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National Theater Project Evaluation Report

March 17, 2023

The New England Foundation for the Arts (NEFA) is one of six regional arts organizations established with funding from the National Endowment for the Arts. Each program and project that is brought to life at NEFA is created with the underlying goal of building a stronger and more dynamic infrastructure for the arts. In 2010, NEFA piloted the National Theater Project (NTP), modeled on NEFA's National Dance Project. NTP supports innovative devised and ensemble theater artists with building a network of organizations committed to strengthening opportunities and cultivating audiences for their work. Since 2012, NTP has not only provided funding but also has cultivated an informed, interactive network of producing theaters, presenters, and ensembles that promote the funded projects and the development of the field as a whole.In January 2022, NEFA hired McNeil Creative Enterprises (MCE) to examine and document the impact of NTP over the last ten years. MCE worked closely with NTP's staff utilizing a participatory research approach to frame the evaluation goals, data collection priorities, and the modes of analysis.The growth opportunities that emerged during the evaluation — if implemented — will enable NTP and ultimately NEFA to be even more effective and efficient in achieving its goals. It is our hope that the strategic considerations provided (and in greater detail in the report) support NTP's efforts to support sustainable growth and a strong vision for the future of the program.

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.

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.

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.

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.

The African Health Initiative’s Role in Advancing the Use of Embedded Implementation Research for Health Systems Strengthening

September 15, 2022

Embedded implementation research (EIR) is an approach to integrating knowledge generation and decision making about policy and program implementation that has been conceptualized and promoted by the Alliance for Health Policy and Systems Research (AHPSR) since 2012. The understanding and use of EIR as an approach to address knowledge gaps in health systems is gaining traction within the global health community. The African Health Initiative (AHI) has built on the EIR approach and demonstrated notable success in pursuing the twin agendas of health systems strengthening and research capacity strengthening. Since its inception, the AHI has produced more than 350 publications; trained more than 3,000 researchers, decision makers, and health workers; and strengthened the institutional capacities of more than 300 health facilities and research institutions across Africa. In addition to having influenced the policies and practices of many countries, this work has also helped to shape the thinking of researchers, policy makers, and development partners on the use of EIR as a means of health systems strengthening. This longstanding collaboration has engendered extensive learning about the effectiveness of the EIR approach and its contributions to improving the use of knowledge to strengthen health systems. In this commentary, we trace the history and growth of EIR and encapsulate its key learnings through the AHI's work.

Applying the Consolidated Framework for Implementation Research to Identify Implementation Determinants for the Integrated District Evidence-to-Action Program, Mozambique

September 15, 2022

Introduction: The Integrated District Evidence-to-Action program is an audit and feedback intervention introduced in 2017 in Manica and Sofala provinces, Mozambique, to reduce mortality in children younger than 5 years. We describe barriers and facilitators to early-stage effectiveness of that intervention.Method: We embedded the Consolidated Framework for Implementation Research (CFIR) into an extended case study design to inform sampling, data collection, analysis, and interpretation. We collected data in 4 districts in Manica and Sofala Provinces in November 2018. Data collection included document review, 22 in-depth individual interviews, and 2 focus group discussions (FGDs) with 19 provincial, district, and facility managers and nurses. Most participants (70.2%) were nurses and facility managers and the majority were women (87.8%). We audio-recorded all but 2 interviews and FGDs and conducted a consensus-based iterative analysis.Results: Facilitators of effective intervention implementation included: implementation of the core intervention components of audit and feedback meetings, supportive supervision and mentorship, and small grants as originally planned; positive pressure from district managers and study nurses on health facility staff to strive for excellence; and easy access to knowledge and information about the intervention. Implementation barriers were the intervention's lack of compatibility in not addressing the scarcity of human and financial resources and inadequate infrastructures for maternal and child health services at district and facility levels and; the intervention's lack of adaptability in having little flexibility in the design and decision making about the use of intervention funds and data collection tools.Discussion: Our comprehensive and systematic use of the CFIR within an extended case study design generated granular evidence on CFIR's contribution to implementation science efforts to describe determinants of early-stage intervention implementation. It also provided baseline findings to assess subsequent implementation phases, considering similarities and differences in barriers and facilitators across study districts and facilities. Sharing preliminary findings with stakeholders promoted timely decision making about intervention implementation.

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.

The Use of Research for Health Systems Policy Development and Implementation in Mozambique: A Descriptive Study

September 15, 2022

Health policy and systems research (HPSR) is generating an increasing amount of evidence in Mozambique, where implementation of a wide range of public health policies and interventions, and innovative technologies and solutions, is underway. We used qualitative methods to explore the relationship between HPSR and policy development and implementation in Mozambique. We conducted a literature review and in-depth interviews with researchers, experts, and policy makers. Through our analysis, we assessed barriers to the use of research evidence in the development and implementation of national health policies and identified potential opportunities to improve evidence use in this context.We found an increasing number of research institutions producing solid scientific evidence in the country, with activities in health in general and health systems specifically. There is also a growing trend for decision makers and policy makers to use the results of research during the design, formulation, and implementation of health policies. Most HPSR conducted in Mozambique is funded by international donors and focused on research questions of international interest. Therefore, research generated in Mozambique does not always address questions that are relevant to the local health system development agenda.While Mozambique has a lot of "gray literature" outlets, few of its publications support the translation of research evidence into policy. Much of the evidence generated in country is disseminated through project reports and briefings, not peer-reviewed literature. Furthermore, when the research evidence generated is not locally relevant, results may be published only in English and in scientific articles, instead of in formats useful to Mozambican policy makers—to the detriment of national-level understanding and use. We recommend that research institutions and policy makers in Mozambique collaborate on developing a platform that consolidates HPSR, making it more accessible and useful to policy makers.

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.

Maternal and Child Health Care Service Disruptions and Recovery in Mozambique After Cyclone Idai: An Uncontrolled Interrupted Time Series Analysis

September 15, 2022

Introduction: Climate change-related extreme weather events have increased in frequency and intensity, threatening people's health, particularly in places with weak health systems. In March 2019, Cyclone Idai devastated Mozambique's central region, causing infrastructure destruction, population displacement, and death. We assessed the impact of Idai on maternal and child health services and recovery in the Sofala and Manica provinces.Methods: Using monthly district-level routine data from November 2016 to March 2020, we performed an uncontrolled interrupted time series analysis to assess changes in 10 maternal and child health indicators in all 25 districts before and after Idai. We applied a Bayesian hierarchical negative binomial model with district-level random intercepts and slopes to estimate Idai-related service disruptions and recovery.Results: Of the 4.44 million people in Sofala and Manica, 1.83 (41.2%) million were affected. Buzi, Nhamatanda, and Dondo (all in Sofala province) had the highest proportion of people affected. After Idai, all 10 indicators showed an abrupt substantial decrease. First antenatal care visits per 100,000 women of reproductive age decreased by 23% (95% confidence interval [CI]=0.62, 0.96) in March and 11% (95% CI=0.75, 1.07) in April. BCG vaccinations per 1,000 children under age 5 years declined by 21% (95% CI=0.69, 0.90) and measles vaccinations decreased by 25% (95% CI=0.64, 0.87) in March and remained similar in April. Within 3 months post-cyclone, almost all districts recovered to pre-Idai levels, including Buzi, which showed a 22% and 13% relative increase in the number of first antenatal care visits and BCG, respectively.Conclusion: We found substantial health service disruptions immediately after Idai, with greater impact in the most affected districts. The findings suggest impressive recovery post-Idai, emphasizing the need to build resilient health systems to ensure quality health care during and after natural disasters.

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.