Lauren Taylor

Community Health Workers in Low- and Middle-Income Countries: What Do We Know About Scaling Up and Sustainability?

OBJECTIVES We sought to provide a systematic review of the determinants of success in scaling up and sustaining community health worker (CHW) programs in low- and middle-income countries (LMICs). METHODS We searched 11 electronic databases for academic literature published through December 2010 (n = 603 articles). Two independent reviewers applied exclusion criteria to identify articles that provided empirical evidence about the scale-up or sustainability of CHW programs in LMICs, then extracted data from each article by using a standardized form. We analyzed the resulting data for determinants and themes through iterated categorization. RESULTS The final sample of articles (n = 19) present data on CHW programs in 16 countries. We identified 23 enabling factors and 15 barriers to scale-up and sustainability, which were grouped into 3 thematic categories: program design and management, community fit, and integration with the broader environment. CONCLUSIONS Scaling up and sustaining CHW programs in LMICs requires effective program design and management, including adequate training, supervision, motivation, and funding; acceptability of the program to the communities served; and securing support for the program from political leaders and other health care providers.

Variation In Health Outcomes: The Role Of Spending On Social Services, Public Health, And Health Care, 2000–09

Although spending rates on health care and social services vary substantially across the states, little is known about the possible association between variation in state-level health outcomes and the allocation of state spending between health care and social services. To estimate that association, we used state-level repeated measures multivariable modeling for the period 2000-09, with region and time fixed effects adjusted for total spending and state demographic and economic characteristics and with one- and two-year lags. We found that states with a higher ratio of social to health spending (calculated as the sum of social service spending and public health spending divided by the sum of Medicare spending and Medicaid spending) had significantly better subsequent health outcomes for the following seven measures: adult obesity; asthma; mentally unhealthy days; days with activity limitations; and mortality rates for lung cancer, acute myocardial infarction, and type 2 diabetes. Our study suggests that broadening the debate beyond what should be spent on health care to include what should be invested in health-not only in health care but also in social services and public health-is warranted.

A model for scale up of family health innovations in low-income and middle-income settings: a mixed methods study.

Background Many family health innovations that have been shown to be both efficacious and cost-effective fail to scale up for widespread use particularly in low-income and middle-income countries (LMIC). Although individual cases of successful scale-up, in which widespread take up occurs, have been described, we lack an integrated and practical model of scale-up that may be applicable to a wide range of public health innovations in LMIC. Objective To develop an integrated and practical model of scale-up that synthesises experiences of family health programmes in LMICs. Data sources We conducted a mixed methods study that included in-depth interviews with 33 key informants and a systematic review of peer-reviewed and grey literature from 11 electronic databases and 20 global health agency web sites. Study eligibility criteria, participants and interventions We included key informants and studies that reported on the scale up of several family health innovations including Depo-Provera as an example of a product innovation, exclusive breastfeeding as an example of a health behaviour innovation, community health workers (CHWs) as an example of an organisational innovation and social marketing as an example of a business model innovation. Key informants were drawn from non-governmental, government and international organisations using snowball sampling. An article was excluded if the article: did not meet the studys definition of the innovation; did not address dissemination, diffusion, scale up or sustainability of the innovation; did not address low-income or middle-income countries; was superficial in its discussion and/or did not provide empirical evidence about scale-up of the innovation; was not available online in full text; or was not available in English, French, Spanish or Portuguese, resulting in a final sample of 41 peer-reviewed articles and 30 grey literature sources. Study appraisal and synthesis methods We used the constant comparative method of qualitative data analysis to extract recurrent themes from the interviews, and we integrated these themes with findings from the literature review to generate the proposed model of scale-up. For the systematic review, screening was conducted independently by two team members to ensure consistent application of the predetermined exclusion criteria. Data extraction from the final sample of peer-reviewed and grey literature was conducted independently by two team members using a pre-established data extraction form to list the enabling factors and barriers to dissemination, diffusion, scale up and sustainability. Results The resulting model—the AIDED model—includes five non-linear, interrelated components: (1) assess the landscape, (2) innovate to fit user receptivity, (3) develop support, (4) engage user groups and (5) devolve efforts for spreading innovation. Our findings suggest that successful scale-up occurs within a complex adaptive system, characterised by interdependent parts, multiple feedback loops and several potential paths to achieve intended outcomes. Failure to scale up may be attributable to insufficient assessment of user groups in context, lack of fit of the innovation with user receptivity, inability to address resistance from stakeholders and inadequate engagement with user groups. Limitations The inductive approach used to construct the AIDED model did not allow for simultaneous empirical testing of the model. Furthermore, the literature may have publication bias in which negative studies are under-represented, although we did find examples of unsuccessful scale-up. Last, the AIDED model did not address long-term, sustained use of innovations that are successfully scaled up, which would require longer-term follow-up than is common in the literature. Conclusions and implications of key findings Flexible strategies of assessment, innovation, development, engagement and devolution are required to enable effective change in the use of family health innovations in LMIC.

Leveraging the Social Determinants of Health: What Works?

