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Quality of care from the perspective of people obtaining abortion: a qualitative study in four countries

September 19, 2023

Objective This qualitative study aimed to identify person-centred domains that would contribute to the definition and measurement of abortion quality of care based on the perceptions, experiences and priorities of people seeking abortion.Methods We conducted interviews with people seeking abortion aged 15–41 who obtained care in Argentina, Bangladesh, Ethiopia or Nigeria. Participants were recruited from hospitals, clinics, pharmacies, call centres and accompaniment models. We conducted thematic analysis and quantified key domains of quality identified by the participants.Results We identified six themes that contributed to high-quality abortion care from the clients' perspective, with particular focus on interpersonal dynamics. These themes emerged as participants described their abortion experience, reflected on their interactions with providers and defined good and bad care. The six themes included (1) kindness and respect, (2) information exchange, (3) emotional support, (4) attentive care throughout the process, (5) privacy and confidentiality and (6) prepared for and able to cope with pain.Conclusions People seeking abortion across multiple country contexts and among various care models have confirmed the importance of interpersonal care in quality. These findings provide guidance on six priority areas which could be used to sharpen the definition of abortion quality, improve measurement, and design interventions to improve quality.

The World's Most Neglected Displacement Crises 2022

June 1, 2023

Each year, the Norwegian Refugee Council (NRC) publishes a report of the ten most neglected displacement crises in the world. The purpose is to focus on the plight of people whose suffering rarely makes international headlines, who receive little or no assistance, and who never become the centre of attention for international diplomacy efforts. This is the list for 2022.

Annual Impact Report, Fiscal Year 2022: July 2021 to June 2022

November 1, 2022

EngenderHealth's fiscal year 2022 (FY22) impact report illustrates our progress across 22 projects, while countries continued to grapple with the immediate and longer-term effects of the COVID-19 pandemic. Our progress and associated impacts are guided by our organizational Strategic Plan and complementary Theory of Change (see Figure 1). This report highlights our overall impact and examines findings related to each level of the socioecological model represented in our theory of change, including our influence on policies, laws, and processes; our contributions to health systems; and our impact on communities and individuals at the center of our work. We also illustrate our achievements in relation to our three core impact areas: sexual and reproductive health and rights (SRHR) (including contraception care, abortion care, and more), gender-based violence (GBV), and maternal and obstetric care—all of which critically support EngenderHealth's mission. Furthermore, the report highlights how we achieve our results through specific pathways to change, including community engagement, digital health, and health systems strengthening; and via our priority approaches of gender-transformative change, localization of leadership, meaningful youth participation, and partnerships. All our achievements are accelerated through partnerships, learning, and leadership, and through our emphasis on organizational effectiveness and gender equity, which amplifies our impact.

Lessons Learned From the Capacity-Building and Mentorship Program to Improve Health Information Systems in 11 Districts of Ethiopia

September 15, 2022

Introduction: Health information systems (HIS) performance in Ethiopia is currently insufficient, and improvements are required to ensure that decision making is data driven. We share our experiences from the early-stage implementation of a package of HIS capacity-strengthening interventions as part of an innovative academic-government collaboration that addresses challenges in HIS performance.Methods: We used routine program data to assess HIS performance using the Performance of Routine Information System Management (PRISM) assessment tools. The assessment employed a pre-post design and was conducted in a total of 24 selected health facilities (6 hospitals and 18 health centers) from 11 districts in Ethiopia at project baseline (2018) and midline (2020).Results: Source document completeness rate reached less than 80% for the majority of the assessed data elements. Improvements were observed in quarterly report completeness (26% vs. 83%) and timeliness (17% vs. 48%). Though data inaccuracies are noted for all assessed data elements in 2020, the majority (83%) of skilled birth attendance and HIV reports (68%) fall within the acceptable range of reporting accuracy. The identification of performance-related problems, using performance monitoring team (PMT) meetings, improved between 2018 and 2020 (67% vs 89%). Similar improvements were also observed in developing action plans to solve identified problems via the PMT (52% in 2018 vs. 89% in 2020). Data use for planning and target setting (65% in 2018 vs. 90% in 2020), reviewing performance (58% in 2018 vs. 60% in 2020), and supervision (51% in 2018 vs. 53% in 2020) all improved among assessed health facilities.Discussion: This study showed that a capacity-building and mentorship program that engages experts from multiple disciplines and sectors can improve the quality and use of health data. This partnership enabled engagement between government and academic stakeholders and allowed for a more robust exchange of resources and expertise toward HIS improvement.

