debate by: i) reflecting on how other scholars captured context during LM development in theory-driven evaluations; and ii) explaining how we explored context during logic model development for realist evaluation of the CHW programme in Nigeria. Data collection methods that informed our logic model development included documents review, email discussions and teleconferences with programme stakeholders and a technical workshop with researchers to clarify programme goals and untangle relationships among programme elements. One of the most important findings is that, rather than being an end in itself, logic model development is an essential step for identifying initial hypotheses for tentative relevant contexts, mechanisms and outcomes (CMOs) and CMO configurations of how programmes produce change. The logic model also informed development of a methodology handbook that is guiding verification and consolidation of underlying programme theories.
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http://dx.doi.org/10.1016/j.evalprogplan.2018.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6403102PMC
April 2019

Improving household surveys and use of data to address health inequities in three Asian cities: protocol for the Surveys for Urban Equity (SUE) mixed methods and feasibility study.

BMJ Open 2018 11 25;8(11):e024182. Epub 2018 Nov 25.

School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia.

Introduction: As rapid urbanisation transforms the sociodemographic structures within cities, standard survey methods, which have remained unchanged for many years, under-represent the urban poorest. This leads to an overly positive picture of urban health, distorting appropriate allocation of resources between rural and urban and within urban areas. Here, we present a protocol for our study which (i) tests novel methods to improve representation of urban populations in household surveys and measure mental health and injuries, (ii) explores urban poverty and compares measures of poverty and 'slumness' and (iii) works with city authorities to understand, and potentially improve, utilisation of data on urban health for planning more equitable services.

Methods And Analysis: We will conduct household surveys in Kathmandu, Hanoi and Dhaka to test novel methods: (i) gridded population sampling; (ii) enumeration using open-access online maps and (iii) one-stage versus two-stage cluster sampling. We will test reliability of an observational tool to categorise neighbourhoods as slum areas. Within the survey, we will assess the appropriateness of a short set of questions to measure depression and injuries. Questionnaire data will also be used to compare asset-based, consumption-based and income-based measures of poverty. Participatory methods will identify perceptions of wealth in two communities in each city. The analysis will combine quantitative and qualitative findings to recommend appropriate measures of poverty in urban areas. We will conduct qualitative interviews and establish communities of practice with government staff in each city on use of data for planning. Framework approach will be used to analyse qualitative data allowing comparison across city settings.

Ethics And Dissemination: Ethical approvals have been granted by ethics committees from the UK, Nepal, Bangladesh and Vietnam. Findings will be disseminated through conference papers, peer-reviewed open access articles and workshops with policy-makers and survey experts in Kathmandu, Hanoi and Dhaka.
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http://dx.doi.org/10.1136/bmjopen-2018-024182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6254496PMC
November 2018

Impact of using eHealth tools to extend health services to rural areas of Nigeria: protocol for a mixed-method, non-randomised cluster trial.

BMJ Open 2018 10 18;8(10):e022174. Epub 2018 Oct 18.

Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK.

Introduction: eHealth solutions that use internet and related technologies to deliver and enhance health services and information are emerging as novel approaches to support healthcare delivery in sub-Saharan Africa. Using digital technology in this way can support cost-effectiveness of care delivery and extend the reach of services to remote locations. Despite the burgeoning literature on eHealth approaches, little is known about the effectiveness of eHealth tools for improving the quality and efficiency of health systems functions or client outcomes in resource-limited countries. eHealth tools including satellite communications are currently being implemented at scale, to extend health services to rural areas of Nigeria, in Ondo and Kano States and the Federal Capital Territory. This paper shares the protocol for a 2-year project ('EXTEND') that aims to evaluate the impact of eHealth tools on health system functions and health outcomes.

Methodology And Analysis: This multisite, mixed-method evaluation includes a non-randomised, cluster trial design. The study comprises three phases-baseline, midline and endline evaluations-that involve: (1) process evaluation of video training and digitisation of health data interventions; (2) evaluation of contextual influences on the implementation of interventions; and (3) impact evaluation of results of the project. A convergent mixed-method model will be adopted to allow integration of quantitative and qualitative findings to achieve study objectives. Multiple quantitative and qualitative datasets will be repeatedly analysed and triangulated to facilitate better understanding of impact of eHealth tools on health worker knowledge, quality and efficiency of health systems and client outcomes.