We summarized the recently published, peer-reviewed literature that examined the impact of investments in social services or investments in integrated models of health care and social services on health outcomes and health care spending. Of 39 articles that met criteria for inclusion in the review, 32 (82%) reported some significant positive effects on either health outcomes (N = 20), health care costs (N = 5), or both (N = 7). Of the remaining 7 (18%) studies, 3 had non-significant results, 2 had mixed results, and 2 had negative results in which the interventions were associated with poorer health outcomes. Our analysis of the literature indicates that several interventions in the areas of housing, income support, nutrition support, and care coordination and community outreach have had positive impact in terms of health improvements or health care spending reductions. These interventions may be of interest to health care policymakers and practitioners seeking to leverage social services to improve health or reduce costs. Further testing of models that achieve better outcomes at less cost is needed.

Management Matters: A Leverage Point for Health Systems Strengthening in Global Health

Despite a renewed focus in the field of global health on strengthening health systems, inadequate attention has been directed to a key ingredient of high-performing health systems: management. We aimed to develop the argument that management - defined here as the process of achieving predetermined objectives through human, financial, and technical resources - is a cross-cutting function necessary for success in all World Health Organization (WHO) building blocks of health systems strengthening. Management within health systems is particularly critical in low-income settings where the efficient use of scarce resources is paramount to attaining health goals. More generally, investments in management capacity may be viewed as a key leverage point in grand strategy, as strong management enables the achievement of large ends with limited means. We also sought to delineate a set of core competencies and identify key roles to be targeted for management capacity building efforts. Several effective examples of management interventions have been described in the research literature. Together, the existing evidence underscores the importance of country ownership of management capacity building efforts, which often challenge the status quo and thus need country leadership to sustain despite inevitable friction. The literature also recognizes that management capacity efforts, as a key ingredient of effective systems change, take time to embed, as new protocols and ways of working become habitual and integrated as standard operating procedures. Despite these challenges, the field of health management as part of global health system strengthening efforts holds promise as a fundamental leverage point for achieving health system performance goals with existing human, technical, and financial resources. The evidence base consistently supports the role of management in performance improvement but would benefit from additional research with improved methodological rigor and longer-time horizon investigations. Meanwhile, greater emphasis on management as a critical element of global health efforts may open new and sustainable avenues for advancing health systems performance.

Recruitment and Retention of Mental Health Workers in Ghana

Introduction The lack of trained mental health workers is a primary contributor to the mental health treatment gap worldwide. Despite the great need to recruit and retain mental health workers in low-income countries, little is known about how these workers perceive their jobs and what drives them to work in mental health care. Using qualitative interviews, we aimed to explore factors motivating mental health workers in order to inform interventions to increase recruitment and retention. Methods We conducted 28 in-depth, open-ended interviews with staff in Ghana’s three public psychiatric hospitals. We used the snowballing method to recruit participants and the constant comparative method for qualitative data analysis, with multiple members of the research team participating in data coding to enhance the validity and reliability of the analysis. The use of qualitative methods allowed us to understand the range and depth of motivating and demotivating factors. Results Respondents described many factors that influenced their choice to enter and remain in mental health care. Motivating factors included 1) desire to help patients who are vulnerable and in need, 2) positive day-to-day interactions with patients, 3) intellectual or academic interest in psychiatry or behavior, and 4) good relationships with colleagues. Demotivating factors included 1) lack of resources at the hospital, 2) a rigid supervisory hierarchy, 3) lack of positive or negative feedback on work performance, and 4) few opportunities for career advancement within mental health. Conclusions Because many of the factors are related to relationships, these findings suggest that strengthening the interpersonal and team dynamics may be a critical and relatively low cost way to increase worker motivation. The data also allowed us to highlight key areas for resource allocation to improve both recruitment and retention, including risk pay, adequate tools for patient care, improved hospital work environment, and stigma reduction efforts.

Experiences of leadership in health care in sub-Saharan Africa.

BackgroundLeadership is widely regarded as central to effective health-care systems, and resources are increasingly devoted to the cultivation of strong health-care leadership. Nevertheless, the literature regarding leadership capacity building has been developed primarily in the context of high-income settings. Less research has been done on leadership in low-income settings, including sub-Saharan Africa, particularly in health care, with attention to historical, political and sociocultural context. We sought to characterize the experiences of individuals in key health-care leadership roles in sub-Saharan Africa.MethodsWe conducted a qualitative study using in-person interviews with individuals (n = 17) in health-care leadership roles in four countries in sub-Saharan Africa: the Federal Democratic Republic of Ethiopia, the Republic of Ghana, the Republic of Liberia and the Republic of Rwanda. Individuals were identified by their country’s minister of health as key leaders in the health sector and were nominated to serve as delegates to a global health leadership conference in June 2010, at Yale University in the United States. Interviews were audio recorded and professionally transcribed. Data analysis was performed by a five-person multidisciplinary team using the constant comparative method, facilitated by ATLAS.ti 5.0 software.ResultsFive key themes emerged as important to participants in their leadership roles: having an aspirational, value-based vision for improving the future health of the country, being self-aware and having the ability to identify and use complementary skills of others, tending to relationships, using data in decision making, and sustaining a commitment to learning.ConclusionsCurrent models of leadership capacity building address the need for core technical and management competencies. While these competencies are important, skills relevant to managing relationships are also critical in the sub-Saharan African context. Developing such skills may require more time and a deeper level of engagement and collaboration than is typically invested in efforts to strengthen health systems.