Maternal Service Coverage and Its Relationship To Health Information System Performance: A Linked Facility and Population-Based Survey in Ethiopia

September 15, 2022

Background: Studies in Ethiopia show an increasing trend in maternal health service use, such as having at least 4 visits of antenatal care (ANC4+) and skilled birth attendance (SBA). Improving the health information system (HIS) is an intervention that can improve service uptake and quality. We conducted a baseline study to measure current maternal service coverage, HIS performance status, and their relationship.Methods: We conducted a linked health facility-level and population-based survey from September 2020 to October 2020. The study covers all regions of Ethiopia. For the population-based survey, 3,016 mothers were included. Overall, 81 health posts, 71 health centers, and 15 hospitals were selected for the facility survey. A two-stage sampling procedure was applied to select target households. The study used modified Performance of Routine Information System Management tools for the facility survey and a structured questionnaire for the household survey. Multilevel logistic regression was employed to account for clustering and control for likely confounders.Results: Maternal service indicators, ANC4+ visits (54.0%), SBA (75.8%), postnatal care (70.6%), and cesarean delivery (9%) showed good service uptake. All data quality and use indicators showed lower performance compared to the national target of 90%. Maternal education and higher levels of wealth index were significantly and positively associated with all selected maternal service indicators. Longer distance from health facilities was significantly and negatively associated with SBA and the maternal care composite indicator. Among HIS-related indicators, availability of electronic HIS tools was significantly associated with maternal care composite indicator and ANC4+.Conclusions: Maternal service indicators showed promising performance. However, current HIS performance is suboptimal. Both service user and HIS-related factors were associated with maternal service uptake. Conducting similar research outside of the project sites will be helpful to have a wider understanding and better coverage.

Drivers and Barriers to Improved Data Quality and Data-Use Practices: An Interpretative Qualitative Study in Addis Ababa, Ethiopia

September 15, 2022

Introduction: An objective of the Information Revolution Roadmap of Ethiopia's Health Sector Transformation Plan was to improve health management information system (HMIS) data quality and data use at the point of health service delivery. We aimed to assess drivers of and barriers to improving HMIS data quality and use, focusing on key Information Revolution strategies including Connected Woreda, capacity building, performance monitoring teams, and motivational incentives.Methods: We conducted an interpretative qualitative study across all 11 health centers in 3 subcities of Addis Ababa, Ethiopia: Yeka, Akaki-Kaliti, and Ledeta. A total of 40 key informant interviews and 6 focus group discussions with a total of 43 discussants were conducted. We coded information gathered line-by-line and grouped responses under thematic codes as they emerged. Findings were triangulated and validated.Results: Our findings indicate that the main drivers of data quality and use at the point of service delivery were the use of the Connected Woreda strategy and its tools, capacity-building activities including mentorship, performance monitoring-team activities that led to active leadership engagement, and motivational incentives for data producers and users. Barriers to optimal data-use practices were the use of duplicative data collection tools at health facilities, under-developed health information system infrastructure, inadequate health information technician staffing and capacity limitations at the health facility level, insufficient leadership commitment, and unfavorable health worker attitudes toward data.Discussion: Improvements in quality and use of HMIS data at health facilities are expected to result in delivering better-quality health services to the community as data enable health workers to identify gaps in health care, fix them, and monitor improvements. Future investments should focus on strengthening the promising data-use practices, resolving bottlenecks caused by duplicative data collection tools, enhancing individual and institutional capacity, addressing suboptimal health worker attitudes toward data, and overcoming infrastructure and connectivity challenges.