Ethics And Dissemination: Ethics approvals were obtained from the University of Leeds and three States' Ministries of Health in Nigeria. All data collected for this study will be anonymised and reports will not contain information that could identify respondents. Study findings will be presented to Ministries of Health at scientific conferences and published in peer-reviewed journals.

Trial Registration Number: ISRCTN32105372; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2018-022174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6196841PMC
October 2018

Key strategies to improve systems for managing patient complaints within health facilities - what can we learn from the existing literature?

Glob Health Action 2018 ;11(1):1458938

b Nossal Institute for Global Health, Melbourne School of Population and Global Health , University of Melbourne , Melbourne , Australia.

Background: Information from patient complaints - a widely accepted measure of patient satisfaction with services - can inform improvements in service quality, and contribute towards overall health systems performance. While analyses of data from patient complaints received much emphasis, there is limited published literature on key interventions to improve complaint management systems.

Objectives: The objectives are two-fold: first, to synthesise existing evidence and provide practical options to inform future policy and practice and, second, to identify key outstanding gaps in the existing literature to inform agenda for future research.

Methods: We report results of review of the existing literature. Peer-reviewed published literature was searched in OVID Medline, OVID Global Health and PubMed. In addition, relevant citations from the reviewed articles were followed up, and we also report grey literature from the UK and the Netherlands.

Results: Effective interventions can improve collection of complaints (e.g. establishing easy-to-use channels and raising patients' awareness of these), analysis of complaint data (e.g. creating structures and spaces for analysis and learning from complaints data), and subsequent action (e.g. timely feedback to complainants and integrating learning from complaints into service quality improvement). No one single measure can be sufficient, and any intervention to improve patient complaint management system must include different components, which need to be feasible, effective, scalable, and sustainable within local context.

Conclusions: Effective interventions to strengthen patient complaints systems need to be: comprehensive, integrated within existing systems, context-specific and cognizant of the information asymmetry and the unequal power relations between the key actors. Four gaps in the published literature represent an agenda for future research: limited understanding of contexts of effective interventions, absence of system-wide approaches, lack of evidence from low- and middle-income countries and absence of focused empirical assessments of behaviour of staff who manage patient complaints.
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http://dx.doi.org/10.1080/16549716.2018.1458938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5912438PMC
October 2018

Utilization of Services Provided by Village-Based Ethnic Minority Midwives in Vietnam: Lessons From Implementation Research.

J Public Health Manag Pract 2018 Mar/Apr;24 Suppl 2:S9-S18

Hanoi University of Public Health, Hanoi, Vietnam (Ms Doan and Dr Bui); Nuffield Centre for International Health & Development, University of Leeds, Leeds, United Kingdom (Dr Mirzoev); and Department of Scientific Research, Hanoi Obstetrics & Gynecology Hospital, Hanoi, Vietnam (Dr Nguyen).

Background: Global progress in reducing maternal mortality requires improving access to maternal and child health services for the most vulnerable groups. This article reports results of implementation research that aimed to increase the acceptability of village-based ethnic minority midwives (EMMs) by local communities in Vietnam through implementing an integrated interventions package.

Methods: The study was carried out in 2 provinces in Vietnam, Dien Bien and Kon Tum. A quasi-experimental survey with pretest/posttest design was adopted, which included 6 months of intervention implementation. The interventions package included introductory "launch" meetings, monthly review meetings at community health centers, and 5-day refresher training for EMMs. A mixed-methods approach was used involving both quantitative and qualitative data. A structured questionnaire was used in the pre- and posttest surveys, complemented by in-depth interviews and focus group discussions with EMMs, relatives of pregnant women, community representatives, and health managers.

Results: Introductions of EMMs to their local communities by local authorities and supervision of performance of EMMs contributed to significant increases in utilization of services provided by EMMs, from 58.6% to 87.7%. Key facilitators included information on how to contact EMMs, awareness of services provided by EMMs, and trust in services provided by EMMs. The main barriers to utilization of EMM services, which may affect sustainability of the EMM scheme, were low self-esteem of EMMs and small allowances to EMMs, which also affected the recognition of EMMs in the community.

