Sarah Wood Pallas

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.

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.

Responses to Donor Proliferation in Ghana's Health Sector: A Qualitative Case Study

Abstract Objective To investigate how donors and government agencies responded to a proliferation of donors providing aid to Ghana’s health sector between 1995 and 2012. Methods We interviewed 39 key informants from donor agencies, central government and nongovernmental organizations in Accra. These respondents were purposively selected to provide local and international views from the three types of institutions. Data collected from the respondents were compared with relevant documentary materials – e.g. reports and media articles – collected during interviews and through online research. Findings Ghana’s response to donor proliferation included creation of a sector-wide approach, a shift to sector budget support, the institutionalization of a Health Sector Working Group and anticipation of donor withdrawal following the country’s change from low-income to lower-middle income status. Key themes included the importance of leadership and political support, the internalization of norms for harmonization, alignment and ownership, tension between the different methods used to improve aid effectiveness, and a shift to a unidirectional accountability paradigm for health-sector performance. Conclusion In 1995–2012, the country’s central government and donors responded to donor proliferation in health-sector aid by promoting harmonization and alignment. This response was motivated by Ghana’s need for foreign aid, constraints on the capacity of governmental human resources and inefficiencies created by donor proliferation. Although this decreased the government’s transaction costs, it also increased the donors’ coordination costs and reduced the government’s negotiation options. Harmonization and alignment measures may have prompted donors to return to stand-alone projects to increase accountability and identification with beneficial impacts of projects.

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.

Improving health service delivery organisational performance in health systems: a taxonomy of strategy areas and conceptual framework for strategy selection.

Health systems strengthening (HSS) is a priority for global health funders, policy-makers and practitioners. Although many HSS efforts have focused on policy levers such as financing approaches, payment schemes or regulatory reforms, less attention has been directed to targeting the organisations that deliver health services such as hospitals, health centres and clinics. Evidence suggests that the impact of organisation-level interventions varies by context; however, we lack a general framework for integrating organisational context into performance improvement strategies for health service delivery organisations. Drawing on open systems theories from organisational behaviour and management as well as a review of 181 empirical studies of health service delivery organisations in low- and middle-income countries, we propose a taxonomy of seven strategy areas for improving organisational performance as well as a multistage conceptual framework for selecting among them. We propose that the choice of strategy for improving health service delivery organisational performance should be informed by: (i) the root cause of the organisations performance gap; (ii) the environmental conditions facing the organisation; and (iii) the implementation capability of the organisation. We also highlight conditions under which different strategy areas may be expected to be optimally effective. The approaches presented in this paper offer a way for health system decision-makers and researchers to systematically assess and incorporate organisational context in the process of developing strategies to improve the performance of health service delivery organisations and, ultimately, of health systems.

How Connecticut Health Directors Deal With Public Health Budget Cuts at the Local Level

OBJECTIVES We investigated the perspectives of local health jurisdiction (LHJ) directors on coping mechanisms used to respond to budget reductions and constraints on their decision-making. METHODS We conducted in-depth interviews with 17 LHJ directors. Interviews were audio recorded, transcribed, and analyzed using the constant comparative method. RESULTS LHJ directors use a range of coping mechanisms, including identifying alternative revenue sources, adjusting services, amending staffing arrangements, appealing to local political leaders, and forming strategic partnerships. LHJs also face constraints on their decision-making because of state and local statutory requirements, political priorities, pressures from other LHJs, and LHJ structure. CONCLUSIONS LHJs respond creatively to budget cuts to maintain important public health services. Some LHJ adjustments to administrative resources may obscure the long-term costs of public health budget cuts in such areas as staff morale and turnover. Not all coping strategies are available to each LHJ because of the contextual constraints of its locality, pointing to important policy questions on identifying optimum jurisdiction size and improving efficiency.

Does donor proliferation in development aid for health affect health service delivery and population health? Cross-country regression analysis from 1995 to 2010

Background Previous literature suggests that increasing numbers of development aid donors can reduce aid effectiveness but this has not been tested in the health sector, which has experienced substantial recent growth in aid volume and number of donors. Methods Based on annual data for 1995-2010 on 139 low- and middle-income countries that received health sector aid from donors reporting to the OECDs Creditor Reporting System, the study used two-step system generalized method of moments regression models to test whether the number of health aid donors and an index of health aid donor fragmentation affect health services (measured by DTP3 immunization rate) or health outcomes (measured by infant mortality rate) for three subsectors of health aid. Results For total health aid and for the general and basic health aid subsector, controlling for economic and political conditions, increases in the number of donors were associated with increases in DTP3 immunization rate and reductions in infant mortality while increases in the donor fragmentation index were associated with decreases in DTP3 immunization rate and increases in infant mortality, though none of these relationships were statistically significant. For the population and reproductive health aid subsector, a one percent increase in the number of donors was associated with a 0.23 percent decrease in DTP3 immunization ( P <  0.01) while a one percent increase in donor fragmentation was associated with a 0.54 percent increase in DTP3 immunization rate ( P <  0.01); associations with infant mortality rates for this subsector were similar to those for total health aid. Conclusion The results do not provide clear evidence in support of the hypothesis that donor proliferation negatively impacts development results in the health sector. Aid effectiveness policy prescriptions should distinguish responses to donor proliferation versus donor fragmentation and be adapted to specific subsectors of health aid.