Square peg in a round hole: re-thinking our approach to evaluating health system strengthening in low-income and middle-income countries

Borghi, Josephine; Chalabi, Zaid

doi:10.1136/bmjgh-2017-000406

Cited by 17 publications

(15 citation statements)

References 29 publications

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“…The inadequacy or unavailability of drugs and supplies, equipment, transport and infrastructure meant the health system was unable to support the successful implementation of the policy. This is synonymous with settings in low- and middle-income countries, where the outbreak of epidemics and other emergencies, for example, the outbreak of the Ebola Virus in West Africa, exposed the vulnerability and weaknesses of the health system [ 30 , 31 ]. Strong health systems are required to attain health goals [ 32 , 33 ], provide routine or usual services and to contain disease outbreaks [ 34 , 35 ].…”

Section: Main Textmentioning

confidence: 99%

The implementation of the free maternal health policy in rural Northern Ghana: synthesised results and lessons learnt

2018

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ObjectiveA free maternal health policy was implemented under Ghana’s National Health Insurance Scheme to promote the use of maternal health services. Under the policy, women are entitled to free services throughout pregnancy and at childbirth. A mixed methods study involving women, providers and insurance managers was carried out in the Kassena-Nankana municipality of Ghana. It explored the affordability, availability, acceptability and quality of services. In this manuscript, we present synthesised results categorised as facilitators and barriers to access as well as lessons learnt (implications).ResultsReasonable waiting times, cleanliness of facilities as well as good interpersonal relationships with providers were the facilitators to access. Barriers included out of pocket payments, lack of, or inadequate supply of drugs and commodities, equipment, water, electricity and emergency transport. Four lessons (implications) were identified. Firstly, out of pocket payments persisted. Secondly, the health system was not strengthened before implementing the free maternal health policy. Thirdly, lower level facilities were poorly resourced. Finally, the lack of essential inputs and infrastructure affected quality of care and therefore, access to care. It is suggested that the Government of Ghana, the Health Insurance Scheme and other stakeholders improve the provision of resources to facilities.

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Section: Main Textmentioning

confidence: 99%

The implementation of the free maternal health policy in rural Northern Ghana: synthesised results and lessons learnt

2018

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“…For example, epidemiological methods can describe well the aggregate experiences of migrant exploitation and health outcomes, such as the health outcomes of human trafficking [13], but they do not capture the complex system dynamics of labor migration and modern slavery. ABM has recently been recognized by the public health research community as a complex systems approach that can explore causal complexities inherent to human behavior and population health [14][15][16].…”

Section: Why Explore Abm For Research On Migration and Modern Slavery?mentioning

confidence: 99%

“…For example, public health and health systems research has employed ABM methods to study communicable and non-communicable diseases, health behaviors, and other topics in social epidemiology [21]. These methods are increasingly recommended to evaluate complex health systems and prevention interventions [15,22].…”

Section: Agent-based Modeling For Complex Social Systemsmentioning

confidence: 99%

Agent-based modeling for migration and modern slavery research: a systematic review

et al. 2020

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This systematic review aims to synthesize how agent-based modeling (ABM) has been used in migration and modern slavery research and provide the basis to model development for social science researchers exploring the use of ABM. We searched five bibliographic databases using two terminology categories: (1) migration or modern slavery terminology; (2) complex system methods terminology. Two reviewers conducted independent article screening. Peer-reviewed articles presenting original migration or modern slavery ABMs were included. Data extraction included model development steps and model characteristics. The dataset was synthesized and compared across studies. We identified 28 articles for inclusion. Many of the ABMs tested theories and about half were based on empirical data. Model development varied considerably and reported methods were extremely opaque. Only five studies used a structured development framework. The most common model involved agents deciding whether and where to migrate and attempting migration. Climate change was a common exogenous scenario modeled. Most of the ABMs did not undergo any sensitivity analysis or validation.ABM has a greater capacity to account for heterogeneous and dynamic decision-making than more frequently applied methods in research on migration and modern slavery. However, there is still a paucity of studies adopting ABM methods. These reviewed ABMs highlight gaps in the reporting and implementing of model development. ABM is a promising technique to address many urgent and complex questions in research on migration and modern slavery to better support decision-makers, but addressing current methodological gaps is a critical first step.