Conclusions: Providing continuous support and integration of EMMs within frontline service provision and ensuring adequate local budget for monthly allowances are the key factors that should allow sustainability of the EMM scheme and continued improvement of access to maternal and child health care among poor ethnic minority people living in mountainous areas in Vietnam.
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http://dx.doi.org/10.1097/PHH.0000000000000689DOI Listing
November 2019

What is health systems responsiveness? Review of existing knowledge and proposed conceptual framework.

BMJ Glob Health 2017 31;2(4):e000486. Epub 2017 Oct 31.

KIT Royal Tropical Institute, Amsterdam, The Netherlands.

Responsiveness is a key objective of national health systems. Responsive health systems anticipate and adapt to existing and future health needs, thus contributing to better health outcomes. Of all the health systems objectives, responsiveness is the least studied, which perhaps reflects lack of comprehensive frameworks that go beyond the normative characteristics of responsive services. This paper contributes to a growing, yet limited, knowledge on this topic. Herewith, we review the current frameworks for understanding health systems responsiveness and drawing on these, as well as key frameworks from the wider public services literature, propose a comprehensive conceptual framework for health systems responsiveness. This paper should be of interest to different stakeholders who are engaged in analysing and improving health systems responsiveness. Our review shows that existing knowledge on health systems responsiveness can be extended along the three areas. First, responsiveness entails an actual experience of people's interaction with their health system, which confirms or disconfirms their initial expectations of the system. Second, the experience of interaction is shaped by both the people and the health systems sides of this interaction. Third, different influences shape people's interaction with their health system, ultimately affecting their resultant experiences. Therefore, recognition of both people and health systems sides of interaction and their key determinants would enhance the conceptualisations of responsiveness. Our proposed framework builds on, and advances, the core frameworks in the health systems literature. It positions the experience of interaction between people and health system as the centrepiece and recognises the determinants of responsiveness experience both from the health systems (eg, actors, processes) and the people (eg, initial expectations) sides. While we hope to trigger further thinking on the conceptualisation of health system responsiveness, the proposed framework can guide assessments of, and interventions to strengthen, health systems responsiveness.
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http://dx.doi.org/10.1136/bmjgh-2017-000486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5717934PMC
October 2017

Protocol for a mixed-methods realist evaluation of a health service user feedback system in Bangladesh.

BMJ Open 2017 07 5;7(6):e017743. Epub 2017 Jul 5.

Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK.

Introduction: Responsiveness to service users' views is a widely recognised objective of health systems. A key component of responsive health systems is effective interaction between users and service providers. Despite a growing literature on patient feedback from high-income settings, less is known about effectiveness of such systems in low-income and middle-income countries.

Methodology And Analysis: This paper disseminates the protocol for an 18-month 'RESPOND' project that aims to evaluate the system of collecting and responding to user feedback in Bangladesh. This mixed-method study uses a realist evaluation approach to examine user feedback systems at two Upazila health complexes in Comilla District of Bangladesh, and comprises three steps: (1) initial theory development; (2) theory validation; and (3) theory refinement and development of lessons learnt. The project also uses (1) process evaluation to understand and ; (2) statistical analysis of patient feedback to clarify the nature of issues reported; (3) social science methods to illuminate feedback processes and user and provider experiences; and (4) health policy and systems research to clarify issues related to integration of feedback systems with quality assurance and human resource management. During data analysis, qualitative and quantitative findings will be integrated throughout to help achieve study objectives. Analysis of qualitative and quantitative data will be done using a convergent mixed-methods model, involving continuous triangulation of multiple data sets to facilitate greater understanding of the context of user feedback systems including the links with relevant policies, practices and programmes.

Ethics And Dissemination: Ethics approvals were obtained from the University of Leeds and the Bangladesh Medical Research Council. All data collected for this study will be anonymised, and identifying characteristics of respondents will not appear in a final manuscript or reports. The study findings will be presented at scientific conferences and published in peer-reviewed journals.
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http://dx.doi.org/10.1136/bmjopen-2017-017743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734574PMC
July 2017

Contribution of health workforce to health outcomes: empirical evidence from Vietnam.