Health Policy and Systems Research Capacities in Ethiopia and Ghana: Findings From a Self-Assessment

September 15, 2022

Introduction: Health systems are complex. Policies targeted at health system development may be informed by health policy and systems research (HPSR). This study assesses HPSR capacity to generate evidence and inform policy in Ethiopia and Ghana.Methods: We used a mixed-methods approach including a self-administered survey at selected HPSR institutes and in-depth interviews of policy makers.Results: Both countries have limited capacity to generate HPSR evidence, especially in terms of mobilizing adequate funding and retaining a critical number of competent researchers who understand complex policy processes, have the skills to influence policy, and know policy makers' demands for evidence. Common challenges are limited government research funding, rigidity in executing the research budget, and reliance on donor funding that might not respond to national health priorities. There are no large research programs in either country. The annual number of HPSR projects per research institute in Ethiopia (10 projects) was higher than in Ghana (2.5 projects), Ethiopia has a significantly smaller annual budget for health research. Policy makers in the 2 countries increasingly recognize the importance of evidence-informed policy making, but various challenges remain in building effective interactions with HPSR institutes.Conclusion: We propose 3 synergistic recommendations to strengthen HPSR capacity in Ethiopia and Ghana. First, strengthen researchers' capacity and enhance their opportunities to know policy actors; engage with the policy community; and identify and work with policy entrepreneurs, who have attributes, skills, and strategies to achieve a successful policy. Second, deliver policy-relevant research findings in a timely way and embed research into key health programs to guide effective implementation. Third, mobilize local and international funding to strengthen HPSR capacities as well as address challenges with recruiting and retaining a critical number of talented researchers. These recommendations may be applied to other low- and middle-income countries to strengthen HPSR capacities.

Barriers and Facilitators to Data Use for Decision Making: The Experience of the African Health Initiative Partnerships in Ethiopia, Ghana, and Mozambique

September 15, 2022

Background: Three African Health Initiative (AHI) partnership projects in Ethiopia, Ghana, and Mozambique implemented strategies to improve the quality and evaluation of routinely collected data at the primary health care level and stimulate its use in evidence-based decision making. We compare how these programs designed and carried out data for decision-making (DDM) strategies, elaborate on barriers and facilitators to implementation success, and offer recommendations for future DDM programming.Methods: Researchers from each project collaboratively wrote a cross-country protocol based on these objectives. By adapting the Consolidated Framework for Implementation Research (CFIR) through a qualitative theme reduction process, they harmonized lines of inquiry on the design of the respective DDM strategies and the barriers and facilitators of effective implementation. We conducted in-depth interviews and focus group discussions with stakeholders from the primary health care systems in each country, and we carried out multistage, thematic analyses using a deductive lens.Results: Effective implementation of DDM depended on whether implementers felt that DDM was adaptable to context, feasible to trial, and easy to introduce and maintain. The prevailing policy and political environment in the wider health system, learning climate and absorptive capacity for evidence-based change in DDM settings, engagement of external change agents and internal change leaders, and promotion of opportunities and means for team-based reflection and evaluations of what works influenced the success or failure of DDM strategies.Conclusion: Opportunities for team-based capacity building and individual mentorship led to effective DDM programming. External policies and associated incentives bolstered this but occasionally led to unintended consequences. Leadership engagement and availability of resources to act on recommendations; respond to capacity-building needs; and facilitate collaborations between peers, within hierarchies, and across the local health system proved crucial to DDM, as was encouraging adaptation and opportunities for iterative on-the-job learning.

Improving Primary Care Quality Through Supportive Supervision and Mentoring: Lessons From the African Health Initiative in Ethiopia, Ghana, and Mozambique