Prayer camps and biomedical care in Ghana: Is collaboration in mental health care possible?

Background Experts have suggested that intersectoral partnerships between prayer camps and biomedical care providers may be an effective strategy to address the overwhelming shortage of mental health care workers in Africa and other low-income settings. Nevertheless, previous studies have not explored whether the prayer camp and biomedical staff beliefs and practices provide sufficient common ground to enable cooperative relationships. Therefore, we sought to examine the beliefs and practices of prayer camp staff and the perspective of biomedical care providers, with the goal of characterizing interest in—and potential for—intersectoral partnership between prayer camp staff and biomedical care providers. Methods We conducted 50 open-ended, semi-structured interviews with prophets and staff at nine Christian prayer camps in Ghana, and with staff within Ghana’s three public psychiatric hospitals. We used the purposive sampling method to recruit participants and the constant comparative method for qualitative data analysis. Results Prayer camp staff expressed interest in collaboration with biomedical mental health care providers, particularly if partnerships could provide technical support introducing medications in the prayer camp and address key shortcomings in their infrastructure and hygienic conditions. Nevertheless, challenges for collaboration were apparent as prayer camp staff expressed strong beliefs in a spiritual rather than biomedical explanatory model for mental illness, frequently used fasting and chained restraints in the course of treatment, and endorsed only short-term use of medication to treat mental illness—expressing concerns that long-term medication regimens masked underlying spiritual causes of illness. Biomedical providers were skeptical about the spiritual interpretations of mental illness held by faith healers, and were concerned by the use of chains, fasting, and the lack of adequate living facilities for patients in prayer camps; many, however, expressed interest in engaging with prayer camps to expand access to clinical care for patients residing in the camps. Conclusions The findings demonstrate that biomedical care providers are interested in engaging with prayer camps. Key areas where partnerships may best improve conditions for patients at prayer camps include collaborating on creating safe and secure physical spaces and delivering medication for mental illness to patients living in prayer camps. However, while prayer camp staff are willing to engage biomedical knowledge, deeply held beliefs and routine practices of faith and biomedical healers are difficult to reconcile Additional discussion is needed to find the common ground on which the scarce resources for mental health care in Ghana can collaborate most effectively.

Achieving large ends with limited means: grand strategy in global health

Unprecedented attention is focused on global health, with a four-fold increase in development assistance in the last 15 years and the scope of global health expanding beyond infectious disease to include chronic disease and health systems strengthening. As the global impact of health is more widely understood, it has become a crucial element of international relations, economic development, and foreign affairs. At this potential leverage point in the global health movement, the application of grand strategy is of critical importance. Grand strategy, i.e., the development and implementation of comprehensive plans of action to achieve large ends with limited means, has been refined through centuries of international relations and the management of states but has been inadequately applied to global health policy and implementation. We review key principles of grand strategy and demonstrate their applicability to a central global health issue: maternal mortality. The principles include: start with the end in mind, take an ecological approach, recognize that tactics matter, use positive deviance to characterize practical solutions and foster scale-up, and integrate timely intelligence and data into health interventions and improvement efforts. We advocate for the greater use of grand strategy in global health.

Scaling up depot medroxyprogesterone acetate (DMPA): a systematic literature review illustrating the AIDED model

BackgroundUse of depot medroxyprogesterone acetate (DMPA), often known by the brand name Depo-Provera, has increased globally, particularly in multiple low- and middle-income countries (LMICs). As a reproductive health technology that has scaled up in diverse contexts, DMPA is an exemplar product innovation with which to illustrate the utility of the AIDED model for scaling up family health innovations.MethodsWe conducted a systematic review of the enabling factors and barriers to scaling up DMPA use in LMICs. We searched 11 electronic databases for academic literature published through January 2013 (n = 284 articles), and grey literature from major health organizations. We applied exclusion criteria to identify relevant articles from peer-reviewed (n = 10) and grey literature (n = 9), extracting data on scale up of DMPA in 13 countries. We then mapped the resulting factors to the five AIDED model components: ASSESS, INNOVATE, DEVELOP, ENGAGE, and DEVOLVE.ResultsThe final sample of sources included studies representing variation in geographies and methodologies. We identified 15 enabling factors and 10 barriers to dissemination, diffusion, scale up, and/or sustainability of DMPA use. The greatest number of factors were mapped to the ASSESS, DEVELOP, and ENGAGE components.ConclusionsFindings offer early empirical support for the AIDED model, and provide insights into scale up of DMPA that may be relevant for other family planning product innovations.