Hum Resour Health 2016 11 16;14(1):68. Epub 2016 Nov 16.

Hanoi University of Public Health, 1A Duc Thang, Duc Thang ward, Bac Tu Liem district, Hanoi, Vietnam.

Background: In Vietnam, a lower-middle income country, while the overall skill- and knowledge-based quality of health workforce is improving, health workers are disproportionately distributed across different economic regions. A similar trend appears to be in relation to health outcomes between those regions. It is unclear, however, whether there is any relationship between the distribution of health workers and the achievement of health outcomes in the context of Vietnam. This study examines the statistical relationship between the availability of health workers and health outcomes across the different economic regions in Vietnam.

Methods: We constructed a panel data of six economic regions covering 8 years (2006-2013) and used principal components analysis regressions to estimate the impact of health workforce on health outcomes. The dependent variables representing the outcomes included life expectancy at birth, infant mortality, and under-five mortality rates. Besides the health workforce as our target explanatory variable, we also controlled for key demographic factors including regional income per capita, poverty rate, illiteracy rate, and population density.

Results: The numbers of doctors, nurses, midwives, and pharmacists have been rising in the country over the last decade. However, there are notable differences across the different categories. For example, while the numbers of nurses increased considerably between 2006 and 2013, the number of pharmacists slightly decreased between 2011 and 2013. We found statistically significant evidence of the impact of density of doctors, nurses, midwives, and pharmacists on improvement to life expectancy and reduction of infant and under-five mortality rates.

Conclusions: Availability of different categories of health workforce can positively contribute to improvements in health outcomes and ultimately extend the life expectancy of populations. Therefore, increasing investment into more equitable distribution of four main categories of health workforce (doctors, nurses, midwives, and pharmacists) can be an important strategy for improving health outcomes in Vietnam and other similar contexts. Future interventions will also need to consider an integrated approach, building on the link between the health and the development.
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http://dx.doi.org/10.1186/s12960-016-0165-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5112617PMC
November 2016

Utilization of services provided by village based ethnic minority midwives in mountainous villages of Vietnam.

Int J Womens Health 2016 20;8:571-580. Epub 2016 Oct 20.

Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.

Introduction: Since 2011, the Vietnam's Ministry of Health implemented the ethnic minority midwives (EMMs) scheme in order to increase the utilization of maternal health services by women from ethnic minorities and those living in hard-to-reach mountainous areas. This paper analyzes the utilization of antenatal, delivery, and postpartum care provided by EMMs and reports the key determinants of utilization of EMM services as perceived by service users.

Methods: A structured questionnaire was administered in 2015 to all mothers (n=320) who gave birth to a live-born during a 1-year period in 31 villages which had EMM in two provinces, Dien Bien and Kon Tum. A multivariate logistic regression model was used to examine the association between all potential factors and the use of services provided by EMMs.

Results: We found that EMMs provided more antenatal care and postnatal care as compared with delivery services, which corresponded to their job descriptions. The results also showed that utilization of antenatal care provided by EMMs was lower than that of postnatal care. The proportion of those who never heard about EMM was high (24%). Among the mothers who knew about EMM services, 33.4% had antenatal checkups, 20.1% were attended during home deliveries, and 57.3% had postnatal visits by an EMM. Key factors that determined the use of EMM services included knowledge of the location of EMM's house, being aware about EMMs by health workers, trust in services provided by EMMs, and perception that many others mothers in a village also knew about EMM services.

Conclusion: EMM seems to be an important mechanism to ensure assistance during home births and postnatal care for ethnic minority groups, who are often resistant to attend health facilities. Building trust and engaging with communities are the key facilitators to increase the utilization of services provided by EMMs. Communication campaigns to raise awareness about EMMs and to promote their services in the village, particularly by other health workers, represent an important strategy to further improve effectiveness of EMM scheme.
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http://dx.doi.org/10.2147/IJWH.S112996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5077125PMC
October 2016

Study protocol: realist evaluation of effectiveness and sustainability of a community health workers programme in improving maternal and child health in Nigeria.