September 15, 2022

Introduction: Supportive supervision and mentoring (SSM) is crucial to primary care quality and effectiveness. Yet, there is little clarity on how to design and implement SSM and make it sustainable in primary health care (PHC) systems. The 3 African Health Initiative partnership projects introduced strategies to do this in Ethiopia, Ghana, and Mozambique. We describe: (1) how each partnership adapted SSM implementation strategies, (2) the dynamics of implementation and change that ensued after intervening within PHC systems, and (3) insights on the SSM sustainability as a mainstay of PHC.Methods: Researchers from each project collaboratively wrote a cross-country protocol based on those objectives. For this, they adapted implementation science frameworks—the Exploration, Preparation, Implementation, and Sustainment model and the Consolidated Framework for Implementation Research—through a qualitative theme reduction process. This resulted in harmonized lines of inquiry on the design, implementation, and potential sustainability of each project's SSM strategy. In-depth interviews and focus group discussions were conducted with stakeholders from PHC systems in each country and thematic analyses ensued.Results: Across the projects, SSM strategies acquired multiple components to address individual, systems, and process-related determinants. Benefits arose from efforts that addressed worker-level attitudes and barriers, promoted a wider learning environment, and enhanced collaborative structures and tools for monitoring performance. Peer exchanges and embedded implementation research were critical to the perceived effectiveness of SSM strategies.Discussion: Despite differences in their approach to SSM implementation, there are common crucial ingredients across the SSM strategies of the 3 AHI partner projects from which important lessons arise: (1) positioning learning and adaptation opportunities within the routine workings of PHC systems, facilitation, and technical support to reflect and utilize new knowledge; (2) multisectoral collaboration, particularly with academic organizations; and (3) building PHC decision-makers' and implementation teams' capacity for evidence-informed change.

Embedding Research on Implementation of Primary Health Care Systems Strengthening: A Commentary on Collaborative Experiences in Ethiopia, Ghana, and Mozambique

September 15, 2022

Achieving universal health care coverage requires the adoption of primary health care policies and delivery strategies that are evidence based. Although this has been confronted by manifold challenges, particularly in the health systems of sub-Saharan Africa, there are promising approaches for accomplishing this objective. Salient among these is embedding implementation research (i.e., the study of methods to promote the systematic uptake of evidence-based interventions (EBIs) into routine practice) into policy making and implementation processes. Since 2007, the African Health Initiative of the Doris Duke Charitable Foundation supported partnerships that strengthened primary health systems and policy implementation in 7 countries in sub-Saharan Africa using the embedded implementation research as a core strategy. This programmatic review and analysis aims to identify the core features and processes that characterized how the partnerships operationalized the embedded implementation research approach and understand the factors that helped and constrained partnerships' effective use of this approach. For this, we drew upon findings from a desk review that consisted of 30 examples of embedded implementation research conducted by 3 African Health Initiative partnerships between 2016 and 2021 in Ethiopia, Ghana, and Mozambique. In addition, we conducted and analyzed 13 in-depth interviews with embedded implementation research stakeholders of the 3 projects.Core features and processes of embedded implementation research were: (1) the leadership role of policy decision makers and implementation leaders; (2) positioning research with program implementation at multiple levels of health systems; (3) multidisciplinary and multisectoral partnerships; (4) focus on research capacity building; and (5) real-time feedback loops and knowledge translation.Factors influencing the effectiveness of the embedded implementation research experiences involved: (1) the implementation climate and leadership; (2) opportunities and capacities to circulate and absorb new information; and (3) stakeholders' baseline knowledge and embedded scientists' identification within their organizations.

Learning Health Systems to Bridge the Evidence-Policy-Practice Gap in Primary Health Care: Lessons From the African Health Initiative

September 15, 2022

The authors provide a brief history of the African Health Initiative and introduce the articles of the Global Health: Science and Practice journal supplement, highlighting the importance of evidence-based interventions (EBI) in global health and summarizing key takeaways.

No One Is Spared: Abuses Against Older People in Armed Conflict

February 1, 2022

This report describes patterns of abuses against older people affected by armed conflict in Burkina Faso, Central African Republic, Ethiopia, Israel and the Occupied Palestinian Territory, Mali, Mozambique, Niger, South Sudan, Syria, and Ukraine. It also draws on the situation of serious protracted violence in two English-speaking regions of Cameroon, Myanmar security force atrocities against older ethnic Rohingya in Rakhine State, and the experiences of older refugees in Lebanon displaced by conflict in Syria. It also includes abuses against older people in the 2020 armed conflict in the ethnic-Armenian-majority enclave of Nagorno-Karabakh.