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“…(6) As such, HSS requires an approach to design and evaluate complex public health interventions, in real-world contexts, that accounts for the multiple interconnecting components and actors. (9) A systems-level approach to the design and evaluation of HSS interventions views a complex intervention as a system in itself, interacting with other building blocks of the underlying health system in which the intervention embeds itself, setting off reactions that may well be unexpected or unpredictable. (6) Applying this approach to the design and evaluation of HSS interventions requires an evaluation of not only their main effects, but also inputs, outputs, initial, intermediate and eventual outcomes, feedback processes and contexts within the underlying health system.…”

Section: Introductionmentioning

confidence: 99%

Implementation Science Protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER)

Seward

Murdoch

Hanlon

et al. 2021

Preprint

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BackgroundASSET (Health System Strengthening in Sub-Saharan Africa) is a health system strengthening (HSS) programme that aims to develop and evaluate effective and sustainable solutions that support high-quality care that involve eight work packages across four sub-Saharan African countries. Here we present the protocol for the implementation science (IS) theme within ASSET that aims to (1) understand what HSS interventions work, for whom and how; and (2) how implementation science methodologies can be adapted to improve the design and evaluation of HSS interventions within resource-poor contexts.MethodsPre-implementation phaseThe IS theme, jointly with ASSET work-packages, applies IS determinant frameworks to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work packages also theorise selective mechanisms to achieve the expected outcomes.Piloting phase and rolling implementation phaseWork-packages pilot the HSS interventions. An iterative process then begins involving evaluation, refection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers and enablers to implementation in a series of workshops, surveys and interviews. Selective mechanisms of action are also investigated. In a final workshop, ASSET teams come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use.Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data is analysed using means and proportions.ConclusionsWe use a novel combination of implementation science methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study will also contribute conceptual development and clarification at the underdeveloped interface of implementation science, HSS and global health.Strengths and limitations of this studyThe purpose of this protocol paper is to describe the methodology for the implementation science theme within ASSET (ASSET-ImplementER).The overall aim of the ASSET-ImplementER theme is to advance our understanding of how to design and evaluate HSS interventions using a systems level approach informed by implementation science, across different health systems and contexts.This is one of the first large-scale implementation research programmes for health system strengthening in Sub-Saharan Africa that spanning three care platforms (primary care for the integrated treatment of chronic conditions in adults, maternal and newborn care, surgical care), involving eight work packages in four sub-Saharan African countries that aims to apply robust, implementation science and other theory-informed approaches to understand what works for whom and how. Equally as important, we aim to improve implementation science methodologies to design and evaluate HSS interventions within LMIC settings.Although our programme is theory-informed through the use of ToC workshops andimplementation science determinant frameworks, we have not used implementation science theories or other middle-range theories to guide the design and evaluate of ASSET as a programme. This is a pragmatic approach given many of the work-packages teams were unfamiliar with implementation science methods at the time of ASSET set-up.To mitigate the effects of this approach to our research, we work with the different work packages throughout the different phases of research, to theorise and conceptualise how the selected determinants interact with mechanisms introduced by the selected HSS on implementation outcomes.Although there are limitations to our approach, we expect to begin advance our understanding of what HSS work for whom, and how. It is also hoped that we will start to address the issues in understanding the complexity surrounding how to effectively strengthen health systems in resource-poor contexts within LMICs.

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Square peg in a round hole: re-thinking our approach to evaluating health system strengthening in low-income and middle-income countries

Cited by 17 publications

References 29 publications

The implementation of the free maternal health policy in rural Northern Ghana: synthesised results and lessons learnt

The implementation of the free maternal health policy in rural Northern Ghana: synthesised results and lessons learnt

Agent-based modeling for migration and modern slavery research: a systematic review

Implementation Science Protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER)

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