Implement Sci 2016 06 7;11(1):83. Epub 2016 Jun 7.

Nuffield Centre for International Health and Development, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK.

Background: Achievement of improved maternal and child health (MCH) outcomes continues to be an issue of international priority, particularly for sub-Saharan African countries such as Nigeria. Evidence suggests that the use of Community Health Workers (CHWs) can be effective in broadening access to, and coverage of, health services and improving MCH outcomes in such countries.

Methods/design: In this paper, we report the methodology for a 5-year study which aims to evaluate the context, processes, outcomes and longer-term sustainability of a Nigerian CHW scheme. Evaluation of complex interventions requires a comprehensive understanding of intervention context, mechanisms and outcomes. The multidisciplinary and mixed-method realist approach will facilitate such evaluation. A favourable policy environment within which the study is conducted will ensure the successful uptake of results into policy and practice. A realist evaluation provides an overall methodological framework for this multidisciplinary and mixed methods research, which will be undertaken in Anambra state. The study will draw upon health economics, social sciences and statistics. The study comprises three steps: (1) initial theory development; (2) theory validation and (3) theory refinement and development of lessons learned. Specific methods for data collection will include in-depth interviews and focus group discussions with purposefully identified key stakeholders (managers, service providers and service users), document reviews, analyses of quantitative data from the CHW programme and health information system, and a small-scale survey. The impact of the programme on key output and outcome indicators will be assessed through an interrupted time-series analysis (ITS) of monthly quantitative data from health information system and programme reports. Ethics approvals for this study were obtained from the University of Leeds and the University of Nigeria.

Discussion: This study will provide a timely and important contribution to health systems strengthening specifically within Anambra state in southeast Nigeria but also more widely across Nigeria. This paper should be of interest to researchers who are interested in adapting and applying robust methodologies for assessing complex health system interventions. The paper will also be useful to policymakers and practitioners who are interested in commissioning and engaging in such complex evaluations to inform policies and practices.
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http://dx.doi.org/10.1186/s13012-016-0443-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896007PMC
June 2016

Strengthening post-graduate educational capacity for health policy and systems research and analysis: the strategy of the Consortium for Health Policy and Systems Analysis in Africa.

Health Res Policy Syst 2016 Apr 12;14:29. Epub 2016 Apr 12.

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

Background: The last 5-10 years have seen significant international momentum build around the field of health policy and systems research and analysis (HPSR + A). Strengthening post-graduate teaching is seen as central to the further development of this field in low- and middle-income countries. However, thus far, there has been little reflection on and documentation of what is taught in this field, how teaching is carried out, educators' challenges and what future teaching might look like.

Methods: Contributing to such reflection and documentation, this paper reports on a situation analysis and inventory of HPSR + A post-graduate teaching conducted among the 11 African and European partners of the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA), a capacity development collaboration. A first questionnaire completed by the partners collected information on organisational teaching contexts, while a second collected information on 104 individual courses (more in-depth information was subsequently collected on 17 of the courses). The questionnaires yielded a mix of qualitative and quantitative data, which were analysed through counts, cross-tabulations, and the inductive grouping of material into themes. In addition, this paper draws information from internal reports on CHEPSAA's activities, as well as its external evaluation.

Results: The analysis highlighted the fluid boundaries of HPSR + A and the range and variability of the courses addressing the field, the important, though not exclusive, role of schools of public health in teaching relevant material, large variations in the time investments required to complete courses, the diversity of student target audiences, the limited availability of distance and non-classroom learning activities, and the continued importance of old-fashioned teaching styles and activities.

Conclusions: This paper argues that in order to improve post-graduate teaching and continue to build the field of HPSR + A, key questions need to be addressed around educational practice issues such as the time allocated for HPSR + A courses, teaching activities, and assessments, whether HPSR + A should be taught as a cross-cutting theme in post-graduate degrees or an area of specialisation, and the organisation of teaching given the multi-disciplinary nature of the field. It ends by describing some of CHEPSAA's key post-graduate teaching development activities and how these activities have addressed the key questions.
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http://dx.doi.org/10.1186/s12961-016-0097-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830003PMC
April 2016