HeAlth System StrEngThening in Four Sub_Saharan African Countries (ASSET) to Achieve High-quality, Evidence-informed Surgical, Maternal and Newborn, and Primary Care: Protocol for Pre-implementation Phase Studies

Abstract

ObjectivesTo achieve universal health coverage, health systems need to be strengthened to support the consistent delivery of high-quality, evidence-informed care at scale. The aim of the National Institute for Health Research (NIHR) Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme spanning three healthcare platforms (primary health care for the integrated treatment of chronic conditions in adults, maternal and newborn, surgical care) involving eight work packages. This paper describes the pre-implementation phase research protocols that assess: (1) barriers to accessing care; (2) health system bottlenecks in care process and pathways; (3) quality of care, and; (4) people centredness. Findings from this research are used to engage stakeholders and to inform the selection of a set of health system strengthening interventions (HSSIs) and subsequent methodology for evaluation. SettingsPublicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe.Population Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers.Study methodologies and deliveryIn each work package, we apply a mixed-methods approach, including: literature reviews; situation analyses; cohort studies; cross-sectional surveys; ethnographic observations; semi-structured interviews, and; focus group discussions. At the end of the pre-implementation phase, findings are fed back to stakeholders in participatory theory of change workshops that are used to select/adapt an initial set of contextually relevant HSSIs. To ensure a theory-informed approach across ASSET, implementation science determinant frameworks are also applied, to help identify any additional contextual barriers and enablers and complementary HSSIs. Outputs from these activities are used to finalise underlying assumptions, potential unintended consequences, process indicators and implementation and clinical outcomes.ConclusionsASSET places a strong emphasis of the pre-implementation phase of the programme in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and active stakeholder engagement. This approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.

Costs, catastrophic out-of-pocket payments and impoverishment related to accessing surgical care among households in rural Ethiopia

“…This study was conducted as part of the pre-implementation phase of the ASSET programme (Health System Strengthening in sub-Saharan Africa). The goal of ASSET was to identify system bottlenecks to accessing quality surgical, maternal and primary healthcare in Ethiopia, Sierra Leone, South Africa and Zimbabwe [21]. In this paper, we present findings from Ethiopia.…”

Health systems strengthening interventions for perinatal common mental disorders and experiences of domestic violence in Cape Town, South Africa: protocol for a pilot implementation study

“…The pre-implementation phase [ 23 ] took place in four MOUs and in the ten non-profit organisations (NPOs) mandated to provide facility- and community-based support to patients attending those facilities. The MOUs were purposively selected by DoH managers to represent each of the four sub-districts in the Cape Metropolitan health district in Cape Town.…”

Lessons Learned from Development and Implementation of the National Surgical, Obstetric and Anaesthesia Plan in Ethiopia: a qualitative study

“…The study design was qualitative, nested within the surgical work package of the ASSET (HeAlth System StrEngThening in sub-Saharan Africa) National Institute of Health Research Global Health Unit [9], a health system strengthening research program working across four sub-Saharan African countries (Ethiopia, Sierra Leone, South Africa, Zimbabwe) and three platforms of care (surgery, primary care and maternal care).…”